Breakout 2.5 Service improvement for everyone - Catherine Blackaby National Improvement Lead Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Service improvement for everyone
Catherine Blackaby
National Improvement Lead
This session will cover…
• Why a structured approach to
improvement is important
• An introduction to some of the key tools
and techniques to help you get started
• How to find out more
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2. NHS Service Improvement
Surely it’s not that difficult?
X Y
Just do it Efficient
system
IHI and RC Lloyd & Associates 2008
2

3. Surely it’s not that difficult?
X Y
Patient encounter Healthy
with health satisfied
professional patient
IHI and RC Lloyd & Associates 2008
X
3

4. MODEL FOR IMPROVEMENT
“All models are wrong but
some are useful”
• W Deming
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5. Model for improvement
What are we trying to aims
accomplish?
How will we know that a measurements
change is an improvement?
What changes can we make that will interventions
result in the improvements that we
seek ?
Act Plan
Study Do
WHAT IS OUR AIM?
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6. Define your aim
A good aim
• What we are trying to achieve
• For whom
• How much
• By when
• Compared to what
• And why?
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7. By July 2011 in 100% of key practices 75% of
patients on COPD register will have had a review
in the last 15 months and have a British Lung
Foundation (BLF) Self Care management Plan.
Patients will have a better understanding of their
disease, their medication, how to manage
exacerbations and when to seek help. This will
lead to a reduction in emergency admissions and
readmissions and better use of healthcare
resources for these patients.
WHERE ARE WE STARTING
FROM?
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8. Understanding the system & the problem
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9. Process mapping
• Everyone involved in the process
• Make visible what happens at each step
• One step = one sticky note
• Who does What
• Ask:
– How long? How many? How often?
– Time between steps?
– Why?
• If you don’t know, find out
<Process Name>
ISSUE Consultant review by; ISSUE
Medical on- Respiratory Repeat assessment. Variation in discharge information practice?
* On-call Team (non respiratory)
call team Nurse Is this effiecent? Transfer Co-ordinators?
* Elderly care
AMU Assessment
* Respiratory
NO NO
GP Physio, OT,
Patient SW etc
Discharge? YES YES Discharge? ISSUE
breathless
What happens
Self Dept of Junior Doctor
Ambulance on general
management 999 Medicine assess on-call Respiratory
response ward? (OT
Elderly DOME team Nurse Discharge? YES
NO YES Discharge? Physio?)
assessment
OOH
DOME NO General Ward
outreach ISSUE Registrar LOS
What does this Daily
A&E Review on- assessment NO
CHAPS do? How does call team Respiratory Ward
access work? Mon-Fri by Dr
LOS (6-10 days
No onward path??? stay)
CDU Social Services
Pulmonary Home care hrs
rehab referral No onward path??? available
Letter to GP from Out of
Hours?
ISSUE
Part-time SW Social Worker /
causing delay OT referral 3/7 Hospital OT
slowing system wait to see
<Function>
Equipment Healthcare Medication? Transport?
Environmental Equipment – TTOS Tax? Carers
-equipment Medical transport?
equipment
YES Discharge?
Clarify Source of TTOS? No onward path???
Discharge to
Residential / Pulmonary
community
Nursing home rehab
services CHAP
Referral to
LTOT Community RNS
assessment Appt with
community Matron
No onward path???
Home Post hospital review ??? BI annual review
Self referral to community Letter to GP from Consultant?
services?, hopsital? Letter to CHAPS from RNS?
Letter to GP from Respiratory
Nurse?
Outpatient appointment Letter to GP from A&E?
with copies of;
Nursing MDT letter
Copy of discharge letter
Letter to GP
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10. All improvement is change –
but not all change is
improvement…
HOW WILL WE KNOW IF A
CHANGE IS AN
IMPROVEMENT?
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11. How will we know whether a change is
an improvement?
• Measure…
• Measure the baseline
• Measure the minimum & what is useful
• Make measurement part of the daily
routine.
• Measure over time, measure variation &
don’t measure averages!
Why not just use averages?
‘If I stick my right foot in a
bucket of boiling water
and my left foot in a
bucket of ice water, on
average, I’d feel pretty
comfortable.’
Davis Balestracci
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12. Measurement for Improvement
5
4.9
4.8
4.7
4.6 Mortality
4.5
4.4
4.3
4.2
Last year This year
Average
The real picture
12
New
10 protocol
introduced
8
6 Mortality
4
2
0
Jan Mar May July Sept Nov Jan Mar May July
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13. How to measure
• Befriend an analyst
• Use what is there already
• Use what is useful
• Don’t judge, be curious
• Tools:
– NHS Improvement Data Guide
– NHS Improvement System SPC tool
www.improvement.nhs.uk
WHAT CHANGES CAN WE
MAKE?
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14. <Process Name>
ISSUE Consultant review by; ISSUE
Medical on- Respiratory Repeat assessment. Variation in discharge information practice?
* On-call Team (non respiratory)
call team Nurse Is this effiecent? Transfer Co-ordinators?
* Elderly care
AMU Assessment
* Respiratory
NO NO
GP Physio, OT,
Patient SW etc
Discharge? YES YES Discharge? ISSUE
breathless
What happens
Self Dept of Junior Doctor
Ambulance on general
management 999 Medicine assess on-call Respiratory
response ward? (OT
Elderly DOME team Nurse Discharge? YES
NO YES Discharge? Physio?)
assessment
OOH
DOME NO General Ward
outreach ISSUE Registrar LOS
What does this Daily
A&E Review on- assessment NO
CHAPS do? How does call team Respiratory Ward
access work? Mon-Fri by Dr
LOS (6-10 days
No onward path??? stay)
CDU Social Services
Pulmonary Home care hrs
rehab referral No onward path??? available
Letter to GP from Out of
Hours?
ISSUE
Part-time SW Social Worker /
causing delay OT referral 3/7 Hospital OT
slowing system wait to see
<Function>
Equipment Healthcare Medication? Transport?
Environmental Equipment – TTOS Tax? Carers
-equipment Medical transport?
equipment
YES Discharge?
Clarify Source of TTOS? No onward path???
Discharge to
Residential / Pulmonary
community
Nursing home rehab
services CHAP
Referral to
LTOT Community RNS
assessment Appt with
community Matron
No onward path???
Home Post hospital review ??? BI annual review
Self referral to community Letter to GP from Consultant?
services?, hopsital? Letter to CHAPS from RNS?
Letter to GP from Respiratory
Nurse?
Outpatient appointment Letter to GP from A&E?
with copies of;
Nursing MDT letter
Copy of discharge letter
Letter to GP
For every complex human
problem there is always one
easy answer that is neat,
plausible…
…and wrong
HL Mencken
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15. Change Ideas All high risk COPD
Patients to have
Having a written plan plans
Knowing what to do
Regular review
Standardise use of
Rescue Meds
Availability of rescue
Aim meds
increase the no of patients Confident, active
who can effectively Patients & carers
Self manage exacerbations Information for patients
Education & carers on COPD
& managing
breathlessness
Available support competent staff
Access to Contact numbers for
appointments / advice COPD nurses
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16. PDSA
Developing improvement Implementing new
procedures & systems
with PDSAs - sustaining change
Testing and
refining ideas
Bright
idea!
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17. Developing improvement
Improvement
with PDSAs
Improvement
? ?
?
?
Improvement
? ?
Bright
idea!
Nosocomial Infection Rates
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18. Making it happen
• Leadership is not about position or title
• Create the vision, identify the first steps,
make people uncomfortable about doing
nothing
• Perseverance
• Action
• Communication
• Believe you can do it!
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19. In summary…
• Take a structured approach to messy
problems
• Know what you want to achieve
• Know where you are starting from and
what really happens now
• Prioritise action & take small steps
• Measure impact and review progress
• Communicate learning and success
• Don’t be afraid to have a go
Getting started
The secret of getting ahead is getting
started. The secret of getting started is
breaking your complex overwhelming tasks
into small manageable tasks, and then
starting on the first one.
Mark Twain
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20. Find out more
Visit the NHS Improvement stand
Information on service improvement techniques,
case studies and using data
Visit our website:
www.improvement.nhs.uk
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