1

Catherine Blackaby

National Improvement Lead

Service improvement for everyone

This session will cover…

• Why a structured approach to

improvement is important

• An introduction to some of the key tools

and techniques to help you get started

• How to find out more

2

NHS Service Improvement

Surely it’s not that difficult?

X Y

Just do it Efficient

system

IHI and RC Lloyd & Associates 2008

3

X Y

Patient encounter

with health

professional

Healthy

satisfied

patient

IHI and RC Lloyd & Associates 2008

Surely it’s not that difficult?

X

4

MODEL FOR IMPROVEMENT

“All models are wrong but

some are useful”

• W Deming

5

What are we trying to

accomplish?

How will we know that a

change is an improvement? What changes can we make that will result in the improvements that we

seek ?

Model for improvement

Act Plan

Study Do

aims

measurements

interventions

WHAT IS OUR AIM?

6

Define your aim

A good aim

• What we are trying to achieve

• For whom

• How much

• By when

• Compared to what

• And why?

7

By July 2011 in 100% of key practices 75% of

patients on COPD register will have had a review

in the last 15 months and have a British Lung

Foundation (BLF) Self Care management Plan.

Patients will have a better understanding of their

disease, their medication, how to manage

exacerbations and when to seek help. This will

lead to a reduction in emergency admissions and

readmissions and better use of healthcare

resources for these patients.

WHERE ARE WE STARTING

FROM?

8

Understanding the system & the problem

9

Process mapping • Everyone involved in the process

• Make visible what happens at each step

• One step = one sticky note

• Who does What

• Ask:

– How long? How many? How often?

– Time between steps?

– Why?

• If you don’t know, find out

<Process Name>

<F

un

ctio

n>

ISSUE

Repeat assessment.

Is this effiecent?

No onward path???

NO

ISSUE

What does this

do? How does

access work?

YES

NO

NO

YES

YES

ISSUE

Variation in discharge information practice?

Transfer Co-ordinators?

NO

ISSUE

What happens

on general

ward? (OT

Physio?)

No onward path???

NO

YES

with copies of;

Nursing MDT letter

Copy of discharge letter

Letter to GP

No onward path???

Social Services

Home care hrs

available

ISSUE

Part-time SW

causing delay

slowing system

Patient

breathless

Pulmonary

rehab referral

Daily

assessment

Mon-Fri by Dr

Consultant review by;

* On-call Team (non respiratory)

* Elderly care

* Respiratory

CDU

A&E

Post hospital review

LTOT

assessment

Social Worker /

OT referral 3/7

wait to see

Hospital OT

Outpatient appointment

Discharge?

Discharge to

community

services CHAP

Discharge?

DOME

outreach

Pulmonary

rehab

Respiratory

Nurse

Assessment

Respiratory

Nurse

assessment

GP

Junior Doctor

assess on-call

team

Discharge?

Appt with

community Matron

Registrar

Review on-

call team Respiratory Ward

LOS (6-10 days

stay)

Ambulance

response

??? BI annual review

Physio, OT,

SW etc

Residential /

Nursing home

Discharge?

999

General Ward

LOS

CHAPS

OOH

Self referral to community

services?, hopsital?

Dept of

Medicine

Elderly DOME

Medical on-

call team

AMU

Self

management

Referral to

Community RNS

Home

Equipment

Environmental

-equipment

Healthcare

Equipment –

Medical

equipment

Medication?

TTOS

Transport?

Tax? Carers

transport?

Discharge?YESNo onward path???

Letter to GP from Out of

Hours?

Letter to GP from Consultant?

Letter to CHAPS from RNS?

Letter to GP from Respiratory

Nurse?

Letter to GP from A&E?

Clarify Source of TTOS?

10

All improvement is change –

but not all change is

improvement…

HOW WILL WE KNOW IF A

CHANGE IS AN

IMPROVEMENT?

11

How will we know whether a change is

an improvement? • Measure…

• Measure the baseline

• Measure the minimum & what is useful

• Make measurement part of the daily

routine.

• Measure over time, measure variation &

don’t measure averages!

Why not just use averages?

‘If I stick my right foot in a

bucket of boiling water

and my left foot in a

bucket of ice water, on

average, I’d feel pretty

comfortable.’ Davis Balestracci

12

Measurement for Improvement

4.2

4.3

4.4

4.5

4.6

4.7

4.8

4.9

5

Last year This year

Mortality

Average

The real picture

0

2

4

6

8

10

12

Jan Mar May July Sept Nov Jan Mar May July

Mortality

New

protocol

introduced

13

How to measure

• Befriend an analyst

• Use what is there already

• Use what is useful

• Don’t judge, be curious

• Tools:

– NHS Improvement Data Guide

– NHS Improvement System SPC tool

www.improvement.nhs.uk

WHAT CHANGES CAN WE

MAKE?

14

<Process Name>

<F

un

ctio

n>

ISSUE

Repeat assessment.

Is this effiecent?

No onward path???

NO

ISSUE

What does this

do? How does

access work?

YES

NO

NO

YES

YES

ISSUE

Variation in discharge information practice?

Transfer Co-ordinators?

NO

ISSUE

What happens

on general

ward? (OT

Physio?)

No onward path???

NO

YES

with copies of;

Nursing MDT letter

Copy of discharge letter

Letter to GP

No onward path???

Social Services

Home care hrs

available

ISSUE

Part-time SW

causing delay

slowing system

Patient

breathless

Pulmonary

rehab referral

Daily

assessment

Mon-Fri by Dr

Consultant review by;

* On-call Team (non respiratory)

* Elderly care

* Respiratory

CDU

A&E

Post hospital review

LTOT

assessment

Social Worker /

OT referral 3/7

wait to see

Hospital OT

Outpatient appointment

Discharge?

Discharge to

community

services CHAP

Discharge?

DOME

outreach

Pulmonary

rehab

Respiratory

Nurse

Assessment

Respiratory

Nurse

assessment

GP

Junior Doctor

assess on-call

team

Discharge?

Appt with

community Matron

Registrar

Review on-

call team Respiratory Ward

LOS (6-10 days

stay)

Ambulance

response

??? BI annual review

Physio, OT,

SW etc

Residential /

Nursing home

Discharge?

999

General Ward

LOS

CHAPS

OOH

Self referral to community

services?, hopsital?

Dept of

Medicine

Elderly DOME

Medical on-

call team

AMU

Self

management

Referral to

Community RNS

Home

Equipment

Environmental

-equipment

Healthcare

Equipment –

Medical

equipment

Medication?

TTOS

Transport?

Tax? Carers

transport?

Discharge?YESNo onward path???

Letter to GP from Out of

Hours?

Letter to GP from Consultant?

Letter to CHAPS from RNS?

Letter to GP from Respiratory

Nurse?

Letter to GP from A&E?

Clarify Source of TTOS?

For every complex human problem there is always one easy answer that is neat, plausible…

…and wrong

HL Mencken

15

Change Ideas

Knowing what to do

Aim

increase the no of patients

who can effectively

Self manage exacerbations

Confident, active

Patients & carers

Available support

Having a written plan

Regular review

Availability of rescue

meds

competent staff

Access to

appointments / advice

Education

All high risk COPD

Patients to have

plans

Standardise use of

Rescue Meds

Information for patients

& carers on COPD

& managing

breathlessness

Contact numbers for

COPD nurses

16

PDSA

Testing and

refining ideas

Implementing new

procedures & systems

- sustaining change

Bright

idea!

Developing improvement

with PDSAs

17

Bright

idea!

Improvement

Improvement

?

?

Improvement

?

?

?

?

Developing improvement

with PDSAs

Nosocomial Infection Rates

18

Making it happen

• Leadership is not about position or title

• Create the vision, identify the first steps,

make people uncomfortable about doing

nothing

• Perseverance

• Action

• Communication

• Believe you can do it!

19

In summary… • Take a structured approach to messy

problems

• Know what you want to achieve

• Know where you are starting from and

what really happens now

• Prioritise action & take small steps

• Measure impact and review progress

• Communicate learning and success

• Don’t be afraid to have a go

Getting started The secret of getting ahead is getting

started. The secret of getting started is

breaking your complex overwhelming tasks

into small manageable tasks, and then

starting on the first one.

Mark Twain

20

Find out more

Visit the NHS Improvement stand

Information on service improvement techniques,

case studies and using data

Visit our website:

www.improvement.nhs.uk