Session 4: Using QI methodologies to inform
commissioning and create better care
Professor Moira Livingston
Clinical Director NHS IQ
www.hqip.org.uk
Using QI methodologies to inform commissioning
and create better care
• Outline
• Why are we here
• The NHS Change model :a framework for
change
• Commissioning for quality and transformation
• Measurement and method
• Key messages
Why are we here?
Everyone Everywhere Every time
experiences the safest and highest quality healthcare
•
•
•
•
•
Financial challenges
Quality: Safety, outcomes and experience, is the focus
Rising expectations
Increasing complex health needs
Unacceptable variation
We need to do more, for less... and better
Requirement,
Specification or Target
No action
taken
here
Better
Quality
Reject
defectives
Worse
Old Way
(Quality Assurance)
Source: Robert Lloyd, Ph.D.
Action taken on
all occurrences
Better
Quality
Worse
New Way
(Quality Improvement)
Quality
Quality Improvement
Transformation
Source: Robert Lloyd, Ph.D.
Aim
Measurement
Drivers (changes)
Common Shared Purpose
Mental models of change
How we think about engagement
It’s all about BALANCE.
Commissioning for quality and
transformation
The commissioning cycle is a
familiar model of the stages of
commissioning services in the
public sector. It can provide a
framework for planning
activity and evaluating
development needs.
This version of the cycle has
some unique features,
emphasising the particular
issues in building
commissioning which is
community oriented, clinically
led, collaborative and
comprehensive.
At its heart is the
NHS Change Model, helping
commissioners ensure their
change leadership efforts
achieve maximum impact for
sustained transformation.
It is tempting to start here. This
imposes an incremental
approach (not
transformational), oriented
around managing existing
activity rather than improving
population outcomes.
Forging effective relationships
with key partners is an
essential pre-requisite for
developing quality sustainable
plans. These provide the
foundations for all other
activity, ensuring a
collaborative approach.
To improve population
outcomes, commissioning
priorities should be based on a
robust understanding of the
population’s health. This helps
orientate activity around
patients rather than services.
Most health and social care
involves complex longitudinal
journeys. Designing integrated
pathways of care before
considering individual services
helps improve safety,
effectiveness and value.
Specifying service contracts
and shaping the provider
market for the future is a key
part of achieving the services
the community needs. The goal
is to ensure each component of
a pathway contributes to the
whole.
Commissioners’ responsibility
does not end with agreeing
contracts. Clinical
commissioners are well placed
to contribute to continuous
improvement of services,
collaborating between
providers.
Transparent Measurement
Data…Information…Knowledge
Transparent Measurement
Data… Information…knowledge
Average CABG Mortality
Before and After the Implementation of a New Protocol
Percent Mortality
5.2
WOW!
5.0%
A “significant drop”
from 5% to 4%
4.0%
3.8
Time 1
Time 2
Conclusion -The protocol was a success!
A 20% drop in the average mortality!
Average CABG Mortality
Before and After the Implementation of a New Protocol
A Second Look at the Data
9.0
Percent Mortality
Protocol implemented here
UCL= 6.0
5.0
CL = 4.0
LCL = 2.0
1.0
24 Months
Now what do you conclude about the impact of the protocol?
Characteristic
Measurement for
research
Measurement for
compliance
Primary aim
Measurement for
improvement
Create new
Achieve a target
knowledge
Key question
Are there better ways Are there any “outliers”
underpinning the of caring for patients? in terms of deviation
measurement
from minimally
acceptable patient
outcomes?
Improve a service or
outcome for patients
How can we improve
service or outcomes for
every patient?
Hypothesis
Fixed hypothesis to
be tested in research
process
No hypothesis
Flexible hypothesis that
changes as tests
conducted and learning
takes place
End point of
measurement
process
Proving or disproving
of hypothesis
Measurement chart that
shows comparative
performance from which
judgement is made
Measurement chart that
shows progress since last
measure and potential for
improvement
Determining if
change is an
improvement
Use of statistic tests
(t-test, F-test, chisquare, p-values)
No change focus
Subsequent use of Run
charts or SPC charts to
show improvement over
time
Source: adapted by Helen Bevan and Moira Livingston from The Three Faces of Performance Measurement: Improvement,
Accountability and Research.” Solberg, L, Mosser, G and McDonald, S Journal on Quality Improvement. March 1997, Vol.23, No. 3.
Moving beyond audit to quality improvement
Audit
Quality Improvement
We collect “before and after” data
We collect continuous data
We collect a lot of data (“Just in
case”)
We collect just enough data
Typically little testing of solutions
Continuous testing, learning as we
go
Implement change as a
consequence of the audit
The process of measuring is integral
to the change process (“plan, do,
study, act”)
Key Messages
•
•
•
•
Clarity of purpose at the start
Improvement takes leadership: Commitment
Be curious: understand the issues
Seek data to answer the questions: don’t start
with the data you have
• Relationships: collaborate with partners
• Start again: continuous cycle/process
THANKYOU
@NHSIQ and @IQMoira
moira.livingston@nhsiq.nhs.uk
enquiries@nhsiq.nhs.uk
www.england.nhs.uk/nhsiq