Annette Bartley RGN BA (Hon) MSc MPH
Director of the Safer Patient Network
Health Foundation/ IHI Fellow
Co-facilitator of CHAIN QI sub-group
4/8/2015
© Annette Bartley Consulting Limited
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Why do we need to improve?
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©Annette Bartley Consulting Limited
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Institute of Medicine Aims
 Safe (no needless deaths)
 Timely (no unwanted waiting)
 Efficient (no waste)
 Effective (No needless pain or suffering)
 Patient and family centred (no helplessness)
 Equitable (for all)
IOM= Crossing the Quality chasm 2001 (IHI)
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First do no harm…
Fundamentals of patient safety
 Prevention
 Detection
 Mitigation
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The Reality in Practice
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System-Level Redesign
Every system is perfectly designed to
achieve exactly the results it gets.
New levels of performance can only
be achieved through dramatic
system-level redesign.
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“Quality
improvement begins with
love and vision. Love of your patients.
Love of your work. If you begin with
technique, improvement won’t be
achieved.”
A. Donabedian, M.D
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Bringing the Work of Many Initiatives into a
Coherent Whole
Health Foundation
Safer Communities
NHS III
LIPs
Productive
Series
NICE
Quality Standards
National Patient
Safety Agency
(NPSA)
Safety Alerts
Matching Michigan
CNO High Impact Changes
The Patient Safety First
Campaign
QIPP
WHO World Alliance
for Patient Safety
Safer Patients
Network (SPN)
The Health Foundation
(with IHI)
Department of Health
(DoH)
High Quality Care for All
IP&C
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CMO England
VTE
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From what… to how
 A little less conversation a little more action
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Deming’s Thoughts on Transformation
Metanoia:
• Reorientation of one’s way of life
(The New Economics. Deming, p. 95, 1993)
• Begins with individual
• More than a change
• Develop new habits of mind
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Where to begin
Will
Ideas
Execution
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Executive Perceptions vs.
Frontline Perceptions:
Executives overestimate:
Teamwork Climate 4X
Safety Climate 2.5X
Executive Confidence vs.
Executive Accuracy:
-Often wrong but rarely in doubt…
-Currently no incoming data-streams
-Halo Effects
-Frontline data fills the gap
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Health Care Processes
Current Variable, lots of
autonomy
not owned,
poor if any
feedback for
improvement,
constantly altered by
individual changes,
performance stable
at low levels
Terry Borman, MD Mayo Health System
4/8/2015
Desired - variation
based on clinical
criteria, no individual
autonomy to change
the process,
process owned from
start to finish,
can learn from
defects before harm
occurs, constantly
improved by
collective wisdom variation
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Reliability
•Post office
•Ritz Carlton
•Mc Donald’s
•Virgin Flights
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New Methods and Tools
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The Model for Improvement...
Aims
Measurement
Ideas, evidence,
hunches,
other people etc.
The fourth
question:
how to make
changes
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What are we trying to
accomplish?
How will we know that a
change is an improvement?
The
three
fundamental
questions for
improvement
What changes can we make that will
result in the improvements we seek ?
Act
Plan
Study
Do
Langley, Nolan et al 199618
Repeated Use of the PDSA Cycle
Changes That
Result in
Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
A P
What change can we make that
will result in improvement?
S D
Implementation
of Change
Hunches
Theories
Ideas
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A P
S D
Very Small
Scale Test
Followup Tests
Wide-Scale
Tests of
Change
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Small Scale Tests of Change on:
 One clinic
 One patient
 One doctor
 One nurse
 One day / shift
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Where do I begin?
 Hunches & Theories
 Gap in knowledge
 Set about testing your
theory
 Cause & Effect
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Steps to reliable care
 Do the acid test?
 Segment your population
 Design an articulated process goal,
 Agree a clear outcome goal connected to the
process with some supporting evidence.
 Use the prevent, detect, mitigate theoretical
design to understand failures and to learn how
to redesign
 Design your first test of change
 Determine the tempo of change
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Improvement requires a clear aim
Measurement
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Action
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Process Eyes
 Make the process for preventing
Pressure Ulcers (&Falls) visible to ALL
 Measure it -so we can ‘see’ if it is
adhered to and effective
 Make it easy for others to do the right
thing (simple checklists, reminders)
 The right process with high %
compliance WILL influence outcomes
Ward 9 Comparisons
Percentage of Time by Activity
70.00
59.1
60.00
60.2
50.9
%age of Time
50.00
42.3
May-08
40.00
Oct-08
Feb-09
30.00
Jul-09
19.8
20.00
16.5
16.3
15.4
12.9 12.9
13.8
10.7
9.9
8.2
7.7
10.00
4.8
2.5
3.6
4.9
7.7
6.2
5.0 5.5
3.1
0.00
Discussion
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Interruptions
Motion
Other
Admin
Patient Care
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Days without a hospital acquired
pressure ulcer (ABM LHB Wales)
Clear Aim
Engaged Team
Simple measuresjust enough data
638
Tests of change
Results
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Patients as partners
 “ If quality is to be at the heart of everything we
do, it must be understood from the perspective
of patients.”
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Nothing about me without me
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The Value of Networks
 “Good Networks are horizontal partnerships
which value professional expertise and mutual
learning. In doing so, they overcome hierarchy
and create connections between different levels
of the system. They are support structures for
improving the quality of care and patient safety ”
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How can CHAIN assist the
Allied Health Professions?
 Motivate and inspire
 Making Connections between individual improvers
 Empowering professionals to use evidence
 Sharing knowledge and experience
 Tools and Techniques for Improving practice
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Research / online communities
Lurking
Linking
Learning
Leading
 John Seeley-Brown 4 L’s
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Distributed leadership
Marshall Ganz
 “We got used to the politics of disappointment -- figuring
out how soon we were going to be let down. ... There’s a
different dynamic in the ... politics of hope. It’s much more
challenging. It means you’ve got to get up and do
something. There’s opportunity. If you don’t take advantage
of that opportunity, you really have to bear responsibility for
not doing so. That’s how I see the time we’re in. ”
 Marshall Ganz
 http://mitworld.mit.edu/speaker/view/1047
 http://www.youtube.com/watch?v=NglXpj94Z2o
 http://www.youtube.com/watch?v=LhCoz5hMhTI
The Politics of hope
 Get organised!
 Find your carpenters!
 Provide them with the tools!
 Stand back as they get going!
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Michelangelo’s Thoughts on Transformation
“In every block of marble I see a statue as plain as though it stood
before me, shaped and perfect in attitude and action. I have only to
hew away the rough walls that imprison the lovely apparition to
reveal it to the other eyes as mine see it.” -- Michelangelo
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Questions?
Hey… what’s a mountain goat doing
way up here in a cloud bank?
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Managing improvement in the
context of multidisciplinary teams
 What does this mean to you?
 Does anyone have experience/examples of working within




an effective team?
What are the key characteristics of an effective team?
What about working in an ineffective team?
What might that look like?
What do teams need to enable them to improve the quality
of care?
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