Agenda Part 1: The benefits and limits of Top Down Change Lessons learnt from establishing and managing the National Clinical Programmes Part 2: Relearning how to use improvement tools in health care Measurement: Hip Fracture Pathway & ECHO Utilisation Mapping patient flow: Dementia Pathway Influencing change: Chemo Drug Savings Part 3: Observations on teaching clinicians QI RCPI Diploma in Leadership & Quality Part 4: Sustaining change Building a Directorate Model that imbeds continuous improvement Close: 5 years “Learning” on a page
Key Improvement tools 95% 5% Data analysis Flow analysis Change Management Measuring Variation Process mapping 410 -411 Stakeholder Management (Chp 8) Illustrating Identifying waste Communication planning (Chp 8) • Run Charts (Chp 2 & 3)) • Pareto charts -436 -437 Influencing styles
Q: Why do we measure? A: To influence behaviour
In Health care, the Art of measurement is as important as the Act of measurement
Charles Joesph Minard's graphic depicts Napoleon's Army's march from Paris to Moscow. The width of the gray striped area is the size of the Army going to Moscow, placed over a geographic map. Notice how the width of the band shrinks, especially when crossing rivers. The solid black area/line reveals the size of the Army returning to Paris. The bottom line graph displays the temperatures encountered on the return. French casualties in Moscow were light. Yet the Army was consumed in the march. Only 10, 000 of the original 432, 000 survived.
Measures Outcome Measures = Yo • Measure of project Aim - Voice of the customer or patient. How is the system performing? What is the result? Process Measures = X • Voice of the workings of the system. Are the parts/steps in the system performing as planned? Balancing Measures = Yb • Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e. g. unanticipated consequences, other factors influencing outcome) Yo = f (X , X , ……………. X ) But Yb 1 2 3 n http: //www. ihi. org/resources/Pages/Howto. Improve/Scienceof. Improvement. Establishing. Measures. aspx
Yo = f (X , X , ……………. X ) 1 2 3 Measure & illustrate “Y” - the measure of your aim Run charts n
May-Aug 2012 average activity (No. of Patients seen)
Individual activity May. August 2012
Why is understanding Variation important Frequency e. g. No. of Patients B Aim A No. of patients experiencing a level of care outside the desired standard Distribution e. g. Avlos Hospital A & B have the same average performance But patient experience in Hospital A is much more varied than in hospital B 13
Yo = f (X , X , ……………. X ) 1 2 3 Measure & illustrate “X” - the causes of variation Bar & Pareto charts n
Reasons for Delays Theatre 10/11: 5/8/14 to 14/8/14
Reasons for delays through out the Day - Theatre 10 & 11 Within our control Vs not in our control 16
Illustrating causes of variation: Pareto & Bar Charts Count of frequency of reasons Reasons as a % of total count of reasons X 1 X 2 X 3 X 4 X 5 X 6 X 7 X 8 X 9 X 10 Y = f(X 1, X 2, X 3, X 4, X 5……Xn) Fix the critical X first – then move on to PDSA’s for other Xs Which is the critical X – the factor that causes the greatest level of variation?
1. 2. 3. 4. Reorder data with the most frequent reason at the top Calculate what % each reason type is of total reasons Create Bar chart of count of reasons Overlay with line chart which accumulates % of reasons Frequency Reason for delayed discharge Home care package decision House being adapted Fair deal delay Medical Complications Familly decision awaited No response from Physician Count of reason 5 1 25 5 11 6 53 % 100% 30 25 20 15 90% 80% 70% 60% 50% 40% 10 30% 20% 5 10%
Measurement Plan Measure title X Operational definition or Y Medication Y An adverse (drug) reaction is a error response to a medicinal product which is noxious and unintended Data source Sample Who When? size collects? Medication error reports 30 Ward incidents nurse How? Display type? Start Review Run Chart 1/5/14 reports end showing trend of week by day
Bringing “X” & “Y” together - to tell a story ”
Hip Fracture Pathway 117 Hrs : Echo requested by Anaesthesia 98 Hrs: MR within 24 hrs, waited for bone scan 72 Hrs: NOAC, 59 Hrs: rivaroxiba Ortho. n held 66 Hrs: awaited Medically cardiology unfit RV 77 Hrs: No Reason logged 65 Hrs: No Reason logged
Reasons for variation can be hidden
Note: Times were an ECHO test was done but the report was not written up till hours later have been excluded as they would eschew the data incorrectly.
Actual utilisation rate = 65% (Two machines) The level of variation is +/- 12% (Note third machine is not used) Calculation The Actual Utilisation time is calculated based on: The recorded total time for patients in and out plus the time to complete the ECHO report. Where there was no time recorded or there was a significant gap between doing the ECHO test and completing the report the median time (17 Mins to test, 11 Mins to report) was used instead The Potential time was estimated at 13 Hrs for the two machines per day – formula below Model for estimating potential utilisation time Work day (8: 30 -16: 30) Less Lunch 1 Hr Breaks x 2 30 Mins No. of Hrs if one machine utilised 100% of time 8 Hrs 01: 30 06: 30 X 2 No. of Hrs if two machines utilised 100% of time 13: 00
Consequences of variation • Wait list for other outpatient ECHO referrals = 800 • • Patient safety Delayed care = impaired outcomes • Patients kept as In Patients just for ECHO = Bed days lost = ? • Anecdotal 1 patient = 7 Days • Delays in access to surgery and theatre late starts? • • Hip Fractures Theatre 10 & 11 late starts • ECHO technician team working through lunch and risk of general burn out • Combination of unstructured work and environment impacts motivation of key staff • NOTE: Patients do not experience delays waiting outside the ECHO room – (1 exception due to miscommunication between Secretarial staff & ECHO team)
ECHO/ECG Technician WTE & Competency • • • Key points: WTE at 76% of capacity Approval to fill open vacancies but if not skilled new joiners will require training Approval for HCA – HCA will improve work environment but not improve capacity significantly 68% of available team not trained in ECHO – prevents rotation between ECG & ECHO plus over reliance/preassure on Chief Technician to both train and do ECHOs 24% of total WTEs (12. 5) can do ECHOs unsupervised or with minimum supervision
Reasons for varition: ECHO Driver Diagram Key reasons Primary Drivers The number of ECHO machines available The level of demand for the service 45 Accurate ECHOS are completed per day (8: 30 – 9: 30) Optimising available time Motivated staff Effective leadership & management Secondary Drivers The number of fully trained technicians available - Cardio Clinic demand - Other OPD demand - Inpatient demand - Scheduling - Work environment Work load Staff rotation Recognition - Effective Cardio team meeting - Visibility of variation - Operations & change management skills - Clinical Leadership Target Areas of improvement • The number of vacancies • The level of experience of new recruits • The quality and pace of training • Forecasting demand e. g. 25 to 35% of Cardio Clinic patients require Echo • Ability to control inappropriate demand using agreed referral criteria • Standardised Scheduling practice • CVIS • Adequate notice to inpatients • Porter availability to bring inpatients to ECHO Dept • HCA to assist with patient prep • Area to have lunch • Ability to take scheduled breaks • Team working & support from Consultant team • CVIS System • ECHO dashboard • Multidiscipline operations management meeting • Continuous improvement Vs Ad-hoc management
Scenario 1: Afternoon Cardio OPD Clinic Actual Patient arrival times Allocating these patients to nearest “ 25”minute scheduled slot Conclusions: • Staff would have been able to take breaks • 17 Slots would have remained unfilled – approx 50% of capacity • Only one Cardio patient would have had to wait for a significantly longer period outside the ECHO room
Actual number of ECHOs completed 5/8/14 - 25/8/14 (15 Days) Potential output over same period (15 days) If daily target met
Sustainability
f Module 1: Measuring variation (Y= (X 1. X 2. X 3. X 4……. . Xn) Y= X n= X 1 X 2 X 3 X 4 X 5 X 6 X 7 X 8 X 9 X 10
Electronic dashboard showing Y & X real time Month Bar Can be widened or narrowed Time axis Actual Start time 8. 30 Aim Day of week List of actual start times Filter options: By Speciality, Theatre or Day of week Reasons for delay
Key Improvement tools 95% 5% Data analysis Flow analysis Change Management Measuring Variation Process mapping 410 -411 Stakeholder Management (Chp 8) Illustrating Identifying waste Communication planning (Chp 8) • Run Charts (Chp 2 & 3)) • Pareto charts -436 -437 Influencing styles
Process mapping symbols and steps Process mapping symbols Process title Receive referral Indicates the start point (trigger) of a process & the end point of a process (final output) A Schedule appointment Describes each process step (verb noun construction) Is ventilation required? Yes No Describes decision points A Used to link a process that flows on to second page Swim lanes – one per role or team. Used to illustrate who does which step and where the hand off occurs Process mapping steps Identify the teams/roles involved in the process (1)Draw a swim lane for each role/team (2)Identify the start point (trigger) and end points (3)Draw start and end symbols in the appropriate swim lanes (4)Identify the process steps and link them using arrows (5)Discuss process issues / opportunities to improve process as you create the map (6)Document map and issues & validate with users
Process mapping – Key lessons • • Do Observation 1 st Map the pathway through individual interview Log issues as you go along Hold a meeting to validate map & suggest improvements Hold sub meetings to tease out detail design of each solution – using map to “pedantically” facilitate the discussion PDSA tests as you go – don’t do big bang implementation Complete “to be” design map and convert to SOP KEY point • It’s the structured conversation you have while mapping rather than the map itself is of vale. • A map with out a log of issues and suggestions is of no value • Mapping is an art not a science
Dementia Scheduled & unscheduled pathway 1. carers in crisis have little alternative to going to ED - phone support 2. ED is not the appropriate place to manage carers in crisis – - rapid access crisis clinic - carer Education programme required
Dementia Scheduled & unscheduled pathway 1. Difficult to identify quickly if previous diagnosis of Dementia exists. Community history of patient is not available - PAS system Flag - Can MRN number be used to link to Old Age Psych patient record? - Introduce “this is me” form 2. No Triage Protocol for Confused/ Delirium patients - Agree Triage Protocol 3. Assessment for Delirium/ Cognitive impairment not part of standard Triage/ED Assessment bundle – single short test to be incorporated in ED Assessment 4. No specifically designed assessment Area - Identify and furnish assessment area 5. Not all staff trained in management and assessment of Confused patients – nurses , HCAs, specials etc – Design awareness training
Dementia Scheduled & unscheduled pathway • Doesn’t appear to be a clear pathway for previously diagnosed Dementia patients who are admitted - agree pre diagnosed dementia pathway - Is a Dementia specific team required/
Key Improvement tools 95% 5% Data analysis Flow analysis Change Management Measuring Variation Process mapping 410 -411 Stakeholder Management (Chp 8) Illustrating Identifying waste Communication planning (Chp 8) • Run Charts (Chp 2 & 3)) • Pareto charts -436 -437 Influencing styles
Why is Change Management important ? Top 10 Success Factors % of 500 organisations Ensuring senior management sponsorship 82% Treating people fairly Involving staff Giving quality communications Providing sufficient training Using clear performance measures 82% 75% 70% 68% 65% Building teams 62% Focusing on culture/skill changes 62% Rewarding success 60% Using internal champions 60% 9 out of 10 change project success factors are people related Source: iibm Mori Survey 1997
Flattening the change curve Stakeholder Perceptions + - High Expectations With effective Implementation Realisation of effort and complexity Better than before Light at the end of the tunnel Change Implementation Despair —Unmanaged Change —Managed Change
Influence mapping Level of influence H i g h M e d i u m L o w Low Medium Support for change High
Getting buy-in – Lisa’s project Stakeholder Initial Level of support influence Key Concern Steps to getting buy in Pharmacy H H Fear Constant communication & reassurance Management L H Other priorities Communication & data; ownership (made to feel part of solution) – Its about money CNS Staff L H “Waste is not part of our responsibility” Constant communication – Its about safety Patients L H Extra visits Communication and improved service, improved care Consultants L H Unaware of data and significance Data
Transactional Analysis Nurturing Parent – Provides support, non-judgemental NP CP acceptance, and assists in healthy growth Critical Parent – Prescriptive, tells, obsessed with rules, judgemental, authoritarian, discounting, divisive A Adult – Does clear thinking, questions, is assertive and generates options to help with problem solving, planning, and productive procedures Innovative Child – Generates ideas, comes up with creative IC RC SC solutions, sees things from different perspectives, open minded, is fun to be with, creates energy Rebellious Child – Doesn’t obey/follow rules and procedures. Rebels against any form of authority. They send I am OK, you are not OK messages Sulking Child – Submissive. Feels and acts like a victim. Sends you are OK, I am not OK messages.
Agenda Part 1: The benefits and limits of Top Down Change Lessons learnt from establishing and managing the National Clinical Programmes Part 2: Relearning how to use improvement tools in health care Measurement: Hip Fracture Pathway & ECHO Utilisation Mapping patient flow: Dementia Pathway Influencing change: Chemo Drug Savings Part 3: Observations on teaching clinicians QI RCPI Diploma in Leadership & Quality Part 4: Sustaining change Building a Directorate Model that imbeds continuous improvement Close: 5 years “Learning” on a page
Observations about training Clinicians in QI • Realising they needed a “babel fish” to understand what I was saying – Keep language/ terminology simple • As a non clinician I was never going to get over the credibility gap – Front training with Clinicians ( Train the Trainer training) • • Expose them to what is possible by having speakers from other hospitals with a QI culture e. g. Cincinnati Hospital Use SCYPE so they can connect virtually to the class room Coaching is key – training alone won’t build confidence – use Web meetings to coach Clinicians need time to absorb and adjust there mind set – Intensive sessions over long period seems to work – it’s a form of therapy – the light goes on at different timed for different people Strong focus on leadership and self reflection – they need to vent and articulate anger / frustration – but bring them back to believing they can make a difference Mantra of making one difference to one patient – works – steer them away from curing world hunger Make change fun – it increases the chances of success – don’t be afraid to encourage them to be creative Back at base – regular lunch and learns seems to be better than class room courses
Understand the problem 1 st choose the method second Pathway/ Process maturity Quality Safety & Capacity improvement 6 Disruptive innovation when capacity is optimised & change is required to meet demand High Reliability 5 Flow defect free e. g. 6 -sigma review 4 Reliable patient centred care e. g. IHI – QI Method and Reliability theory 3 End to end Flow efficiency e. g. Lean review 2 Flow standardised e. g. documented SOP, guideline, algorithm, ICP. 1 Organisational Fundamentals are present e. g. defined pathway objective, Metric(s), clear accountability, scheduled performance review meeting, (Micro Systems) Low High Level of analysis required
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