Welcome to NHS Tayside. The Unique Role of Organisation Leaders Set the tone and values system in their organisations, Establish strategic goals for activities.

Welcome to NHS Tayside

The Unique Role of Organisation Leaders• Set the tone and values system in their organisations, • Establish strategic goals for activities to be undertaken, • Align efforts within the organisation to achieve those

goals, • Provide resources for the creation of effective systems

remove obstacles for staff, and• Require adherence to revised practices• Create leverage for continuous improvement

Leadership

• Patient Safety as a Strategic Imperative• Clear Goals and Measurement • Reduce variability, waste and harm• Skill building • Encouragement with expectations• Ask important questions- What is preventing

movement? How can we help?• Expectations without capability breeds fear

and hopelessness

Jutland

ShetlandShetland

GrampianGrampian

HighlandHighland

WesternWesternIslesIsles

BordersBorders

FifeFife

LothianLothian

GreaterGreaterGlasgow ClydeGlasgow Clyde

Ayrshire Ayrshire & Arran& Arran

OrkneyOrkney

Forth ValleyForth Valley

LanarkshireLanarkshire

Dumfries &Dumfries &GallowayGalloway

Scotland’s Pop. 5.2 millionScotland’s Pop. 5.2 million

14 health Boards 150,000 staff14 health Boards 150,000 staff

TaysideTayside

And 7 Special Boards NHS 24NHS Education ScotlandNHS Health ScotlandHealth Improvment Scotland Scottish Ambulance State Hospitals Board The National Waiting Times

Projected Scottish Government spending

20,000

22,000

24,000

26,000

28,000

30,000

32,000

£ M

illio

ns (

2010

-11

Pric

es)

2009-10 2025-2616 years

£42 billion

• Population - 400,000

• Services; Acute/Teaching Hospital , Mental Health, Community Services, Primary Care & Regional Services

• 22 Hospitals – 1192 Beds

• 68 GP Practices - 322 GPs

• 3 Local Authorities

• Budget c£800m

• Efficiency Savings Target 2011/12 – £27m

NHS Tayside Profile

Proposed New Quality Aims

1. To make NHS Scotland a world leader in healthcare quality improvement.

2. To do so in a way that is meaningful to all.

Inst

itu

te o

f M

edic

ine’

s

6 D

imen

sion

s of

Qu

alit

y

Ninewells HospitalPerth Royal Infirmary

Stracathro Hospital

S + P = O

Source: Donabedian, A. Explorations in+ Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment.

Ann Arbor, MI, Health Administration Press, 1980.

The Theory for Change

Structure + Process = OutcomesStructure + Process = Outcomes

+Culture

13

Appreciation of a system

Understanding Variation

Theory of Knowledge

Psychology

A

im or V

alues

The Lens of Profound Knowledge

QI

The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations. It provides an opportunity for dialogue and learning!

14

Appreciation for a System• Interdependence, dynamism• World is not deterministic• Optimization, interactions• System must have an aim• Whole is greater than sum of the parts

Understanding Variation• Variation is to be expected• Common or special causes• Ranking, tampering• Potential mistakes

Theory of Knowledge• Prediction• Learning from theory, experience• Operational definitions • PDSA for learning and improvement

Psychology• Interaction between people• Intrinsic motivation, movement• Beliefs, assumptions • Will to change

What insights might be obtained by looking through the Lens of Profound

Knowledge?

Exercise

• Work with the person next to you • For 5 minutes discuss your project and

theories and assumptions that relate to your local projects

• Consider appreciation of the system• Theory of knowledge

The “Quality Curve”

Shift and narrow the curve:What is the norm?

Shift and narrow the curve:What is the norm?

Cut the tail:What is unacceptable?

Cut the tail:What is unacceptable?

Extend the ambition: What is great? (What is possible?)

Extend the ambition: What is great? (What is possible?)

11

22

33

Mesosystem

Macrosystem

Microsystem

Nursing Services

Nursing Divisions

FrontlineNursingUnits

Source: G. Hendriks & M. Bojestig, Jonkoping County Council, Sweden

System Level Thinking: Jonkoping Sweden

The beginning…………

A History of Quality as a Business A History of Quality as a Business Strategy in TaysideStrategy in Tayside

Source: System thinking and spreading knowledge, Bojestic M., Henriks, G., Provost L. IHI European Forum, Prague 2006

Awareness•Safer Patient Initiative•Change & Innovation Plan

Education•Learning from Qulturum and IHI•Patient Safety Officer training•Improvement experts and practitioners training •Board Effectiveness Development Programme

Process Thinking•Lean and Rapid Improvement work•Real time data and measurement for improvement

Redesign•Improvement as a Systems Property•Steps to Better Healthcare•Triple Aim

Movement•Triple Aim •System Infrastructure - TCOE•Creating breakthrough

Full Scale•Public Sector Infrastructure to support improvement •Working with Communities

2006 2007 2008 2009 2010 2011 Beyond

W. E. Deming, The New Economics for Industry, Government, Education. MIT, 1993

"One need not be eminent in any part of profound knowledge in order to understand it and to

apply it. The various segments of the system of profound

knowledge cannot be separated. They interact with each other. For

example knowledge about psychology is incomplete without

knowledge of variation."

Profound - having intellectual depth and insight (Webster)

Appreciation of a System

Theory of Knowledge

Psychology

UnderstandingVariation

Factors used by leading QI organisations to deliver improved outcomes

Build Infrastructure

& Capacity

Quality program organisation Education

Leadership development

Priorities maintained during crises Stability of general management and

program management Choosing tools to support staff in their “day job”

of improvement

Program logisticsMeasurement systemsInformation systems

Culture:• Will and commitment• Measurement• Evidence based learning• Learning organisation

A Staines 2009

NHS Tayside Governance DashboardsNHS Tayside Governance Dashboards

Board

ET

EMT

Directorate / CHP

Ward / Team Level

Patient / Practitioner Level

ASSURANCE

Validated Data for 6 domains: Access, Efficiency, Infection & Prevention, Quality & Patient

Experience, Patient Safety and Data Quality

PERFORMANCE

Validated and un-validated data across 6 domains:Clinical Excellence, Finance & Activity, Valuing Staff, Capacity &

Activity Planning, Patient Experience and Patient Safety

Impr

ovem

ent

Patient to Board

“focusing on information and data to provide assurance on improvement and quality to deliver better, safer care”.

Perf

orm

ance

Assu

ranc

e

Dat

a an

d M

easu

rem

ent f

or

IMPROVEMENT

Un-validated data provided in real time through Unified Patient Tracking, Clinical Portal and operational dashboard with metrics covering Patient Flow, Inpatient Activity, Out Patients, Waiting

Times, Patient Safety, Infection Control, Clinical Outcomes

Steps to Better Healthcare Programme

Mental Health

OutPatients

Elective Care

Workforce Integrated Care

Older People

Optimisation of Health Facilities

across Tayside

Medicines Leadership

Finance Support

Workforce Support

Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases

Workforce Modelling, Engagement, Partnership & Communications with staff

Comms SupportCommunications with public and staff

OE SupportOrganisational Effectiveness support

Productivity and EfficiencyCompliance with Tayside Area Formulary - PCDevelopment of Specialist formularies – SC

Service OptimisationElimination of waste Procurement and supplies

CRESCost minimisationMinimising variation in prescribing across TaysideWorkforce efficiency savings

Service TransformationReduce harmful prescribing in the elderlyImprove repeat prescribing systemsCoeliac patient pathwayPain patient pathway

TACTICAL STRATEGIC

DEALING WITH THE 5% SPENDING THE 95% BETTER

Medicines Leadership WorkstreamObjectives 2011/12

Efficiency and Productivity Strands

Whole Systems Approach

Whole system Improvement

Experts OperationalLeaders (Executives)

ChangeAgents

(Middle Managers, Stewards, project leads)

Everyone

(Staff, Supervisors,UBT lead triad)

Unit Based Teams

Continuum of PI Knowledge and Skills

Deep Knowledge

Many People Few People

Our approach will be to make sure that each group receives the knowledge and skill sets they need when they need them and in the appropriate amounts.

A key operating assumption of building capacity is that different groups of people will have different levels of need for PI knowledge and skill.

Content: What Skills Do We Need?

Source: Kaiser Permanente, 2008

SharedKnowledge

The Primary Drivers of Improvement

Will

Ideas Execution

Having the Will (desire) to change the current state to one that is better

Developing Ideas that will contribute to making processes and outcome better

Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas

QI

The Improvement Guide, API, 1996

A Model for Learning and Change

When you combine the 3 questions with the…

…the Model for Improvement.PDSA cycle,

you get…

PDSA(Please Do Something, Anything!)

The Sequence for Improvement

Spreading a change to other

locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Degree of belief that the changes

will result in improvement

High

Prototype Pilot Adapt & Spread

Successful changes

Changes still need further testing. There is a risk of moving to spread.

Unsuccessful proposed changes

Low

Moder- ate

Where is Your Project?

Scottish Patient Safety ProgrammeGeneral Ward Driver Diagram

Outcomes

Primary DriversProcesses, Rules ofConduct, Structure

Secondary DriversComponents, Activities

Improved generalward outcomes(Reduced infections,crash calls,

Provide reliable, timely, care using evidence-based therapies

Create a collaborative team and safety culture

Develop infrastructure that promotesquality care

Ensure patient and family centered care

*Early identification of patient deterioration (EWS) *Early response system to respond to deterioration (Outreach or RRTs) *Prevent healthcare associated infections Sepsis bundle Reliable planning, communication and collaboration of multi disciplinary team

Involve Pt./family into goal setting Process

Communications team & Family

Clarify care wishes and planning

Ensure patients physical comfort

Appropriate infrastructure to provide reliable, evidence based care

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sustain & Spread

Sequential building of knowledge under a wide range of conditions

Secondary DriversComplications from Ventilators

Complications from CVCs

Optimal Glucose Control

Hospital Acquired Infections

Sepsis Recognition and Treatment

Aim: Provide appropriate, reliable and timely care to critically ill patients using evidence-based therapies in Hospital X, Pilot Site

Y, by December 2010

Change Concep

t 1

Change Concep

t 2

Change Concep

t 3

Change Concep

t 4

Change Concep

t 1

Change Concep

t 2

Change Concep

t 3

Change Concep

t 4

Change Concep

t 1

Change Concep

t 2

Change Concep

t 3

Change Concep

t 4

Change Concep

t 1

Change Concep

t 2

Change Concep

t 3

Change Concep

t 4

Change Concep

t 1

Change Concep

t 2

Change Concep

t 3

Change Concep

t 4

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

Central Line Insertion Bundle

CVC Maintenance Bundle

Partner with Accident and Emergency and Operating Theatres for Standardisation

Standardise Process:Line Carts and Dressing Kits

Lead 1 Lead 2Lead 1 Lead 3

Aim: Reduce Complications from CVCs in Hospital X, Pilot Site by October 2010

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

Daily Checking and Need for CVC

Dressing in Tact and Changed w/i 7 Days

Hand Hygiene Prior to Access

CVC Hub Decontamination

A P

S D

A PS D

A P

S D

D S

P A

Chlorhexidine Gluconate

Lead A Lead A Lead B Lead B Lead C

Aim: Design a Reliable Process for CVC Maintenance Bundle by September 2010

39

Key Components* Self-Assessment • Will (to change)• Ideas• Execution

• Low Medium High• Low Medium High• Low Medium High

*All three components MUST be viewed together. Focusing on one or even two of the components will guarantee suboptimized performance. Systems thinking lies at the heart of CQI!

How prepared is your organization?

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Creativity Tools• Brainstorming

• Mind mapping

• Six thinking hats

• Innovation/IDEO

Measurement Tools• Cost of quality analysis

• Benchmarking

• Dashboards/indicators

• Survey analysis

Design Tools• QFD

• FMEA

Statistical Tools• SPC

• Descriptive statistics

• Multivariate statistics

CQI Tools by Function

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Tools to Understand Variation in Data

Waiting Time for Clinic Visit

20

25

30

35

40

45

50

55

60

Ave

rage

Day

s

Waiting Time for Clinic Visit

20

25

30

35

40

45

50

55

60

Ave

rage

Day

s

Distribution of Wait Times

0

10

20

30

40

50

60

5 15 25 35 45 55 65 75 85 95 105Wait time (days) for Visit

num

ber of

vis

its

Clinic Wait Times > 30 days

0

2

4

6

8

10

12

14

16

C F G D A J H K B I L EClinic ID

# of

wai

ts >

30 d

ays

Relationship Between Long Waits and Capacity

0

5

10

15

20

75 95Capacity Used

# w

ait tim

es >

30

day

s

Run Chart Shewhart Chart

Frequency Plot Pareto Chart Scatterplot

IH p. 8-34

Cultural Elements• Robust Governance and Risk management

arrangements• A preoccupancy with failure • A culture of openness• Abandoning blame as a major mode of action • Trust in the workforce• Involvement of patients and families

PULL

PUSH

1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortable

Make the future attractive

3. Build Will• Plan for Improvement• Set Aims/Allocate Resources• Measure System Performance• Provide Encouragement• Make Financial Linkages• Learn Subject Matter

5. Execute Change• Use Model for Improvement for Design and Redesign• Review and Guide Key Initiatives• Spread Ideas• Communicate results• Sustain improved levels of performance

4. Generate Ideas• Understand Organization as a System• Read and Scan Widely, Learning from

other Industries & Disciplines• Benchmark to Find Ideas• Listen to Patients• Invest in Research & Development• Manage Knowledge

Framework: Leadership for Improvement

2. Establish the Foundation• Prepare Personally• Choose and Align the Senior Team

• Build Relationships• Develop Future Leaders

• Reframe Operating Values• Build Improvement Capability

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Where we want to be!

Where we are!

How do you

bridge the gap

between these

two conditions?

Considerations

• The context within which the program will apply

• Pre-existing capacities to support change• Sphere of influence to effect change

– Individual – Team – Organisation

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“We are what we repeatedly do. Excellence then, is not an act but a

habit!

Aristotle (384 – 322 BC)