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Service improvement for
better, safer healthcare
Most people would like to ‘do something
about quality’ but don't have the time.
They are too busy dealing with complaints,
making good (correcting) mistakes, doing the
wrong things right and doing what they do
twice.
paraphrased from Øvretveit 1992
There are 2,231 words
meaning drunk …
but only one word for quality
What is quality?
Quality does not necessarily mean
excellence …
Quality means:
fit for the purpose.
The Model for Providing Care
Functional
Health
Status
Access
System
Patient with
needs
Assess
Diagnose
Treat
Satisfaction
against
need
Clinical
Outcomes
Follow-up
Total Costs
Balanced measure of care
Nelson et al (1996)
6 components of Quality
–
–
–
–
–
–
Access
Relevance to need
Effectiveness
Equity
Acceptability
Efficiency
– Humanity
(Maxwell 1984)
It is the system …
Every system is perfectly
designed to produce the
outcome it achieves!
paraphrased from Berwick (1996)
Process mapping …
Select a process
e.g. A Cake
Process mapping …
Select a process
Map the process
Map the process
Process mapping …
Select a process
Map the process
Analyse the current situation
Analyse current situation
bottlenecks
Reworked loops
Lots of steps
delays
Reworked loops
Process mapping …
Select a process
Map the process
Analyse the current situation
Identify opportunities to improve
Identify opportunities to improve
With as few steps as possible
Each step must add value to the process.
The health service has many heroes. The staff
who - work harder - predict problems and
compensate for short comings.
Heroic thoroughness may make patients lives
a little safer - but - a real improvement in the
quality of care provided to patients is not
created by heroes who compensate for the
flawed processes.
The real heroes are those who change the
system to remove the flaws!
How do we make the
necessary changes???
Use a model for improvement
A model for improvement
Aims
What are you trying to
accomplish?
Three
fundamental
questions for
improvement
Langley et al (1996) – cited in NHS III (2007)
A model for improvement
Aims
Measurement
What are you trying to
accomplish?
How will you know that a
change is an improvement?
Three
fundamental
questions for
improvement
A model for improvement
Aims
Measurement
Ideas, hunches,
etc.
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make that
will result in the improvements
you seek ?
Three
fundamental
questions for
improvement
The PDSA Cycle
How to
make
change
happen …
Act
• What changes
are to be made?
• Next cycle?
Study
• Analyse the data
• What did or didn’t
work?
• Summarise what
was learnt
Plan
• Objective
• What do we want to do?
• Plan to carry out the cycle
(who, what, where, when)
•Plan for data collection
Do
• Just do it!
• Carry out the plan
• Document problems
and unexpected
observations
Walton (1989)
Repeated PDSA Cycles
A P
S D
A P
S D
A P
S D
A P
S D
Hunches
Theories
Ideas
Changes
that result in
improvement
Aims
Measurement
Ideas, hunches,
other people etc.
How to make
change happen
What are you trying to
accomplish?
How will you know that a
change is an improvement?
Three
fundamental
questions for
improvement
What changes can you make that will
result in the improvements you seek ?
Act
Plan
Study
Do
Langley et al (1996) – cited in NHS III (2007)
A real example of process
mapping in practice …
Burns Unit Quality Improvement Team
• Team Members:
Consultant Surgeon, Ward Sister, Nursing Staff, Clinical
Psychologist, Physiotherapist
• Aim:
“to improve the quality of care to adults with major burns
so that they receive the care they need”
Burns Unit Quality Improvement Team
Accepting
referral
Assessing
Treating
Evaluating
Discharging
from acute
phase
Burns Unit Quality Improvement Team
Accepting
referral
-Enquiring
about the
patient
- Preparing
for arrival
- Advising on
initial
treatment
Assessing
- Taking
Clinical
baseline
- Informing
relatives and
carers
-Taking
swabs and
photos
Treating
-Treating
other
medical
conditions
-Responding
to Psych
needs
- Mobilising
and moving
- Managing
pain
- Planning
for discharge
Evaluating
- Evaluating
wound
- Evaluating
Psych
progress
- Sharing
info at case
conf.
- Feeding
back to
patient and
carers
- Evaluating
infection
status
Discharging
from acute
phase
-Organising
follow-up
appointment
- Writing &
sending
discharge
letter
- Providing
appropriate
patient info
- Giving SOS
contact
Some areas for improvement
• Providing appropriate information to patients
and carers when they need it
• Receiving and accepting referrals
• Criteria for agreeing surgery
• Identifying patients who need psychological
support
Burns Unit Quality Improvement Team
Accepting
referral
-Enquiring
about the
patient
- Preparing
for arrival
- Advising on
initial
treatment
Assessing
- Taking
Clinical
baseline
- Informing
relatives and
carers
-Taking
swabs and
photos
Treating
-Treating other
medical
conditions
-Responding
to Psych
needs
- Mobilising
and moving
- Managing
pain
- Planning for
discharge
Evaluating
- Evaluating
wound
- Evaluating
Psych
progress
- Sharing
info at case
conf.
- Feeding
back to
patient and
carers
- Evaluating
infection
status
Discharging
from acute
phase
-Organising
follow-up
appointment
- Writing &
sending
discharge
letter
- Providing
appropriate
patient info
- Giving SOS
contact
Burns Unit Quality Improvement Team
A key area for improvement
To improve the identification of patients
who need psychological support
How the Burns Unit QI Team
used the model for improvement
…
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you seek?
What are we trying to accomplish?
to improve detection of psychological distress
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you seek?
What are we trying to accomplish?
to improve detection of psychological distress
How will we know a change is an improvement?
- screening results will be available in notes
- appropriate referrals to psychology
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
What are we trying to accomplish?
to improve detection of psychological distress
How will we know a change is an improvement?
- screening results will be available in notes
- appropriate referrals to psychology
What changes can we make that will lead to
improvement?
- introduce a screening tool for selected patients
- try a pilot with 5 patients
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
Act
Plan
Study
Do
PDSA 1
A P
S D
Do: - tested screening tool
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
Act
Plan
Study
Do
PDSA 1
A P
S D
Study: - inclusion/exclusion criteria were unclear
- errors in scoring
Do: - tested screening tool
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
Act
Plan
Study
Do
PDSA 2
A P
S D
PDSA 1
A P
Plan: - refine criteria
S D
- workshops for nurses
Study: - inclusion/exclusion criteria were unclear
- errors in scoring
Do: - tested screening tool
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
Act
Plan
Study
Do
PDSA 2
A P
S D
Study: - screening was more accurate
PDSA 1
A P
S D
- implementation was patchy
Plan: - refine criteria
- workshops for nurses
Study: - inclusion/exclusion criteria were unclear
- errors in scoring
Do: - tested screening tool
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
Act
Plan
Study
Do
PDSA 3
A P
S D
PDSA 2
A P
Plan: - build reminders into ward routines
S D
Study: - screening was more accurate
PDSA 1
A P
S D
- implementation was patchy
Plan: - refine criteria
- workshops for nurses
Study: - inclusion/exclusion criteria were unclear
- errors in scoring
Do: - tested screening tool
What are you trying to
accomplish?
How will you know that a
change is an improvement?
What changes can you make
that will result in the
improvements you see?
Act
Plan
Study
Do
PDSA 3
A P
S D
PDSA 2
A P
Study: - showed significant
improvements
Plan: - build reminders into ward routines
S D
Study: - screening was more accurate
PDSA 1
A P
S D
- implementation was patchy
Plan: - refine criteria
- workshops for nurses
Study: - inclusion/exclusion criteria were unclear
- errors in scoring
Do: - tested screening tool
Burns Unit Quality Improvement Team
Results after third PDSA
• 91% of patients were being checked
• Approximately 30% were found to need psychological
support for anxiety, depression or PTSD
Referrals to Clinical Psychology increased by 600%
Overview of Improvement
– Success is defined as improving how we safely
meet the needs of our patients
– Focus on processes, not blaming others
– Success depends on gathering and using data
and information to identify changes and to learn
from testing them out
………
………
Overview
(cont.)
– Using rapid small changes engages staff and
creates continuous improvement
– Success requires collaboration and innovation
from team members working together
– Combining professional knowledge with
improvement knowledge is very powerful for
providing safer and better care
In every work place (and home) there are 4 people named
Everybody, Somebody, Anybody and Nobody.
When there is a job to be done Everybody is asked to do it.
Everybody is sure Somebody will do it. Anybody could do it,
but Nobody does it.
Somebody will get angry about that because it is
Everybody’s job to do it.
However, Everybody thinks Anybody could do it and Nobody
realises that Everybody won’t do it, unless Somebody does.
It will end up with Everybody blaming Somebody because
Nobody does what Anybody could do.
The tribal wisdom of the Dakota Indians, passed from
generation to generation, states that when you discover that you
are riding a dead horse the best strategy is to dismount.
However modern management best practice within
government and large organisations has developed other
strategies, including the following:
Change Riders.
Say things like “this the way we always ride horses”
Appoint a committee to study the horse.
Arrange to visit other sites to see how they ride dead horses.
Hold training sessions to improve dead horse riding ability.
Compare the state of dead horses in today’s environment.
Re-classify the dead horse as “living, impaired”.
Pass legislation declaring that “this horse is not dead”
Harness several dead horses together for increased the speed.
Do a cost analysis study to see if contractors can ride it cheaper.
Offer the horse career counselling and the option of a
transfer to a less stressful position of equivalent status.
Check with IT Support to see if the whole network is down,
or if it is just the horse.
Promote the dead horse to a Senior Management position.
Bibliography
Batalden PB & Stoltz PK (1993) A Framework for the Continual Improvement of Healthcare: Building
and Applying Professional and Improvement Knowledge to Test Changes in Daily Work. Journal
on Quality Improvement, October. 19 (10) 424-452
Berwick DM (1996) A primer on leading the improvement of systems. BMJ 312 619-622
Cox S, Wilcock P & Young J (1999) Improving the Repeat Prescribing Process in a Busy General
Practice - A study using continuous quality improvement methodology, Quality in Health Care, 8
119-125
Maxwell RJ (1984) Quality assessment in health. BMJ; 288: 1470-2
Nelson G, Batalden P, Plume S, Mohr J (1996) Improving Health Care Part 2 - A Clinical
Improvement Worksheet and Users’ Manual. The Joint Commission Journal on Quality
Improvement. 22 (8) 531-548
NHS Institute for Innovation and Improvement (2007) The Improvement Leaders’ Guide to Process
Mapping, Analysis and Redesign. NHS III
Available on line at; http://www.institute.nhs.uk/improvementleadersguide
Øvretveit J. (1992) Health Services Quality: An introduction to quality methods for health services.
Blackwell Scientific. London
Scholtes PR, Joiner BL, Streibel JL (2003) The Team Handbook – 3rd Edition. Pub: Oriel Inc.
Improvement Leaders’ Guides
General
Improvement
Skills
Process and
systems
thinking
Personal and
organisational
development
• Improvement knowledge & skills
• Process mapping, analysis and redesign
• Working with groups
• Involving patients and carers
• Evaluating improvement
• Sustainability
•Technology in improvement
•Delivering improvement
• Measurement for improvement
• Matching capacity and demand
• Improving flow
• Working in systems
• Managing the human dimensions of change
• Redesigning roles
• Building and nurturing an improvement culture
• Leading improvement
www.institute.nhs.uk/improvementleadersguides
Useful Links
www.institute.nhs.uk
NHS Institute for Innovation and Improvement
www.tin.nhs.uk
NHS Trent Improvement Network
www.ihi.org
Institute for Health Care Improvement (USA)
www.inprovementskills.org
The Healthcare Improvement Skills Center
www.teamhandbook.com
Website for the Scholtes et al (2003) referenced above