Agenda
Part 1: The benefits and limits of Top Down Change
Lessons learnt from establishing and managing the National Clinical Programmes
Part 2: Relearning how to use improvement tools in health care
Measurement: Hip Fracture Pathway & ECHO Utilisation
Mapping patient flow: Dementia Pathway
Influencing change: Chemo Drug Savings
Part 3: Observations on teaching clinicians QI
RCPI Diploma in Leadership & Quality
Part 4: Sustaining change
Building a Directorate Model that imbeds continuous improvement
Close: 5 years “Learning” on a page
I feel isolated between
my peers & management
I’ve got to get out of
here ASAP to fix 10
things urgently.
Where is the
structure? Who is in
charge? Who is holding
who accountable?
What is
my role
&
authorit
y?
Clinical Director
Directorate Manager
Directorate Nurse
Manager
A clinical Directorate team?
Business Manager
PAMs/AHP Rep
Am I a rep
or a member
of the team?
Quality & Safety Manager
HR Liaison
Finance Liaison
How do I get safety
No.1 on the agenda?
What is the rest of my
role about?
Patients &
Families
I wonder if they
ever talk about my
experience?
How do I get them
to think savings and
efficiency?
What’s this
meeting got to
do with me? I
can’t help
them?
It was simpler when I
could talk direct to the
CEO! What are they up to?
Speciality/Service
Unit Lead
V
V
07/09/2014
BetterWay?
3
Same Management process:
A clinically led management cycle of
continuous Improvement
A clinically led management cycle of
Continuous Improvement
Shared Values
High Reliability

Preoccupation with Safety
(Relentless focus on avoiding patient harm)

Reluctance to simplify interpretations
(No subjective analysis)

Sensitivity to operations
(Transparent measurement of patient experience & safety)

Commitment to resilience
(Ability to get back up after taking an organisational knock)

Deference to expertise
(Everyone is free to express safety concerns irrespective of title or grade)
A clinically led management cycle of
Continuous Improvement
Shared Mission
To provide Best Care for patients, based on Patient Experience,
Safety, Clinical Excellence and Innovation
Patient Experience
Safety
Clinical Excellence
Innovation
– Satisfied patients and families
– Zero Harm
– Best Patient Outcomes
– Continuous improvement
Shared Aims
Patient
Safety
Patient
Access
Patient
Flow
Patient
Outcomes
Patient
Experience
Team
Research & Innovation
Training & Knowledge Sharing
Equitable resource allocation & waste avoidance
A clinically led management cycle of
Continuous Improvement
Patient pathway description levels
Level 1: Systems level Pathway
- Shows flow between core Primary, Secondary & Tertiary Services - macro level
Level 2: Directorate specific Pathway
- Shows the flow of those parts of a patient pathway directly managed by a Directorate
Level 3: Speciality specific Pathways
- Lists the scope of services and pathways managed directly by a speciality or service
Level 4: Condition specific Pathways
- Shows the flow of an integrated care pathway that crosses specialities, professions & care settings micro level e.g. Hip fracture, Dementia, Epilepsy, etc.
11
End to end systems pathway (level 1)
Patient
Patient information
web site
Self Management
Walk-in
GP/Primary Care
Team
Ambulance
Triage and EWS
Critical Care
(ICU/HDU)
Emergency Department
Triage and/EWS
Chronic disease
management
Initial Assessment
Acute Medical Unit (AMU)
Incl.AMAU/MAU
Community
Pharmacy
GP Diagnostic
requests
EWS
Radiology
Diagnostics
Ambulatory Care
(Day) Services
Surgical Assessment Unit
Speciality
Pathology
Diagnostics Diagnostics e.g.
Cardiovascular
Outreach Service
Working Diagnosis
Out Patient
Clinics
Elective
Surgery
Emergency
Surgery
Rapid Access
Clinics
OPAT
Mortuary
Community
Intervention Team
Bed
management
EWS
Community Rehab
services
Discharge
management
Admission
to wards
Long term care
Specialist
Wards
Home
In Patient Palliative
Care
Care plan
EWS
Short stay unit
EWS
Condition Specific Services e.g.
Stroke, PCI, CPAU, Epilepsy,
PCI, Diabetes, Rehab, etc.
EWS
Hospital retrieval
Transfer
2
Hospital
Network
Hospice Care
Medical
Pathway
(Level
MEDPatient
Pathway
(level
2) 2)
ICU
Unscheduled Care
Acute
Floor
Surgery MedEL
Home
3. CPAU
5.
Specialist
Assessment
4. PCI
Ambulance
1.
ED
Assessment
Walk - in
GP referral
Y
Discharge?
Demand &
Capacity analysis
2.
AMU
Assessment
Cancer
N
Specialist
Assess ment
required?
Y
Discharge?
GP
Bed demand &
Capacity analysis
N
Admit
6.
Bed
N
Admit Management
7.
Manage inpatient care
(incl. SSU)
8.
Manage In
Patient
Discharge
Intermediary
care
LTC
Y
OPD Referral
Y
Rapid Access
Scheduled Care
OPD demand &
Capacity analysis
GP referral
8. Plan &
schedule
outpatient
clinics
Day Care demand
& Capacity analysis
10. Chronic
Disease
Programmes
9. Manage
outpatient
clinics
Admission
required?
Other referral
Discharge
13
N
11. Plan &
Schedule
Day Care
clinics
12. Day
Care
Procedures
Individual MED Speciality & Services pathways (level 3)
Specialities
•
Acute/Gen Medicine/ Clinical Pharmacology
•
Emergency Medicine
•
Cardiology
•
Respiratory
•
Rheumatology
•
Dermatology
•
Endocrinology
•
Nephrology
•
Neurology/ Neurophysiology
•
Gastro Hepatology
•
GUM & ID
•
Psychological Medicine
Clinical Measurement
Cardiac
Respiratory
Neurophysiology
Administration & Scheduling
•
Clerical Admin
•
Out patients
•
Data management
Wards
R Adams
H Heuston
V Synge
P1H
H5 Unit 2
Acute floor
•
AMAU (Kevin's & wilde)
•
Obs Ward
•
CPAU
•
John Cheyne
– Trans Unit
Private 1 (Shared)
Private 3 (Shared)
Day Care Procedure Services
Endoscopy
Cath. Labs
Mohs
Dialysis
Infusions (suite)
GUIDE Day Unit
MDT Day Care Services
Diabetes (DDC)
Epilepsey
GUIDE
Heart Failure
Hepatology
Respiratory Ass. Unit
14
Rheumatology
A clinically led management cycle of
Continuous Improvement
MED Management Structure
ICU
Unscheduled Care
Acute
Floor
Surgery MedEL
Home
3. CPAU
5.
Specialist
Assessment
4. PCI
Ambulance
Cancer
1.
Acute
Floor
Y
ED
Assessment
Walk - in
GP referral
Discharge?
Demand &
Capacity analysis
2.
AMU
Assessment
N
Specialist
Assess ment
required?
Y
Discharge?
In-patient
Care
Bed demand &
Capacity analysis
N
Admit
6.
Bed
N
Admit Management
7.
Manage inpatient care
(incl. SSU)
8.
Manage In
Patient
Discharge
GP
Intermediary
care
LTC
Y
OPD Referral
Y
Rapid Access
OPD demand &
Capacity analysis
Scheduled Care
GP referral
8. Plan &
schedule
outpatient
clinics
Other referral
Day Care demand
& Capacity analysis
10. Chronic
Disease
Programmes
9. Manage
outpatient
clinics
Out patient and
Chronic Disease
Programmes
Discharge
Admission
required?
N
11. Plan &
Schedule
Day Care
clinics
12. Day
Care
Procedures
Day Procedures
COO
Speciality Group
Leads
x 12
Clinical Director
DON
Operations Manager
Directorate Services
Managers (DSM)
ADONs
Quality and Safety
lead (ADON)
Data analyst
Acute Floor DSM
ED
AMU/SSU(AMAU)
Day Services DSM
Day Services
Chronic Disease/Nat Clin Progs/ADON
Acute floor ADON
·
·
·
·
·
·
Inpatients ADON
·
·
·
·
·
·
·
·
ED
AMU (Obs ward)(8)
AMAU (59)
CPAU (4)
John Cheyne(16)
TU (10)
Day Services ADON
R Adams (31)
John Heuston (31)
Victor Synge (31)
P1H (31/11Med20 Surg)
H&H (14)
H5/2 (28)
Private 3 (30)
CCU ? (10)
·
·
·
·
·
·
·
·
Endoscopy
Cath lab / ?CCU (10)
Infusion suite (Neuro/Rheum/GI)
Dialysis
MOHS
GUIDE day ward
H&H day beds
X-ray
Incl all OPDs & day centres
·
GUM/ID (H5)
·
DDC (Diabetes) (H5)
·
H5 Dermatology (phototherapy/Mohs) (H5)
·
RDC (Rheumatology day care centre)
·
Hepatology (Hepatology centre)
·
Outreach – Epilpesy/COPD/Diabetes/OPAT
·
Heart Failure Unit
·
Resp Assess Unit
Chronic diseases DSM
Chronic Diseases/Nat Clin Progs
ED/AMU flow co-ordinator
(CNM II ED)
OPD clinic co-ordinator
with SACC (new role)
Bed management/Site Management out of hours
Discharge Co-ordinator
with SACC
(bed management function
/hours of work)
17
A clinically led management cycle of
Continuous Improvement
MED Key Measures
Month Bar
Can be widened or narrowed
Time
axis
Actual Start time
8.30 Aim
Day of week
List of actual start times
Filter options:
By Speciality, Theatre or Day of week
Reasons for delay
A clinically led management cycle of
Continuous Improvement
Operational management meeting process
Meeting tracker
Fixed agenda
Used at all organisation levels
Agenda: Directorate management team
1. Review of status of actions arising
from last meeting
2. Identification of variation in key
metrics
Medical patients overall Avlos
12.0
11.5
• Patient Experience, safety &
outcomes
11.0
10.5
10.0
• Access & Flow
9.5
• Team
8.5
9.0
8.0
7.5
• Resource & waste
7.0
6.5
• Training & research
6.0
5.5
5.0
3. Agreement on actions to address
variation (JDI or QI)
4.5
5. AOB
“Crisis” dealt with last not first
Target overall Avlos for Medical Patients
13
13
29
/1
2
/2
0
13
22
/1
2
/2
0
13
15
/1
2
/2
0
13
/1
2
/2
0
13
/2
0
/1
2
01
08
13
24
/1
1
/2
0
13
17
/1
1
/2
0
13
10
/1
1
/2
0
13
03
/1
1
/2
0
13
27
/1
0
/2
0
13
20
/1
0
/2
0
13
13
/1
0
/2
0
13
06
/1
0
/2
0
13
29
/0
9
/2
0
13
/2
0
/0
9
/2
0
22
/0
9
/0
9
15
08
4. Review of progress of improvement
projects
/2
0
13
4.0
Actual overall Avlos for medical patients
Objective: Organisational Alignment
Shared
Objectives
agreed
Outcome & process
data circulated
Speciality
/Service
Team
Review
Variation
against
Objectives
& action
Inform &
discuss
Directorate
Inform &
Management Team discuss
• Access & Flow
• Team
• Training &
Research
Team
Tracker
COO
CEO
EMG
• Patient
experience,
safety &
outcomes
Directorate
Tracker
Positive tension
Board
Inform &
discuss
National
Director
of
Hospitals
/SDU
Negative tension
Objective: Avoid Command & Control
Patient & family
Clinician/Nurse/AHP
Kicking reaches here…..
Mid Staff ?
Pathway/Service Unit Team
Directorate Management Team
Senior Management Team
CEO
National Director of Hospitals
A. Set narrow set of targets & expectations
without appreciating hospitals capacity &
capability to deliver change
= creates fuel for the kicking
B. Hold Minister to their promises
Minister/Advisors/DOH
Media/ Opposition
C. Kicking starts here & works its way
down
How?: A clinically led management cycle of
Continuous Improvement
Agenda
Part 1: The benefits and limits of Top Down Change
Lessons learnt from establishing and managing the National Clinical Programmes
Part 2: Relearning how to use improvement tools in health care
Measurement: Hip Fracture Pathway & ECHO Utilisation
Mapping patient flow: Dementia Pathway
Influencing change: Chemo Drug Savings
Part 3: Observations on teaching clinicians QI
RCPI Diploma in Leadership & Quality
Part 4: Sustaining change
Building a Directorate Model that imbeds continuous improvement
Close: 5 years “Learning” on a page
Key lessons learnt
Its about:
• Clinical Leadership not involvement
• Money follows the patient works – with clinical engagement
• Implementing a clinically led management process that imbeds continuous
improvement - its not about organisation structures and governance
• Investing in producing real time data that shows both the level of variation and the
reasons for it – its not about managing through anecdotes
• Safety and Cost being part of the same discussion not two separate discussions
• Unwinding peoples anger so that we can have more adult conversations
• Developing internal coaches not training everyone in QI
• Running effective, data driven , action orientated meetings not having “groundhog
day "meetings
• the partnership between motivating clinical leaders and professional operational
managers
• Focusing on Patient Safety, Outcomes and experience – if you do you will be
default be improving access, flow and cost
• Reducing waste and variation for moral not cost reasons
• Having a shared set of aims
• Celebrating success and sharing lessons from failure.