Getting to Zero-Safer Care
Improvement Programme
Annette Bartley RGN BA MSc MPH
Health Foundation/IHI Quality Improvement Fellow
©Annette Bartley Consulting Limited 2011
Learning Session 1 Overview
09.00-09.15
09.15- 10.00
Welcome & Introductions
Background and Context
Programme aims & objectives
Links to other work
10.00-11.00
Overview of Quality Improvement
Tools & techniques
Measurement for improvement
The role of local coaches
11.00-11.30
11.30- 13.00
13.00-13.45
13.45-15.00
15.00-15.15
15.15-16.15
16.15-16.30
Refreshment break
Team Presentations / Storyboard rounding
Lunch
The Snorkel – Generating Ideas from frontline staff
Refreshment break
Action planning and report out
Summary next steps and close
Understanding the
context of frontline care
What’s good about it?
 What’s not so good?
 What could be improved?

©Annette Bartley Consulting Limited 2011
It’s a Fact that …
“Without good and careful nursing many must suffer
greatly, and probably perish, that might have been
restored to health and comfort, and become useful to
themselves, their families, and the public, for many years
after.”
Benjamin Franklin (1751)
©Annette Bartley Consulting Limited 2011
The Reality in Practice
How do we make sense of all the expectations
& bring the work into a coherent whole
Health Foundation
Safer Communities
NHS III
LIPs
Productive
Series
National Patient
Safety Agency
(NPSA)
Safety Alerts
Matching Michigan
WHO World Alliance
for Patient Safety
NICE
Quality Standards
CNO High Impact Changes
QUIPP & Safety Express
Safer Patients
Network (SPN)
The Health Foundation
(with IHI)
Department of Health
(DoH)
High Quality Care for All
IP&C
CQUIN targets
Getting to Goal
Will
 Ideas
 Execution

©Annette Bartley Consulting Limited 2011
The politics of hope

“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
©Annette Bartley Consulting Limited 2011
Transforming Patient Experience
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
©Annette Bartley Consulting Limited 2011
Where to begin
Will
Ideas
Execution
©Annette Bartley Consulting Limited 2011
Programme Aims
Alignment with Safety Express
 To reduce the incidence of Avoidable
Hospital /Community Acquired Pressure
Ulcer
 Reduce of Falls (falls with harm)
 Reduce Catheter Associated Urinary
Tract Infections (CAUTI)
 Prevention of Venous Thromboembolism

( VTE)
©Annette Bartley Consulting Limited 2011
Programme overview
The IHI Collaborative Model
Website
Participants (10-100 teams)
Select
Topic
(develop
mission)
Expert
Meeting
Tools &
Guidance,
Publications
Prework
Develop
Framework
& Changes
Planning
Group
P
A
P
D
A
S
LS 1
P
D
A
S
LS 2
D
S
LS 3
Supports
Email
Visits
Phone
Assessments
Monthly Team Reports
Underpinning principles
Transformational Leadership
 Safety & Reliability
 Patient and Family Centred Care
 Value-added care
 Teamwork and Vitality

©Annette Bartley Consulting Limited 2011
Patients as partners

“ If quality is to be at the heart of
everything we do, it must be understood
from the perspective of patients.”
©Annette Bartley Consulting Limited 2011
Alignment -Harm Free Care
©Annette Bartley Consulting Limited 2011
Prevention of Pressure Ulcers
©Annette Bartley Consulting Limited 2011
Transforming Care at the Bedside framework
!
Spread the Learning and celebrate the successes
Content Area
Drivers
Leadership
engagement
Prevent the
Incidence of
Pressure
Ulcers, Falls,
CAUTI, by
April 2012
using the
Intentional
rounding
process
Team work
Reliable
Implementation of the
The Intentional
Rounding process
Patient and Family
Centred Care
Training & Education
Interventions
 Ensure there is leadership support for this
work at every level in the organization
 Transformation Leadership at ward/unit level
 Engage the wider MDT team
 Set sims and plan tests together
 Share learning
Address the 8 key behaviours and incorporate the :
SKIN Bundle
Surface
Keep Moving
Incontinence
Nutrition
Create Patient centred healing environment –
Use the ESTHER story
Support and Involve patients and families
Provide spiritual and emotional support
Ensure patients rights , privacty and dignity are
maintaines
Educate staff regarding the assessment process,
identification and classification of, and treatment of
pressure ulcers
Educate Patients & family
Develop patient information pack
Pressure Ulcers
The “Case for Change”
◦ National Focus on Patient Safety
◦ I in 10 patients harmed by what we do
◦ Poor Public Perception of Care
◦ Impact of financial cutbacks
◦ Pressure Ulcer Incidence 1 in 5
◦ As high as 1 in 3
©Annette Bartley Consulting Limited 2011
Prevention of Falls (Harm from falls)
•Falls prevention is a complex issue crossing the boundaries
of healthcare, social care, public heath and accident
prevention.
•Across England and Wales, approximately 152,000 falls are
reported in acute hospitals every year, with over 26,000
reported from mental health units and 28,000 from
community hospitals.
•A significant number of falls result in death or severe or
moderate injury, at an estimated cost of £15 million per
annum for immediate healthcare treatment alone (NPSA,
2007).
©Annette Bartley Consulting Limited 2011
Facts

Pressure sores are an increasing problem that
affect thousands of people unnecessarily every
year..

They are painful, debilitating and can be life
threatening

The cost of treating a pressure ulcer varies
from £1,064 -£10,551 with the estimated total
cost in the UK of between £1.4–£2.1 billion
annually- 4% of total NHS expenditure (Bennett
et al 2004)
©Annette Bartley Consulting Limited 2011
What matters most to inpatients.

Consistency and coordination of care

Treatment with respect and dignity

Involvement

Doctors

Nurses

Cleanliness

Pain control
©Annette Bartley Consulting Limited 2011
Methods and Tools
Change vs. Improvement
Of all changes I’ve observed, about 5%
were improvements, the rest, at best, were
illusions of progress.
W. Edwards Deming
◦ We must become masters of improvement
◦ We must learn how to improve rapidly
◦ We must learn to discern the difference
between improvement and illusions of progress
©Annette Bartley Consulting Limited 2011
The Lens of Profound knowledge

Deming
Appreciation
of a system
Aims or values
Theory of
Knowledge
C
Q
I
Understanding
Variation
Psychology
Quality Improvement Methods /Tools
The Model for Improvement
 The Science of Reliability
 Driver Diagram
 Change Package
 Lean/5S
 Safety Cross/ Safety Thermometer
 SSKIN Bundle/ Intentional Rounding

©Annette Bartley Consulting Limited 2011
The Model for Improvement will underpin the programme,
enabling teams to connecting an aim to action and measurement
which will enable you to demonstrate their progress.
©Annette Bartley Consulting Limited 2011
Improvement requires a clear aim
Measurement
&
Action
©Annette Bartley Consulting Limited 2011
AIM

Aims infuse meaning and hope in our lives, they
create a target to achieve and inspire and motivate us
to achieve it.
How good do you want to be and by when?
 Make your aims SMART

•
•
•
•
•
Specific
Measurable
Achievable
Realistic
Timely
©Annette Bartley Consulting Limited 2011
Developing a systems-based approach to the
prevention of hospital acquired pressure ulcers
What will success look like?
Risk Identification
Risk Assessment
Communication of
Risk status
Appropriate preventative
strategy implemented
Evaluation of outcome
The “Case for Change”
◦ National Focus on Patient Safety
◦ I in 10 patients harmed by what we do
◦ Public Perception of Care
◦ Impact of financial cutbacks
◦ Strong link between Patient Satisfaction
& Employee Satisfaction
©Annette Bartley Consulting Limited 2011
Purpose of Using Data
& Measuring
The purpose of measuring is to answer
critical questions and to guide intelligent
action.
Cliff Norman- Associates in Process Improvement
©Annette Bartley Consulting Limited 2011
“In God we trust.
All others bring data.”
W. E. Deming
©Annette Bartley Consulting Limited 2011
S+P=0
S=Structure
 The environment in which health care is
provided
 P=Process
 The method by which health care is
provided
 O=Outcome
 The consequence of the health care
provided

©Annette Bartley Consulting Limited 2011
Research
vs
Measurement for Improvement
©Annette Bartley Consulting Limited 2011
Three Types of Measures
Outcome Measures:Voice of the customer or patient. How is the
system performing? What is the result?
Process Measures: Voice of the workings of the system. Are the
parts/steps in the system performing as planned?
Balancing Measures: Looking at a system from different
directions/dimensions. What happened to the system as we
improved the outcome and process measures? (e.g. unanticipated
consequences, other factors influencing outcome)
Measurement Guidelines





A few key measures that clarify a team’s aim and make
it tangible should be reported, and studied by the
team, each month
Be careful about over-doing process measures for
monthly reports
Make use of available data bases to develop the
measures
Integrate data collection for measures into the daily
routine
Plot data on the key measures each month during the
life of the project
©Annette Bartley Consulting Limited 2011
Measurement Guidelines

The question - How will we know that a
change is an improvement? - usually
requires more than one measure
• A balanced set of five to eight measures will ensure
that the system is improved
• Balancing measures are needed to assess whether the
system as a whole is being improved
©Annette Bartley Consulting Limited 2011
Measurement- It is YOUR data!!
(data MUST be locally owned)

Outcome measures
◦ Incidence ( count on safety cross)
◦ Days between events

Process measures
◦ Percent Compliance with risk assessment
◦ Percent Compliance with process ( bundle)
◦ Percent compliance with Intentional Rounding tool

Balancing measures

Patient Experience

Staff satisfaction

Length of Stay

Complaints

Staff turnover /Sickness rates

Budget implication
©Annette Bartley Consulting Limited 2011
Visual Measurement
1
2
3
4
5
6 (3)
7
8 (1)
9
10
11
12
13
14
15
16
17
18
19
20 (1)
21
22
23
24 (1)
25 (1)
26
27
28 (1)
Days since last...
___ days
29
30
31
Real Time Data for improvement – Process
©Annette Bartley Consulting Limited 2011
It’s time…

A little less conversation a little more action
©Annette Bartley Consulting Limited 2011
Getting it right
Co-ordinating Care
©Annette Bartley Consulting Limited 2011
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
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
Intentional Rounding
The Evidence
The Studer Group
 Alliance for Health Care Research

◦ 38% Reduction in Call Lights
◦ 12 point mean increase in Pt Satisfaction
◦ 50% reduction in patient falls
◦ 14% reduction in pressure ulcers
Flaws in the study but…
©Annette Bartley Consulting Limited 2011
On Finding What Works…
“We need to standardize, simplify, and steal
shamelessly from everyone who can
contribute, because we’ve reached a point
where no excuses are allowable.”
Roger Resar, MD
Senior Fellow, IHI
©Annette Bartley Consulting Limited 2011
Intentional Rounding – What is it?
Structured process where frontline staff regularly round
on patients and reliably perform scheduled/required tasks
 Rounding with purpose- linked to an aim
 8 key behaviors
1. Opening key words – managing up
2. Perform scheduled tasks
3. Address the 3 p’s of pain, potty? position (SKIN
Bundle)(toileting), and
4. Assess comfort needs
5. Environmental assessment
6. Closing key words
7. Explain when you or others will return
8. Document the round on the log

©Annette Bartley Consulting Limited 2011
OMHS Intentional Rounding - wins

59% reduction in Pressure ulcers
54% reduction in call lights
 (2878 fewer calls after rounding)
 Patient feedback – ‘I know someone will be back to
check on me, when they come…’
 Improved employee satisfaction – 5.67 on a 7 point
scale compared to national norm of 4.66 (Baird and
Borling)
 Reduction in cost
◦ $3.02/pt 6 month avg. prior
◦ $2.39/pt 8 months avg. following

©Annette Bartley Consulting Limited 2011
Tools – Rounding Log
©Annette Bartley Consulting Limited 2011
Tools – Badge Card
©Annette Bartley Consulting Limited 2011
Tools – Accountability Tool
©Annette Bartley Consulting Limited 2011
Rounding
commenced
Intentional Rounding -Benefits
• Provide staff with better control of
their time
• Improved outcomes / promote safety
• Results
• Increase Patient Satisfaction
• Decreases anxiety
• Increase trust and give sense of
comfort
• Increase Employee Satisfaction
©Annette Bartley Consulting Limited 2011
Additional Benefits
Centred on patients/Catches all
 Provides a quality assurance framework
for nursing care
 Helps to evidences what nurses do
 Helps demonstrates the impact on patient
outcomes
 Potential to impact on the bottom line

©Annette Bartley Consulting Limited 2011
57
What they are not…
A radical change to a system /process
 Full blown trust-wide implementation
 Mini projects (monumental proportion)
 Top down directives

‘PDSA’s' ‘test’ a proposed change
©Annette Bartley Consulting Limited 2011
Paper Plane Exercise

Aim – To design a paper plan that will fly the
longest distance
◦ Assign a design team
◦ Assign someone to assemble the plane
◦ Assign a measurement person to measure the
distance flown (in feet)
Run your tests a few times?
 What are you learning?
 How are you factoring your leanring into the
next test?

©Annette Bartley Consulting Limited 2011
Patient &family centred care
People are treated with respect and dignity.
Health care providers communicate and share complete
and unbiased information with patients and families in
ways that are affirming and useful.
Individuals and families build on their strengths through
participation in experiences that enhance control and
independence.
Collaboration among patients, families, and
providers occurs in policy and program development
and professional education, as well as in the delivery of
care.
Source: Institute for Family Centred Care, Bethesda USA
©Annette Bartley Consulting Limited 2011
Local Coaches/Facilitators
Group of volunteers
 Willing to play a key role locally as
coaches /facilitators
 Support participants and help to
accelerate momentum and the progress
 They will be the links between you and
the programme team

©Annette Bartley Consulting Limited 2011
Storyboard rounding
Split up into your teams
 Identify a space to display your storyboard
 Select at least one member to present the
findings
 Everyone else will rotate around the teams
 Approximately 7-8 mins to describe your
team/aspirations/learning from pre-work
 Bell will sound and teams will rotate to the
next space

©Annette Bartley Consulting Limited 2011
Harvest

Identify three things you learnt during the
rounding
◦ Could be meeting new people
◦ Harvesting Ideas from another team
◦ Results/learning from their pre-work
©Annette Bartley Consulting Limited 2011
The Snorkel
©Annette Bartley Consulting Limited 2011
Fostering Creativity and Brainstorming?
©Annette Bartley Consulting Limited 2011
Methods for
Generating New Ideas









Change Concepts
Using Technology
Critical Thinking
IDEO Brainstorming
Metaphorical Thinking
Observation
Provocation
Prototyping
Idealized Design
©Annette Bartley Consulting Limited 2011
Innovation and Work Redesign
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rate-item
cust-rec
http://theartofinnovation.com/purchase.htm
Resources for “Snorkel”
©Annette Bartley Consulting Limited 2011
Outline of “Snorkel”
Review of Project Vision and Charter
What do we know about ….
Propose a Design Challenge
Storytelling
How might we….?
Brainstorming
Select top ideas (multi-vote)
Prioritize ideas for development
Plan prototypes
Enactments
Design first series of tests
©Annette Bartley Consulting Limited 2011
Storytelling

In lieu of doing actual observations, use storytelling to
“observe” actual experiences

Recall an actual story or experience which relates to
the specific design challenge (personal, friend or family
member or work-related experience)
 Who was involved?
 What happened?
 How did individuals feel and react?

Give an example

Tell stories in small groups (nor more than 2 minutes
each)
©Annette Bartley Consulting Limited 2011
How might we….?
(used to create ideas for the brainstorming)
…. Prevent harm
…Engage Patients and families in preventing harm
…Optimise nutrition
Ideas should be actionable
Write each idea on post-it notes or flip c
©Annette Bartley Consulting Limited 2011
Rules for Brainstorming (20 mins)
Chose one or two “how might we scenarios….







encourage wild ideas
go for quantity – want more than 500 ideas
defer judgment
be visual – draw pictures
one conversation at a time
build on ideas of others
stayed focused on topic (“how might we…”
scenarios)
Write each idea on post-it notes
©Annette Bartley Consulting Limited 2011
Multi-voting to Select Top Ideas

Cluster together similar ideas from brainstorming
exercise

Use dots to vote:
 What are your personal favorites?
 What idea would you most like to try on your
unit?
 What idea do you think will have the biggest
impact toward achieving the “how might we…”

Participants can distribute their dots however they want
–- all on one idea, each dot on a separate idea, or
anything in between

Report out on favorite ideas (where there are most
dots)
©Annette Bartley Consulting Limited 2011
Matrix of Change Ideas
Easy to Implement
Place concepts in matrix. Strive for easy, lowcost solutions. Translate high-cost solutions
into low-cost alternatives.
Low Cost
High Cost
Difficult to Implement
Matrix of Change Ideas
Strive for high-impact , low-cost
solutions.
High Impact
Low Cost
Translate high-cost solutions into lowcost alternatives.
High Cost
Low Impact
Outline of “Snorkel”
Review of Project Vision and Charter
What do we know about……
Propose a Design Challenge
Storytelling
How might we….?
Brainstorming
Select top ideas (multi-vote)
Prioritize ideas for development
Plan prototypes
Enactments
Design first series of tests
©Annette Bartley Consulting Limited 2011
IDEO’s Design Principles
1.
2.
3.
4.
5.
Keep people informed throughout
process
Value people, time, and energy
Enable learning and teaching
Give people appropriate levels of
control
Facilitate connections among people
©Annette Bartley Consulting Limited 2011
Enactments
Create an enactment to illustrate an
extreme future vision for your prototype
 Create storyline and build
 Rehearse and refine
 Present to whole group
 Select elements and build on ideas

©Annette Bartley Consulting Limited 2011
Enactments
©Annette Bartley Consulting Limited 2011
What could you do by next Tuesday?
Think of some changes that you believe
might enable you to get results
 Think of 1 change
 Plan your first PDSA’s

©Annette Bartley Consulting Limited 2011
Small Scale Tests of Change on:
One bay/ward
 One day / shift
 One patient


One nurse
©Annette Bartley Consulting Limited 2011
Action Planning Session
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
Wide-Scale Tests
of Change
A P
S
D
Very Small
Scale Test
Follow-up
Tests
Next Steps

ACTION PERIOD
◦
◦
◦
◦
Seek out a coach/facilitator
Get measures in place
Test the rounding process small scale
Connect with Tina Chambers/calls
 Learning session 2
◦ Is all about YOU
◦ We want to hear your progress and see some
results
©Annette Bartley Consulting Limited 2011
PDSA Cycle No 1 : General Wards 9 & Ward 4
Worksheet for Testing Change
Aim: To reduce Pressure Ulcer Incidence to zero by December 2012
(Overall goal you would like to reach)
Every goal will require multiple smaller tests of change
Describe your first (or next) test of change
Test SSKIN Bundle on one patient on one ward next Tuesday
Person
Responsible
When to
be done
Where
to be
done
JD&
RW
Week
commen
cing
18th April
Ward 4 &
Ward 9
Person
Responsible
When to
be done
Where to
be done
JD
W/C
18TH
April
Plan
List the tasks needed to set up this test of change
1)Identify similar information from other Trusts
2)Discuss with team
3)Identify a nurse and patient who are prepared to participate.
4)Identify a suitable patient and seek their permission
Predict what will happen when the test is carried out
The patient & nurse will understand the reason’s for the
test and be happy to participate
The test will go well
The patients’ risk of HAPU is reduced
Measures to determine if prediction succeeds
Views of patients and professionals will be sought
Do:
Study:
What happened?
What did you learn?
What surprised you?
Act:
What will you differently as a result of your test?
What will your next test be?
You are this Hospital
You are what people see when they arrive here.
Yours are the eyes they look into when they’re frightened and
lonely.
Yours are the voices people hear when they are in the lifts and
when they try to sleep and when they try to forget their problems.
You are what they hear on their way to appointments that could
affect their destinies and what they hear after they leave those
appointments.
Yours are the comments people hear when you think they can’t.
Yours is the intelligence and caring that people hope they’ll find
here. If you’re noisy, so is the hospital. If you’re rude, so is the
hospital. And if you’re wonderful – so is the hospital.
No visitors, no patients can ever know the real you, the you that
you know is there — unless you let them see it. All they can know
is what they see and hear and experience.
And so I have a stake in your attitude and in the collective attitudes
of everyone who works at Cooley Dickinson Hospital. We are
judged by your performance. It is judged by the care you give, the
attention you pay and the courtesies you extend.
Thank you for all you are doing. CEO Cooley Dickinson Healthcare Org
Thank You!
Questions?
abartley@ihi.org
©Annette Bartley Consulting Limited 2011