Insert name of presentation on Master Slide Improving quality by changing the service.

Insert name of presentation on Master Slide

Improving quality by changing the service

A model for improvement

www.1000livesplus.wales.nhs.uk

What are you trying toaccomplish?

How will you know that achange is an improvement?

What changes can you make that willresult in the improvements you seek ?

Aims

Measurement

Ideas, hunches,other people etc.

Three fundamental questions for improvement

Act Plan

Study Do

How to make change happen

Langley et al (1996) – cited 1000 Lives plus (2012)



Aims


Measurement

What changes can you make that will result in the improvements you seek ?

Ideas, hunches,etc.


The PDSA Cycle


How to make change happen …

Act Plan

Study Do

Walton (1989)

• Objective• What do we want to do?• Plan to carry out the cycle (who, what, where, when)•Plan for data collection


In every work place (and home) there are 4 people named Everybody, Somebody, Anybody and Nobody.

When there is a job to be done Everybody is is asked to do it.

Everybody is sure Somebody will do it. Anybody could do it, but Nobody does it.

Somebody will get angry about that because it is Everybody’s job to do it.

However, Everybody thinks Anybody could do it and Nobody realises that Everybody won’t do it, unless Somebody does.

It will end up with Everybody blaming Somebody because Nobody does what Anybody could do.

The PDSA Cycle


How to make change happen …

Act Plan

Study Do

Walton (1989)

• Objective• What do we want to do?• Plan to carry out the cycle (who, what, where, when)•Plan for data collection

• Just do it!• Carry out the plan• Document problems and unexpected observations

• Analyse the data• What did or didn’t work?• Summarise what was learnt

• What changes are to be made?• Next cycle?

Repeated PDSA Cycles


HunchesTheoriesIdeas

Changesthat result inimprovement

DS

A P

DS

A P

DS

A P

DS

A P

A model for improvement




What changes can you make that willresult in the improvements you seek ?

Aims

Measurement

Ideas, hunches,other people etc.


Act Plan

Study Do

How to make change happen

Langley et al (1996) – cited 1000 Lives plus (2012)

A real example of process mapping in practice …


Burns Unit Quality Improvement Team

• Team Members: – Consultant Surgeon, Ward Sister, Nursing Staff, Clinical

Psychologist, Physiotherapist

• Aim: – “to improve the quality of care to adults with major burns so

that they receive the care they need”


Top-down Process mapping


Accepting referral

Discharging from acute

phase

Assessing Treating Evaluating



Accepting referral


phase

Assessing

-Enquiring about the patient

- Preparing for arrival

- Advising on initial treatment

- Taking Clinical baseline

- Informing relatives and carers

-Taking swabs and photos

-Treating other medical conditions

-Responding to Psych needs

- Mobilising and moving

- Managing pain

- Planning for discharge

- Evaluating wound

- Evaluating Psych progress

- Sharing info at case conf.

- Feeding back to patient and carers

- Evaluating infection status

-Organising follow-up appointment

- Writing & sending discharge letter

- Providing appropriate patient info

- Giving SOS contact

Treating




Evaluating

Some areas identified for improvement

• Providing appropriate information to patients and carers when they need it

• Receiving and accepting referrals

• Criteria for agreeing surgery

• Identifying patients who need psychological support


Accepting referral


phase

Assessing Treating Evaluating




- Taking Clinical baseline

- Informing relatives and carers

-Taking swabs and photos

-Treating other medical conditions

-Responding to Psych needs

- Mobilising and moving

- Managing pain

- Planning for discharge

- Evaluating wound

- Evaluating Psych progress

- Sharing info at case conf.

- Feeding back to patient and carers

- Evaluating infection status

-Organising follow-up appointment

- Writing & sending discharge letter

- Providing appropriate patient info

- Giving SOS contact



Swiss Cheese management model


A key area for improvement


To improve the identification of patients who need psychological support



How will you know that a change is an improvement?

What changes can you make that will result in the improvements you seek?

What are we trying to accomplish?to improve detection of psychological distress




What changes can you make that will result in the improvements you seek?


How will we know a change is an improvement?- screening results will be available in notes- appropriate referrals to psychology




What changes can you make that will result in the improvements you see?


How will we know a change is an improvement?- screening results will be available in notes- appropriate referrals to psychology

What changes can we make that will lead to improvement?- introduce a screening tool for selected patients- try a pilot with 5 patients


Act Plan

Study Do



What changes can you make that will result in the improvements you see?

Study: - inclusion/exclusion criteria were unclear

and there were errors in scoring

Do: - tested screening tool

Plan: - refine criteria

- workshops for nurses

Study: - screening was more accurate but

implementation was patchy

Plan: - build reminders into ward routines

DSA P

PDSA 1

Study: - showed significant improvements

DSA P

PDSA 2DS

A PPDSA 3


Results after third PDSA

• 91% of patients were being checked

• Approximately 30% were found to need psychological support for anxiety, depression or PTSD

Referrals to Clinical Psychology increased by 600%

Burns Unit Quality Improvement Team

Listen to the Story


– How does listening to the story make you feel from a personal point of view?

– If you had this situation presented to you, what would you do about it?

An Overview of Improvement


– Success is defined as improving how we safely and humanely meet the needs of our patients

– Focus on processes, not blaming others

– Success depends on gathering and using data and information to identify changes and to learn from testing them out

… … …

… … … Overview (cont.)


– Using rapid small changes engages staff and creates continuous improvement

– Success requires collaboration and innovation from team members working together

– Combining professional knowledge with improvement knowledge is very powerful for providing safer and better care


Workshop activity • Report back on the activity (waiting

room or following signs) and discuss how patient focused they are.

• Go back to the process map you have undertaken and consider the PDSA cycle … Plan a change (the P of PDSA)Consider all the changes you can.

BibliographyBatalden PB & Stoltz PK (1993) A Framework for the Continual Improvement of Healthcare: Building and

Applying Professional and Improvement Knowledge to Test Changes in Daily Work. Journal on Quality Improvement, October. 19 (10) 424-452

Berwick DM (1996) A primer on leading the improvement of systems. BMJ 312 619-622

Cox S, Wilcock P & Young J (1999) Improving the Repeat Prescribing Process in a Busy General Practice - A study using continuous quality improvement methodology, Quality in Health Care, 8 119-125

Maxwell RJ (1984) Quality assessment in health. BMJ; 288: 1470-2

Nelson G, Batalden P, Plume S, Mohr J (1996) Improving Health Care Part 2 - A Clinical Improvement Worksheet and Users’ Manual. The Joint Commission Journal on Quality Improvement. 22 (8) 531-548

1000 Lives Plus (2012) The Quality Improvement Guide for Educators and Students. Available on line at; www.1000livesplus.wales.nhs.uk

Øvretveit J. (1992) Health Services Quality: An introduction to quality methods for health services. Blackwell Scientific. London

Scholtes PR, Joiner BL, Streibel JL (2003) The Team Handbook – 3rd Edition. Pub: Oriel Inc.


Useful Links

www.1000livesplus.wales.nhs.uk 1000 Lives Plus , NHS Wales

www.ihi.org Institute for Health Care Improvement (USA)

www.teamhandbook.com Website for the Scholtes et al (2003) referenced above

www.patientvoices.org.uk Recordings of patient experiences.


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