The art of the possible will

National Leadershipand Innovation

AgencyFor HealthcareAsiantaeth

GenedlaetholArweiniad ac Arloesoldeb

dros Ofal Iechyd




dros Ofal Iechyd

Methods for ImprovementMethods for ImprovementWhere is the Will?Where is the Will?

David I GozzardDavid I Gozzard

Quality Improvement FellowQuality Improvement Fellow

Health FoundationHealth Foundation

IN HEALTHCARE!

Improvement Improvement MantraMantra

•Will•Ideas•Execution

…..then Scrutiny

WILLWILL

• The mental faculty by which one chooses or decides upon a course of action

• The act of exercising the will• Diligent purposefulness; Determination• Self-control; Self-discipline• A desire, purpose or determination,

especially one in authority• Free discretion, inclination or pleasure• Bearing or attitude towards others;

disposition

Problems around Problems around WillWill

• Data• “Somebody else's data, doesn’t relate

to my clinic or practice”

• Discomfort• “Discomfort Zone”

• Denial/Disbelief• “Nothing wrong with my practice”• “It’s the uniqueness of my patients”

Clinician CommentsClinician Comments

• “Too busy……..admin and over-busy clinical time”• “It’s a nursing thing – I just deal with my own patients”• “Quality suffers because of the outliers, lack of junior

staff, the lack of continuity – SPI is just around the margins”

• “I am not paid to do this”• “My cases are high quality – it’s the other ward that is

dirty”• “Things are not like they used to be - we used to work

harder and be more vigilant”• “No clear vision from Government – yet another

initiative”• “It’s not in the targets set by my General manager”• “I don’t believe the data”• “You have gone over to the dark side”

Improvement Improvement Culture:Culture:

A Useful GuideA Useful Guide

“Every enterprise has four organisations: the one that is written down, the one that most people believe exists, the one that people wished existed and finally, the one that the organisation really needs”

NHS Chief Executive

The Discomfort ZoneThe Discomfort ZoneComfort Zone: People stay here, don’t change, don’t learn

Discomfort Zone: People uncertain, but most likely to change, most likely to learn

Panic Zone: People freeze, will not change, will not learn

To encourage people to leave a comfort zone, you need to help them feel safe. You can do this by creating the right environment and culture, ensuring that there is no blame.

The Individual:The Individual:Readiness to ChangeReadiness to Change

Prochaska et al 1992

Descriptor Behaviour Action

Pre-contemplation The individual is not ready to discuss or consider change

Consciousness raising

Contemplation The individual is willing to listen and to consider a change

Emphasis on benefits

Preparation The individual gets ready to do something concrete

Provide support

Action The individual starts to work with the change

Continue support in addition to encouragement and praise

Maintenance The individual strives not to slip back to old behaviours

Scrutiny of process?

The Nature of The Nature of ChangeChange

Change can be…..

Collective Everyone in a group must decide to adopt or not

Authoritative The individual is told to adopt

Contingent The individual cannot choose to adopt until the organisation has sanctioned it

The Scepticism ContinuumThe Scepticism Continuum

behaviour behaviourattitude

active passive scepticism neutrality acceptance commitment activeresistance resistance involvement

Scepticism: The questioning or doubting of accepted opinion

Resistance: Through actions and arguments prevent someone from doing something, or prevent something from happening

The Value of ResistanceThe Value of Resistance

“Commercial practice, for example, often interprets resistance to change as a natural and

necessary force for exposing and resolving conflict, and consequently for planning and

implementing change effectively.

“Organisations need resistance to change in order to prevent bad and poorly developed ideas

from being implemented.

Mabin et al 2001

Schön 1963

The Involvement The Involvement ConundrumConundrum

Impact on personal status,

patients and the

organisation

Political considerations

Timing

Degree of information

or understandin

g

Complexity Impact

Skills required

Priority

Source

Focus

The individual contemplating

change

The proposed change

Time Context

Trust Reported IncidentsTrust Reported Incidents

Errors

Errors that cause no harm to the patient(Near Misses)

Errors that harm the patient

Errors and harm - are Errors and harm - are they the same thing?they the same thing?

Harm

Harm caused by “normal care”

HarmHarm

• Every system is designed to produce the outcome it gets

• We have systems of care designed to produce certain levels of harm

• These levels of harm have become acceptable as a property of the

system• All harm is theoretically preventable

Errors:Errors:

• Failure of a planned action to be completed as intended• Error of execution

• Use of a wrong plan to achieve an aim• Error of planning

What Could we Measure?What Could we Measure?

• Performance management requirements

• Contractual items• Number of patients

• Patient episodes• Trends in attendances

• Waiting times

• Number of critical incidents• Incident reporting and categorisation

No link here

Why are Why are youyoumeasuring?measuring?

The answer to this question will guide your entire The answer to this question will guide your entire quality measurement journey!quality measurement journey!

ImprovementImprovement??

Judgment?

Judgment?Research

?

Research

?

The Three Faces of The Three Faces of Performance MeasurementPerformance Measurement

Aspect Improvement Accountability Research

Aim Improvement of care Comparison, choice, reassurance

New knowledge

Methods:Test Observability

Tests are observable No test; merely evaluate current performance

Test blinded or controlled tests

Bias Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

Sample Size “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

Flexibility of Hypothesis

Hypothesis flexible, changes with learning

No hypothesis Fixed hypothesis

Testing Strategy Sequential tests No tests One large test

Determining if change is an imrovement

Run charts or Shewhart control charts

No change focus Hypothesis, statistical tests

Confidentiality of the Data

Data used only by those involved with improvement

Data available for public consumption and review

Research subjects’ identities protected

Bob Lloyd, IHI

Measuring QualityMeasuring Quality• No system in place to measure quality• What are our quality indicators?

• Data for performance management• Data for research• Data for quality improvement

• 40 “measures”• Each required a new system to measure• Mostly via laborious case note audit

• But it had to be done!

Hope is Not a Plan




dros Ofal Iechyd




dros Ofal Iechyd

Boards think quality is a Boards think quality is a lot better than the lot better than the

managers, doctors and managers, doctors and nurses do.nurses do.

Results from NPSF/AIG Results from NPSF/AIG andand

Estes Park SurveyEstes Park Survey

1 2 3 4 5

How comfortable are you with your level of engagement safety?

9 37 32 14 7 % Mgmt

4 42 46 6 2% BoardC-Suite

Does patient safety trump productivity in your work organization?

9 18 41 20 12 % Mgmt


Are you able to engage your staff in patient safety activities?

13 31 41 13 0 % Mgmt


Definitely Not at all

1 2 3 4 5

Executive leadership and the board are visibly engaged in patient safety

10 31 36 15 8 % Mgmt

19 65 14 1 1

% BoardC-Suite

Executive leadership provides the tools and training to be effective

9 30 37 17 7 % Mgmt

14 58 25 2 1

% BoardC-Suite

Physician leadership is actively engaged in patient safety efforts

5 18 33 31 12 % Mgmt

20 48 26 5 1

% BoardC-Suite

Definitely

Not at all

Results from NPSF/AIG Results from NPSF/AIG andand

Estes Park SurveyEstes Park Survey

Better Outcomes Are Better Outcomes Are Associated With Hospitals in Associated With Hospitals in

Which . . .Which . . .

• The board spends more than 25% of its time on quality issues.

• The board receives a formal quality performance measurement report.

• There is a high level of interaction between the board and the medical staff on quality strategy.

• The senior executives’ compensation is based in part on QI performance.

• The CEO is identified as the person with the greatest impact on QI, especially when so

identified by the QI Executive.

Vaughn T, Koepke M, Kroch et. al. 2006

Board Stages in Quality Board Stages in Quality

Engaged

Capable

No Yes

No

Q is just fine, thanks, and

besides, it’s not our problem

Frustrated and confused about

how

Yes

If we could only light the fire…

How do we do this even better?

Changing the old

Making the future attractive

Framework: Leadership for Improvement

Will

Ideas Execution

Establish the Foundation

Setting Direction: Mission, Vision and Strategy

PULL

PUSH

PULL

PUSH

1. Set Direction: 100% or Zero

Make the status quo uncomfortable

Make the future attractive

3. Build Will• Involve patients and families • Understand the gap between

your current performance, the best in class and the theoretical ideal

• Use stories and data• Go transparent• Show courage

5. Execute Change• Establish accountability for results• Establish good oversight process

on “are we achieving our aims?”•Watch your own dots•Weekly or monthly data•25% Board time on quality

4. Generate Ideas

Framework: Board Leadership of Quality

2. Establish the Foundation

• Quality education standards for board

• Build a board culture of healthy conversations with MEC and administration

• Establish Quality Committee• Bring knowledgeable quality leaders onto the board

The Best Boards…The Best Boards…

• Aim high• “Our aim is to achieve zero

central line infections…” • Aim broad

• “…for the entire institution, across all services…”

• Take dead aim• “…by August 31, 2009.”

Mission &Strategy

OrganisationObjectives

LocalObjectives

ImprovementProjects

Individual

PDP

Projects not aligned to organisation objectives are doomed to failure as senior staff will have no interest in

their outcome

The Audit CycleThe Audit Cycle

Consists of…Observation of existing practiceThe setting of standardsComparison between observed and set standardsImplementation of changeRe-audit of clinical practice

Audit and Audit and ImprovementImprovement

©National Leadership and Innovation Agency for Healthcare Asiantaeth Genedlaethol Arweiniad ac Arloesoldeb dros Ofal

Iechyd

Prototype PilotAdapt and

Spread

Improvement project

Audit Audit

Audit as Initiator and Scrutiny

A True Measure of a QI Programme




dros Ofal Iechyd




dros Ofal Iechyd

The Lessons of The Lessons of JönköpingJönköping

Sweden

Jönköping county

Europe

Jönköping County Council is responsible for the public health care services

Jönköping

Höglandet

Värnamo

160 new patients staying over night at the hospitals/day 9 newborns/day

3 Hospitals 34 Primary care centers

9,500 employees350,000 inhabitants

6.100 visits per day 1.500 visit a specialist/day 1.300 visit to GP/day (300 visits to private doctors/day)

The Esther The Esther ProjectProject

“Esther” is not a realpatient but her persona as a grey-haired, ailing, but competent elderlySwedish woman with a chronic condition and occasional acute needs has inspired impressive improvement in how patients flow through a complex network of providers and care settings in Höglandet, Sweden

“What is best for Esther?”

Objectives of Esther Objectives of Esther ProjectProject

1. Security for Esther2. Better working relationships in the

entire care chain3. Higher competence through the

care chain4. Shared medical documentation5. Quality through the entire care

chain6. Documentation and communication

of improvements

Projects to support Projects to support EstherEsther

• Develop flexible organisation with patient value in focus• Design more efficient and improved prescription and

medication routines• Create ways in which documentation and

communication of information can be adapted to the next link on care chain

• Develop an efficient IT-support through whole care chain• Develop and introduce a diagnosis system for

community care• Develop a virtual competence centre for better transfer

and improvement of competence through the care chain

The Inspiration of The Inspiration of EstherEsther

Improvements 1998 2003

Hospital Admissions 9,300 7,300

Hospital Days for CHF 3,500 2,500

(yr 2000)

Waiting times to see a neurologist

85d 14d

Waiting times to see a gastroenterologist

48d 14d

Patient focused

“Activities and sub processes organised

after prioritised patient values”

Patient ask for

Primary Care

Examinationprimary care

treatment

Hospital

Diagnosis & decisionon treatment Prim.C/Hospital

RehabilitationPrimary Care

TreatmentHospital

RehabilitationMunicipality/Community Care

EstherSix Primary care units

RehabERMedicine

Hospital in the town Eksjö

Six municipalities

Traditional

“Functional"

Patienttreatmentfinished

Patientwith disease

Lab

Pharmacy

From a Functional to a Patient Oriented Healthcare

Organisation

The art of the possible will

Education

nature of change change

dont change

change emphasis

patient harm harm

individual contemplating

errors errors

discomfort zone comfort

improvement culture