Patient Safety Champions Programme

Day 1

The AQuA Team

• Amanda• Bernie

• Hannah

Join the conversation..

#SaferNHS

@AQUA_Inform

Programme Objectives

Understand the trust context and principles of patient safety

Develop a measureable safety initiativeExplore the challenges that impact safety efforts Recognise & encompass human factors Increase likelihood of success & sustainability.

Programme Flow

Kirkpatrick Model

Getting to Know You

Please take a post-it note from your desk and write a random fact about yourself on it – it can be work

or non-work related and the more random the better!

You must be willing to share your fact during the course, and it must be something that can be

shared in public but please keep it secret for now!

Please write your name at the bottom, fold it up and give it to one of the facilitators

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Along the way…

Skills Assessment

Online Via:https://www.surveymonkey.net/r/?

sm=CNDiUI4j3V%2bB93xgLmcvsmSYPQ14C%2f8mqldG9sOAQou4W%2flxfv%2fjMUC2o1LIRIowwHgvi3Zs1Ko1tZH0UXrZobnHtoKvKohZbXtJ0TdN0MA%3d

Additional Input

• Initiative support / poster planning

• eleanor.barnard-croft@tgh.nhs.uk

• AQuA site (sign up needed)

Day 1 Objectives

Have a better understanding about your

organisations approach to safety

Understand how we know (and measure)

if change has improved safety

Be able to understand changes that can be

made to improve safety

Quality & Safety

Safe

Improvement science and profound knowledge

Patient Centered

Quality Healthcare

Timely EfficientEquity Effective

6 Dimensions of Quality Healthcare

Crossing the Quality Chasm: A New Health System for the 21st Century, 2001 Institute of Medicine

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NPSA 2004

Maintaining safety in our current climate ….

Safety & QI isn't a new thing, it’s the right thing

Scuatari Barracks Hospital Turkey 1854

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Florence Nightingale (1859)

Notes on Hospitals

Reviewed best practice across Europe & UK

Avoidable deaths reduced by 99% in a year

Took positive local action (stopped immediate cause of harm)

Patient safety leader

Francis. Feb 13

Berwick. Aug 13

Keogh.July 13

150 years on …..

Quality Improvement The Science

Improvement Science - What is it?

Improvement science is an emerging field of study focused on the methods, theories and approaches that facilitate or hinder efforts to improve quality and the scientific study of these approaches.

Source: The Health Foundation, Improvement Science Evidence Scan, Jan 2011

‘the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better outcomes (health), better system performance (care) and better professional development (learning).’

Paul Batalden & Frank Davidoff 2007

Safety & QI isn't a new thing, it’s the right thing

Scuatari Barracks Hospital Turkey 1854

27

Florence Nightingale (1859)

Notes on Hospitals

Reviewed best practice across Europe & UK

16000 or 18000 avoidable deaths reduced by 99% in a year

Took positive local action (stopped immediate cause of harm)

Patient safety leader

Francis. Feb 13

Berwick. Aug 13

Keogh.July 13

150 years on …..

30

Two Types of Knowledge

Subject Matter Knowledge

Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.

Profound Knowledge: The interaction of the theories of

systems, variation, knowledge, and psychology.

Profound Knowledge

Deming’s System of Profound Knowledge

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The aim chapter is to provide an outside view – a lens – that I call a system of profound Knowledge. It provides a map of theory by which to understand the organizations that we work in.” (Deming 1993 p. 92)

Appreciation of a System

Understanding Variation

Theory of Knowledge Psycholog

y

Subject Matter Knowledge

Knowledge for Improvement

Paul BataldenDartmouth Medical School,

New Hampshire, USA.

“Every system is perfectly designed to get the results

it achieves”

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“Real improvement comes from changing

systems, not changing within systems.”

– Berwick

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Reactive change• Made to solve immediate

problems or react to a special circumstance.

• Often result in putting the system back to where it was sometime before.

• Result is usually felt immediately or in the near future

Proactive change• Initiate changes before

problems occur• Causing something to

happen rather than waiting for it to happen

• Result felt later on-not always obvious

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Reactive vs Proactive

Initiative planning using a quality improvement

model

Development & Success

• The Model for Improvement has been proven nationally and internationally over the past 20

years• Work led by the Institute for Healthcare

Improvement (IHI) and other organizations that focus on operational efficiency and improved

clinical outcomes in health care.

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if achange is an improvement?

CHANGE: What changes can we makethat will result in improvement?

Model for Improvement

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Empathy the Human Connection to Patient Care Video

The Wigan Empathy video

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What does your initiative mean to patients, staff, carers, family,

friends?

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What is the evidence to support the need?

 

Who has an interest in this area? Would they be on your expert panel?

 

How is it aligned to your organisation’s quality and safety strategy?

 

Who are your stakeholders?

 

How will it impact patient care, staff satisfaction & involvement and the wider health economy?

 

Initiative Rationale

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Setting a safety aim

• What are you trying to accomplish?• By how much? • By when? • For whom(or what system)?

Remember to be SMART & Safe

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When writing an aim statement consider ….

• Brief rationale• What’s the problem? • Why is it important? • What are we going to do about it?• What exactly are you trying to achieve?• For whom are you going to improve it for?• By how much will you improve it?• By when are you aiming to achieve it?

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Adapted from

Diagnosing your problem

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Sometimes its obvious when things need to change…

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But before we start………do you really understand the problem??

Solution vs Problem

© 2014 AQuA

How do you know what needs improving?

Quantitative data Qualitative data

Why, why, why?!‘Results indicate that when preschoolers ask "why" questions, they're not merely trying to prolong conversation, they're trying to get to the bottom of things.’

© 2014 AQuA

http://www.sciencedaily.com/releases/2009/11/091113083254.htmFrazier et al. Preschoolers' Search for Explanatory Information Within Adult-Child Conversation. Child Development, 2009; 80 (6): 1592 DOI

Consider using 5 whys

• This could take any number of “whys” to get to the root cause of the problem

• Do not stop until you reach what you believe is a “cause” and not a “symptom”

• If you reach a cause that cannot be controlled, such as weather, go back one level and see if eliminating that cause will help

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X

Process mapping is……

…..a methodology to assist in the streamlining of processes in a system, and assist with the elimination of waste (such as time and resources) by focusing on the values of its practices to the people that

use them.

Maps

Process Map

Value Stream Map

What is a process?• Definition : a process is a series of

connected steps or actions to achieve an outcome

• Scope: it has a first step and a last step• Processes: cross organisational,

departmental and professional boundaries

- There are usually constraints and or bottlenecks- It can be mapped to different levels of detail

Diagrams

© 2014 AQuA

Spaghetti

Fishbone

Fishbone diagram

A systematic and structured method for identifying potential root causes of failures

– Classifies potential causes for a failure into

separate categories

– Very logical and analytical method of

determining potential causes for failures

© AQuA Academy 65

Driver Diagrams

67

Driver Diagrams – why use them?

• Breaks down any broad aim, graphically, into increasing levels of detailed actions that must or could be done to achieve the stated aim

• Helps to focus on the cause and effect relationships that exist in complex situations.

• Well defined drivers that can form the focus of improvement efforts.

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What are the component parts?• Aim or goal of the improvement effort

• Primary drivers - system components that contribute directly to the chosen aim or goal. Processes, rules of conduct, structure

• Secondary drivers - elements of the primary drivers and which can be used to create change projects. Components and activities

• Relationship arrows - show the connection between the primary and secondary drivers. A single secondary driver may impact upon a number of primary drivers

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70

© 2010 AQuA 71

Aim

A reduction in the numbers of recorded

STFs by 20% in the Unit

during 2014/15 from

the 13/14 baseline.

Care Planning/Medications

Environment

Workforce

A. Raise awareness of history of fallsB. Introduce a SU advanced statement re care. C. Medication review

A. Post all records (agreed actions) of the community meetings in a central area.B. Post a weekly activity programme at a central point on the wardc. Declutter exercise..

A. Develop a formal process regarding the planning of social & therapeutic activities.B. Introduce a community meeting.C. Redesign zonal observations

Example: Driver Diagram

Primary drivers are the systems changes which will contribute to

achieving the Aim outcome measure.

Secondary drivers are interventions associated with primary drivers. They

can be used to create projects or change packages that will affect the

primary driver.

A. Review and compare data – make data easily available to staff..B. Identify specific times/places/ of falls.C. Provide poster for staff comments re new PDSAs.D. Review process for observation.E. Recruit permanent staff to vacant posts.

Therapeutic

Interventions

Primary DriversSecondary Drivers

Developing Drivers• Dedicate time for team and subject matter

experts – ask them to come prepared!• Revisit your aim statement.• Brainstorm potential Primary Drivers & check

– ’If I made an improvement in this driver what would it achieve?’

– ’If I could influence (or improve) against all of these drivers is there anything else that could go wrong and prevent me achieving my aim?’

© 2010 AQuA 73

Aim

A reduction in the numbers of recorded

STFs by 20% in the Unit

during 2014/15 from

the 13/14 baseline.

Care Planning/Medications

Environment

Workforce

A. Raise awareness of history of fallsB. Introduce a SU advanced statement re care. C. Medication review

A. Post all records (agreed actions) of the community meetings in a central area.B. Post a weekly activity programme at a central point on the wardc. Declutter exercise..

A. Develop a formal process regarding the planning of social & therapeutic activities.B. Introduce a community meeting.C. Redesign zonal observations

Have a Go: Driver Diagram

Primary drivers are the systems changes which will contribute to

achieving the Aim outcome measure.

Secondary drivers are interventions associated with primary drivers. They

can be used to create projects or change packages that will affect the

primary driver.

A. Review and compare data – make data easily available to staff..B. Identify specific times/places/ of falls.C. Provide poster for staff comments re new PDSAs.D. Review process for observation.E. Recruit permanent staff to vacant posts.

Therapeutic

Interventions

Primary DriversSecondary Drivers

Lift Speech• Develop elevator pitch to ‘sell this’ to the

team you are meeting• 30 second speech to explain project/ focus

areas for QI to others.• Snappy….so it’s remembered!• Should reflect the Aim• Used consistently

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PDSA In Action!

PDSA Cycles

Pace & pressure

• Smaller Scale Tests: One patient, one staff, try it once to get started, talk it through before trying

• Test Multiple Drivers: Assign individual responsibility for testing changes

• Test Multiple Change Ideas: Work in parallel to accelerate learning

• Use Volunteers: Don’t waste time persuading!• Instant feedback: PDSA means you know if it

worked & you don’t need to wait 2 weeks for someone to tell you!

PDSA your project• Use workbook• 5 mins today• Revisit day 2 and 3• Think small!

QI is a journey taken in baby steps not giant leaps

Presenting data, knowing you’re making a difference

© 2014 AQuA

© 2014 AQuA

© 2014 AQuA

Cause & effect: driver diagrams

• Helps you to think about the aim that you want to achieve and more importantly what necessary changes you need to make

• Simple way of organising visually the actions that will help you achieve your aim

© 2014 AQuA

© 2014 AQuA

For day 3 (15TH dec)initiative support

• Complete your reflective log and consider the impact of todays learning on your initiative

• ‘Firm up’ and bring your revised initiative aim statement

• Complete a draft driver diagram• Draft a measurement plan (bring data)• Consider a small PDSA test