PUTZ Falls Improvement Collaborative

CHAMPION EDUCATE PARTNER ENABLE www.qualityimprovement.ie @NationalQI

National Quality Improvement Team

PUTZ Falls Improvement

Collaborative

@nationalQI

Day One Cork 02/10/2019

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Welcome

Maria Lordan Dunphy

Assistant National Director




National Quality Improvement Team Strategic Plan 2020 - 2024

Our purpose is to support and enable lasting improvements across our health service.

We aim to:

1. use our leadership, knowledge and skills to support services to innovate and sustainably improve quality of care and practice

2. support a co-ordinated and prioritised approach to improvement work within the CCO.


Chief Clinical Officer


Our programme of work

National QI team programmes of work


Core Elements to develop a safety culture and QI Focused Health Service

1. Develop real partnerships with people 2. Collaborate and share learning across our system 3. Invest in QI and create QI posts in all our organisations 4. Commit to QI training for all staff 5. Work on relationships and culture so that staff feel valued and their input is encouraged 6. Work with our managers to create a work environment where staff are enabled to work on improving care 7. Use measurement for improvement approaches to understand our data better 8. Ensure we have quality at the centre of our management and governance of health care 9. Work to integrate services 10. Partner with communities so that we contribute to improving the social issues that profoundly affect health outcomes


Some National QI Safety Achievements

Pressure Ulcers to Zero (PUTZ)

Collaborative: Phase 1 (2014): 21 Teams -

73% reduction Phase 2 (2015): 26 Teams -

49% reduction Phase 3 (2017 -2018): 23 teams - 67.5% reduction

Medication safety Intensive training course

provided to 100 acute hospital staff.

Know check ask medication safety

campaign

Partnering with People who use Health Services

Established Patients for Patient Safety Ireland and the National

Patient Forum. Recruited 61 members for the

National Patient Representative Panel.

VTE Collaborative Over third increase in appropriate blood clot

prevention (from median 61% to 81%

Decontamination Programme

(26 acute decontamination teams, 2

primary care dental, QI masterclasses to 420

participants)

Clinical audit training to 1,858

staff in 3 years National clinical audits and QI programmes in major trauma, ICU, hip fracture, orthopaedics hospital mortality, GI endoscopy, radiology and histopathology

Leadership skills for staff

engagement sessions - over 1000 staff

Leadership Skills for Engaging Staff in Improving Quality Toolkit

Schwartz rounds - 22 teams

HSE/RCPI Diploma in

Leadership and Quality in

Healthcare

(489 People - 183 Projects). Examples of QI projects

Reduction in broad

spectrum antibiotic use from 45% to 16.8% in Out of Hour

GP co-operative in Cork

Frail older person care pathway redesign. Median

length of stay reduced from 12.6 days to 9.7 days yearly

saving €3 million

Reduced the waiting times for access to pulmonary

rehabilitation service from 22.4 months to 4.3 months


• Enablers

• When combined together create the environment and acceleration for sustained improvement

HSE Framework for Improving Quality


Roisin Breen

Introductions




Share with us:

Your name?

Your teams name?

Where you are from/ Area of work?

PUTZ or Falls?



Twitter: @NationalQI

Web: www.qualityimprovement.ie

Email:

1. Follow @nationalQI

2. Please tweet using #QIreland #QIPUTZ #QIFalls

3. Add items to the cark park

GDPR


Eileen Tormey

Speed networking




Outcome types and examples

15

System-level Outcomes

• Increased capacity and capability for QI

• Improved staff / service user engagement

• Improved decision-making skills

• More person-centred culture of improvement and innovation

• Better use of evidence to inform QI initiatives

• Senior management buy in

Organisational-level Outcomes

• Improved reflection on

processes of care

• Improved leadership and governance

• Better use of data and measurement to inform service development

• Better support for expansion and embedding of QI practices (e.g. success of pressure ulcer / falls collaborative)

Staff – Outcomes

• Improved quality of clinical care data

• Greater access and

better use of QI methodology and tools

Service User – Outcomes

• Reduction and

prevention of falls

• Improved bone health awareness

• Improved prevention and management of newly acquired pressure ulcers


Collaborative evaluation - in addition to clinical outcomes we will also evaluate:

1. Knowledge and skills (at start of day 1 and end of day 3)

Assessment of:

a) Quality Improvement

b) Clinical content: PUTZ/Falls

2. Collaborative day feedback form (end of day one)

a) Experience and suggestions for how we may improve the collaborative day


3. IHI team effectiveness scale (during story boards)

To help us determine how well teams are doing in meeting improvement goals and implementing changes.

4. AAR for National QI Team after each collaborative

day

5.Partnership evaluation – Process (after the

collaborative)

Help us determine what elements of the partnership worked well / what didn’t work e.g. site visits/ web-exes/ element of one to one interviews with site leads


10 minutes

Knowledge and Skills

Questionnaire

Take 10 minutes to complete

& hand into one of the National Quality Improvement Team



Brid Boyce & Teresa O’Callaghan

Why Falls, and Bone Health?

Why Pressure Ulcers?

Why a QI collaborative is a suitable

approach?


Quality Improvement – A Collaborative Approach

Collaborate for

Improvement

Background and Context to the PU & Falls collaborative ( Why)

• Leading SRE

• System wide challenge

• Agreed system priority

• Framework for Improving Quality underpinning support to drive sustainable improvement

What is an Improvement Collaborative?

A collaborative is a short-term (6- to 15-month)

learning system that brings together a number of teams from healthcare settings to seek improvement in a focused topic area.

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003

How- Applying IHI Collaborative Model methodology

The Role of Collaboratives in Improvement Culture

• Support health care organisations to make "breakthrough" improvements in quality for better care outcomes.

• Help organisations to create a structure in which interested teams can easily learn from each other and from recognised topic and improvement experts in areas where they want to make changes.

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003

Understand the context of Front line care

• What is good about it?

• What’s not so good about it?

• What could be improved?

Underpinned by the Framework for Improving Quality (2016)

Whole system approach

Applicable across all settings and

services

Tool to aid system leaders, managers

to focus efforts towards key areas

Tool to aid front line staff as a sense check of areas that

require continuously improvement

Recognises significant service

constraints & challenges

Key Supports to Collaborative's

Framework for

Improving Quality drivers (2016)

Knowledge & Skills guide

(2017)

Values in Action

Stakeholder mapping

Communication plan

Safe space to think

Benefits of Collaboratives

Positive impact for patients

Improve interdependence between teams

Developing QI knowledge, skills and expertise for staff

Standardise norms

Successful collaborative's to date..

PUTZ 1DNE 2014

Reduce PU by 50% in DNE by end of 9 months

CAWT 2014

Reduced Falls by 58% across social care in DNE by 9mts

PUTZ 2 2015-2016

Reduce PU by 50% across IEHG and CHO5, 789 by 9mts

Challenge of prevention, who can help?

Family

Person

Friends

General and specialist nurses

GP/ Geriatrician

Catering staff/ Cleaning staff

Health care assistant

OT, Physio, Pharmacist, Dietician

Health & Safety colleagues

Key supports to collaboration

Flexibility

Reflection on processes

Coordination

Communication

Resources

Collective decision making

Shared goals

Interdependence

Partnership

Teamwork

Collaborative Goal

Collaborative objective

K&S Team (In prep for School of QI)

Patient Safety

There is one in 1 000 000 chance of a traveller being harmed

while on an aircraft. In comparison, there is a one in 300 chance of a patient being

harmed during health care. (WHO 10 Facts about Patient

Safety ,2018)

Why Falls (WHO, 2018)

Falls are the second leading cause of accidental or unintentional injury deaths worldwide.

Each year an estimated 646 000 individuals die from falls globally of which over 80% are in low- and middle-income countries.

Adults older than 65 years of age suffer the greatest number of fatal falls.

37.3 million falls that are severe enough to require medical attention occur each year.

Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.

Why Falls in Ireland

Aging population

•Prolonged hospitalisation

Contributes to death

•Some are preventable

EU Policy (European Commission & WHO, 2010)

Publication on progress achieved by European Countries in implementing the EC

recommendations on the prevention of injury and the promotion of safety demonstrated:

Lack of National Policy to address

this issue

Lack of key interventions ( i.e. exercise and

balance)

Why is this work so Important?

• Bone health can be improved

• Quality of life is impacted (pt & Family)

• Impact on other parts of the system when a serious fall occurs

• Associated with contributing to death

• Some are preventable

• Economic cost

Why Pressure Ulcers

• A reportable SRE

• Debilitating

• Painful

• Preventable

• Can sometimes be only reason for hospital admission

• Impact on patient and family Quality of Life

• Cost

“If quality is to be at the heart of everything we do, it must be understood from the Perspectives

of the patients “ (Lord Darzi)

How do you view Patients and

families as partners?


Eileen Tormey

Team Values



MAKING CULTURE VISIBLE

Every day thousands of our staff live our values of care, compassion, trust and

learning. Sometimes this is visible, sometimes it is not.

In order to shape our culture around these values, so that they are evident every

day in every workplace, we have translated our values from words into behaviours

that we can all demonstrate.


Behaviours that make culture visible


Quality Improvement is a collective role


What do effective QI teams look like?

Team aim and vision for Improvement

Team Goal / Priority setting

Role Clarity for all team members

Measuring, Communicating

and Sharing Learning

Collective Leadership *Everyone is a leader for Improvement*


Team Crest


Design Your Team Crest


Patient Story

Liz Maddox

Older Persons Council



Tea and Networking



Dr Michael Carton

Quality Improvement




Learning Objectives for this session

1. Understand what Quality and Quality Improvement mean

2. Understand what quantitative and qualitative data are

3. Understand the model for improvement (IHI)

4. Understand how to develop a SMART aim statement

5. Know what the term PDSA means and what ‘A small test of change’ means


Institute of Medicine definition of Quality (2001)

Patient centred

Safety

Effectiveness Equality

Timeliness Efficiency


Irish National Definition of Quality

Person Centred

respective & responsive, inclusive in care design and delivery

Effective

evidence based care to optimise patient outcomes

Safe-

cause no harm, learns from when things go wrong

Better health & wellbeing

seek opportunities to support/partner with patients in improving their own health & wellbeing

QUALITY CARE


Quality is…

“Quality is goodness…it is the extent to which we meet the needs and wants of those we care for” Don Berwick


Irish study on service users expectation of quality in healthcare- Person Centred Quality (Brilli et al., 2014)

Don’t harm me

Cure me

Respect me

Guide my care

Keep us well


HSE Executive Management Team

Equity


Characteristics of a Quality Service

• Continuously improve the quality and safety of their care and focus on achieving best outcomes for their service users

• Provide safe, effective, person-centred care that promotes

better health and wellbeing for those using their service • Have good leadership, clear accountability, effective

management and a well-organised effective workforce • Effectively use information to plan and deliver high quality safe

services

• Effectively and efficiently use available resources to achieve best outcomes for their service users. (SSBHC. HIQA, 2012)


Quality Improvement in Healthcare

58

“In healthcare everyone has two jobs: to do your work and to improve it.”

Professor Paul Batalden, Senior Fellow

Institute for Healthcare Improvement, 2007


What is Quality Improvement?

Combined and unceasing efforts of everyone – (incl. healthcare professionals, patients and families) to make the changes that will lead to:

•Better patient outcomes

•Better experiences of care

•Continued development and

supported staff

Defining Quality Improvement (HSE, 2016) (adapted from Batalden, Davidoff Qualty Saf Health Care 2007)


Building planes in the sky

• https://www.youtube.com/watch?v=Y7XW-mewUm8&list=RDY7XW-mewUm8&index=1

https://www.youtube.com/watch?v=Y7XW-mewUm8&list=RDY7XW-mewUm8&index=1







How to get to Quality?

QUALITY


The Framework for Improving Quality in our Health Service


Which way I ought to go from here?

“ Would you tell me please, which way I ought to go from here?” said Alice.

“That depends a good deal on where you want to get

to” said the Cat. “ I don't much care where” replied Alice. “Well then it doesn't much matter which way you

go.” said the Cat

Alice in Wonderland Lewis Carroll


What does Quality look like for you?

https://www.google.ie/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwjH5LLm7tjkAhWjolwKHdTJAuoQjRx6BAgBEAQ&url=https://participatorymedicine.org/epatients/2012/01/star-tribune-simple-pharmacy-change-produces-major-quality-improvement.html&psig=AOvVaw1VbalimWcSOFoDIDl6nCZV&ust=1568844344375165


How do we get there?

• Even when we know where we want to go, we still need a method for getting there

• The Science of Quality Improvement is one of a number of ways


Model for

Improvement


Q1 What are we trying to accomplish?

• Right care, in the right place, at the right time

• Better care for every one

• Patient centred efficient pathway


Q1 What are we trying to accomplish?

Specific: who, what, where, when

Measurable: numeric goals

Actionable and Achievable

Relevant to stakeholders and organization

Timeframe: short cycles of tests, by when


Is this a good Aim Statement?

• to get some patients off the waiting list soon

“Some is not a number, soon is not a time”

Don Berwick


What should & should not be in the aim statement?

• The (patient) outcome you wish to achieve

• The solution you wish to implement


Tips

• Is the aim too large?

• Who is impacted?

• Can the aim be achieved in the time allowed?

• Be Honest, Be Brave, Be Transparent, – But Manage Expectations

• Is it supported by evidence or experience?

• Where will the change occur?

• Does the aim have meaning for staff & patients?


SMART Aim Statement structure

“In: _______________________________ (Population impacted)

We will increase / decrease: _____________________ (outcome)

from: ____________________________ (baseline %, rate, #, etc)

to:____________________________ (future state %, rate, #, etc)

by: __________________________ (date, 3-6 month timeframe)”


Why spend time on an aim statement?

To answer and clarify “what are we trying to accomplish?”

To develop a shared language

To facilitate organisational conversation

To develop accountability

To know what to measure


Aim Statements

Aim Statement SMART Score

1. To improve patient satisfaction in the ED from 20% to 50%

2. To reduce the waiting time for an OPD appointment by 50% in 2015

3. To increase reporting of incidents on labour ward from 3 per 100 births to 6 per 100 births.

4. To ensure 100% compliance with all CVL bundle elements in ICU1 by medical and nursing staff by March 31st 2015.


CREATE A SMART Aim Statement

SPECIFIC Specifies the goal or intent Focus on achieving ONE thing only

MEASURABLE Direct relationship between the increase and the decrease of a measure and the achievement or the loss of the goal Increase/Decrease or with Improve/Reduce…then describe what is to be measured, and quantify by how much

ACHIEVABLE Ensure that the team will be able to take action to overcome any anticipated barriers to achieving the goal(measurable results)

RELEVANT Ensure the goal is relevant and within the teams ability to achieve, control, or influence

TIMEBOUND The goal has a target date ..by when


Q2 How will we know that a change is an improvement?

• If our Aim Statement is Measureable, we can collect some data that will help us answer this question


Reactions to Conversations about data

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Data in Healthcare

• Take the example of the medical record

It contains:

– e.g. Clinical Notes

– E.g. diagnostic results


Qualitative and Quantitative Data

• Qualitative Information

Words, experiences, observations, feedback

• Quantitative Information

Numbers, percentages, rates

Together, they lead to Understanding

“No data without stories, no stories without data”


The Three Faces of Performance Measurement Improvement Accountability Research

Who? Audience Medical group Purchasers Science community (Customers) Quality improvement team Payers General public Providers and staff Patients / members Users (clinicians) Administrators Medical groups Why? Purpose Understanding of Comparison New knowledge, without regard for it's (a) process Basis for choice applicability (b) customers Reassurance Motivation and focus Spur for change Baseline Evaluation of changes What? Scope Specific to an individual medical site Specific to an individual medical group Universal (though often limited and process and process generalisability) Measures Few Very few Many Easy to collect Complex calculation Complex calculation Approximate Precise and valid Very precise and valid Time period Short, current Long, past Long, past Confounders Consider, but rarely measure Describe and try to measure Measure or control How? Measurers Internal and at least involved in the External External and usually prefer to control selection of measures both process and collection Sample size Small Large Large Collection process Simple and requires minimal time, cost, Complex and requires moderate effort Extremely complex and expensive and expertise and cost May be planned for several repeats Usually repeated Need for Very high None for objects of comparison - the goal High, especially for the confidentiality (Organisation and people) is exposure individual subjects

Solberg et al. (1997)


Some basic principles of Measurement for Improvement


The role of Subject Matter Experts

• To understand what the data is saying, subject matter experts need to be involved in interpreting the data.


Give me an example of subject matter experts in the service you work in?

YOU!


The Banana Measurement Exercise

Instructions:

1. As a team, measure the length of your banana

2. Document how you measured the banana

3. Tell one of the facilitators your answer

4. Swap the definition and banana with another group

5. Follow their instructions and measure their banana

6. Tell one of the facilitators the answer


The importance of the operational definition

• How does this relate to the collection of data using your safety cross?


• “if you don’t know where you came from, you can’t know where you are going”


Baseline

• Baseline – you need some data to tell you what your starting point is

• It is important

• …but don’t put off improving just to get great baseline data


Q3 What changes can we make that will result in improvement?

• We need to generate some ideas on what changes we can make that would help us achieve our aim


Where do the ideas for Improvement come from?

• Subject matter experts

• Clinical insight

• Identified Risks

Hunches

• KPIs

• Audit

• Complaints

Data • HIQA

• MHC

Standards

• Published Studies

• Conference Proceedings

Evidence


Service Users and Families

• Have a unique insight into how your service is working


Avoid Inspirational Overload


How do you eat an elephant?


The Driver Diagram

Primary Drivers (What must be present to achieve our aim )

Secondary Drivers (What must be present to deliver each driver )

Project Aim


• Heat measure • Timer • Measure of cooked meat

A motivated person/Team

Reliable & safe

Equipment

Documented recipe/guide & safety

instructions

Right Ingredients

Right environment

Clear measurement process

• Standard recipe • Easily accessible

• Whats in it for them is clearly understood and comunicated

• Proper training

• Appropriate dining facility • Appropriate serving equipment

• Selected supplier • Appropriate storage • Stock management & reorder system

• Appropriate and tested oven

Primary Drivers (What must be present to achieve our aim )

Secondary Drivers (What must be present to deliver each driver )

Driver Diagram for - The Perfect Roast Chicken


How to Develop and Use a Driver Diagram

1. Overall aim statement – a clear, action orientated statement

2. Primary drivers – system components which will contribute to achieving the aim ( identify what you want)

3. Secondary drivers – elements within the associated primary driver ( identify how to achieve primary drivers, what you need)

4. Ideas for tests of change

Tasks and tests


Small Tests of Change

The PDSA Cycle

• Plan

• Do

• Study

• Act


Video

• October Sky


“Insanity: doing the same

thing over and over again

and expecting different

results.”

Albert Einstein


Plan – Do – Study - Act

• Plan- predict/ plan and agree the who, what, how and when of your test (after your base line measure is undertaken and SMART aim agreed)

• Do – Carry out your agreed changes in different circumstances (days, nights, weekends)

• Study – examine the difference beside your baseline noting improvements or NOT

• Act- decide to adopt the change in practice or start again!


• Plan- predict/ plan and agree the who, what, how and when of your test (after your base line measure is undertaken and SMART aim agreed)


• Do – Carry out your agreed changes in different circumstances (days, nights, weekends)


• Study – examine the difference beside your baseline noting improvements or NOT


• Act- decide to adopt the change in practice or start again!

• Accept

• Adopt

• Discard


Lets Practice PDSA’s with a coin toss Objective of the game is to reach the desired target with your coin.

• Prediction- Plan: Decide who is going to toss the coin/ what type of coin/style of throwing

• Do: stand behind a line and throw the coin as close to the target as possible. Measure the distance from the coin to the target location.

• Study: did you reach the target? How near were you?

• Act : New prediction/plan

• Don’t forget to keep a record of your tests!


Cycles of Tests build Confidence

BASELINE Measurements

Proposals Theories Hunches Intuitions

Changes that will result in

improvement

Adapted from IHI (2013)


Top Tip

• Don’t be afraid to include PDSA cycles that have not resulted in the desired effect – there can be just as much learning in these tests

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The principles of PDSA’s

• Break down change into manageable bite-sized time-limited chunks

• A PDSA cannot be too small !!!!!!

It can be too big !!

• Small changes can be tested without causing upheaval to the whole system

Tell other’s what you are doing

• If it doesn't work, try something different based on your learning

Document what did/didn’t work


Appreciation

of a System

Understanding Variation

Theory of Knowledge

Psychology

The Foundation of the Science of Improvement


Quality Improvement Toolkit


National QI Team Improvement Methods Toolkit

• Michael insert slides

Available on internet for use and a webinar will be scheduled between Learning day one and two


Twitter: @NationalQI

Web: www.qualityimprovement.ie

Email:

Any questions

You may contact : Falls Lead –Dr Teresa O’Callaghan

PUTZ Lead -Brid Boyce

[email protected] – 0872264615

[email protected] - 0870522845

mailto:[email protected]


Dr Michael Carton

Next steps and Close



PUTZ Falls Improvement Collaborative

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Transcript of PUTZ Falls Improvement Collaborative