Leading Better Care – Delivering for Patients

Unlocking the next stage of the journey

Welcome

Follow the conference on Twitter at #LBC2013

Hugh MastersAssociate Chief Nursing

Officer

Welcome

Michael HeppellInternational Speaker, Success Coach and Best

Selling Author

How to be Brilliant!

Midget Gems

Susan ChisholmLead Diabetes Specialist

NurseNHS Tayside

Leading Better Care: An Experience

Susan Chisholm, Lead Diabetes Specialist Nurse

Tayside Diabetes Specialist Nurse Service

Autumn 2012 – It’s a disaster!

LBC: The right time

Tayside Diabetes Specialist Nurse Service 1986-2013• 1986 - 1st Specialist Nurse for diabetes

• 1997 - 4 DSN’s: diabetes pop 6,500

• All DSN posts Grade G, 2 H posts

• Health Visitor/District nurse/Practice nurse

What do we do?

• Out-patient specialist service• In patient service• Telephone advisory service• Community support/ home visits • Patient education programmes • Health care professional education

DSN Team: 2013

• 2012 - 11 posts, diabetes pop >20,000

• Lead DSN (2009)

• Senior DSN

• DSN

• Diabetes Nurse

“A sense of humour is part of the art of leadership, of getting along with people, of getting things done”.

Dwight D. Eisenhower34th American President

LBC: 3 Day programme

• Protected time/self analysis/reflection

• Networking: building and establishing

• Affirming what I do: increased confidence

• Senior nurses: faces to names

• Talk the talk

LBC: Putting it into practice

• Project: Patient experience

• Team Vitality

• Pink book/Evidence

2013: PLAN

• 4 Senior DSN: request LBC programme

• 2 senior DSN: Pink book in progress

• Confidence and competence

Angela CarlinSenior Charge MidwifeNHS Greater Glasgow &

Clyde

My Senior Charge Midwife experience using LBC

Leading Better Care – Delivering for Patients 20TH February 2013

Angela Carlin

LBC – My Thoughts

At Last… a resource tool to help me…

Engage with policy change Develop myself to an advanced level of autonomy Utilise critical thinking Participate in a higher level of decision making Give myself permission to put problem solving techniques in

place Influence values and to establish a culture of productivity to

improve care Develop my team to embrace measuring quality outcomes Lead on safety issues and redefine roles and responsibilities to

enhance the patient experience

Realise that this will be a transformational journey for me!!!!

LBC - Learning

What was my own leadership style?

What kind of a leader I needed to be?

How could I could build on the skills I had learned previously?

LBC – Permission To take time out

to reflect and develop an action plan that facilitated fulfilling my ward vision as well as working towards delivering on the quality agenda

To reflect to look at the patient journey to make adjustments to improve their experience where needed

To refresh Chance to re-visit issues with my team in order that we could plan, discuss and be

visionary to finding solutions to long term issues

To enhance knowledge Utilise workforce, workload planning from the NES toolkit Vision of what I needed to change in order to achieve improved quality Provided me with confidence when discussing/ negotiating with my Lead Midwife on

ward requirements

To apply the knowledge of workforce planning to appropriately delegate workload right to

deliver safe, effective and person-centered care

LBC – Role Development

LBC let me understand… that I shouldn’t feel constrained - I already had the skills for the job, I just need to

give myself the permission to apply them more effectively

LBC gave me the tools… to put into practice my knowledge and experience as labour ward sister and

Community Midwifery Team Leader

LBC increased my self awareness… to lead the team more effectively by becoming more informed and responsive to

future programmes and initiatives

LBC developed my confidence to reassure me that I could be a more effective SCM, who was on the right path,

it showed me how I could keep on the path and without taking the scenic route

LBC - Personal changes Improved communication style

I now talk WITH rather than TO my staff

Implemented daily verbal updates

To reinforce and discuss our vision To discuss the requirements to perform our ward measures To ensure they were aware of what local or national initiatives we would be implementing

making the team more informed and involved in planning for the ward and the care we provide

Introduction of a 2pm huddle

To act on the permission I had given myself to move the ward forward for implementing quality improvement initiatives’ such as RTC, Better Together

To tap into the resourcefulness of the team to make successful improvements and time to fulfill everyone’s needs.

Less firefighting Reduced change management issues resulting less of me firefighting and instead allowed me to support the

team through the embedding process of change

LBC – Light Bulb Moment

Think about your own area of practice……

LBC EXERCISE (1)…..

What activities are carried out in your ward/team that do not add value to patient care?

Then……

LBC EXERCISE (2)…..

Consider ways to shift the balance of work so that more time is spent on direct patient care, without employing more staff.Think about the staff you have and how you might deploy them in a different or better way.

LBC – Ward Changes Utilisation of the NMWWP Learning Toolkit

My “Bible” – applying the toolkit allowed me to effectively change the skill mix within my ward, whilst keeping within my budgeted establishment

Combining LBC learning and the NMWWP toolkit Allowed me to engage in quality improvement initiatives e.g. RTC activity

tracking Enabled me to apply PDSA to improve safety, efficacy and person centered care

within my ward e.g. breast feeding Improvements

Utilised NA workforce in a different way to meet the standard 10 steps for UNICEF accreditation to become baby friendly certified

to achieve compliance for our NHSGGC breastfeeding Clinical Quality Indicators

Developments NA’s received UNICEF Baby friendly breast feeding training NA’s now support women and midwife colleagues with breast feeding to achieve

the standards set

During team huddle time it was suggested we should add to our team!

I reflected and thought this chap might meet the bill.

However I realised he’d cause too

many interruptions……!

So I Introduced the Housekeeper

Role

LBC – Further Developments

Redeployment of Workload identified the staff group that I would utilise in a more effective way

Releasing Time to Care gave evidence to demonstrate that NA’s needed released from daily house

keeping duties to redirect their time to the bedside ensured timely assistance for Mum’s whilst reducing interruptions for

midwives to concentrate on direct patient care that only they could provide

Implementation Discussions with Lead Midwife, 6 month trial period a newly developed housekeeper/clerk role

Result A ‘Win Win’ result was achieved!

LBC - Impact As a ward we haven't looked back.

We have consistently achieved 100% for our monthly breast feeding CQI’s since May 2012

We have maintained our UNICEF Baby Friendly accreditation

Success was recognised last year with the housekeeper/clerk receiving a nomination and award for her contribution to patient care in the NHSGGC Facing the Future Awards

House keeper role is now being replicated with success in most departments and sites with the Women and Children's Directorate and beyond

LBC – My Thoughts

At Last… a resource tool to help me…

Engage with policy change Develop myself to an advanced level of autonomy Utilise critical thinking Participate in a higher level of decision making Give myself permission to put problem solving techniques in

place Influence values and to establish a culture of productivity to

improve care Develop my team to embrace measuring quality outcomes Lead on safety issues and redefine roles and responsibilities to

enhance the patient experience

Realise that this will be a transformational journey for me!!!!

LBC - Outcome

I’ve loved it.

It was what I was waiting for, a personal challenge, I enjoy developing my team and people in general – so by developing myself through LBC this had a beneficial effect for everyone not only myself.

LBC - Update Implementing and integrating examination

of low risk new-born babies into midwives daily remit, an area previously undertaken by paediatric colleagues

Continual review of staffing workload and remit this time focusing on MCA and Nursery nurse roles

Benefits from this service improvement:

Improved patient experience through continuity of care and carer.

Reduces discharge delays for families through improved planning and communication.

Enhancement of midwifery skills to improve confidence and problem solving abilities, thus allowing participation for the person centered journey

LBC – My Top Tips

Intermittently observe each grade of staff and what they do

Modify where appropriate

However:

Adopt the NES NMWWP Toolkit as your “Bible” SCM/N need to develop a personal ward action plan to

help maintain the momentum for change management and ALSO to support sustainability

My thought for today!

LBC taught me that to be a successful SCM/SCN …….was NOT to wait for the storm to pass...... but to learn “THE SKILLS” to dance in the rain!

Linda King & Mhairi Buchanan

Senior Charge NursesNHS Lanarkshire

Supporting Senior Charge Nurses to Lead Better Care

Linda KingSenior Charge Nurse

Mhairi BuchananSenior Charge Nurse

Aim

• Support Senior Charge Nurses to work effectively within Leading Better Care role framework

• Testing two models to identify if one had greater impact than the other.

• To inform NHS Lanarkshire Board with regards to future investment

The Pilots

10 wardsAdditional

Band 5 Registered

Nurse

10 wardsAdditional

Band 2 Clinical Support Worker

JANUARY – APRIL 2012

MEDICAL, SURGICAL, OLDER PEOPLE’S CARE, MATERNITY/NEONATAL

Adapting Person Centred

Frustrations

Staff development

Role modelling

Frustrations

Before Pilot

During Pilot

Now

Linda King

Challenges

Looking forward…

I realised how much I achieved and the value of

the pilot.

Leading a new team

Attitudes and behaviour

Frustrations

Visible and accessible

Feeling valued

Professional development

Before Pilot

During Pilot

Now

Mhairi Buchanan

Succession planning

Challenges

I feel like, for the first time, I’m a Senior Charge

Nurse the way it’s meant to be!

Investment in supervisory role 22.5 hours per

week. Phased roll out

Research and Evaluation –

impact of investment

Combination of additional

Registered Nurse & Support

Worker hours

Report to NHS Board November

2013

Future

Gladys HainingAlzheimer Scotland

Dementia Nurse Consultant

NHS Dumfries & Galloway

Leading Better Care.A Personal Perspective.

Gladys Haining

20th February 2013

CMHNT Leaders

Common Themes

Variation in service delivery across localities

Lets link this to other programmes currently being undertaken

The Improvement Project

Dedicated time for project

Support of senior managers

Team building with peers

Seeing improvement in service delivery

Recovery Focussed Person Centred Care

ghaining@nhs.net

David Thomson, National ICP Coordinator & Associate

Inspector of prisons, Healthcare Improvement Scotland and Steve Elliot, Senior Charge Nurse, NHS

Lothian

Going Against Instinct, Look for an Impact

David ThomsonNational Coordinator for Integrated Care Pathways & Inspector of Prisons

dthomson2@nhs.net

David ThomsonNational Coordinator for Integrated Care Pathways & Inspector of Prisons

dthomson2@nhs.net

Going against instinct – looking for the impact Leading Better Care (LBC)

Delivering for Patients; demonstrating the impact

We are programmed to avoid impact

We are programmed to avoid impact

Impact ObjectiveImpact Objective

Developing an approach to support SCNs/Ms/TLs to demonstrate theimpact of their role as well as realising their potential in demonstratingtheir achievement of advance practice status against the LBCcomponents.

Impact ObjectiveImpact Objective

Individually, locally and nationally we need to demonstrate that thesupport and development of the SCN, SCM and TL role (and its resultingoutputs and outcomes) do make a positive difference to the quality ofcare to patients and their families and carers

Impact ObjectiveImpact Objective

Measuring effectiveness/ impact can help individuals and theirorganisations to improve plans, policies and practices and ensuremaximum benefit for the patient/client/family, team and organisation

Defining the role

MeasuringImpact?

Implementing the framework

Developing Capability

LeadingBetterCare

Education &Development

Framework

Developing Capacity

Defining the role

MeasuringImpact

Implementing the framework

Developing Capability

LeadingBetterCare

Education &Development

Framework

Developing Capacity

Demonstrating the impact of the SCN, SCM and TL role

Demonstrating the impact of the SCN, SCM and TL role

Measuring effectiveness/ impact can help you and your organisation toimprove plans, policies and practices and ensure maximum benefit forthe patient/client/family, team and organisation.

It’s about demonstrating to ourselves and others how we are making a difference by:

assessing whether what we do is effective in reaching our aims acknowledging and sharing information about what has been less

effective feeding back knowledge and understanding of activities creating transparency in what we do targeting funding and commitment on effective interventions enabling those involved to share their experiences and turn them into

learning.

Adapted from NICE (2005)

Measuring effectiveness/ impact can help you and your organisation toimprove plans, policies and practices and ensure maximum benefit forthe patient/client/family, team and organisation.

It’s about demonstrating to ourselves and others how we are making a difference by:

assessing whether what we do is effective in reaching our aims acknowledging and sharing information about what has been less

effective feeding back knowledge and understanding of activities creating transparency in what we do targeting funding and commitment on effective interventions enabling those involved to share their experiences and turn them into

learning.

Adapted from NICE (2005)

What do we mean by impact?What do we mean by impact?

What do we mean by impact?What do we mean by impact?

Impact is simply all the changes resulting from an activity, project,service or organisation. It includes intended as well as unintended effects, negative as well

aspositive, and long-term as well as short-term impact

Some commonly used terminology is given below: Outputs are direct products of programme activities and may

include types, levels and targets of services to be delivered by the programme.

An Outcome is a result. Outcomes are all the changes and effects that happen as a result of your work, and are linked to words reflecting ‘change’; improvement, decrease, reduction, expansion, development, sustain.

Impact is the effect that outcomes have on systems and processes, and refers to broader, longer-term change. If benefits to participants are shown to have been achieved, then changes in organisations, communities or systems might be expected to occur

Impact is simply all the changes resulting from an activity, project,service or organisation. It includes intended as well as unintended effects, negative as well

aspositive, and long-term as well as short-term impact

Some commonly used terminology is given below: Outputs are direct products of programme activities and may

include types, levels and targets of services to be delivered by the programme.

An Outcome is a result. Outcomes are all the changes and effects that happen as a result of your work, and are linked to words reflecting ‘change’; improvement, decrease, reduction, expansion, development, sustain.

Impact is the effect that outcomes have on systems and processes, and refers to broader, longer-term change. If benefits to participants are shown to have been achieved, then changes in organisations, communities or systems might be expected to occur

What we have done…..What we have done…..

Developed an electronic resource that supports SCN, SCM and TL’s to demonstrate the impact of their role

The resource is aligned to both the LBC components and the Quality Ambitions

The resource is linked to the NES Education and Development framework for SCN, SCM and TL’s

The resource is also aligned and integrated with; eKSF, Advance Practice/Post-Reg Career framework and Local PDP resources

Developed an electronic resource that supports SCN, SCM and TL’s to demonstrate the impact of their role

The resource is aligned to both the LBC components and the Quality Ambitions

The resource is linked to the NES Education and Development framework for SCN, SCM and TL’s

The resource is also aligned and integrated with; eKSF, Advance Practice/Post-Reg Career framework and Local PDP resources

The resource allows you to build a body of evidence and act as a repository of information that can be used to support and evidence eKSF, ePORTFOLIO and your PDP

Piloted the resource (we tested in 4 Boards, across many specialities in hospital and community settings)

Conducted a survey of test sites

The resource allows you to build a body of evidence and act as a repository of information that can be used to support and evidence eKSF, ePORTFOLIO and your PDP

Piloted the resource (we tested in 4 Boards, across many specialities in hospital and community settings)

Conducted a survey of test sites

What we have done…..What we have done…..

Now for the clever bit!Now for the clever bit!

www.LBCimpact.comwww.LBCimpact.com

Using the Toolkit

SCN Steve Elliott

Initial ThoughtsRepetition of the ‘scorecard’

More office time and less clinical time

Thoughts after using the Toolkit

• Encompasses all aspects of our role• Some repetition of data• Made me re-evaluate what evidence I need to

be sure my team are providing safe, effective, patient centred care.

Specific Issues

• Repetition, e.g. SPSP data:Dimension 1- How are we doingDimension 4-Why are we doing it• EvidenceRTC/Compassionate care ‘post it’ comments are

just as valid as a full Patient Satisfaction Survey.

Summary

• Easy to use• As an experienced SCN it made me re-evaluate

if I could evidence my role. • I can use it as part of my KSF evidence.

Levels of access• User - all users of site, i.e. SCNs,

SCMs and Team Leaders • Test User - access to site same as

users, but information will not be included in reports etc i.e. facilitators, trainers, nurse mangers etc

• Board Admin - access to site in admin mode, but again information will not be included in reports, but user can produce reports for individual Board

• Admin -access to site in admin mode, but again information will not be included in reports, but user can produce reports across NHS Scotland

Administration access (Board admin and Admin)

Administration access (Board admin and Admin)

Reports / ReportingReports / Reporting

SCNs, SCMs and Team Leaders

SCNs, SCMs and Team Leaders

Will get a monthly emailGiving a PDF of their dashboard at

that timeWill be advised to save PDF in LBC

evidence / own IT system

Will get a monthly emailGiving a PDF of their dashboard at

that timeWill be advised to save PDF in LBC

evidence / own IT system

BoardsBoards

Will have admin access Admin access showing all capabilities and

outcomes with %’s A report with bar charts, per dimension

showing % per Will have full access of own Board Then further broken down to speciality as

chosen when registering i.e.: Mental Health Ward Community General Midwifery etc etc

Will have admin access Admin access showing all capabilities and

outcomes with %’s A report with bar charts, per dimension

showing % per Will have full access of own Board Then further broken down to speciality as

chosen when registering i.e.: Mental Health Ward Community General Midwifery etc etc

National AdministratorNational Administrator

Admin access showing all capabilities and outcomes with %’s

Will be able to pick all boards or a number of..

Then further broken down to speciality as chosen at registration i.e.:

Mental Health WardCommunity GeneralMidwiferyetc etc

Admin access showing all capabilities and outcomes with %’s

Will be able to pick all boards or a number of..

Then further broken down to speciality as chosen at registration i.e.:

Mental Health WardCommunity GeneralMidwiferyetc etc

The ‘so what’ about impact

The ‘so what’ about impact

Sometimes impact is not evident immediately

The ‘so what’ about impact

The ‘so what’ about impact

Impact of your actions can be predictable with local benefits being obvious.Share your success with others and global impact is possible.

You are the difference!You are the difference!

The impact resource is to support you in an efficient way

It will aid in recognising and sharing success

Never forget that it is always worth while to slow things down for a second and appreciate the impact of what you do

Never forget that it is always worth while to slow things down for a second and appreciate the impact of what you do

www.LBCimpact.comwww.LBCimpact.com

Thank you for your attention

dthomson2@nhs.net

Thank you for your attention

dthomson2@nhs.net

Hugh MastersAssociate Chief Nursing

Officer

Welcome back

Prof Angela Wallace, Executive Nurse Director, NHS Forth Valley and LBC Programme Board Chair and Vicky Thompson, National

Lead - LBC

Unlocking the next stage of the journey

Unlocking the next stage of the LBC journey

Prof Angela Wallace – Executive Nurse Director, NHS Forth Valley & chair LBC programme board

Vicky Thompson – National Lead, LBC

Session aims & objectives

To seek your views on LBCTo seek your views of future stages of

LBCA reminder of the great work achieved

through LBC

Identify the following peopleChief Nursing Officer for Scotland?

A B C

Paul Martin previous CNO

Ros Moore current CNO

Jane Cummings CNO England

Identify the following peopleDirector-General Health & Social

Care and Chief Executive of NHSScotland

A B C

A B C

Derek Feeley Jason Leitch Harry Burns

Is this (A) Health Policy (B) Professional Policy (C) Organisational Strategy

A. Health Policy

B. Professional Policy

C. Organisational Strategy

Is this (A) Health Policy (B) Professional Policy (C) Organisational Strategy

A. Health Policy

B. Professional Policy

C. Organisational Strategy

Is this (A) Health Policy (B) Professional Policy (C) Organisational Strategy

A. Health Policy

B. Professional Policy

C. Organisational Strategy

Is this (A) Health Policy (B) Professional Policy (C) Organisational Strategy

A. Health Policy

B. Professional Policy

C. Organisational Strategy

Which one of these is not a LBC dimension / component

A. - To ensure safe and effective clinical practice

B. - To enhance the patients experience

C. - To manage and develop the performance of the multi – disciplinary team

D. - To ensure effective contribution to the delivery of the organisations objectives

A. - To ensure safe and effective clinical practice

B. - To enhance the patients experience

C. - To manage and develop the performance of the multi – disciplinary team

D. - To ensure effective contribution to the delivery of the organisations objectives

How many SCNs, SCMs, Team Leaders and Band 6s have been supported by LBC by September 2012?

A. 3315

B. 2100

C. 1500

A. 3315

B. 2100

C. 1500

How many wards are using the Food, Fluid and Nutrition CQI as of September 2012?

A. 813

B. 653

C. 947

A. 813

B. 653

C. 947

What are you most proud of that you have achieved through LBC?

A. Knowing how we are doing with respect to patient care

B. Knowing my role is important and I am being developed to reach my full potential

C. I can understand and demonstrate that patient experience is improved

D. I am able to develop my team as required

What have been the success of Leading Better Care?

A. Consistent ways of working that recognise and support the SCN, SCM and Team Leader role

B. The learning, sharing and development opportunities for ongoing improvements in patient care

C. The ambition to improve the standards of patient care and experience

D. A whole country approach to improving patient care through leadership of the SCN, SCM and Team Leader and their teams

What has worked well as part of Leading Better Care?

A. The NES education & development framework (pink book)

B. Local LBC development / training opportunities

C. The leadership / support from within your boards

What has been the most challenging aspects of you implementing LBC?

A. Time for implementation of the revised role

B. The need for ongoing dedicated time for education / training

C. Time to undertake data collection and subsequent improvements in patient care

D. Carrying a clinical day to day caseload

What would help you to further implement LBC? – Nationally

A. On going commitment to the SCN, SCM and Team leader role

B. Exploring the possibility of space and time to fulfil the role

C. A culture that supports leadership which includes a genuine will to learn when we get it wrong

D. A strategy for coherently integrating all quality improvement programmes and activities

What would help you to further implement LBC? – Locally

A. Ongoing leadership that removes barriers and challenges

B. De-cluttering of Nursing & Midwifery documentation

C. De-cluttering of Nursing & Midwifery quality improvement activity and the resulting data burden

D. Ongoing commitment to supporting the SCN, SCM and Team Leader role

What would help you to further implement LBC? – Enablers

A. Ongoing facilitation / Board facilitators of LBC

B. Dedicated time to implement the role

C. Knowledge and skills to manage human factors

D. Finding true partnerships with patients, families and carers

As part of the continued work of LBC, which of these would be most helpful?

A. An LBC programme for Line Mangers of SCNs, SCMs and Team Leaders

B. Further education / development opportunities for SCNs, SCMs and Team Leaders

C. Team education / development opportunities

D. All of the above

Unlocking the next stage....

Conference Postcards Wordle This session

Focus groups 5 undertaken to date High level themes –

NES Education & Development framework / local LBC programmes Supervisory / limited case load Networking / sharing opportunities invaluable Administration support Succession planning Team involvement

Good News Stories 1

My experience of LBC has had a positive effect on myself and my

team, many positive changes have been introduced due to my

knowledge being enhanced and my confidence and understanding

increasing, and also I now have the tools that enable me to evidence

the high standard of patient centred care that was being delivered.

As a SCN I believe I have made positive changes within my team,

and my team and I feel this was helped by attending LBC. The whole

experience was enjoyable and informative and for once SCNs were

all together in one room sharing their experiences, worries and

successes.”

Good News Stories 2

When I began the LBC programme, I saw myservice as being very widely dispersed, whichmeant there were limited opportunities tonetwork with colleagues on issues other than those thatare very pragmatic, like bank usage and sickness levels.On the programme, I was fortunate to be grouped withseveral learning disability colleagues, giving us verypositive networking opportunities. I know many of mycolleagues felt similar to me at the start, andstrengthening our common bond has been hugelyhelpful.

Good News Stories 3...

I became involved LBC over 4 years ago. I wasasked to be a pilot ward for CQI’s and review ofSCN role. Initially I was extremely sceptical howthis would be of any benefit to patients and staff and feltit would be an impossible task to implement within theexisting resources. I was very much “hands on” andcase load holding within the ward being included in thedaily ward numbers. This meant I was continuallyjuggling both clinical and managerial roles but regularlynot doing justice to either.

see next slide....

Good News Stories 3 cont…

LBC and fulfilling the revised SCN role has givenme control back over my full ward. I can supervise,coordinate and manage efficiently andeffectively, identifying what is happening withinthe ward to both patients and staff. It allows me toidentify any issues or problems and addressthese promptly. I have opportunity to support allmy staff, and introduce myself to all patients. Ican manage ward capacity and ensure thatall agendas are being addressed.

Good News Stories 4

The publication of Leading Better Care outlines thesenior charge nurse role for us and I hope that all NHSboards pay attention to it in the way that mine does. Forme, it is essential that I do not carry a daily case load and I like the fact that the clinical quality indicators allowus to evidence our care clearly. It is a document that weshould be working to. It was published for a reason.We SCNs are key to influencing care and ensuring theprovision of high quality care to our patients. They relyon us. And, just in case you’re still wondering….You can’t be astaff nurse and a SCN at the same time!

Ros MooreChief Nursing Officer

The Challenges of Caring

Jason LeitchClinical Director, Quality

Directorate

Take Your Card, Then Your Money

“Take your card then your money”

Reliability and human factors

At some level all of the challenges we face are reliability

challenges

Jim’s Story

• Retired Joiner• Married to Mary • 2 children and 6

grandchildren• Keen bowler• Interested in politics• Enjoys gardening and

his allotment

Susanne Forrest, NES, 2012

Jim’s story – Scenario 1

• Admitted via A&E with chest pain • The fact that he has a diagnosis of dementia is not established.• Limited information is requested /obtained from Mary and his wider

family.• Jim is admitted to the medical receiving ward for “further tests”.• Jim becomes very anxious and disorientated in the new

environment – he is then moved to three different wards• His community mental health nurse is not contacted.• Staff understanding and tolerance of dementia is poor.• Jim gets quite agitated – staff identify him as at risk of “wandering

and aggression”.

Susanne Forrest, NES, 2012

Jim’s story – Scenario 1 (cont)• Jim is commenced on psychotropic medication to “calm him down”.• The sedative effects lead to Jim having reduced mobility and being

at risk of falls, increased incontinence, disturbed sleep pattern and being less able to take meals and drinks.

• Jim is catheterised due to increased incontinence – this leads to a urinary tract infection.

• Jim develops delirium, leading to increased dependency and confusion.

• Jim suffers a number of falls; while no serious injuries are sustained, he is now covered in bruises and continues to lose weight.

• The staff have now put Jim on one to one observation level to manage “risk”.

• After a 35 day stay, Jim is transferred to a care home as the staff and Mary feel he will no longer be able to be supported at home.

Susanne Forrest, NES, 2012

“Expectations will always exceed capacity. The service must

always be changing, growing and improving…”.

Aneurin Bevan, 1948

“Every system is perfectly designed to get the results

it gets.”

Senge

To be safe and effective, you need a reliable process based

on human factors design.

Definition Of Reliability for Health Care

Failure free operation over time

David Garvin Harvard Business School

Quantifying Reliability

• Reliability = Number of actions that achieve the intended result Total number of actions taken

• Defect rate = 1 minus Reliability

Example: in a 10 day period, your friend picks you up for work 6 days on time

Reliability = # of total intended actions = 6 = 60% # of actions taken 10

Defect Rate= 100%-60%= 40%

According to Homer…

But every time I learn something new, it pushes something old out of my brain ....

What are Human Factors?

• Fatigue

• Sleep Deprivation

• Shift work

• Training and experience

• Overload

• Psychosocial factors…

“Health care is the only industry that does not believe that fatigue diminishes performance.”

Lucian LeapeLucian Leape

Hazard- Castle Bridge

PARISIN THE

THE SPRING

Evidence based medicine Evidence based care delivery

Evidence – SIGN

• 1++ High quality meta-analyses, systematic reviews of RCTs or RCTs with a very low risk of bias

• 1+ Well conducted meta-analyses, systematic reviews of RCTs or RCTs with a low risk of bias

• 1- Meta-analyses, systematic reviews or RCTs with a high risk of bias

• 2++ High quality systematic reviews of case control or cohort studies

• 2+ Well conducted case control or cohort studies• 2- Case control or cohort studies with a high risk of

confounding• 3 Non-analytic studies – case reports, case series• 4 Expert opinion

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised

controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461

• Aim: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

• Design: Systematic review of randomised controlled trials

• Results: Our search strategy did not find any randomised controlled trials of the parachute.

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised

controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461

Conclusion:

As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.

Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data.

We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute

The aspirin example

• In patients who have had a stroke or TIA aspirin reduces risk by 23%

• 100,000 patients – 23,000 fewer strokes

• 58% of eligible patients receive aspirin = 13,340 fewer strokes

Two options

• Fidelity – increase to 100% of eligible patients = 9,660 strokes

• Efficacy – requires a proportional improvement over aspirin of 74%

• Clopidogrel = 10% more efficacy than aspirin

Normalisation of Deviance

PERFORMANCE

Systemic Migration to Boundaries

VE

RY

UN

SA

FE

SP

AC

E

The posted speed limit is 50 mph- the ‘legal’ space

Belief Systems.

Life Pressures

INDIVIDUAL BENEFITS

Driving 60 mph- the ‘Illegal-normal’ space

Driving80 mph – the ‘illegal-illegal’ space (for almost all of us!)

Perceivedvulnerability

PERFORMANCE

Systemic Migration to Boundaries

VE

RY

UN

SA

FE

SP

AC

E

Handwashing – every patient, every time

Belief Systems.

Life Pressures

INDIVIDUAL BENEFITS

Handwashing when patient has MRSA

Only wash hands on audit days

Perceivedvulnerability

High reliability organisations?

If we want a new level of performance, we must get a new system

• Most problems in organisations do not come from individual workers.

• Most problems come from the structure of the systems themselves, and people are only parts of those systems.

• Changing the people, or pushing them to "try harder" or "do better" will not result in improved performance.

Human Factors

• physical demands, • skill demands, • mental workload,

and • other such factors

• adequate lighting, • limited noise, or other

distractions • device design, and • team dynamics

Human Factors Engineering: Examines a particular activity in terms of its component tasks and then considers each task in terms of:

Human Factors Violations

• Fatigue• Lack of sleep• Illness• Drugs or alcohol• Boredom• Frustration• Fear • Stress• Shift work• Reliance on

memory

• Reliance on vigilance• Distractions• Noise• Heat• Clutter• Motion• Lighting• Too many handoffs• Unnatural workflow

What is a Bundle?

• Combining reliability theory and human factors

• It is a set of evidence based steps that experts believe are critical 

• Having the steps joined provides a “forcing function.”

Bundle Implementation

• The steps must all be completed to succeed

• The “all or none” feature is the source of the bundle’s power

• Pass/fail

Patient Measure 1 Measure 2 Measure 3 Measure 4 All measures?

1 Yes Yes Yes Yes Yes

2 Yes No Yes Yes No

3 Yes Yes No No No

4 Yes Yes Yes Yes Yes

5 Yes Yes Yes No No

6 Yes No Yes No No

7 No Yes Yes No No

8 Yes Yes Yes Yes Yes

9 Yes No No Yes No

10 Yes Yes Yes Yes Yes

Reliability .90 .70 .80 .60 .40

Ventilator Care bundle

• Head of bed elevation 30 degrees

• Sedation vacation

• PUD prophylaxis

• DVT prophylaxis

• Multi Disciplinary Rounds Daily goals

Reality!

• Measurement of the ventilator bundle elements for 8 patients– Head of Bed > 30 degrees = 35%– Sedation Hold = 50%– PUD prophylaxis = 85%– DVT prophylaxis = 100%– Bundle ‘ All or nothing concept’

0% compliance to the ventilator bundle

Aim: Reduce VAP rates by 30% by Oct 2006 by implementing the VAP care bundle in Intensive care

Cycle 1a: Test sedation hold element of bundle on one patient with one nurse and one anaesthetist

Cycle 1c: Test sedation hold element of bundle on three patients with three nurses and one anaesthetist using feedback from first test

Cycle 1e: Test sedation hold on all patients with completion of a ventilator bundle sticker

Cycle 1d: Test sedation hold guideline with exclusions five patients with five nurses and one anaesthetist

Cycle 1b:Test repeated with another patient with different nurse and anesthetist

Process Change: Testing the sedation hold element of the ventilator bundle with frontline staff

Measures

NHS Tayside – Ninewells, ventilator associated pneumonia

Implementation of daily goals

TREND

SHIFT

Oral hygiene element of VAP bundle implemented

Current Improvement methods in healthcare are highly

dependent on vigilance and hard work

The Reliability Gap - Reason 1

The focus on outcomes tends to exaggerate the reliability within healthcare giving clinicians a

false sense of security

The Reliability Gap - Reason 2

Permissive clinical autonomy creates and allows wide

performance margins

The Reliability Gap - Reason 3

The use of deliberate designs to articulated reliability goals

seldom occurs

The Reliability Gap - Reason 4

Current Common Standardization Strategies

• Experts over multiple meetings design a comprehensive protocol using evidence based medicine

• The protocol is usually presented as a finished product

• Customisation is infrequently tolerated after the protocol is finished (but done in secret)

• Standardised protocols commonly are expected to be stand alone and the end of the design

New Standardisation Concepts

• Standardisation is done to provide the appropriate infrastructure

• Initial standardised protocols should have very small time investment by experts

• Customisation in the initial stages should be required and encouraged

• Changes in the protocol when generally accepted are possible but monitored

• Defects are used to move to a learning system

Error Reduction StrategiesError Reduction Strategies• Avoid reliance on memory• Simplify• Standardise• Use constraints/forcing functions• Use protocols and checklists• Improve information access • Reduce handoffs• Decrease look-alikes• Automate carefully• Take advantage of habits and patterns• Promote effective team functioning

Jim’s Story – Scenario 2

When Jim is admitted• Full Information about Jim’s dementia and how he

currently copes was obtained from Mary and other family members. This is Me document completed and Butterfly Scheme discussed with family.

• Jim’s community mental health nurse was contacted and visited Jim and his family in hospital and also provided the staff with advice about how to support him.

• Jim was admitted to the assessment ward for further tests but no further ward moves occurred. Butterfly displayed.

Susanne Forrest, NES, 2012

Jim’s Story – Scenario 2

• Staff in the ward had a good understanding and management of dementia and delirium.

• Mary and other family members stayed with Jim to support him and help out with his care.

• Staff work in partnership with Mary, other family members, and Jim’s community mental health nurse to support Jim to maintain his optimal abilities

• Jim was discharged home after three days

Susanne Forrest, NES, 2012

Derek FeeleyDirector – General Health &

Social Care and Chief Executive NHSScotland

Leading Better Care

Derek Feeley

Chief Executive NHS Scotland

6 Key Challenges

• Political

• Economic

• Demographic

• Epidemiological

• Population Health

• Changing Expectations

And so…..

Questions;

Is the answer to this range of challenges likely to be one dimensional?

Is the optimal response likely to lie in just doing more of the same or just changing everything?

How should healthcare leaders deploy our combined efforts?

It’s complicated….

Too bad all the people who know how to run the country are busy driving cabs and cutting hair.

-- George Burns

Triple Aim

Health of the

Population

Experience of Care

Best Value for Money

The Triple Aim

Integration

The future – Gathering all 3 curves

Time

Perform

ance

Performance

Improvement

Co-production& assets

The only show in town

• Clear strategy• Integrated governance• Shared outcomes• Better implementation• Better spread• The right thing to do

3 Quality Ambitions

• Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

• No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

• The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

Our ‘2020 Vision’

EVERYONE IS ABLE TO LIVE LONGER HEALTHIER LIVES, AT HOME, OR IN A HOMELEY SETTING

• We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management.

• When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm.

• Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions.

• There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

“The 3rd Curve” Prevention, Co-production and

Population Health

• Given the challenges – hard to see sustainable route without this – can’t treat our way through this.

• Untapped potential of public activation

• Patients tell us that healthy living is a key outcome for them

Institute for Healthcare ImprovementFramework for Leadership for Improvement

Assets vs Deficits

Assets thinking•Strengths based•How can we create community spirit?•What can I do?•We’re all in this together•We’re getting there•Work with engaged people•People have the answers•People control their lives

Deficit thinking•Problem orientated•How to fix this problem?•Someone needs to sort this•Us versus them•Problems are embedded•Do things to people •People are a problem•People can’t be trusted to decide/be in control

Theory 1

• The leaders of the future need to be experts in performance, quality and co-production. They will be comfortable with complexity and conflict and generous with power.

Theory 2

• Reliability of values, ethics and behaviours is likely to be just as important as reliable clinical practice.

What will it take?

• Redesign, creativity and innovation• New technologies and better use of

existing technology• Prevention, assets and activation• Up our game on safe, effective and person

centred care• Continued focus on performance and

improvement• Shared and renewed ethics and values

Some final thoughts about leadership

Leadership is about getting people to want to do the right thing.

Great things are accomplished by talented people who believe they will accomplish them.

Warren G. Bennis

Question & Answers session with Derek Feeley

& Ros Moore

Prof Angela Wallace

Running Up That Hill…. (with no problem)

Hugh MastersAssociate Chief Nursing

Officer

Closing remarks

Thank you Safe Journey Home

www.leadingbettercare.scot.nhs.uk