Advancing Quality

David Fillingham 7th/8th March 2013

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“Up and down the country there are brilliant examples of pioneering work, great ideas and

fantastic improvements in service. But, so often, these are isolated examples”

Sir David Nicolson, 2011

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How can we get much better at spreading more widely and more rapidly and what works?

• Evidence based care bundles

• Technological innovations

• Innovations in service design

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• A bit about AQuA

• The problem with Sauerkraut

• Lessons from experience (it’s the people, stupid)

• AQuA’s Model for Spread: - Advancing Quality - Discovery Community on Integration

• Some final thoughts and questions

About AQuA

• A membership organisation – funded by 68 CCGs and providers in the North West of England

• Our mission is to support our members to improve the quality of healthcare

• All sectors, commissioners and providers – a whole system approach • Firmly rooted in the North West but beginning to work more widely • Encouraging radical service transformation • Fully aligned with the North West’s two proposed Academic Health

Science Networks

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• Infectious diseases •Hospitals

predominate • Acute intervention • Silo working • Paper based • Doctor knows best

• Chronic diseases • Community based Services • Prevention and self care • Integrated delivery network • Smart use of technology • Shared Decision Making

Industrial Age Medicine

Information Age Healthcare

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And new for 2013/14…

• First Do No Harm… AQuA’s Response to the Francis Report • “Advancing Innovation” – in conjunction with the AHSNs • AQuA Academy support for senior leaders and improvement

experts • A strong focus on the needs of frail older people

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The Sauerkraut Problem

How quickly does innovation spread? – the case of Scurvy amongst Seafarers

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1497 Vasco de Gamas voyage around the Cape of Good Hope – 100 of 160 men lost to scurvy

1601 Captain James Lancaster – controlled ‘trial’ with lemon juice

1747 Dr James Lind – confirms citrus as effective

1768-80 Captain James Cook – Sauerkraut as a cure

1865 British Board of Trade mandates a healthy diet on all marine vessels

Time elapsed from definitive trial to full implementation = 264 years

Some theoretical perspectives…

• Rogers E. – The Diffusion of Innovation, 1995 • IHI White Paper – A framework for Spread , 2006 • USAID Technical Report – Options for large scale spread of simple high impact

interventions, 2010 • Greater Manchester's CLAHRC – Spreading Improvement and Innovation, 2010 • Greenhalgh et al – Diffusion of Innovations in Service Organisations Mill Bank

Quarterly Vol. 82 No. 4, 2004 • Dixon-Woods et al – Quality Improvement Through Clinical Communities, Journal

of Health Organisation and Management, Vol 26, Issue 2, 2012 • Fraser S. – Accelerates the Spread of Good Practice, 2002 • Gladwell M. – The Tipping Point, 2000

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3 interacting factors… • The innovation itself (“stickiness”)

• The characteristics of the innovators

• The organisational context

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Source: Rogers, E.M.

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“Sauerkraut, Sobriety and the Spread of Change”

1. Find sound innovations

2. Find and support innovators

3. Invest in early adopters

4. Make early adopters activity visible

5. Trust and enable re-invention

6. Create slack for change

7. Lead by example

Berwick: Escape Fire

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Lessons From Experience

(It’s the people, stupid)

Fillingham’s Motivational Matrix

Positive

Negative Out

look

on

Life

Disillusioned Sceptic

Enthusiastic Pragmatist

Embittered Cynic

Naïve Idealist

Grip on Reality

High Low

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Converting the Sceptics

• Tackle stress and burnout – develop resilience • Make it specific to ‘my’ service • Use rigorous improvement methods • Robust and convincing data • Hands on experience • Reinforce through changed management system and

leadership style

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AQuA’s Model of Spread

Change Champions and Communities of

Practice

Evidence and Intelligence

Peer to Peer Learning

Robust Improvement Methods

Incentives

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Advancing Quality - AQ

• Programme established in 2007

• Adapted from Premier’s HQID programme in the US

• Now the dominant Regional CQUINS in the North West

• Has significantly improved reliability of evidence based processes leading to improved outcomes and productivity

Acute myocardial infarction (AMI)

1. Aspirin at arrival 2. Aspirin prescribed at discharge 3. ACE or ARB for LVSD 4. Smoking cessation advice/counseling 5. Beta blocker at arrival 6. Beta blocker prescribed at discharge 7. Thrombolytic received within 30 minutes of

hospital arrival 8. PCI received within 90 minutes of hospital

arrival

Hip and knee replacement

1. Prophylactic antibiotic received within one hour prior to surgical incision

2. Prophylactic antibiotic selection for surgical patients

3. Prophylactic antibiotics discontinued within 24 hours after surgery end time

4. Recommended Venous Thromboembolism prophylaxis ordered

5. Appropriate Venous Thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

Community-acquired pneumonia (CAP) 1. Oxygenation assessment within 24 hours

prior to or after hospital arrival 2. Initial antibiotic selection 3. Blood culture collected prior to first

antibiotic administration 4. Antibiotic timing, first dose of antibiotics

within six hours after hospital arrival 5. Smoking cessation advice/counseling

Coronary artery bypass graft (CABG)

1. Aspirin prescribed at discharge 2. Prophylactic antibiotic received within one

hour prior to surgical incision 3. Prophylactic antibiotic selection for surgical

patients 4. Prophylactic antibiotics discontinued within

48 hours after surgery end time Heart failure (HF)

1. Left Ventricular Systolic (LVS) assessment 2. Detailed discharge instructions 3. ACEI or ARB for LVSD 4. Smoking cessation advice/counseling

Evidence Based Measures

• Need robust data – to identify opportunities to improve – to benchmark

• Rules based / algorithmic approach – Identifying patient cohorts – every patient – Data dictionary & reasons for exclusion from a

measure

• Web based measure data collection – Utilise existing data where available

Patient 1 Patient 2 Patient 3 Overall Trust Scores

Measure 1 2 of 3 = 66.6% Measure 2 3 of 3 = 100% Measure 3 1 of 3 = 33.3% Measure 4 3 of 3 = 100% Measure 5 3 of 3 = 100% Opportunities taken

4 of 5 5 of 5 3 of 5 12 of 15

Composite Process Score

80% 100% 60% 80%

Patient Appropriate Care (all or nothing)

0 of 1 1 of 1 0 of 1 1 of 3

Appropriate Care Score

33.3%

Robust data collection

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A culture of change & collaboration • Regular collaborative learning events • Involvement from all provider & commissioner

organisations • Created networks of clinical and non clinical

communities • A willingness to share and learn

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Incentives

• Additional financial rewards – first 18 months – top performers / top improvers

• Absorbed into CQUIN – regional scheme (0.01%)

• Benchmarking and friendly competition

• Public reporting www.advancingqualitynw.nhs.uk

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Rapid improvement, sustained

Steady improvement, sustained

Raised the bar with a new measure!

Marathon not a sprint!

New condition

Reducing variation

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http://www.nhsidentity.nhs.uk/content/cmsimages/b/b23-nhs-blue-logo-lrg-1067.jpg

Outcomes & cost effectiveness

• Overall (3 conditions) statistically significant reductions in mortality & LoS

• NW mortality gain greater than rest of England – >1% point reduction in mortality rate (>5% relative

rate) = c890 deaths averted.

• >20,000 hospital days saved (~£5m)

• >6000 QALYs gained as result of mortality reductions – based on healthy life expectancy of people in general population of

same age as the patient population. – Health gain of c£120m (£20k threshold, c£180m @ £30k) – 10 times more cost effective than break-even point

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AQuA Discovery Community on Integration • We don’t have one accepted “right” model we can copy

• We don’t even have a single definition of integration

• The aim is to: - Steal with pride from elsewhere (creatively adapting) - Stimulate invention - Accelerate progress by mutual sharing and learning

• 8 Health Economies in cohort 1; 11 more in cohort 2

Discovery Community Model

Your

Learning

Learning from each other

Emerging national policy context

National and international case

studies

Faculty input

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The Framework

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Integration to Improve • Safety • Effectiveness • Population health • Use of resources

Service Design

Governance

Patient and Carer

Engagement

Leadership

Workforce

• Role design • Skills • Capacity

Infrastructure and IT

Financial and Contractual mechanisms

Culture

Healthcare value

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Richard Gleave

AQuA’s Model of Spread

Change Champions and Communities of

Practice

Evidence and Intelligence

Peer to Peer Learning

Robust Improvement Methods

Incentives

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AWR “Accelerated Wheel Reinvention”

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A new ‘Context’ for Improvement and Spread

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Some Final Thoughts and Questions…

• What are the most important priorities for spread? • Do we have enough “enthusiastic pragmatists”? • Is it “hit and hope” or do we have an aligned, systematic

approach? • How can we use the new improvement “context” to our

advantage? • How we can counter pessimism and setbacks with resilience,

energy and hope?