The art of the possible will
-
Upload
howardcooper -
Category
Education
-
view
167 -
download
1
description
Transcript of The art of the possible will
National Leadershipand Innovation
AgencyFor HealthcareAsiantaeth
GenedlaetholArweiniad ac Arloesoldeb
dros Ofal Iechyd
National Leadershipand Innovation
AgencyFor HealthcareAsiantaeth
GenedlaetholArweiniad ac Arloesoldeb
dros Ofal Iechyd
Methods for ImprovementMethods for ImprovementWhere is the Will?Where is the Will?
David I GozzardDavid I Gozzard
Quality Improvement FellowQuality Improvement Fellow
Health FoundationHealth Foundation
IN HEALTHCARE!
Improvement Improvement MantraMantra
•Will•Ideas•Execution
…..then Scrutiny
WILLWILL
• The mental faculty by which one chooses or decides upon a course of action
• The act of exercising the will• Diligent purposefulness; Determination• Self-control; Self-discipline• A desire, purpose or determination,
especially one in authority• Free discretion, inclination or pleasure• Bearing or attitude towards others;
disposition
Problems around Problems around WillWill
• Data• “Somebody else's data, doesn’t relate
to my clinic or practice”
• Discomfort• “Discomfort Zone”
• Denial/Disbelief• “Nothing wrong with my practice”• “It’s the uniqueness of my patients”
Clinician CommentsClinician Comments
• “Too busy……..admin and over-busy clinical time”• “It’s a nursing thing – I just deal with my own patients”• “Quality suffers because of the outliers, lack of junior
staff, the lack of continuity – SPI is just around the margins”
• “I am not paid to do this”• “My cases are high quality – it’s the other ward that is
dirty”• “Things are not like they used to be - we used to work
harder and be more vigilant”• “No clear vision from Government – yet another
initiative”• “It’s not in the targets set by my General manager”• “I don’t believe the data”• “You have gone over to the dark side”
Improvement Improvement Culture:Culture:
A Useful GuideA Useful Guide
“Every enterprise has four organisations: the one that is written down, the one that most people believe exists, the one that people wished existed and finally, the one that the organisation really needs”
NHS Chief Executive
The Discomfort ZoneThe Discomfort ZoneComfort Zone: People stay here, don’t change, don’t learn
Discomfort Zone: People uncertain, but most likely to change, most likely to learn
Panic Zone: People freeze, will not change, will not learn
To encourage people to leave a comfort zone, you need to help them feel safe. You can do this by creating the right environment and culture, ensuring that there is no blame.
The Individual:The Individual:Readiness to ChangeReadiness to Change
Prochaska et al 1992
Descriptor Behaviour Action
Pre-contemplation The individual is not ready to discuss or consider change
Consciousness raising
Contemplation The individual is willing to listen and to consider a change
Emphasis on benefits
Preparation The individual gets ready to do something concrete
Provide support
Action The individual starts to work with the change
Continue support in addition to encouragement and praise
Maintenance The individual strives not to slip back to old behaviours
Scrutiny of process?
The Nature of The Nature of ChangeChange
Change can be…..
Collective Everyone in a group must decide to adopt or not
Authoritative The individual is told to adopt
Contingent The individual cannot choose to adopt until the organisation has sanctioned it
The Scepticism ContinuumThe Scepticism Continuum
behaviour behaviourattitude
active passive scepticism neutrality acceptance commitment activeresistance resistance involvement
Scepticism: The questioning or doubting of accepted opinion
Resistance: Through actions and arguments prevent someone from doing something, or prevent something from happening
The Value of ResistanceThe Value of Resistance
“Commercial practice, for example, often interprets resistance to change as a natural and
necessary force for exposing and resolving conflict, and consequently for planning and
implementing change effectively.
“Organisations need resistance to change in order to prevent bad and poorly developed ideas
from being implemented.
Mabin et al 2001
Schön 1963
The Involvement The Involvement ConundrumConundrum
Impact on personal status,
patients and the
organisation
Political considerations
Timing
Degree of information
or understandin
g
Complexity Impact
Skills required
Priority
Source
Focus
The individual contemplating
change
The proposed change
Time Context
Trust Reported IncidentsTrust Reported Incidents
Errors
Errors that cause no harm to the patient(Near Misses)
Errors that harm the patient
Errors and harm - are Errors and harm - are they the same thing?they the same thing?
Harm
Harm caused by “normal care”
HarmHarm
• Every system is designed to produce the outcome it gets
• We have systems of care designed to produce certain levels of harm
• These levels of harm have become acceptable as a property of the
system• All harm is theoretically preventable
Errors:Errors:
• Failure of a planned action to be completed as intended• Error of execution
• Use of a wrong plan to achieve an aim• Error of planning
What Could we Measure?What Could we Measure?
• Performance management requirements
• Contractual items• Number of patients
• Patient episodes• Trends in attendances
• Waiting times
• Number of critical incidents• Incident reporting and categorisation
No link here
Why are Why are youyoumeasuring?measuring?
The answer to this question will guide your entire The answer to this question will guide your entire quality measurement journey!quality measurement journey!
ImprovementImprovement??
Judgment?
Judgment?Research
?
Research
?
The Three Faces of The Three Faces of Performance MeasurementPerformance Measurement
Aspect Improvement Accountability Research
Aim Improvement of care Comparison, choice, reassurance
New knowledge
Methods:Test Observability
Tests are observable No test; merely evaluate current performance
Test blinded or controlled tests
Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
Sample Size “Just enough” data, small sequential samples
Obtain 100% of available, relevant data
“Just in case” data
Flexibility of Hypothesis
Hypothesis flexible, changes with learning
No hypothesis Fixed hypothesis
Testing Strategy Sequential tests No tests One large test
Determining if change is an imrovement
Run charts or Shewhart control charts
No change focus Hypothesis, statistical tests
Confidentiality of the Data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
Bob Lloyd, IHI
Measuring QualityMeasuring Quality• No system in place to measure quality• What are our quality indicators?
• Data for performance management• Data for research• Data for quality improvement
• 40 “measures”• Each required a new system to measure• Mostly via laborious case note audit
• But it had to be done!
Hope is Not a Plan
National Leadershipand Innovation
AgencyFor HealthcareAsiantaeth
GenedlaetholArweiniad ac Arloesoldeb
dros Ofal Iechyd
National Leadershipand Innovation
AgencyFor HealthcareAsiantaeth
GenedlaetholArweiniad ac Arloesoldeb
dros Ofal Iechyd
Boards think quality is a Boards think quality is a lot better than the lot better than the
managers, doctors and managers, doctors and nurses do.nurses do.
Results from NPSF/AIG Results from NPSF/AIG andand
Estes Park SurveyEstes Park Survey
1 2 3 4 5
How comfortable are you with your level of engagement safety?
9 37 32 14 7 % Mgmt
4 42 46 6 2% BoardC-Suite
Does patient safety trump productivity in your work organization?
9 18 41 20 12 % Mgmt
40 34 20 4 2% BoardC-Suite
Are you able to engage your staff in patient safety activities?
13 31 41 13 0 % Mgmt
41 45 12 2 0% BoardC-Suite
Definitely Not at all
1 2 3 4 5
Executive leadership and the board are visibly engaged in patient safety
10 31 36 15 8 % Mgmt
19 65 14 1 1
% BoardC-Suite
Executive leadership provides the tools and training to be effective
9 30 37 17 7 % Mgmt
14 58 25 2 1
% BoardC-Suite
Physician leadership is actively engaged in patient safety efforts
5 18 33 31 12 % Mgmt
20 48 26 5 1
% BoardC-Suite
Definitely
Not at all
Results from NPSF/AIG Results from NPSF/AIG andand
Estes Park SurveyEstes Park Survey
Better Outcomes Are Better Outcomes Are Associated With Hospitals in Associated With Hospitals in
Which . . .Which . . .
• The board spends more than 25% of its time on quality issues.
• The board receives a formal quality performance measurement report.
• There is a high level of interaction between the board and the medical staff on quality strategy.
• The senior executives’ compensation is based in part on QI performance.
• The CEO is identified as the person with the greatest impact on QI, especially when so
identified by the QI Executive.
Vaughn T, Koepke M, Kroch et. al. 2006
Board Stages in Quality Board Stages in Quality
Engaged
Capable
No Yes
No
Q is just fine, thanks, and
besides, it’s not our problem
Frustrated and confused about
how
Yes
If we could only light the fire…
How do we do this even better?
Changing the old
Making the future attractive
Framework: Leadership for Improvement
Will
Ideas Execution
Establish the Foundation
Setting Direction: Mission, Vision and Strategy
PULL
PUSH
PULL
PUSH
1. Set Direction: 100% or Zero
Make the status quo uncomfortable
Make the future attractive
3. Build Will• Involve patients and families • Understand the gap between
your current performance, the best in class and the theoretical ideal
• Use stories and data• Go transparent• Show courage
5. Execute Change• Establish accountability for results• Establish good oversight process
on “are we achieving our aims?”•Watch your own dots•Weekly or monthly data•25% Board time on quality
4. Generate Ideas
Framework: Board Leadership of Quality
2. Establish the Foundation
• Quality education standards for board
• Build a board culture of healthy conversations with MEC and administration
• Establish Quality Committee• Bring knowledgeable quality leaders onto the board
The Best Boards…The Best Boards…
• Aim high• “Our aim is to achieve zero
central line infections…” • Aim broad
• “…for the entire institution, across all services…”
• Take dead aim• “…by August 31, 2009.”
Mission &Strategy
OrganisationObjectives
LocalObjectives
ImprovementProjects
Individual
PDP
Projects not aligned to organisation objectives are doomed to failure as senior staff will have no interest in
their outcome
The Audit CycleThe Audit Cycle
Consists of…Observation of existing practiceThe setting of standardsComparison between observed and set standardsImplementation of changeRe-audit of clinical practice
Audit and Audit and ImprovementImprovement
©National Leadership and Innovation Agency for Healthcare Asiantaeth Genedlaethol Arweiniad ac Arloesoldeb dros Ofal
Iechyd
Prototype PilotAdapt and
Spread
Improvement project
Audit Audit
Audit as Initiator and Scrutiny
A True Measure of a QI Programme
National Leadershipand Innovation
AgencyFor HealthcareAsiantaeth
GenedlaetholArweiniad ac Arloesoldeb
dros Ofal Iechyd
National Leadershipand Innovation
AgencyFor HealthcareAsiantaeth
GenedlaetholArweiniad ac Arloesoldeb
dros Ofal Iechyd
The Lessons of The Lessons of JönköpingJönköping
Sweden
Jönköping county
Europe
Jönköping County Council is responsible for the public health care services
Jönköping
Höglandet
Värnamo
160 new patients staying over night at the hospitals/day 9 newborns/day
3 Hospitals 34 Primary care centers
9,500 employees350,000 inhabitants
6.100 visits per day 1.500 visit a specialist/day 1.300 visit to GP/day (300 visits to private doctors/day)
The Esther The Esther ProjectProject
“Esther” is not a realpatient but her persona as a grey-haired, ailing, but competent elderlySwedish woman with a chronic condition and occasional acute needs has inspired impressive improvement in how patients flow through a complex network of providers and care settings in Höglandet, Sweden
“What is best for Esther?”
Objectives of Esther Objectives of Esther ProjectProject
1. Security for Esther2. Better working relationships in the
entire care chain3. Higher competence through the
care chain4. Shared medical documentation5. Quality through the entire care
chain6. Documentation and communication
of improvements
Projects to support Projects to support EstherEsther
• Develop flexible organisation with patient value in focus• Design more efficient and improved prescription and
medication routines• Create ways in which documentation and
communication of information can be adapted to the next link on care chain
• Develop an efficient IT-support through whole care chain• Develop and introduce a diagnosis system for
community care• Develop a virtual competence centre for better transfer
and improvement of competence through the care chain
The Inspiration of The Inspiration of EstherEsther
Improvements 1998 2003
Hospital Admissions 9,300 7,300
Hospital Days for CHF 3,500 2,500
(yr 2000)
Waiting times to see a neurologist
85d 14d
Waiting times to see a gastroenterologist
48d 14d
Patient focused
“Activities and sub processes organised
after prioritised patient values”
Patient ask for
Primary Care
Examinationprimary care
treatment
Hospital
Diagnosis & decisionon treatment Prim.C/Hospital
RehabilitationPrimary Care
TreatmentHospital
RehabilitationMunicipality/Community Care
EstherSix Primary care units
RehabERMedicine
Hospital in the town Eksjö
Six municipalities
Traditional
“Functional"
Patienttreatmentfinished
Patientwith disease
Lab
Pharmacy
From a Functional to a Patient Oriented Healthcare
Organisation