Agenda Part 1: The benefits and limits of Top Down Change Lessons learnt from establishing and...
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Transcript of Agenda Part 1: The benefits and limits of Top Down Change Lessons learnt from establishing and...
Agenda
Part 1: The benefits and limits of Top Down ChangeLessons learnt from establishing and managing the National Clinical Programmes
Part 2: Relearning how to use improvement tools in health careMeasurement: 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
Process mapping 410-411
Identifying waste Measuring Variation
Illustrating
•Run Charts (Chp 2 & 3))
•Pareto charts -436-437
Stakeholder Management (Chp 8)
Communication planning (Chp 8)
Influencing styles
Data analysis
Flow analysis
Change Management
5% 95%
Key Improvement tools
Q: Why do we measure?
A: To influence behaviour
In Health care,
the Art of measurement
is as important as
the Act of measurement
Students use of time 12hrs before 15 page essay due
Formating page
Making cover page
Skimming research notes
Crying due to fear of
failure
Writing
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
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
Yo = f (X1, X2, X3, …………….Xn ) But Yb
Measure & illustrate “Y”
- the measure of your aim
Run charts
Yo = f (X1, X2, X3, …………….Xn )
May-Aug 2012 average activity (No. of Patients seen)
Individual activity May-August 2012
13
Distributione.g. Avlos
No. of patients experiencing a level of care outside the desired standard
A
Frequencye.g. No. of Patients
Aim B
Why is understanding Variation important
Hospital A & B have the same average performance
But patient experience in Hospital A is much more varied than in hospital B
Measure & illustrate “X”
- the causes of variation
Bar & Pareto charts
Yo = f (X1, X2, X3, …………….Xn )
Reasons for Delays Theatre 10/11: 5/8/14 to 14/8/14
16
Reasons for delays through out the Day - Theatre 10 & 11Within our control Vs not in our control
Illustrating causes of variation: Pareto & Bar Charts
X1 X2 X3 X4 X5 X6 X7 X8 X9 X10
Y = f(X1, X2, X3, X4, X5……Xn)
Which is the critical X – the factor that causes the greatest level of variation?
Fix the critical X first – then move on to PDSA’s for other Xs
Count of frequency of
reasons
Reasons as a % of total count of
reasons
1. Reorder data with the most frequent reason at the top 2. Calculate what % each reason type is of total reasons 3. Create Bar chart of count of reasons 4. Overlay with line chart which accumulates % of reasons
Reason for delayed discharge Count of reason
Home care package decision 5House being adapted 1Fair deal delay 25Medical Complications 5Familly decision awaited 11No response from Physician 6 53
Frequency%100%
90%
30%
70%
50%
80%
60%
40%
20%
10%
30
25
15
5
20
10
Measurement Plan
Measure title X or Y
Operational definition Data source Sample size
Who collects?
When? How? Display type?
Medication error
Y An adverse (drug) reaction is a response to a medicinal product which is noxious and unintended
Medication error reports
30 incidents
Ward nurse
Start 1/5/14
Review reports end of week
Run Chart showing trend by day
Bringing “X” & “Y” together - to tell a story ”
Hip Fracture Pathway
117Hrs :Echo requested by Anaesthesia
59Hrs: Ortho. awaited cardiology RV
72 Hrs: NOAC, rivaroxiban held 66 Hrs:
Medically unfit
98Hrs: MR within 24hrs, waited for bone scan
77Hrs: 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 the third machine is not used)
CalculationThe 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) 8 Hrs
Less Lunch 1 Hr
Breaks x 2 30 Mins 01:30No. of Hrs if one machine utilised 100% of time 06:30
X2No. 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
45 Accurate ECHOS are completed per day (8:30 – 9:30)
Primary Drivers Secondary Drivers
Motivated staff
The number of ECHO machines available
The level of demand for the service
Optimising available time
- Work environment - Work load - Staff rotation - Recognition
- Scheduling
- Cardio Clinic demand - Other OPD demand - Inpatient demand
The number of fully trained technicians available
Reasons for varition: ECHO Driver Diagram
• The number of vacancies • The level of experience of
new recruits • The quality and pace of
training
Target Areas of improvement
• 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
Effective leadership & management
- Effective Cardio team meeting
- Visibility of variation - Operations & change
management skills- Clinical Leadership
• ECHO dashboard• Multidiscipline operations
management meeting• Continuous improvement
Vs Ad-hoc management
Key reasons
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
Module 1: Measuring variation (Y=f(X1.X2.X3.X4……..Xn)
Mean CL: 17.48
-12.66
47.63
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Ind
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Y=
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X1 X2 X3 X4 X5 X6 X7 X8 X9 X10
8.30 Aim
Actual Start timeTime axis
Day of week
Month BarCan be widened or narrowed
Filter options: By Speciality, Theatre or Day of week
Reasons for delay List of actual start times
Electronic dashboard showing Y & X real time
Process mapping 410-411
Identifying waste Measuring Variation
Illustrating
•Run Charts (Chp 2 & 3))
•Pareto charts -436-437
Stakeholder Management (Chp 8)
Communication planning (Chp 8)
Influencing styles
Data analysis
Flow analysis
Change Management
5% 95%
Key Improvement tools
Process mapping symbols
Process mapping symbols and steps
Receive referral
Indicates the start point (trigger) of a process & the end point of a process (final output)
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
TRAINING PENSIONS PROCESS EXAMPLE
Pro
cess
ing
Te
am
Pa
yme
nts
Te
am
Po
st T
ea
m
2. SortPost
1 Post received3. Distribute
Post
5. Is all Infopresent ?
4. ReviewForm
7. EnterContribution
details
6. RequestInformation
No8. Is customer
eligible?9. Send
NotificationNo
10. Set upPayment
11. Sendnotificationof payment
Yes
12. Put awayclaim
Swim lanes – one per role or team. Used to illustrate who does which step and where the hand off occurs
Process mapping stepsIdentify 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 title
A
Process mapping – Key lessons
• Do Observation 1st • 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/
Process mapping 410-411
Identifying waste Measuring Variation
Illustrating
•Run Charts (Chp 2 & 3))
•Pareto charts -436-437
Stakeholder Management (Chp 8)
Communication planning (Chp 8)
Influencing styles
Data analysis
Flow analysis
Change Management
5% 95%
Key Improvement tools
9 out of 10 change project success factors are people related
Top 10 Success Factors
% of 500 organisations
Ensuring senior management
sponsorship 82%
Treating people fairly 82%
Involving staff 75%
Giving quality communications 70%
Providing sufficient training 68%
Using clear performance measures 65%
Building teams 62%
Focusing on culture/skill changes 62%
Rewarding success 60%
Using internal champions 60%
Source: iibm Mori Survey 1997
Why is Change Management important ?
Flattening the change curve
High Expectations
Realisation of effort and complexity
Despair
Light at the end of the tunnel
Stak
ehol
der
Per
cept
ions
Change Implementation
—Unmanaged Change—Managed Change
Better than beforeWith effective
Implementation++
--
HighLow Medium
Support for change
Lev
el o
f in
flu
en
ce
High
Medium
Low
Influence mapping
Stakeholder Initial support
Level of 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
Getting buy-in – Lisa’s project
Transactional Analysis
NP
A
Nurturing Parent – Provides support, non-judgemental acceptance, and assists in healthy growth
Critical Parent – Prescriptive, tells, obsessed with rules, judgemental, authoritarian, discounting, divisive
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 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.
CP
IC
RC
SC
Agenda
Part 1: The benefits and limits of Top Down ChangeLessons learnt from establishing and managing the National Clinical Programmes
Part 2: Relearning how to use improvement tools in health careMeasurement: 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 1st choose the method second
1 Organisational Fundamentals are present
e.g. defined pathway objective, Metric(s), clear accountability, scheduled performance review meeting, (Micro Systems)
2 Flow standardised
e.g. documented SOP, guideline, algorithm, ICP.
3 End to end Flow efficiency
e.g. Lean review
5 Flow defect free
e.g. 6-sigma review
6 Disruptive innovation
when capacity is optimised & change is required to meet demand
Pathway/ Process maturity
Low
High
Quality Safety & Capacity improvement
Level of analysis required High
4 Reliable patient centred care
e.g. IHI – QI Method and Reliability theory
High Reliability