The Quality Agenda
Fiona McQueen
Executive Nurse Director
What is world class healthcare?
Where are we now?
Where do we want to be
• 2 years
• 5 years
• 20 years
Call to action for the journey
Cabinet Secretary
NHSScotland Healthcare Quality Strategy
At its heart is a simple but very ambitious aim:
“To make the NHS in Scotland a world leader in
the quality of health care services that it
delivers.”
“That aim is not just good for patients, it is also
right for staff.”
Scottish Parliament, Debate 13 May 2010
Quality Strategy built on people’s
priorities
•Caring and Compassionate health services
•Collaborating with patients and everyone working for
and with NHSScotland
•providing a Clean and safe care environment
•improved access and Continuity of care
•Confidence and trust in healthcare services
•delivering Clinical excellence
• 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,
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.
Safe
Quality
Effective
Person
Centred
Quality occurs more frequently when the three
ambitions are delivered together
Aim
Everyone gets
the best start in
life and is able
to live a longer
healthier life at
home or in the
community .
Healthcare is
safe for every
person every
time and every
experience of
healthcare will
be positive,
delivered by
staff who feel
supported and
engaged.
Primary
Driver
Secondary Driver
The Care Experience
of patients and their
families is improved
•Leadership – executive leaders demonstrate that
everything in the culture is patient focused
•Nothing about me without me
•Healthcare systems deliver reliable, quality care
•The care team installs confidence by providing
collaborative, evidence based care
•Patients get the outcomes of care they expect
All services are coproduced
•Partnership working with communities served as equal
partners
•Asset based service redesign
•Services reflect an asset based approach (placebased, relationship-based, citizen-led and promote
social justice/equality)
•Outcomes based commissioning
There are no
needless deaths
There is no needless
harm
Staff experience and
well being is
improved
•Hospital Standardised Mortality Ratio are best in
class for Scotland
•Clinicians review all unexpected deaths as a
matter of routine and continuously learn and make
improvement
•No patient is subjected to needles harm due to
unreliable systems and or processes
•Any episode of harm is reviewed as a matter of
routine and continuously learn and make
improvements
•Staff are recruited for values
•Staff governance standards are adhered to consistently
•An asset based approach to staff well-being is taken
•Compassionate communication and teamwork are
essential competencies
•‘One set of rules’ for all
•Community benefit in all employee contracts
World Class Healthcare
•The people of Ayrshire and Arran have the best possible start
and live longer healthier lives in settings of their choice
whenever possible.
•Care is co-produced to deliver no needless waits
•There are no needless deaths
•There is no needless harm
•Every experience of Healthcare is positive
•All staff who deliver healthcare feel supported engaged and
valued
Do you agree?
•Take 10 minutes to discuss at your tables
•Is this what world class healthcare looks
like? Tell us what is missing
High performing organisations
• Culture and leadership focus – high value organisations
define and relentlessly and consistently demonstrates
values
• Specification and planning: high-value organisations
base operational and core clinical decisions on explicit
criteria and organise effectively
•
Infrastructure design: High-value organisations create
highly effective teams at the micro level, to meet the needs
of patient and families.
High performing organisations
• Measurement and oversight: High-value
organisations use measurements of clinical operations
for internal process monitoring to drive improvement.
• Staff focus - high value organisations ensure staff
involvement and ownership
• The learning organisation: high value organisations
examine positive and negative deviations in care and
outcomes, using the information create common tools
to improve outcomes.
How will we get there?
Culture
Your culture is an outcome of the way
employees behave.
So how are we encouraging our employees to
behave?
Lived values = positive behaviours
Relentless modelling of positive behaviours
delivers positive attitudes.
Current values
•Team work
•Efficiency
•Equality
•Excellence
•Care
•Improvement
What behaviours are required to build a
culture of excellence?
Select your top five behaviours from the cards
at your table.
As a board what is your role in the delivery of
‘lived’ values to improve culture ?
What’s in a Wordle?
Insert wordle
What’s in a Wordle?
Does this Wordle capture our ambitions?
How should we promote these behaviours?
What should be the consequence for those
who don’t adhere to them?
What we think we “know”
•Better quality costs more money
•If you want to ― get “Safe Care” it will
cost MUCH more money
Now here is the “truth”
• Good quality care costs LESS than
poor quality care
• Safe, harm-free care SAVES Money. It
costs less to provide, and avoids costs
of correction.
Learning from the Henry Ford Health
System
So, where to focus our efforts?
?
Safe care
Harm
Free
Care
Unsafe
care
Where are we now?
Safe, Effective and Person Centred
•Leadership
•Critical Care
•General Ward
•Peri-operative
•Medicines Management
Maternity
Mental Health
Primary Care
Sepsis
VTE collaborative
Outcome aims
• Mortality: 15% reduction
• Adverse Events: 30% reduction
• Ventilator Associated Pneumonia: 0 or 300
days between
• Central Line Bloodstream Infection: 0 or 300
days between
• Blood Sugars w/in Range (ITU/HDU): 80% or
> w/in range
• MRSA Bloodstream Infection: 30% reduction
• Crash Calls: 30% reduction
Hospital Standardised Mortality Rates
(all patients) -2007/08
6
A
5
B
Z
4
P
Rate(%)
H
C
F
3
G
E
K
L
I
O
X
N
Q
T
U
Y
S
M
AA
W
V
AC
AB
R
2
J
D
1
0
0
5,000
10,000
15,000
20,000
25,000
Number of Patients
30,000
35,000
40,000
45,000
“When something goes wrong it is
how the organisation acts that
redefines and reshapes the culture.”
Jeanette Clough, President & Chief Executive Officer
Mount Auburn Hospital, Boston, MA, USA
What did we find?
Failures
Clinical
Observation
•Identification of sick
patients
Need for
Palliative
and End of
Life Care
•Planning and
execution of care
and treatment
•Rescue of
deteriorating
patients
Unreliable
and
Variable
Care
Variation in
Record
Keeping
Coding
Clinical
Escalation
DNA CPR
Failure to
Rescue
Infection
and Falls
Scotland HSMR – 9.3% reduction
Standardised Mortality Ratio (SMR)
Regression line
Standardised Mortality Ratio
1.5
1.0
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- JulDec Mar
Jun Sep Dec
Mar
Jun Sep Dec Mar
Jun
Sep Dec Mar
Jun
Sep Dec Mar
Jun
Sep
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011p 2011p 2011p
Ayr – 9.8% reduction
Crosshouse - 27% reduction
Improvement methodology
SPSP tools and methods to
support implementation of
improved practices
Plan-Do-Study–Act (PDSA)
cycles to develop
improvements in clinical
practice
Engaging all staff to ensure
ownership of new ways of
working
Involvement
Teams must own the processes to
achieve improvement
Teams
Improvement
Experts
Spread
Plan, do, study, act
Improvement
Sustain
Ayr Hospital
General ward spread
Back to Basics programme
spread across Crosshouse. completed in all in-patient areas.
All wards monitoring and
measuring MEWS, Safety Brief
and SBAR plus all other GW
measures
Improvement programme
spreading at Ayr – 6 wards
complete and monitoring and
measuring compliance with all
BTB /General Ward measures.
Spread to continue through to
March 2013
Ja
n08
Ap
r- 0
8
Ju
l-0
8
O
ct
-0
8
Ja
n09
Ap
r- 0
9
Ju
l-0
9
O
ct
-0
9
Ja
n10
Ap
r- 1
0
Ju
l-1
0
O
ct
-1
0
Ja
n11
Ap
r- 1
1
Ju
l-1
1
O
ct
-1
1
Scottish VAP rate
(per thousand ventilator days)
20
18
16
14
12
10
8
6
4
2
0
61% reduction
9.11
3.54
Ja
n08
Ap
r- 0
8
Ju
l-0
8
O
ct
-0
8
Ja
n09
Ap
r- 0
9
Ju
l-0
9
O
ct
-0
9
Ja
n10
Ap
r- 1
0
Ju
l-1
0
O
ct
-1
0
Ja
n11
Ap
r- 1
1
Ju
l-1
1
O
ct
-1
1
Percentage compliance with
surgical briefing
100
95
90
85
80
75
70
65
60
55
50
94%
20% improvement
74%
Spread of work in theatres
Percent of patients who
have peri-operative
briefing.
Excellent compliance
across all theatres in
surgical pause and
briefing prior to
surgery
Person centred – some examples
of the good
• 92% of in-patients said they were treated with
dignity and respect (2011 n=3600)
• 90% of patients rate the overall care
experience received from their GP Surgery
as positive (2012 n=8672)
• Patients rate the quality of consultation with
many doctors, nurses and AHP’s highly
(CARE measure mean score 45/50 – mean
score normative data 43/50)
Person centred – some examples of
the not so good
• 40% of all the formal complaints are
customer service related (i.e.
communication, attitude, courtesy, respect)
• Overall customer service satisfaction rating
to be 56.3% positive (2011 n= 752 staff and
patients)
• 47% of patients were not told how long they
would have to wait in A&E (2011 n=3600)
• 22% of patients were unable to book a GP
appointment 3 or more days in advance
(2012 n=8672)
Immediate interventions to support
improvements in Patient Centred Care
• Quality of Consultation - Use of the CARE
measure
• Customer Care Commitments
• Caring Behaviours Assurance System (CBAS)
• ‘Teach back’ approach to improving
communication with patients
• Better Together Programme
• Improving Patient and family involvement in care
• Developing volunteer opportunities
• Developing Co-production approaches
The
stories
behind
the
data
Andy
As a Board Member, do you know the
names of the people who have been
harmed or killed in your hospitals
and healthcare systems because
of unsafe, unreliable systems ?
As a Board Member,
do you know how
many clinicians have
been damaged as a
result of unreliable or
unsafe systems and
processes of care?
What approach would you want the Board to take if
it was your mother, father, partner, child ?
What assurance does the Board need that we are
providing world class health services and that we are
learning from events. Discuss at your table and agree the
top 2 things that would provide you with assurance
Ah … but!
• Safety improvement excellent in pilot sites
• Person centred care excellent in some areas
• Spread taking for all taking longer than we
need to drive improvement
• New commitment to
- 20% reduction in Mortality
- 95% patients receive harm free care
- Improved person centred care
• Capacity and capability building is required
to enable change and improvement
Capability and capacity
• Capability – the people have the
confidence and the knowledge and
skills to lead the change.
• Capacity – having the right number and
level of people who are actively
engaged and able to take action.
Helen Bevan,
Journal of Research
Nursing 2010; 15: 139-148
Take 10 minutes at your table to
discuss …
How the organisation can build
the capacity and capability
necessary to drive quality
improvement at pace and scale
What skills are needed?
Many People
Few People
Change
agents
All
staff
Shared
Knowledge
Middle
Operational
Manager
Leaders
Level
Experts
A key operating
assumption of building
capacity is that
different groups of
people will have
different levels of need
for Improvement
knowledge and skill.
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
Deep
Knowledge
Continuum of Improvement Knowledge and Skills
What do we have currently?
QI capacity and capability
45
40
35
30
25
20
15
10
5
0
change agents
QI Leaders
Experts
What next?
Take five minutes at your
table to discuss as a Board
Member what you will
personally do to drive or
promote the Quality Agenda