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Highland NHS Board 29 November 2016

Item 3.4 HIGHLAND QUALITY APPROACH Report by Cameron Stark, Consultant in Public Health Medicine (Health Services), Gavin Hookway, Senior Quality Improvement Lean (Lean), Pam Cremin, Head of Workforce Planning and Development and Staff Experience, Emma Watson, Director of Medical Education, Maryanne Gillies, Senior Quality Improvement Lead (Patient Safety) and Anne Gent, Director of Human Resources The Board is asked to: • Note and discuss the update report on the Highland Quality Approach (HQA) • Review the feedback from Virginia Mason Institute (VMI) Sensei Visit – Appendix I

1 Background and Summary This Report provides an update to the Board on the work that has been progressed in relation to the utilisation of the HQA as an Improvement Methodology and as a Management System. In relation to the Lean Methodology this Report covers developments in Training, Coaching, Rapid Process Improvement Workshop (RPIWs) and the High Level Value Streams. This Report also provides an update on Staff Engagement through the development of the Physician’s Compact and the Institute of Healthcare Improvement Work-stream on ‘Joy in Work’. An update on the Scottish Patient Safety Programme (SPSP) is also provided. In addition feedback from the recent VMI Sensei Visit is included. 2 Update Report Lean Methodology 2.1 The Highland Quality Approach as a Management System The Highland Quality Approach is the method NHS Highland applies to managing and improving its services.

• NHS Highland identifies improvement priorities, based on an explicit review of current state and likely future developments.

• Priorities are reviewed annually, and altered as required by changing circumstance. • Operational Units and Corporate Teams identify aligned work and develop work plans

to help deliver the required objectives. • Where necessary, cross-functional teams are created, to allow services to be

improved across an entire patient journey, or in multiple areas. Patient Safety work is an example, as is current work on Outpatient Services, and Adult Social Care Services.

• Better visibility of process is used to assist services in monitoring their day to day service delivery.

• Daily or shift-based meetings – known as ‘huddles’ – are undertaken to review progress and to identify any problems.

• Where problems are identified in the course of day to day work, staff are encouraged to take the time to identify the root cause, and to trial ways of making improvements, using improvement cycles.

• Where there is existing evidence of best practice, as in some areas of patient safety, this evidence is used to support the work.

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• Managers coach staff in their use of the approach, and in how to keep a feeling of urgency in the system.

2.2 Role of and Expectations of the Kaizen Promotion Office (KPO) Many people are involved in improvement work in NHS Highland. The Kaizen Promotion Office (KPO) is a 3.8 WTE team that supports the application of the HQA methods, described above, in services, and in the management approach to improvement. There are several approaches to quality improvement. In industry, it is common to have a specialist central team that undertake improvement work. This can make sense in highly technical industries where engineering expertise may be essential. In health and social care, expertise on processes is widely distributed, and patient and service user experience of service use is essential in making improvements. The HQA assumes that the people who deliver services, and the people who use services, are usually best placed to identify problems, and to identify and trial solutions in real time to improve their services. The purpose of the supporting functions is to make it easier for services to do this. Balancing this intent, health and social care services do not have a widespread tradition of root cause identification, and structured use of improvement methods. NHS Highland needs, therefore, to both support the expansion of knowledge on these methods, and to have a way of providing technical support when required. The KPO has been created to deliver these functions. The KPO will:

• Produce and maintain training materials and tools that support the application of the HQA

• Organise and deliver the courses to train people to lead Rapid Process Improvement Workshops, and ensure that coaching is available for this group

• Produce and maintain the materials for other levels of training, including delivering at least fifty places on the Intermediate Lean Training course per year

• Coach and support managers on the method as capacity permits, with a focus on people working in the areas of organisational priority – for example on the High Level Value Streams

• Lead improvement events in the priority areas when urgency dictates • Provide the office functions to support the delivery of training, and the arrangement of

improvement workshops The corollary of these functions is that the entire organisation is responsible for the delivery of improvement. In line with this, the Chief Executive has changed the structure of the weekly accountability meeting or ‘Wall Walk’ with the Senior Leadership Team. Initially, a KPO staff member presented the improvement work. As the services are responsible for improvements in their own area, the relevant Sponsor or operational manager now describes progress on improvements in their area. Similarly, it was the responsibility of the KPO to obtain progress reports from areas which had undertaken Rapid Process Improvement Workshops. This is now the responsibility of the service manager, and the KPO notifies the relevant senior manager if the report is overdue, to facilitate follow-up within the service. 2.3 Role of and Expectations of Operational Units Some NHS functions are intended to produce wider change, such as Health Improvement or some other aspects of Public Health which seek to influence policy and service deliver in other organisations, or in a community group. Other than this type of function, the main role of the NHS is to provide appropriate health and social care services.

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It follows that the main role of corporate services, outside of some wider Public Health functions, is to support service delivery. Services have two functions – to deliver services, and to improve the services they deliver. Pressures within services make it easy to lose focus on improvements in the day to day efforts to deliver services and to meet targets. Balancing this, are the persistent NHS findings that it is very difficult to impose change on people, and that centrally identified improvements do not always deliver as expected, even when they can be pushed through. The HQA tries to square this circle by encouraging staff to work with their service users to identify improvements in their own services, and to approach them in a structured way using methods from the HQA, including improvement cycles and measurement of change. Similarly, for bigger scale change, services are asked to use their own experience and knowledge to decide the best way of meeting challenges within available resource, rather than having a solution imposed upon them. Training

• To identify staff who they wish to attend one of the training courses • To ensure that this is reflected in Personal Development Plans and annual

assessments, and that staff who are required to complete training, do so • To deliver other Intermediate Level Training as required, using their staff who have

been trained to lead events, applying the same standards and requirements Application

• To ensure that their trained staff then apply the methods in practice. • Use the management approaches of standard work, huddles, visual management

and accountability to maintain current performance, and to manage incremental improvement.

• For priority areas, identify actions to produce change, including creating cross-functional teams where required.

• Identify areas which require Rapid Process Improvement Workshops. If the service undertakes these workshops internally, to use accredited Leaders and to follow the standard process including informing the KPO and scheduling report outs.

• To provide appropriate management support to areas that undertake improvement work, including ensuring that follow up takes place and that update reports are produced as part of the process.

2.4 Certified Lean Leader Training NHS Highland has continued work on improving quality improvement capacity. We now have 25 people trained to run improvement events, and another 17 in training, aiming for a total of 50 Certified Lean Leaders across the NHS Highland area with senior leadership responsibilities. A further cohort of 15 people will be trained in November. All the classroom training is now delivered by NHS Highland staff and we will be using our own materials from April onwards. 2.5 Intermediate Lean Leader Training In support of HQA, there is a well developed programme of Certified Lean Leader training, aimed at people who will lead Rapid Process Improvement Workshops (RPIWs). This training is now provided in-house, led by the Kaizen Promotion Office (KPO), using our own NHS Highland Certified Lean Leader Training materials and Handbook.

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Experience from RPIWs and their follow up indicates that people working in middle level management posts sometimes found the context of improvement work, and the follow up, to be unclear. There was a lack of Leader Standard Work and Daily Management being applied to support continuous quality improvement as a result of RPIWs undertaken in manager’s operational areas or in other quality improvement projects. In order to address this, a new training course - Intermediate Lean Training (ILT) has been developed. This course is aimed at middle management on Agenda for Change Band 7 and above who have people management roles – charge nurses; operational unit managers; nurse managers; lead AHPs and Healthcare Scientists etc. The course is delivered in four sessions of 2.5 hours (10 hours of face to face teaching), followed by a Report Out on an improvement project related to the participants area of service delivery. A standard set of teaching materials has been developed. Three cohorts have been delivered to 41 people so far this year. Twenty seven people have successfully completed ILT including the Report Out. Fourteen people have completed some or all of the training and are still completing their projects to Report Out. Seven are currently in training and due to complete in December 2016. Feedback from the courses has been very positive, and participants have undertaken excellent improvement work. Not all participants have completed improvement projects, however, and services are encouraging relevant staff to complete their work. From January 2017, the KPO will plan training dates and venues for a core of Intermediate Training. At least one KPO staff member will lead each course, working with other accredited leaders. The KPO will deliver at least four courses per calendar year, targeted at people in key work streams – particularly prioritised to support propriety areas and the High Level Value Streams. As noted above, services will be free to use their trained Leaders to deliver further courses if they wish, using the standard materials. 2.6 Awareness Raising/Induction A Learn Pro module is being developed for new staff, which will provide a brief introduction to the Highland Quality Approach. Operational Units will be free to use their trained Leaders to provide additional face to face sessions for new staff. 2.7 Coaching We have two Certified Coaches, one who is a Certified Lean Leader and part of the Kaizen Promotion Office (KPO) and one who is a member of the Senior Leadership Team. We plan to increase this to at least five coaches over the next year and a number of Trainee Coaches should soon become certified. Additional Coaches will need to be Certified Lean Leaders and provide Coaching service alongside their organisational role. We estimate that, in the medium term, six coaches should be a sufficient number for our internal needs. 2.8 Outcome from Improvement Events We have held 62 Rapid Process Improvement Workshops (RPIWs) which continue to show positive results. Over 70% of the items measured in events show improvement in the follow up period. Improvement Events are being focussed on the High Level Value Streams and other organisational priorities and progress can be seen on the ‘Accountability Wall’. Non Executive Directors are being encouraged to participate in at least one RPIW if possible. Improvement Events often identify ways of freeing up capacity. Management decisions need to be made about how best use any additional capacity.

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2.9 Friday Report Outs The Friday report outs continue to be well attended, although this varies depending on topic. They are a valuable opportunity for staff to hear about improvement work outside their service or geographical area, and to make new contacts. We have not yet created an organisational expectation that all managers who are available will attend or dial in to Report Outs. We propose to work with operational managers on this over the next three months. Report Outs allow fifteen minutes for update reports, compared to the five minute slots offered at Virginia Mason. This often results in repetition of material from previous report outs, rather than an exclusive focus on new developments, progress and barriers. At the same time, the staff completing the Intermediate Training have no direct route to report their work to the whole organisation; this is a loss, as some projects have included transferable ideas that could be used more widely. It also loses some of the message that staff with limited experience can produce very valuable improvements by applying the methods as part of their day to day work. It also tends to keep a focus on improvement events, rather than continuous improvement. We therefore propose to reduce the time for update report outs to five minutes, for presentation, focusing on the Project Form and the Target Progress Report, and five minutes for discussion. This will then allow time for people to have a ten minute slot to present the work from their Intermediate Course projects. We will keep the times under review. Rather than add to the work of the KPO, we propose to produce a ‘pull’ system. So, for update reports, the Process Owner (the person who follows up the work from an improvement event), knows the date the update is due. They will be asked to send it to their Sponsor (normally a Director) and Operational Unit Manager, and to copy it to the KPO for information. If the KPO receives a copy, they will schedule a slot for the Report Out at the Friday session, so that the report ‘pulls’ the slot. If a copy is not received, the KPO will notify the Sponsor and Operational Unit Manager, and note the overdue nature of the report on the Accountability Wall. There is no judgement in this: there may be perfectly good reasons for the report to be overdue, but that is for the Sponsor and relevant manager to ascertain. The report will continue to show as overdue until the report is received. A similar process will be used for the Intermediate Training projects, with people attending the course asked to book a slot at the Report Out when they are ready to present, and within eight weeks of taught course completion. If this is not received, then the relevant Operational Unit manager will be informed and the information added to a regular update to managers. 2.10 Accountability Wall Walk As noted above, the Accountability Wall Walk has altered over time. The purpose of the ‘Wall Walk’ is to bring together work on improvement – RPIWs and Patient Safety – with performance data every week. Initially reports on improvement work were provided by the KPO, and by the Scottish Patient Safety Team. This has gradually changed, so that improvement work is now reported by the relevant sponsor or service manager. 2.11 Increased Focus and Pace – High Level Value Streams We are working to increase the impact of improvement work by focusing work in 2016/17 on two main areas of work – Outpatient Services and Flow in Adult Health and Social Care Services. Several of the RPIW events in the present year are on these topics, but this will increase to a majority in 2017. The work on these areas is aligned with NHS Highland’s vision and mission statement, and the process is intended to produce better alignment between high level organisational priorities, and improvement work. The expectation is that focusing work on a smaller number of areas will produce greater linked improvements in

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areas that are of particular importance in delivering NHS Highland’s organisational objectives. 3. Staff Engagement and the Highland Quality Approach. A number of work -streams embrace the importance of Staff Engagement in the Highland Quality Approach. 3.1 Physicians Compact NHS Highland Shared Values & Behaviours – Physician Compact The development of a Physicians Compact was commissioned by NHS Highland to improve relationships by exploring shared values and behaviours, engage with medical staff and align with the Highland Quality Approach. A small project team was established to take this forward with the aim of uncovering the current compact and agreeing a compact that will become embedded within organisational ways of working including the recruitment and selection process. To date we have held a large number of workshops with colleagues and an offsite event to discuss the compact and we have heard significant, similar themes emerging from these. There is a need to continue with these workshops to engage with teams that we have not yet met. There is also a need to start addressing the emerging themes as an organisation. We have a draft compact which we have been using with more recent workshops and we will continue to refine this as we progress. A further coaching session in October with Diane Miller from VMI has refocused our approach and the need to strengthen the guiding team. Developing a compact is a demanding process that requires a strong constant message. If, as an organisation we want to be able to implement the results of this process and support our staff and ourselves to change we need to increase communication organisationally about the compact. 3.2 Talent Development – Talent Management and Succession Planning in NHS Highland Further to the presentation given by Kathy Shingleton, Vice President of Human Resources from Virginia Mason Medical Centre on 3rd May, the subsequent Session facilitated by Diane Miller, from VMI on 4th May, 2016 and the Session facilitated by Diane Miller on 6th October, this section outlines how we might develop and manage talent in NHS Highland and how we might develop an approach to succession planning. Talent Management: aligns people capabilities with organisational needs. Succession Planning: identifies individuals with the potential to fill roles. Background Our People Strategy is that ‘We attract and develop the best teams’, and our Annual People Objective is ‘To attract staff and improve our staff experience working for NHS Highland’. Leadership and Culture are key components of the Highland Quality Approach (HQA) and as such leadership talent is an essential organisational asset in organisational transformation and in taking the HQA Agenda forward. This requires clarity of expectations, responsibility and accountability, a culture of feedback, transparency and trust. Leadership is essential in both running our business and improving our business and securing our future sustainability.

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Developing a more explicit approach to Talent Development can;

• Improve overall talent • Aid the Recruitment Process • Identify Talent • Maximise Talent Development • Create a more flexible workforce • Help prioritise the use of development opportunities • Create a Team approach to Talent Review

NHS Highland Vision for Talent Development: ‘Our people matter – we want to attract and develop the best individuals who are excited to deliver, better health, better care and better value for the people of the Highlands, as part of great Teams’. In implementing our vision we want to change the focus from Training and attending courses to experience based development in existing or new role/assignment and relationship based development – role modelling and coaching. Guiding Principles for Talent Development The following principles have been development for Talent Development

• Mutual trust and respect • Evidence based approach • Team approach to Review • Fair and transparent standard process • Talent owned by the whole of the organisation • Executive Leadership is accountable for developing talent • Potentially replicable at all levels of the organisation

Talent Development – Key Actions

1. Agree desired Leadership Qualities Framework 2. Confirm the first Cohort of Leaders to be included in the Talent Review Process and

Talent Development – as those reporting to members of the Senior Leadership Team 3. Create Standard Documentation to support the Talent Development Process – now

completed 4. Further test out the Talent Development Review Process, following a first successful

Review Session 3.3 ‘Joy in Work’ NHS Highland is participating in the Institute of Healthcare Improvement (IHI) ‘Joy in Work’ Prototype testing as part of the NHS Scotland iMatter Team. The Programme comprises of 8 two weekly WebEx sessions of teaching and interaction. Each organisation has to select a small team to apply small tests of change that demonstrate Joy in Work. The Employment Services Team at John Dewar Building is the local team who are testing out ideas, based on a self assessment of current status – Organisation: what do Leaders do? and the Employment Services Team: What do Core Leaders at the Point of Service do? This self assessment of current status has been drafted as a baseline.

Associated actions are then taken forward using Plan-Do-Study-Act approach to test ideas of change and promote staff experience, staff engagement, and address areas of health and wellbeing and resilience in the team.

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These actions are underpinned by the Staff Governance Standard and Everyone Matters 2020 Workforce Vision (our overall approach as a Board is outlined in our Everyone Matters (People) Plan – Creating healthy organisation culture; sustainable workforce; capable workforce; workforce for integrated services and leadership and management development. The Employment Services Team are testing out cycles of change based on the development of their iMatter Action Plan; HQA Team Board; Joy in Work Board; as well as developing a Team Mission and Values and identifying impediments to joy in work. The Employment Services Team are well placed to contribute and demonstrate this work following their participation in 2 RPIWs to improve the Recruitment Process and the engagement of the team and the wider organisation in testing improvement ideas and implementing these. 3.4 HQA Team Boards Work is being taken forward by the Highland Partnership Forum (HPF) to support the development of HQA Team Boards in each department in the Operational Units. Alongside process boards, status boards and various visual controls, such as run charts, that illustrate quality improvement and SPSP position, for health and social care delivery and corporate service supporting functions, HQA Team Boards are designed to show staff information such as iMatter staff engagement, PDP&R status, statutory and mandatory training status and staff health and wellbeing aspects. Essentially, HQA Team Boards are being developed alongside operational processes to illustrate the association between quality outcomes in patient and care experience and improving staff experience. Standard work has been drafted by the HPF so that the HQA Team Boards show the connection – the golden thread between individual and team objectives and NHS Highland Operational Plans and Annual Objectives in particular demonstrate how staff are contributing towards the three People Objectives. The HQA Team Boards are visual and also provide an opportunity for staff to generate everyday lean ideas and celebrate successes. Key to this approach is encouraging staff to incorporate HQA Team Board elements with Daily Huddles that support safe staffing levels, focuses on learning and development needs and underpins staff experience, resilience and well-being – ultimately promoting ‘Joy in Work’ and living our values. 3.5 HQA Awards The HQA Awards are shortly to be re-launched. A review has been undertaken to create a number of ways to make a nomination. Nominations will now be forwarded to the KPO Team who would consider applications, agree if they were above the line and forward those that were to the Judging Panel for consideration. Once a decision was made nominees would be advised and successful staff informed. Certification would be issued to all staff ‘above the line’. Monthly award winners would receive their award in one of 3 categories – People, Quality or Care. Friday Report Outs would be used to give out the awards as appropriate. In addition there would be a once a year – Top HQA Award, in each category.

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4. Lean Accounting and IHI’s Involvement The Board is currently undertaking a ‘proof of concept’ exercise relating to Lean Accounting. Lean Accounting is a methodology that can be used to support continuous value management (i.e. to continuously improve value by reducing cost and increasing quality). Lean Accounting uses a simple balanced scorecard known as a ‘box score’ that includes performance measures, capacity measures and financial measures. The crucial difference with traditional methods is that these measures are reviewed by a multi-disciplinary team all at the same time (e.g. rather than budget statements being reviewed in isolation from quality and safety indicators such as numbers of falls) and in a much more timely manner than most traditional reporting cycles. The trial aims to produce information on a weekly rather than a monthly basis. The proof of concept is being tested on Ward 7A, Raigmore Hospital – primarily because there was good ‘baseline’ information available as a result of a successful RPIW in 2015 and there is enthusiasm for the trial amongst the stakeholders. The project is being supported by IHI. 5. Learning from VMI Sensei Events – Culture Transformation Continuum Diane Miller from VIM visited NHS Highland 4th – 6th October 2016. Overall Diane was positive about our progress (see Appendix I) and supportively challenged us to move to the next phase of our development and the reflections below summarise how we might start to take these next steps. In the main these next steps reflect the ‘Progressing’ stage of the VMMC Executive Transformation Continuum – see Appendix II and many of them have already been implemented. In summary our interpretation of the advice we received on next steps is as follows; Our Management System We need to clarify what our Management method/system is, both to run the business – Leaders Standard Work, Daily Management, (Production Boards, Huddles etc) and to improve the business through Everyday Lean Ideas, continuous improvement and through Improvement Events. Our Management method/system could be the HQA, or the Highland Quality Production or Delivery System. Once we have agreed on our Management method/system, we should talk about our management method/system as a whole, not Lean, SPSP, iMatter etc as separate methodologies. Urgency Our reason to change needs to be understood and communicated right through the organisation. We need to engender a real sense of urgency and pace, into our work, (although it was acknowledged that this is challenging in healthcare) and make sure our resources are prioritised accordingly; this includes ourselves, Senior Operational Managers and the KPO. We also need to accelerate share and spread. Leadership Leaders need to develop Leaders Standard work, lead by being visible on the gemba, by teaching and coaching, developing people and talent and asking the right questions. Leaders need to focus on being Leaders, not just functional or operational managers, demonstrating accountability, and respect for people, discipline and rigour. The Senior Leadership Team would benefit from a further session on Leader Standard Work and Daily Management.

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Talent Development and succession planning is the responsibility of leaders. A standard process needs to be developed to facilitate Talent Management Reviews, to be led by the Chief Executive. The Guiding Team needs to meet more frequently - we may need to review the HQA Leadership Group to accommodate this and oversee the High Level Value Streams. The ‘Catchball Process’ should start off with measuring current state and goals for improvement that can then be re-measured. Role of the KPO We need to use the KPO to increase capability and capacity. KPO activity, other than training and coaching should be focused on organisational priorities. The KPO should have its own High Level Value Stream and work to improve its processes devolving more to the operational line. Operational Units are still relying on the KPO to organise and monitor Improvement Events, Report Outs and provide information for Accountability Walls. We should have clear expectations of our Certified Lean Leaders (CLL) and our Intermediate Lean Leaders (ILL), with Line Managers making sure that expectations are being met, rather than through the KPO. Line Managers now need to take more responsibility for working on their own Value Streams and improving them through their own Kaizen Plans. Accountability Wall The ‘Wall Walk’ should be lead by Sponsors or Process Owners of RPIW's not the KPO. The Wall Walk Leaders and SLT should challenge progress and help overcome blocks to progress. We need to link our current state performance to our improvement work more clearly. We would benefit from assessing the value added by the production of information, especially performance information and how we can prioritise what we need. High Level Value Streams High Level Value Streams are just like any other Value Stream, but wider. They should be improved by using the method - understanding the current state - from data and observations, creating a future state, setting targets, eliminating waste and defects and improving flow. We need to put more resource around the High Level Value Streams and consider parallel, rather than sequential, work. The High Level Value Streams can benefit from more of a Project Management approach using the A3 Project Forms. Engaging Our Staff and Teamwork Our management method should be predicated on the value of engaging staff, through Daily Management Standard Work - Huddles, Productions Boards, Everyday Lean Ideas and Improvement Events. The work on the Physicians Compact needs to continue, with stronger buy in from Medical Leaders and by developing champions who can influence peers positively. Delivering on improving value streams and Daily Management requires great team work.

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6 Scottish Patient Safety Programme High level aim of the Scottish Patient Safety Acute Adult Programme is:

• 10% reduction in HSMR by end December 2018

Further aims are:

• High reliability and 100% spread of all 10 patient safety essentials within 4 acute hospitals.

• Implementation of the 9 point of care priorities: Falls, Catheter Associated Urinary Tract Infection, VTE, Surgical Site Infection, Sepsis, Medicines Management, Deteriorating Patient, Pressure Ulcers and Heart Failure

10 Patient Safety Essentials Data below demonstrated using horizon plots. All areas shaded in red/pink require further improvement effort to achieve 95% or > reliability. The focus and accountability for achievement is in the process of transition to operational management for ongoing improvements.

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9 Point of Care Priorities

• 25% reduction in all falls and 20% reduction in falls with harm There is funded dedicated improvement support to reduce falls across NHS Highland. There has been extensive improvement effort in a number of pilot wards which had the highest falls counts. This has had significant impact on falls reduction as detailed below – reducing this harm for patients in our care.

• 30 % reduction in Catheter Associated Urinary Tract Infections(CAUTI) There has been funded dedicated improvement support to reduce CAUTI across the 4 acute hospitals. There has been extensive improvement effort, initially in the pilot ward and now with full scale implementation of CAUTI prevention, insertion and maintenance bundles. This has had significant impact reducing this severe infection and harm for patients in our care.

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• Less than 10% colo-rectal surgical site infection

The colo-rectal team have applied improvement methodology across 3 separate surgical site infection prevention bundles to achieve improved outcomes for patients, as demonstrated in the superficial surgical site infection chart below. Further improvement effort is required to continue with improvements in deep infections and the safety improvement team have re-aligned support to this work. There is a fully engaged Multi-disciplinary team supporting these improvements.

• 95% or > reliable implementation of Sepsis 6 There is senior clinical engagement with this work stream but they have not benefited from dedicated improvement support. Process data remains variable and further improvement support is required. There is a new definition of sepsis with a national recommendation to move from SIRS to NEWS to identify the septic patient. A senior leadership team, to include the sepsis in primary care pilot have met and drafted a new version of the sepsis protocol for early testing in pilot areas and test where applicable across the transitions of care.

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SEPSIS 6 compliance: demonstrating variability

• 95% or > reliability with VTE assessment protocol There have been challenges providing adequate improvement support to this work stream over past 18 months. Data from surgical ward demonstrating high reliability and the medical wards would benefit from further improvements. The team are keen to test patient self administration with some demonstrable success at Belford hospital, the re-assessment process and the reliable provision of patient information.

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• Deteriorating Patient work stream • 50% reduction in cardiac arrests • 95% or deteriorating patients will have a Scottish Structured Response (SSR) and a

structured clinical review. This has been tested with Medical Emergency Team (MET) who now demonstrating high reliability of the SSR (note data below). A version of a Structured Review is being testing in a number of pilot wards and spread to Belford hospital.

Challenges The core SPSP team have limited capacity to support all the work streams to achieve aims. There are challenges to provide any improvement support to the Medicines Management and the Heart Failure workstreams. The operational units lead on Pressure Ulcer reduction. The demand for QI support is currently under review as part of our local HSMR driver diagram to build local capacity and capability in improvement science. Appendix III. 7. Governance Implications Staff Governance – embedding more effective methodology around staff experience is directly contributing to adherence to all the strands of the Staff Governance Standard. RPIWs, SPSP and the Physician’s Compact are a very effective way of engaging staff and empowering them to make change. Clinical Governance – Having an increase in quality of staff experience is directly contributing to patient experience which is in keeping with the Highland Quality Approach to deliver high quality, safe and effective health care services. Financial Impact – Funding to support the quality improvement infrastructure has been secured through Quality and Efficiency Support Team (QuEST). However there is an expectation that there will be additional resources freed up as part of the return on the investment going forward. 8. Planning for Fairness This is a progress report and as such does not require an impact assessment. Individual elements of improvement work should be subject to appropriate impact assessments.

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9. Engagement and Communication Developing and embedding the Highland Quality Approach requires a significant engagement and communication effort at all levels. By far the greatest challenge is to influence hearts and minds, to get more people trained in quality improvement, delivering quality improvement and demonstrating behaviours consistent with our values. Involvement in training, development of physician’s compact, active participation in RPIWs, Kaizen Events and SPSP Leadership Walkrounds, attending conference and hosting study tours will all help to make a significant contribution. Through corporate communications work is ongoing to promote HQA by looking to increase Brand Awareness (The HQA triangle). Anne Gent Director of Human Resources

Cameron Stark Consultant in Public Health Medicine (Health Services)

Pam Cremin Head of Workforce Planning and Development and Staff Experience

Maryanne Gillies Senior Quality Improvement Lead (Patient Safety)

Gavin Hookway Senior Quality Improvement Lean (Lean)

Emma Watson Director of Medical Education

November 2016

©2016 Virginia Mason Institute

October 28, 2016

To: Elaine Meade

From: Diane Miller

Executive Director

RE: Recent Visit

Please extend my thanks to your entire leadership team for another great visit. It has been a privilege to support you and your team on your journey creating the Highland Quality Approach. While it can be challenging to stay the course while leading culture change, I can see real progress toward your vision and goals during each visit.

We initially introduced everyone to our conceptual model for transformation based on the Virginia Mason experience. This follow up letter is to share with you my thoughts on your progress.

Aligning the vision with the work throughout the organization. Your strategic plan is clearly visible throughout the organization and well understood by the entire executive team. I hear it referenced as you work through any number of issues. I can see this clear statement of what you want to accomplish is supporting your work. I encourage you to continue to connect this vision through the entire organization. Imbedding the connections through standard practices. Dr. Kaplan often says, this is the single most important work we did 16 years ago to support our transformation

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The engagement of the executive leaders, clinical and non-clinical is also an essential element and without full engagement no lasting change will occur. Over these two years the engagement of the senior leaders has significantly improved as they see their roles in leading and sponsoring change. I’ve seen this through the stand-up huddles at the accountability wall, the sponsor meetings to review progress of improvement and best practice of actually leading improvement events. Each of these activities will continue to allow you to reflect on what’s working and what needs modification for continued progress toward the vision and goals. Continue as a senior team to provide time and attention to these important sponsoring activities

APPENDIX I

©2016 Virginia Mason Institute

and create standard work around intentional genba walks routinely to signal the importance and pace for progress.

Building capability of the entire leadership team through certification, lean for leaders training and daily management is well underway and supportive of shifting the organization from discrete improvement activities using lean tools to leading through the use of these methods in daily work. It is through this daily use of the management methods that will truly propel you forward in continuous improvement. Sustainability of change is only achieved as the front line staff use data and improvement methods locally and own the changes. My recent genba walk demonstrated to me you’ve got a great start of that local ownership and now you must accelerate the spread of these competencies throughout the organization. This is not an easy task and will require the KPO and the executive team to coach and support the learning along the way. The KPO should be capturing what’s working well for your organization and creating your leader standard work expectations based on the learning.

Establishing shared expectations of leaders is also a critical element of culture transformation. You now recognize the importance of articulating your talent management and succession planning philosophy. Shared expectations within Highland is also articulated through the physician compact. I’m impressed with this work to date and know this work, while challenging at times, will support your vision in ways not yet realized. The physicians leading this work have the right approach but need your visible support to continue to keep this work progressing. It is not just the document and process of engaging everyone in the work but also as it is fully implemented and used in the coming years that will make the difference.

Applying the method has been well imbedded at Highland for some years primarily as point improvements. Now is the time to dedicate your improvement activities around those areas most important to the organization. KPO must support teaching and coaching in the management method but more importantly at this time they are needed to support the improvement activities in those key value streams which will produce the change you most need this year. Deployment of these expert resources to accelerate the pace is a critical executive role at this time.

Sustaining the results will come when you have fully deployed daily management skills throughout the organization. This will take time but also will require a deliberate plan for where these skills are needed most to achieve your highest priorities. Eventually all leaders will need the skills but for now, prioritizing who is critical to change now is essential.

©2016 Virginia Mason Institute

I know that maintaining the balance of urgency while there is an understanding of the learning needed within the organization can be difficult but you have everything you need to achieve the culture and performance you seek. Keep reflecting and adjusting in a deliberate way. I encourage you to continue to meet as an oversight group to provide the forum to reflect on progress; are you seeing the change you seek and where not, modifying your tactics to ensure progress continues. Periodically review the transformation continuum as a leadership team to support those reflections.

I again thank you for the opportunity to have supported your progress and please don’t hesitate to reach out to us in the future should you need additional assistance.

Warm regards,

Diane

APPENDIX II

R Harvey/M Gillies IN DRAFT version 0.4 31/10

Reduce HSMR by 10% by end December 2018

Achieve high reliability of safe, person-centred and effective clinical care processes

AIM

Comprehensive implementation of the 10 patient safety essentials

Implementation of reliable structured clinical review

Implementation of 9 point of care priorities (As per associated Driver Diagrams & Measurement Plans)

Implementation of reliable administrative recording processes

PRIMARY DRIVERS

QI Infrastructure and Communication

SECONDARY DRIVERS

• Full scale implementation of the applicable 10 patient safety essentials to all clinical areas • 95% or > reliability of the 10 patient safety essentials • Reliable system for internal and external validation of self reported data • Patient safety essentials reviewed as part of daily management at ward and hospital management levels • A system to identify process reliability and to enable appropriate step down or escalation of data reporting

• Reliable person centred response to Deteriorating Patients • Reliable recognition and care delivery for patients with Sepsis • Reliable risk assessment to prevent Venous Thromboembolism • Reliable care delivery for patients with Heart Failure • Reduce Surgical Site Infections (SSI) • Prevent Catheter Associated Urinary Tract Infections (CAUTI) • Reduce Falls • Prevent avoidable Pressure Ulcers • Reliable Implementation of Meds Rec and interventions to improve safety with high risk medicines • A reliable system for all emergency patients to be seen & assessed by a consultant within 14 hours of admission • A reliable system for all emergency patients admitted before 7pm to be seen and assessed in person by a consultant on the

day of admission. • A reliable system for all patients referred for Ambulatory Emergency Care assessment to be seen in person by a consultant

before any decision is taken not to admit • A clear record is maintained of the status of all investigations required and requested • Investigation results actioned in a timescale commensurate with their urgency and within 24 hrs of availability • Structured consultant review & management plan to be recorded at initial assessment and all ward rounds • A robust system in place for all medical handovers • A reliable system to accurately record the patient classification code on PMS on admission • An IDL to be sent to the GP for all patients discharged/transferred and completed prior to discharge/transfer • A final discharge letter containing a core dataset to be sent to GP within a maximum of 2 weeks of discharge • Following urgent ambulatory assessment (not admitted) a typed electronic assessment and management plan is sent to GP

within 24 hrs • Accurate coding to take place within 6 weeks of patient discharge with a validation system in place.

• Each hospital site to identify core leadership team to oversee and drive implementation of this plan • Produce a hospital and organisational communication plan to inform frontline staff of prioritised QI activities • Each hospital site to identify QI capacity and capability to ensure pro-active demonstrable progress against aims • Review of SPSP and KPO core team infrastructure to optimise central QI capacity and capability • Maintain a data platform to ensure that QI data is available & accessible to all healthcare staff to inform improvement • Develop a data dashboard to facilitate daily management with the aim of improving overall quality • Collate thematic analysis from case note review, SAERs, RCAs for organisational learning and improvement

NHS Highland High Level Mortality Reduction Driver Diagram: 4 Acute Hospitals

APPENDIX III