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Scottish Improvement Skills Workshop 1 Day 1 Quality Education for a Healthier Scotland Scottish Improvement Skills Workshop 1 Day 1 Quality Education for a Healthier Scotland

Housekeeping Quality Education for a Healthier Scotland Housekeeping Quality Education for a Healthier Scotland

Getting started • Work context • Quality challenges • Strengths for improvement Quality Education Getting started • Work context • Quality challenges • Strengths for improvement Quality Education for a Healthier Scotland

SIS Objectives • To select appropriate improvement science methods and apply them to improve SIS Objectives • To select appropriate improvement science methods and apply them to improve the safety and quality of services. o Design effective interventions o Construct measurement plans o Use key measurement tools o Communicate about project work to others Quality Education for a Healthier Scotland

Ground Rules Quality Education for a Healthier Scotland Ground Rules Quality Education for a Healthier Scotland

Day 1 • • • Quality Improvement and why it matters Improvement principles Focussing Day 1 • • • Quality Improvement and why it matters Improvement principles Focussing your aim Project charters Developing theories for change Leading local change Quality Education for a Healthier Scotland

Quality Improvement and why it matters By the end of this session you will Quality Improvement and why it matters By the end of this session you will be able to: • outline the policy context for Quality Improvement in Scotland • describe how your improvement project aligns with this policy context. Quality Education for a Healthier Scotland

NHS Scotland 20: 20 Vision Our vision is that by 2020 everyone is able NHS Scotland 20: 20 Vision Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting.

Route map to the 20: 20 Vision Route map to the 20: 20 Vision

Aims: To deliver the highest quality healthcare services to the people of Scotland. For Aims: To deliver the highest quality healthcare services to the people of Scotland. For NHSScotland to be recognised as world-leading in the quality of healthcare it provides.

Quality Ambitions Person-centred: Mutually beneficial partnerships between patients, their families, and those delivering healthcare Quality Ambitions Person-centred: Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Effective: The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe: There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

Six dimensions of quality Six dimensions of quality

“. . . the Quality Strategy will be the means by which we ensure “. . . the Quality Strategy will be the means by which we ensure that these longer -term transformational challenges are addressed. ”

Transformational change A definition: • A change that is not merely an extension or Transformational change A definition: • A change that is not merely an extension or improvement over the past, but a state change. • This state change in social systems can be personal and/or organisational. • Achieving this state change requires altering and expanding the limiting mindset in which the individual/the organisation operates.

Achieving that change • Before the fact the new level of performance envisioned is Achieving that change • Before the fact the new level of performance envisioned is audacious. It calls for a new way to do the work with a new level of fearlessness, of innovation and collaboration. • After the fact, you will say that we have more than a large improvement, we have a different person or organization, a statechange, a transformation.

Quality Education for a Healthier Scotland Quality Education for a Healthier Scotland

"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives. ” William A. Foster 1941

Quality Improvement and why it matters: summary • • • Quality Strategy Six dimensions Quality Improvement and why it matters: summary • • • Quality Strategy Six dimensions of quality 20: 20 Vision Route map to the 20: 20 vision Transformational change Quality Education for a Healthier Scotland

Improvement principles By the end of this session you will be able to: • Improvement principles By the end of this session you will be able to: • explain Deming’s System of Profound Knowledge • apply the System of Profound Knowledge to assist an understanding of complexity in your local context. Quality Education for a Healthier Scotland

What is Quality Improvement? Quality Improvement is defined as the application of: “a systematic What is Quality Improvement? Quality Improvement is defined as the application of: “a systematic approach that uses specific techniques to improve quality. ” Health Foundation 2013

All approaches have the following in common Cycle of improvement involving data collection, problem All approaches have the following in common Cycle of improvement involving data collection, problem definition and diagnosis, generation and selection of potential changes and implementation and evaluation of these changes Set of tools and techniques that support implementation of changes Recognition of importance of organisational context and senior clinical and management leadership Recognition of central importance of engaging those who deliver the service in improvement of that service

System of Profound Knowledge Deming 2000 System of Profound Knowledge Deming 2000

System of Profound Knowledge https: //www. youtube. com/watch? v=x. Kv--YA 8 XJE Deming’s System System of Profound Knowledge https: //www. youtube. com/watch? v=x. Kv--YA 8 XJE Deming’s System of Profound Knowledge 1 Quality Education for a Healthier Scotland

System of Profound Knowledge Deming 2000 System of Profound Knowledge Deming 2000

Appreciation for a system • A common purpose • What’s in a system: structures, Appreciation for a system • A common purpose • What’s in a system: structures, processes, culture • Interdependence, interactions • Whole is greater than the sum of its parts

Appreciation of a System “Dividing an elephant in half does not produce two small Appreciation of a System “Dividing an elephant in half does not produce two small elephants. ” Senge 1992

What is a system? “A system is a set of interrelated parts that work What is a system? “A system is a set of interrelated parts that work together to achieve a common aim” Deming 2000 “A group of items, people or processes working together toward a common purpose” Improvement Guide p 77 -79

Characteristics of a System • Has aim or purpose • Series of factors leading Characteristics of a System • Has aim or purpose • Series of factors leading to outcomes that have value to stakeholders • Structures, processes, people, cultures • It is dynamic • To improve outcomes need to understand system dynamics

Characteristics of a System Structure + Process = Outcome Donabedian (1966) Characteristics of a System Structure + Process = Outcome Donabedian (1966)

Complexity Simple Complicated Complex Complexity Simple Complicated Complex

Appreciation for a system: a personal example • • • Structures Processes People Culture Appreciation for a system: a personal example • • • Structures Processes People Culture Interdependencies

Theory of Knowledge • Current knowledge is expressed as theory • Change involves prediction Theory of Knowledge • Current knowledge is expressed as theory • Change involves prediction • We learn by testing theory and finding our if our prediction succeeds or fails

The typical approach Conference Room DESIGN APPROVE Real World IMPLEMENT The typical approach Conference Room DESIGN APPROVE Real World IMPLEMENT

The Quality Improvement approach Conference Room APPROVE DESIGN IF NECESSARY Real World TEST & The Quality Improvement approach Conference Room APPROVE DESIGN IF NECESSARY Real World TEST & MODIFY START TO IMPLEMENT

Model for Improvement The Improvement Guide Langley J et al 2009 Model for Improvement The Improvement Guide Langley J et al 2009

Theory of Knowledge: a personal example • What do we think we know? • Theory of Knowledge: a personal example • What do we think we know? • What do we think stops us getting the outcomes we want? • What could we do differently, and what do we predict would be the result of that change?

Understanding variation • Random variation – affects everyone, over all outcomes and over time Understanding variation • Random variation – affects everyone, over all outcomes and over time • Non-random variation – arises because of specific circumstances does not affect everyone or all parts of the system all the time

Variation: Random or Non-random? Variation: Random or Non-random?

Variation: Random or Non-random? Variation: Random or Non-random?

Displaying variation in data (1) 16 14 12 10 8 6 4 2 0 Displaying variation in data (1) 16 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Displaying variation in data (2) 16 14 12 10 8 6 4 2 0 Displaying variation in data (2) 16 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Understanding variation: a personal example • What measures might be useful? • For each Understanding variation: a personal example • What measures might be useful? • For each measure, Is variation in the data collected random or non-random? • If non-random, what is the cause of the variation?

Psychology • Interactions between people • Motivation (intrinsic, extrinsic) • Beliefs • Assumptions • Psychology • Interactions between people • Motivation (intrinsic, extrinsic) • Beliefs • Assumptions • Will to engage with and adopt a change.

Psychology: soft or hard? Psychology: soft or hard?

Psychology Psychology

Psychology: a personal example • Interactions between people • Motivation (intrinsic, extrinsic) • Beliefs Psychology: a personal example • Interactions between people • Motivation (intrinsic, extrinsic) • Beliefs • Assumptions • Will to engage with and adopt a change.

System of Profound Knowledge Deming 2000 System of Profound Knowledge Deming 2000

System of Profound Knowledge Deming 2000 System of Profound Knowledge Deming 2000

Model for Improvement The Improvement Guide Langley J et al 2009 Model for Improvement The Improvement Guide Langley J et al 2009

Three questions • What are we trying to accomplish? • How will we know Three questions • What are we trying to accomplish? • How will we know that a change is an improvement? • What change can we make that will result in improvement?

Focussing your aim By the end of this session you will be able to: Focussing your aim By the end of this session you will be able to: • name key components of an aim statement • explain the importance of an effective aim statement for a project • formulate an effective aim statement to guide your improvement work. Quality Education for a Healthier Scotland

Why is an aim statement important? • • • Framework Focus Scale Team membership Why is an aim statement important? • • • Framework Focus Scale Team membership Communications.

Constructing an aim statement (1) • • Specific Timebound Aligned Numeric. Constructing an aim statement (1) • • Specific Timebound Aligned Numeric.

Constructing an aim statement (2) By March 2015, 95% of endoscopy patients at the Constructing an aim statement (2) By March 2015, 95% of endoscopy patients at the Queen Mary Hospital return signed postal consent forms, in line with the Global Rating Scale for Endoscopy, which states: 1. 7 All consent signatures are obtained outside the procedure room.

Constructing an aim statement (2) By March 2015, 95% of endoscopy patients at the Constructing an aim statement (2) By March 2015, 95% of endoscopy patients at the Queen Mary Hospital return signed postal consent forms, in line with the Global Rating Scale for Endoscopy, which states: 1. 7 All consent signatures are obtained outside the procedure room.

Constructing an aim statement (3) By March 2015, 95% of endoscopy patients return signed Constructing an aim statement (3) By March 2015, 95% of endoscopy patients return signed postal consent forms. How good, by when?

Constructing an aim statement (4) Offer all patients registered with the practice same-day access Constructing an aim statement (4) Offer all patients registered with the practice same-day access to a GP within 12 months.

Aim statements Aim statements

Constructing an aim statement (1) • • Specific Timebound Aligned Numeric. Constructing an aim statement (1) • • Specific Timebound Aligned Numeric.

Aim statements 1. All written information on the Physiotherapy unit is available in two Aim statements 1. All written information on the Physiotherapy unit is available in two languages other than English by August 2015, as stated in the CHP business plan.

Aim statements 2. Reduce the incidence of hospital acquired pressure ulcers by 50%. Aim statements 2. Reduce the incidence of hospital acquired pressure ulcers by 50%.

Aim statements 3. Improve the service provided by the Radiology clinic by getting feedback Aim statements 3. Improve the service provided by the Radiology clinic by getting feedback from all patients.

Aim statements 4. To transfer every patient from the ICU to an inpatient bed Aim statements 4. To transfer every patient from the ICU to an inpatient bed within 4 hours of the time the patient is assessed as ready to move from the ICU.

Aim statements 5. Our day case rate for hernia repair is 20% below British Aim statements 5. Our day case rate for hernia repair is 20% below British Association of Day Surgery benchmark. As directed by senior management, we need to meet or exceed that benchmark by December this year.

Project work: aim statement • • Specific Timebound Aligned Numeric How good, by when? Project work: aim statement • • Specific Timebound Aligned Numeric How good, by when? Quality Education for a Healthier Scotland

Focussing our aim: summary • • S T A N Quality Education for a Focussing our aim: summary • • S T A N Quality Education for a Healthier Scotland

Project charter A summary of what you expect to achieve from the improvement project Project charter A summary of what you expect to achieve from the improvement project • Helps to maintain focus • Answers the 3 questions • Identifies appropriate team members

System of Profound Knowledge Deming 2000 System of Profound Knowledge Deming 2000

Three questions 1. What are we trying to accomplish? 2. How will we know Three questions 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What change can we make that will result in improvement?

Developing theories of change By the end of this session you will be able Developing theories of change By the end of this session you will be able to: • name and describe key elements of a driver diagram • construct a driver diagram for your improvement project • use driver diagrams to help others develop theories of change. Quality Education for a Healthier Scotland

A New Healthier Me Aim Primary Drivers Secondary Drivers Calories in meals A new A New Healthier Me Aim Primary Drivers Secondary Drivers Calories in meals A new healthier me! Calories in snacks Calories in drinks Lose 7 pounds by end July 2015 Calories in alcohol Calories out Work activity Leisure activity

Build four driver diagrams • • Portering productivity Promoting staff wellbeing Out of Hours Build four driver diagrams • • Portering productivity Promoting staff wellbeing Out of Hours asthma ICU length of stay

Organising theories for improvement Aim statement: A general description of the desired improvement. (what, Organising theories for improvement Aim statement: A general description of the desired improvement. (what, how much, by when) Primary Drivers A network of factors that drive the outcome/ aim Secondary Drivers Secondary factors which will influence delivery of the primary drivers

Project work: develop your theory ? ? ? Project work: develop your theory ? ? ?

Developing Theories of Change: Summary Developing Theories of Change: Summary

System of Profound Knowledge Deming 2000 System of Profound Knowledge Deming 2000

Leading local change By the end of this session you will be able to: Leading local change By the end of this session you will be able to: • describe the impact of change on team members and others affected by the change • apply change management principles to lead others through the change process. Quality Education for a Healthier Scotland

Reproduced with the permission of International Futures Forum http: //www. iffpraxis. com/three-horizons Reproduced with the permission of International Futures Forum http: //www. iffpraxis. com/three-horizons

Engaging others in change Rogers 2003 Engaging others in change Rogers 2003

Forcefield analysis Present state Forces for change Lewin 1943/1997 Desired state Forces against change Forcefield analysis Present state Forces for change Lewin 1943/1997 Desired state Forces against change

Change is good … you go first Change is good … you go first

Leading local change: summary • • Three Horizons Personal Transition Curve Innovation Adoption Lifecycle Leading local change: summary • • Three Horizons Personal Transition Curve Innovation Adoption Lifecycle Forcefield Analysis Quality Education for a Healthier Scotland

Day 1 • • • Quality Improvement and why it matters Improvement principles Focussing Day 1 • • • Quality Improvement and why it matters Improvement principles Focussing your aim Project charters Developing theories for change Leading local change Quality Education for a Healthier Scotland

References and further resources Scottish Government 2010 The Healthcare Quality Strategy for NHSScotland Edinburgh: References and further resources Scottish Government 2010 The Healthcare Quality Strategy for NHSScotland Edinburgh: Scottish Government http: //www. gov. scot/Publications/2010/05/10102307/0 Scottish Government and NHS Education for Scotland 2011 2020 Vision Scottish Government http: //www. gov. scot/Topics/Health/Policy/2020 -Vision Local policy and strategy documents eg Local delivery plan. Quality Education for a Healthier Scotland

References and further resources Deming W Edwards, 2000, The New Economics 2 nd ed. References and further resources Deming W Edwards, 2000, The New Economics 2 nd ed. Cambridge MA: MIT Press Donabedian A, 1966, Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 44: 166 -206 (Republished 2005) Health Foundation, 2013 Quality Improvement made simple 2 nd ed Langley Gerald J et al, 2009, The Improvement Guide: A Practical Approach to Enhancing Organizational Performance 2 nd ed Wiley Senge Peter M, 1992, The Fifth Discipline: The Art and Practice of the Learning Organization Random House Quality Education for a Healthier Scotland

References and further resources International Futures Forum http: //www. iffpraxis. com/three-horizons J M Fisher References and further resources International Futures Forum http: //www. iffpraxis. com/three-horizons J M Fisher (1999, 2012) Personal Transition Curve www. businessballs. com/personalchangeprocess. htm E M Rogers (2003) Diffusion of Innovations (5 th Ed) Free Press Lewin K. (1943). Defining the "Field at a Given Time. " Psychological Review. 50: 292– 310. Republished in Resolving Social Conflicts & Field Theory in Social Science, Washington, D. C. : American Psychological Association, 1997. Quality Education for a Healthier Scotland