Embedding a Culture of Continuous Quality Improvement - QI Hub qi... · environment, and further...

Embedding a Culture of Continuous Quality

ImprovementImprovement

27th October 2001

Quality Improvement Hub

• Share progress on development of NHS Scotland's Quality Improvement Hub.

• Opportunity to share your boards approach to the development of local quality

improvement plans – (QUEST funding)

• Hub role in supporting building of capacity and capability in Quality Improvement

– input into the development

Session Aims

– input into the development

• To build a national picture of where boards are in terms of co-ordinating for quality

improvement in their local contexts, and to discuss and generate ideas and agree

next steps.

• Bringing together quality improvement leads from all boards in a key networking

environment, and further develop the community of quality improvement leads

and the directory of quality improvement practitioners.

• To explore how the national Quality Improvement Hub can support boards with

the implementation of the Healthcare Quality Strategy and the NHS Scotland

Productivity and Efficiency Framework.


09:30 Coffee and Registration Jane Murkin

10:00 Welcome, Introduction and Aims Jane Murkin

10:10 Building Capacity and Capability for

Sustainable Quality Improvement – Can we

do it?

Jason Leitch

Agenda

do it?

11:10 NHSScotland’s Quality Improvement Hub Jane Murkin/Shona Cowan

11:30 Break – Tea and Coffee Available

11:45 Local Board’s Approach to Co-ordinating for

Quality Improvement

• NHS Lanarkshire experience

• NHS Tayside’s experience

Pam Milliken

Carrie Marr

12:15 Questions and Discussion

12:45 Lunch


1:30 Group Discussions

Small group discussions around:• Implementation support

• Building capacity and capability

Jane Murkin & Harriet Hunter

Jane Murkin

Agenda Continued

• Building capacity and capability

• Data and measurement for improvement

• Finding and Sharing knowledge

Shona Cowan & Suzanne Graeme

Roger Black & Harriet Hunter

Ann Wales & Annette Thain

3:30 Feedback from discussions

3:45 Next Steps Jane Murkin

4:00 Close

Building Capacity and Capability for Sustainable

Quality Improvement – Can Quality Improvement – Can we do it?

Why is it urgent and why we must work together.

Photos are displayed with the kind permission of Mrs. Clarke and her family

The Healthcare Quality Strategy for Scotland

• Person-Centred - Mutually beneficial partnerships

between patients, their families, and those delivering

healthcare services which respect individual needs and

values, and which demonstrate compassion, continuity, clear

communication, and shared decision making.

• Effective - The most appropriate treatments, interventions, • Effective - The most appropriate treatments, interventions,

support, and services will be provided at the right time to

everyone who will benefit, and wasteful or harmful variation

will be eradicated.

• Safe - There will be no avoidable injury or harm to patients

from healthcare they receive, and an appropriate clean and

safe environment will be provided for the delivery of

healthcare services at all times.

6 Quality Outcomes

1. People have the best start in life and are enabled to live longer healthier lives

2. People are supported to live well at home or in the community

3. Everyone has a positive experience of healthcare

4. All staff feel supported and engaged4. All staff feel supported and engaged

5. Healthcare is safe for every person, every time

6. Best possible use is made of available resources

Presumptions

Expertise

Excellence

Motives

“Conquering the world on horseback is easy: it is dismounting and governing that is hard”

Genghis Khan

Central line infection rate (per thousand line days)

6

8

10

12

March 2011:zero central line infections

in whole country

0

2

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6

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NHS Lothian adverse event rate

Rate of Adverse Events per 1000 patient days(as at August 2011)

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RIE, WGH & SJH Rate of Adverse Events per 1000 patient days(as at August 2011)

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RIE, WGH & SJH Rate of Adverse Events per 1000 patient days(as at August 2011)

52

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RIE, WGH & SJH

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Month of Discharge

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8 data points below current median

= a shift in the data. New process

median provisionally 30 per 1000.

This is a 42% reduction from

30

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This is a 42% reduction from 0

10

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This is a 42% reduction from

30

43% reduction

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

Conclusion: The “Defect Rate” in the technical quality of American health care is

45%approximately 45%

Projected Scottish Government spending

26,000

28,000

30,000

32,000

£ M

illio

ns (

20

10

-11

Pri

ce

s)

2009-10 2025-2616 years

£42 billion

20,000

22,000

24,000

26,000

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

2018

/19

2019

/20

2020

/21

2021

/22

2022

/23

2023

/24

2024

/25

2025

/26

2026

/27

£ M

illio

ns (

20

10

-11

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-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

Improvement work?

The “Quality Curve”Shift and narrow the curve:What is the norm?

2

Cut the tail:What is unacceptable?

Extend the ambition: What is great? (What is possible?)

1 3

What does it mean to Build Capacity & Capability for Quality Improvement?

• Having the word “Quality” appear frequently in your Mission, Values and Philosophy statements?

• Developing a compelling Quality Slogan?

• Assigning someone to be the Director of Quality Improvement?


• Applying for a local or national quality award?

• Being recognized as a top performer in a public database?

• Directing all employees to read Deming’s Out of the Crisis?

• Creating a dashboard of quality and safety measures?

• Attending Learning Session 3?

Key TermsCapacity

• The ability to receive, hold or absorb

• The maximum or optimum amount of production

• The ability to learn or retain information.”

• The power, ability, or possibility of doing something or performing

• A measure of volume; the maximum amount that can be held


Capability• The power or ability to generate an outcome

• The ability to execute a specified course of action

• The sum of expertise and capacity

• Knowledge, skill, ability, or characteristic associated with desirable

performance on a job, such as problem solving, analytical

thinking, or leadership

• Some definitions of capability include motives, beliefs, and values

00.5

11.5

22.5

3

Jan-0

8

May-

08

Sep-0

8

Jan-0

9

May-

09

Sep-0

9

Jan-1

0

May-

10

SPSP c. Diff Rate (c. Diff s per 1000 patient days)

Key Terms: Helen Bevan

Capacity – having the right number and level of people who are actively engaged and able to take action.


Capability – the people have the confidence and the knowledge and skills to lead the change.

Helen Beven, “How can we build skills to transform the healthcare system?”

Journal of Research in Nursing 15(2) 139-148, 2010.

To build a sustainable infrastructure that produces highly reliable QI excellence

by (fill in the date).

The Capacity and Capability Aim


by (fill in the date).

How good? By when?

Capacity Building Issue Current Status Future Priority

C IP NS H M L

1. Evaluating your organization's mission,

vision and values to make sure that they

are consistent with QI principles.

2. Educating the following groups in the

theory and tools of QI:

• The Board

• Senior leaders

• Managers

• Clinicians

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

For each item, you should make two

responses. First, indicate the

Current Status of each item within

your organisation by marking one of

the following responses:

Completed (C)

In Process (IP)

Not Started (NS)

Exercise #1Building Capacity Self-Assessment©


• Clinicians

• Staff

____

____

____

____

____

____

____

____

____

____

____

____

3. Restructuring your performance evaluation

system so that it supports your efforts in

quality improvement.

4. Working with suppliers to establish long-

term partnerships that are based on

collaborative efforts to improve quality.

5. Providing employees with the support and

resources they need to participate in QI teams

and work.

6. Setting up process improvement teams.

7. Creating a process to set priorities for

selecting quality improvement initiatives.

8. Developing performance indicators of

quality improvement initiatives.

9. Preparing communication tools that share

information on quality goals and initiatives

with all stakeholders.

Not Started (NS)

Then, assign what you believe will

be your Priority for each item over

the coming twelve months by

marking one of the following

responses:

High (H)

Moderate (M)

Low Priority (L)

Source: R. Lloyd. Quality Health Care: A Guide to

Developing and Using Indicators. Jones & Bartlett

Publishers, Sudbury, MA, 2004.

A Few Key Questions about Building Capacity and Capability

• Will you involve everyone or just a few targeted groups?

• What is your sequence for development and deployment?

• What methods do you plan to use to build capacity and


• What methods do you plan to use to build capacity and capability?

• Do you have a model or framework to guide your journey?

• How will you make sure all this “sticks?”

Adapted and expanded from a conversation with Tom Nolan, Associates in Process Improvement on material he presented at the IHI Strategic Partners Roundtable, April 17-18, 2006.

Who needs to be developed?

Governance?Executives?Managers?

Supervisors?


Supervisors?Front Line Workers?

Improvement Advisors (IAs)?

Adapted from Tom Nolan, Associates in Process Improvement presented at the IHI Strategic Partners Roundtable, April 17-18, 2006

√

How many quality expertsdo we need?

Two suggestions for determining this number:

Number of employees


√ employees

Or…consider that no employee should be more than 2 steps (individuals)

away from a QI expert.

Two steps from an ‘expert improver”

Which way does (should)capacity and capability building flow?

Top Down?

Macrosystem

Details on the Microsystem can be found in:Quality by Design: A Microsystems Approach.

By E. Nelson, P. Batalden and M. Godfrey. Jossey-Bass, 2007.

© 2010 Institute for Healthcare ImprovementBottom Up?

Spread from the Middle?

Mesosystem

Microsystem

Kaiser Permanente’s System for

Performance Improvement

Alide Chase SVP, Care and Service Quality

Lisa Schilling, RN MPH, VP, Healthcare Performance Improvement

Our system is based on the attributes of high performing organizations

Best quality

KP needs to build capability in these six areas

in order to achieve breakthrough performance

32© Kaiser Permanente 2010 reproduce by permission only

Best serviceMost affordableBest place to

work

Experts Operational

Leaders

ChangeAgents

Everyone

(Staff, Supervisors,

Many People Few People

A key operating assumption of

building capacity is that different groups of people will have different levels of

need for PI knowledge and skill.

Content: What Skills Do We Need?

33© Kaiser Permanente 2010 reproduce by permission only

Experts Leaders (Executives)

(Middle Managers, Stewards,

project leads)

Supervisors,UBT lead

triad)

Continuum of PI Knowledge and Skills

Deep Knowledge

Our approach will be to make sure that each group receives the knowledge and skill sets they need

when they need them and in the

appropriate amounts.

SharedKnowledge

BUILDING IMPROVEMENT CAPABILITYCAPABILITY

Uma Kotagal, MBBS, MSc

Sr. Vice President

Quality And Transformation

Capability vs Capacity

• Improvement Capability – An individual’s knowledge & skill to design improvement

initiatives to achieve measurable results & the ability to execute (i.e. develop, test, measure & implement changes)

improvement efforts & sustain results.improvement efforts & sustain results.

• Improvement Capacity– An organization’s resources which enable it to initiate &

sustain a transformation effort. This includes capable individuals but also structures, processes, infrastructure including quality experts & measurement experts.

Leadership Topics

• Business Case for Quality

• Transformational leadership

• Chronic care improvement

• Managing a portfolio of projects

• Implementation & sustaining

• Patient safety

• Research & improvement

Faculty Development

AimTo provide a pathway for interested faculty to develop knowledge & skills to publish advanced QI studies, engage in QI research & lead organization-wide QI

transformation efforts.transformation efforts.

CCHMC Interventions– Advanced Improvement Methods (AIM)

– Quality Scholars Program

Exercise #2Who needs what? (The Dosing Formula)

This Exercise is designed to create a dialogue on what we call the “dosing

formula.” That is, which groups of individuals within your organization need to have what levels of knowledge and skill to successfully build a sustainable

infrastructure that produces highly reliable QI excellence?

The worksheet on the next page provides a list of Skills & Knowledge (the rows)

associated with organizations that have demonstrated QI excellence. For each of


the listed Skills & Knowledge items indicate the level or “dose” of Skill &

Knowledge you think each group (the columns) needs using the following

response scale:

1 = They need to know the basic terms, concepts and methods when they hear them2 = They need to be able to explain the terms, concepts and methods to others3 = They need to be able to teach the terms, concepts and methods to others4 = They need to be seen as an organizational lead and champion for the terms,

concepts and methods

Exercise #2Who needs what? (The Dosing Formula)

Skills & Knowledge

Non-Execs Execs Senior clinicians

(doctors and nurses)

Middle Management, Directors & Supervisors

Frontline Staff

(clinical and non-clinical)

QI Experts

(IAs)

Models for QI (theory &

concepts)

Leadership for


39

Leadership for

improvement & cultural

transformation

Teamwork and

Facilitation

Gathering information

Analyzing and

interpreting data

Presentation skills

Understanding variation

QI tools and methods

Change management

Patient-centered care

The Primary Drivers of Capacity & Capability Building

Will

Having the Will (desire) to change the current state to one that is better


IdeasExecution

QIDeveloping Ideas

that will contribute to making

processes and outcome better

Having the capacity and capability to

apply CQI theories, tools and

techniques that enable the

Execution of the ideas

Key Components Self-Assessment

• Will (to change)

• Ideas

• Low Medium High

• Low Medium High

How prepared is your organization?


• Execution • Low Medium High

"Quality is never an accident; it is always the result of high

intention, sincere effort, intelligent direction and

skillful execution; it

1941, William A. Foster

skillful execution; it represents the wise choice of

many alternatives.”

"If you have a stable system, then there is no use to specify a goal. You will get whatever the system will deliver. A goal beyond the capability of the system will not be reached."

WE Deming – Out of the Crisis.

Collaborating for Quality

NHS Scotland's Quality Improvement Hub

Jane Murkin & Shona Cowan

Context

CONTEXTNHSSCOTLAND’S IMPROVEMENT JOURNEY

Scottish Patient Safety Programme

18 Weeks ServiceRedesign and Transformation

Mental Health Collaborative

Strategic Lean

Long Term ConditionsCollaborative

Diagnostics Collaborative

Planned Care Improvement Programme

Unscheduled Care Collaborative

Redesign and TransformationProgramme

Primary Care Collaborative

Develop the Quality Improvement

Hub, reflecting a new partnership

for improvement between NHS

National Services Scotland (NSS),

NHS Quality improvement Scotland NHS Quality improvement Scotland

(QIS), NHS Heath Scotland, NHS

National Education for Scotland

(NES), and the Scottish Government

Health Directorates Improvement

and Support Team (IST).

Scottish Government, May 2010

The QI Hub aims to bring improvement science into everyday work and language of NHS staff and to support demonstrable improvement in patient care through quality improvement activity. improvement activity.

Building national and local QI capacity and capability

Building on sound foundations

• Global ‘Improvement Movement’ (SPSP)

• Bringing coherence to implementation and improvement support methodology(Healthcare Improvement Scotland/ Quest)Improvement Scotland/ Quest)

• Drawing on NES’ developing educational infrastructure for QI

• Measurement for Improvement (NSS/ISD)

The NHS Scotland Quality Improvement Hub shaped

and developed by NHS boards:

Providing :

1. Implementation support which is flexible and

responsiveresponsive

2. Education and learning about QI which is

Accessible and relevant

3. Measurement of QI which is meaningful

4. Facilitating QI networks for NHS staff

Making it happen....

• Coordinating centre - Elliott House

• Small core team

• QI Hub website development – virtual

communities

Building a Community of Improvement • Building a Community of Improvement

Practitioners (Directory)

• Planned and ‘bespoke’ programmes at macro,

meso, micro levels 1-5

• Board Exec and Improvement Leads

• Hub and spoke model

Creative Space

• A creative and innovative space that enables users to work in an environment conducive to quality improvement

• The space is flexible, • The space is flexible, adaptable, accessible and supportive to make it easy for people to think differently to identify creative and innovative solutions

Implementation Support which is flexible and responsive:

Local• Each board has an infrastructure • Emerging local hubs

National• Supporting NHS boards with the design, testing and implementation • Proof of concept testing to inform next stage

• Think Glucose – prototyping and testing• Think Glucose – prototyping and testing• Building capacity and capability• Person Centeredness, Patient Safety, Older Peoples, Public Health,

Falls, AHP Directors, Out of Hours, Maternity Services, • Advising and supporting boards in relation to coordinating for QI – QI

Mapping• Brokering improvement and topic expertise support• Brokering of design students

The Improvement Journey

EDUCATION AND LEARNING:

QUALITY IMPROVEMENT EDUCATION FRAMEWORK

• Focus on four key staff groups – Foundation, Practitioner, Lead and Board Members

• Identifies knowledge and skills required to be able to

undertake improvement work and links to KSFundertake improvement work and links to KSF• Designed for use by individuals, organisations and

education providers• Quality Improvement Learner Journey will be key - targeted

learning resources will be mapped, where available, and new learning developed to meet gaps

• Opportunity to integrate improvement learning with existing activity

MEASUREMENT:

BUILDING CAPACITY AND INFRASTRUCTURE

• Building capacity in measurement for improvement in information staff

• Leadership in statistical methodology

• Quality improvement data repository to support national improvement programmes

www.qihub.scot.nhs.uk

Quality Improvement Networks

• Great foundations

• Building a community

• Network : Scotland, UK, International

• Network of networks

• What ideas do you have?

• How can we design and co-create?

Quality Improvement Hub Governance Structure

Quality Alliance Board

Partner organisation

boards

Infrastructure

Delivery Group

Delivery Groups

• Safe

• Person centred

• Effective

Operational

Steering Group

Quality

Improvement Hub

Action Group

Strategic

Partnership Group

Hub Web and ICT

Integration Group

Communication

SubgroupOther Subgroups

Action Groups

• Workforce

• Governance

• eHealth

• Quality

Measurement

Framework

Proposal for the

Strategic Partnership

Group to become the

Quality Improvement

Hub Action Group

Embedding a Culture of Embedding a Culture of Continuous Quality Continuous Quality Continuous Quality Continuous Quality

ImprovementImprovement

October 2011

Why we wanted a ‘hub’

• Fragmented initiatives

• Variety of ‘brands’ and ‘terms’ across the organisation

• Opportunity to improve the organisation-wide approach

• Provide ‘meaningful’ support to delivery of services

• Maximising knowledge and skills

Current Development

• Mapping and reviewing current quality improvement activity across the organisation (quality & efficiency)

• Review education provision in context of Quality Improvement Curriculum Framework

• Develop an NHSL Improvement Community

– Integrated improvement toolkits

– Expert tutorials

– Knowledge Bank

Current Development

• Quality Ambitions supported through our organisational values

• Unearth our organisational culture through the use of Appreciative Inquiry

• Improved data management through the development of Dashboard & LanQIP

Communication

• Web Development of integrated approach to Quality information & resources

– National and Local connectivity

• Ensure single language of improvement – translate terms & simplify for use

• Continue to use stories……positive and negative – all provide valuable learning

• Live, Active, ‘GO TO’ Page on the intranet

Within the ‘Hub’

• Short, focused meetings structured to discuss business and learning experiences

• Active, motivated membership – wide ranging • Active, motivated membership – wide ranging membership

• 1st point of reference for the recent Better Together results

Outcomes, Outputs & Progress

How to measure the impact of the Quality Hub?

Embedding a Culture of Continuous Quality Improvement - QI Hub qi... · environment, and further...

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