Getting to Zero-Safer Care Improvement Programme

©Annette Bartley Consulting Limited 2011

Getting to Zero-Safer Getting to Zero-Safer Care Care Improvement ProgrammeImprovement Programme

Annette Bartley RGN BA MSc MPHHealth Foundation/IHI Quality Improvement Fellow

09.00-09.15 Welcome & Introductions

09.15- 10.00 Background and Context Programme aims & objectives

Links to other work

10.00-11.00 Overview of Quality Improvement Tools & techniques

Measurement for improvement

The role of local coaches

11.00-11.30 Refreshment break

11.30- 13.00 Team Presentations / Storyboard rounding

13.00-13.45 Lunch

13.45-15.00 The Snorkel – Generating Ideas from frontline staff

15.00-15.15 Refreshment break

15.15-16.15 Action planning and report out

16.15-16.30 Summary next steps and close

Learning Session 1 Overview


Understanding the Understanding the context of frontline carecontext of frontline care

What’s good about it?What’s not so good?What could be

improved?


It’s a Fact that …“Without good and careful nursing many must

suffer greatly, and probably perish, that might have been restored to health and comfort, and become useful to themselves, their families, and the public, for many years after.”

Benjamin Franklin (1751)

The Reality in Practice

How do we make sense of all the How do we make sense of all the expectations expectations

& bring the work into a coherent & bring the work into a coherent wholewhole

Health FoundationSafer Communities National Patient

Safety Agency(NPSA)

Safety AlertsMatching Michigan

NHS III

LIPsProductive

Series

NICEQuality Standards

QUIPP & Safety Express

Safer Patients Network (SPN)

The Health Foundation(with IHI)

CQUIN targets

WHO World Alliance for Patient Safety

Department of Health

(DoH)High Quality Care for All

IP&C

CNO High Impact Changes


Will Ideas Execution

Getting to Goal


The politics of hope The politics of hope

“We got used to the politics of disappointment -- figuring out how soon we were going to be let down. ... There’s a different dynamic in the ... politics of hope. It’s much more challenging. It means you’ve got to get up and do something. There’s opportunity. If you don’t take advantage of that opportunity, you really have to bear responsibility for not doing so. That’s how I see the time we’re in. ”

Marshall Ganzhttp://mitworld.mit.edu/speaker/view/1047

http://www.youtube.com/watch?v=NglXpj94Z2ohttp://www.youtube.com/watch?v=LhCoz5hMhTI


Transforming Patient Experience

Metanoia: • Reorientation of one’s way of life

(The New Economics. Deming, p. 95, 1993)

• Begins with individual• More than a change• Develop new habits of mind


Where to beginWhere to begin

Will Ideas Execution


Programme AimsProgramme AimsAlignment with Safety Express To reduce the incidence of Avoidable

Hospital /Community Acquired Pressure Ulcer

Reduce of Falls (falls with harm)Reduce Catheter Associated Urinary

Tract Infections (CAUTI)Prevention of Venous

Thromboembolism ( VTE)

Programme overviewProgramme overview

Select Topic

(develop mission)

Planning Group

Develop Framework & Changes

Participants (10-100 teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email Visits

Phone Assessments

Monthly Team Reports

Website

Tools & Guidance,

Publications

A D

P

SExpert

Meeting

The IHI Collaborative Model


Underpinning principlesUnderpinning principlesTransformational LeadershipSafety & ReliabilityPatient and Family Centred CareValue-added careTeamwork and Vitality


Patients as partnersPatients as partners

“ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.”


Alignment -Harm Free Alignment -Harm Free CareCare


Prevention of Pressure Prevention of Pressure UlcersUlcers

Spread the Learning and celebrate the successes

!

Transforming Care at the Bedside framework

Prevent the Incidence of

Pressure Ulcers, Falls,

CAUTI, by April 2012 using the

Intentional rounding process

Patient and Family

Centred Care

Engage the wider MDT team Set sims and plan tests together Share learning

Ensure there is leadership support for this work at every level in the organization

Transformation Leadership at ward/unit level

Team work

Leadership engagement

Reliable Implementation of the

The Intentional Rounding process

Address the 8 key behaviours and incorporate the : SKIN Bundle Surface Keep Moving Incontinence Nutrition

Create Patient centred healing environment – Use the ESTHER story Support and Involve patients and families Provide spiritual and emotional support Ensure patients rights , privacty and dignity are maintaines

Content Area Drivers Interventions

Educate staff regarding the assessment process, identification and classification of, and treatment of pressure ulcers Educate Patients & family Develop patient information pack

Training & Education


Pressure Ulcers Pressure Ulcers The “Case for Change”The “Case for Change”

◦National Focus on Patient Safety◦I in 10 patients harmed by what we do

◦Poor Public Perception of Care◦Impact of financial cutbacks ◦Pressure Ulcer Incidence 1 in 5◦As high as 1 in 3


Prevention of Falls (Harm Prevention of Falls (Harm from falls)from falls)•Falls prevention is a complex issue crossing the boundaries of healthcare, social care, public heath and accident prevention.

•Across England and Wales, approximately 152,000 falls are reported in acute hospitals every year, with over 26,000 reported from mental health units and 28,000 from community hospitals.

•A significant number of falls result in death or severe or moderate injury, at an estimated cost of £15 million per annum for immediate healthcare treatment alone (NPSA, 2007).


FactsFacts

Pressure sores are an increasing problem that affect thousands of people unnecessarily every year..

They are painful, debilitating and can be life threatening

The cost of treating a pressure ulcer varies from £1,064 -£10,551 with the estimated total cost in the UK of between £1.4–£2.1 billion annually- 4% of total NHS expenditure (Bennett et al 2004)


What matters most to What matters most to inpatients.inpatients.Consistency and coordination of care

Treatment with respect and dignity

Involvement

Doctors

Nurses

Cleanliness

Pain control

Methods and ToolsMethods and Tools


◦We must become masters of improvement◦We must learn how to improve rapidly◦We must learn to discern the difference

between improvement and illusions of progress

Change vs. Change vs. ImprovementImprovement

Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.

W. Edwards Deming

The Lens of Profound The Lens of Profound knowledgeknowledge

Deming

Appreciation of a system

PsychologyTheory of Knowledge

Understanding Variation

CQI

Aims or values


Quality Improvement Quality Improvement Methods /ToolsMethods /Tools

The Model for Improvement The Science of ReliabilityDriver DiagramChange Package Lean/5SSafety Cross/ Safety

ThermometerSSKIN Bundle/ Intentional

Rounding


The Model for Improvement will underpin the programme, enabling teams to connecting an aim to action and measurement which will enable you to demonstrate their progress.


Improvement requires a clear aim Improvement requires a clear aim

Measurement & Action


AIMAIM Aims infuse meaning and hope in our lives,

they create a target to achieve and inspire and motivate us to achieve it.

How good do you want to be and by when?Make your aims SMART

• Specific• Measurable• Achievable• Realistic• Timely

Developing a systems-based approach to the prevention of hospital acquired pressure ulcers

Risk Identification

Communication of Risk status

Risk Assessment

Appropriate preventative strategy implemented

Evaluation of outcome

What will success look like?


The “Case for Change”The “Case for Change”

◦National Focus on Patient Safety◦I in 10 patients harmed by what we do

◦Public Perception of Care◦Impact of financial cutbacks ◦Strong link between Patient Satisfaction & Employee Satisfaction


Purpose of Using DataPurpose of Using Data & Measuring & Measuring

The purpose of measuring is to answer critical questions and to guide intelligent action.

Cliff Norman- Associates in Process Improvement


“In God we trust.

All others bring data.”

W. E. Deming


S+P=0S+P=0S=StructureThe environment in which health care is

providedP=ProcessThe method by which health care is

providedO=OutcomeThe consequence of the health care

provided

Avedis Donabedian Physician


Research Research vs vs Measurement for Measurement for ImprovementImprovement

Three Types of MeasuresThree Types of Measures

Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?

Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?

Balancing Measures: 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)


Measurement GuidelinesMeasurement Guidelines

A few key measures that clarify a team’s aim and make it tangible should be reported, and studied by the team, each month

Be careful about over-doing process measures for monthly reports

Make use of available data bases to develop the measures

Integrate data collection for measures into the daily routine

Plot data on the key measures each month during the life of the project


Measurement GuidelinesMeasurement Guidelines

The question - How will we know that a change is an improvement? - usually requires more than one measure• A balanced set of five to eight measures

will ensure that the system is improved• Balancing measures are needed to assess

whether the system as a whole is being improved


Measurement- It is YOUR Measurement- It is YOUR data!! (data MUST be locally data!! (data MUST be locally owned) owned)

Outcome measures ◦ Incidence ( count on safety cross)◦ Days between events

Process measures◦ Percent Compliance with risk assessment◦ Percent Compliance with process ( bundle)◦ Percent compliance with Intentional Rounding tool

Balancing measures Patient Experience Staff satisfaction Length of Stay Complaints Staff turnover /Sickness rates Budget implication

Visual MeasurementVisual Measurement

1 2

3 4

5 6 (3)

7 8 (1) 9 10 11 12

13 14 15 16 17 18

19 20 (1) 21 22 23 24 (1)

25 (1) 26

Days since last... 27 28 (1)

___ days 29 30 31


Real Time Data for improvement – Real Time Data for improvement – ProcessProcess


It’s time…It’s time…

A little less conversation a little more action


Getting it rightGetting it rightCo-ordinating CareCo-ordinating Care

Health Care Processes Health Care Processes

Desired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom - variation

Current - Variable, lots of autonomynot owned,poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels

Terry Borman, MD Mayo Health System


Intentional Rounding Intentional Rounding The EvidenceThe Evidence

The Studer GroupAlliance for Health Care Research

◦38% Reduction in Call Lights◦12 point mean increase in Pt

Satisfaction◦50% reduction in patient falls◦14% reduction in pressure ulcersFlaws in the study but…


On Finding What Works…On Finding What Works…

“We need to standardize, simplify, and steal shamelessly from everyone who can contribute, because we’ve reached a point where no excuses are allowable.”

Roger Resar, MDSenior Fellow, IHI


Intentional Rounding – Intentional Rounding – What is it?What is it?

Structured process where frontline staff regularly round on patients and reliably perform scheduled/required tasks

Rounding with purpose- linked to an aim8 key behaviors

1. Opening key words – managing up2. Perform scheduled tasks3. Address the 3 p’s of pain, potty? position

(SKIN Bundle)(toileting), and4. Assess comfort needs5. Environmental assessment6. Closing key words7. Explain when you or others will return8. Document the round on the log


OMHS Intentional Rounding - OMHS Intentional Rounding - winswins

59% reduction in Pressure ulcers54% reduction in call lights (2878 fewer calls after rounding)Patient feedback – ‘I know someone will be

back to check on me, when they come…’ Improved employee satisfaction – 5.67 on a

7 point scale compared to national norm of 4.66 (Baird and Borling)

Reduction in cost ◦ $3.02/pt 6 month avg. prior◦ $2.39/pt 8 months avg. following


Tools – Rounding LogTools – Rounding Log


Tools – Badge CardTools – Badge Card


Tools – Accountability ToolTools – Accountability Tool

Rounding commenced


Intentional Rounding -Intentional Rounding -Benefits Benefits

• Provide staff with better control of their time

• Improved outcomes / promote safety

• Results • Increase Patient Satisfaction • Decreases anxiety• Increase trust and give sense of comfort

• Increase Employee Satisfaction


Additional BenefitsAdditional Benefits

Centred on patients/Catches allProvides a quality assurance

framework for nursing careHelps to evidences what nurses

doHelps demonstrates the impact

on patient outcomesPotential to impact on the bottom

line


What they are not…What they are not…A radical change to a system

/process Full blown trust-wide

implementation Mini projects (monumental

proportion) Top down directives

‘PDSA’s' ‘test’ a proposed change


Paper Plane ExercisePaper Plane ExerciseAim – To design a paper plan that will

fly the longest distance ◦ Assign a design team◦ Assign someone to assemble the plane◦ Assign a measurement person to measure

the distance flown (in feet)Run your tests a few times?What are you learning?How are you factoring your leanring

into the next test?


People are treated with respect and dignity. Health care providers communicate and share

complete and unbiased information with patients and families in ways that are affirming and useful.

Individuals and families build on their strengths through participation in experiences that enhance control and independence.

Collaboration among patients, families, and providers occurs in policy and program

development and professional education, as well as in the delivery of care.

Source: Institute for Family Centred Care, Bethesda USA

Patient &family centred Patient &family centred care care


Local Coaches/FacilitatorsLocal Coaches/FacilitatorsGroup of volunteersWilling to play a key role locally

as coaches /facilitatorsSupport participants and help to

accelerate momentum and the progress

They will be the links between you and the programme team


Storyboard roundingStoryboard roundingSplit up into your teamsIdentify a space to display your

storyboardSelect at least one member to present the

findingsEveryone else will rotate around the

teams Approximately 7-8 mins to describe your

team/aspirations/learning from pre-workBell will sound and teams will rotate to

the next space


HarvestHarvestIdentify three things you learnt

during the rounding

◦Could be meeting new people◦Harvesting Ideas from another team◦Results/learning from their pre-work


The SnorkelThe Snorkel


Fostering Creativity and Fostering Creativity and Brainstorming?Brainstorming?


Methods for Methods for Generating New IdeasGenerating New Ideas

Change ConceptsUsing TechnologyCritical ThinkingIDEO BrainstormingMetaphorical

ThinkingObservationProvocationPrototypingIdealized Design

Innovation and Work Redesign

http://theartofinnovation.com/purchase.htm

GETncm/justsaycust-recrate-itemcommunittg/stores/dtg/stores/d-


Resources for “Snorkel”Resources for “Snorkel”


Outline of “Snorkel”Outline of “Snorkel”Review of Project Vision and CharterWhat do we know about …. Propose a Design ChallengeStorytellingHow might we….?BrainstormingSelect top ideas (multi-vote)Prioritize ideas for development Plan prototypes EnactmentsDesign first series of tests


StorytellingStorytelling In lieu of doing actual observations, use

storytelling to “observe” actual experiences

Recall an actual story or experience which relates to the specific design challenge (personal, friend or family member or work-related experience)

Who was involved? What happened? How did individuals feel and react?

Give an example

Tell stories in small groups (nor more than 2 minutes each)


How might we….? How might we….? (used to create ideas for the (used to create ideas for the brainstorming)brainstorming)

…. Prevent harm

…Engage Patients and families in preventing harm

…Optimise nutrition

Ideas should be actionable Write each idea on post-it notes or flip c


Rules for Brainstorming (20 Rules for Brainstorming (20 mins)mins)

Chose one or two “how might we scenarios….

encourage wild ideas go for quantity – want more than 500

ideas defer judgment be visual – draw pictures one conversation at a time build on ideas of others stayed focused on topic (“how might

we…” scenarios)

Write each idea on post-it notes


Multi-voting to Select Top Ideas Multi-voting to Select Top Ideas

Cluster together similar ideas from brainstorming exercise

Use dots to vote:

What are your personal favorites? What idea would you most like to try on your

unit? What idea do you think will have the biggest

impact toward achieving the “how might we…”

Participants can distribute their dots however they want –- all on one idea, each dot on a separate idea, or anything in between

Report out on favorite ideas (where there are most dots)

Matrix of Change IdeasMatrix of Change Ideas

Difficult to Implement

Easy to Implement

Low Cost High Cost

Place concepts in matrix. Strive for easy, low-cost solutions. Translate high-cost solutions into low-cost alternatives.

Matrix of Change IdeasMatrix of Change Ideas

Low Impact

High Impact

Low Cost High Cost

Translate high-cost solutions into low-cost alternatives.

Strive for high-impact , low-cost solutions.


Outline of “Snorkel”Outline of “Snorkel”Review of Project Vision and CharterWhat do we know about…… Propose a Design Challenge StorytellingHow might we….?BrainstormingSelect top ideas (multi-vote)Prioritize ideas for development Plan prototypes EnactmentsDesign first series of tests


IDEO’s Design PrinciplesIDEO’s Design Principles

1. Keep people informed throughout process

2. Value people, time, and energy3. Enable learning and teaching4. Give people appropriate levels

of control5. Facilitate connections among

people


EnactmentsEnactments

Create an enactment to illustrate an extreme future vision for your prototype

Create storyline and buildRehearse and refinePresent to whole groupSelect elements and build on

ideas


EnactmentsEnactments


What could you do by next What could you do by next TuesdayTuesday??Think of some changes that you

believe might enable you to get results

Think of 1 changePlan your first PDSA’s


Small Scale Tests of Small Scale Tests of Change on:Change on:

One bay/wardOne day / shiftOne patient

One nurse

Action Planning SessionAction Planning Session

Hunches Theories Ideas

Changes That Result in Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement


Next StepsNext StepsACTION PERIOD

◦Seek out a coach/facilitator◦Get measures in place◦Test the rounding process small scale◦Connect with Tina Chambers/calls

Learning session 2 ◦Is all about YOU◦We want to hear your progress and

see some results

PDSA Cycle No 1 : General Wards 9 & Ward 4Worksheet for Testing Change Aim: To reduce Pressure Ulcer Incidence to zero by December 2012 (Overall goal you would like to reach) Every goal will require multiple smaller tests of change

Describe your first (or next) test of change Person Responsible

When to be done

Where to be done

Test SSKIN Bundle on one patient on one ward next Tuesday JD& RW

Week commencing 18th April

Ward 4 & Ward 9

Plan

List the tasks needed to set up this test of changePerson Responsible

When to be done

Where to be done

1)Identify similar information from other Trusts 2)Discuss with team3)Identify a nurse and patient who are prepared to participate.4)Identify a suitable patient and seek their permission

JD W/C18TH April

Predict what will happen when the test is carried out Measures to determine if prediction succeeds

The patient & nurse will understand the reason’s for the test and be happy to participate The test will go well The patients’ risk of HAPU is reduced

Views of patients and professionals will be sought

Act:What will you differently as a result of your test?What will your next test be?

Do:

Study: What happened? What did you learn?

What surprised you?

You are this HospitalYou are this Hospital You are what people see when they arrive here.

Yours are the eyes they look into when they’re frightened and lonely. Yours are the voices people hear when they are in the lifts and when they try to sleep and when they try to forget their problems. You are what they hear on their way to appointments that could affect their destinies and what they hear after they leave those appointments.

Yours are the comments people hear when you think they can’t. Yours is the intelligence and caring that people hope they’ll find here. If you’re noisy, so is the hospital. If you’re rude, so is the hospital. And if you’re wonderful – so is the hospital.

No visitors, no patients can ever know the real you, the you that you know is there — unless you let them see it. All they can know is what they see and hear and experience.

And so I have a stake in your attitude and in the collective attitudes of everyone who works at Cooley Dickinson Hospital. We are judged by your performance. It is judged by the care you give, the attention you pay and the courtesies you extend.

Thank you for all you are doing. CEO Cooley Dickinson Healthcare Org


Thank You! Questions?

[email protected]

Getting to Zero-Safer Care Improvement Programme

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