Linking measurement to systematic improvement Learning from Improvement

Linking measurement to systematic improvement Learning from Improvement leaders such as IHI in driving quality James Mountford, UCLP Director of Clinical Quality, UCLPartners David Probert, Director of Strategic Development, UCLH WIRED 3 rd April 2014

Background – The Institute of Healthcare Improvement • Formed in the late 1980 s by Prof Don Berwick • A non for profit organisation • Initially focused on spreading best practice in clinical care across the US • Saving 500, 000 lives campaign moving to the international saving 5 million lives • System thinking approach to quality improvement • Blaming systems not people ‘ To err is human’ Report • Demming and the study of process and visualizing systems ‘Every process is perfectly designed to achieve the outcome if gets’

PLAN DO STUDY ACT

Measurement "If you cannot measure it, you cannot manage it. " Prof Don Berwick

The “Quality Journey” Culture Comparison Compliance How we define ‘good’ ▪To meet all Source of motivation to deliver ▪From outside –Imposed ▪From outside –Top-down ▪From inside –Internal, personal ▪Episodic ▪Ongoing Duration required targets ▪To be better than ▪To be the best we others, locally or nationally can possibly be

Salford Royal’s Quality & Safety Journey Source: Salford Royal 2011 -14 Strategy

Salford Royal’s Strategic Aims • Maintain position in 10% of NHS organisations with the lowest risk adjusted mortality rate • 95% of patients receive harm free care as measured by four harms: Pressure Ulcers, Catheter Associated UTI, VTE, falls • Achieve 95% reliability in: Advancing Quality care bundles, Intentional Rounding, Structured Ward Rounds, Infection Bundles • Achieve top 20% for patient and staff experience surveys Source: Salford Royal 2011 -14 Strategy

Linking aims to improvable processes Reduce risk Learn from SUI’s, RCA’s Improve IV access Human factors training Handover Aim: Reduce harm from deterioration: (Reduce cardiac arrests by 50% within 1 year) Monitoring plan Identify deterioration Standardise observation taking CEWS Charts close to child Reliable response to CEWS Respond to deterioration Source: UCLPartners SBARD Simulation training Education on deterioration

In great organisations, what sort of metrics are tracked and who chooses the measures? – Intermountain example Source: Intermountain Healthcare

What matters to patients – Brain Cancer example Experience of Time: Speed vs. Haste Scientific Rigour vs emotional empathy Source: London Cancer, 2011 Mastery over Medical Language Re-instating and Re-creating Identity Life Context: Patient defined outcomes Accountability Taken Together

Measuring Quality across a whole pathway – stroke example Element of pathway Whole-pathway outcome measure 1. Stroke education and public awareness • • Population awareness of risk factors Population awareness of FAST 2. Primary prevention and population risk factors • Population incidence of stroke 3. Stroke and TIA hospital admissions (acute management and treatment) • • • Acute mortality %discharges direct to home from (H)ASU Readmissions 4. Rehabilitation/ access to services/ PROMS/ Mortality • Functional status • Return to pre-stroke life role • SF 36 5. Follow-up/ secondary prevention and • hospital readmissions • 6. Measurement of patient experience Source: UCLPartners • • Secondary incidence Population mortality Was care well-connected? Did you get understand care plan & have chance to make choices?

How you display and report data determines the conclusions you draw: rolling average of 12 months data CHART 1 Source: NHS England, with thanks to Maxine Power

The same data again: by quarter CHART 2 Source: NHS England, with thanks to Maxine Power

The same data again: by month CHART 3 Source: NHS England, with thanks to Maxine Power

And finally, teasing apart two seasonal systems CHART 4 Source: NHS England, with thanks to Maxine Power

(i) Board-level dashboard (ii) Divisional report (iii) Project-level report Source: Salford Royal FT

Major improvements are possible – inputs/processes Source: NHS Scotland.

And in outcomes that matter to patients Source: NHS Scotland.

But measurement alone is not enough Source: NHS Scotland.

0 Date Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 35 Focus on prevention: improving vital sign monitoring 30 20 15 5 Number of Wards Compliant Number of Wards Participating Cardiac Arrest Rate Source: UCLH, with thanks to John Welch 4. 5 4 3. 5 25 3 2. 5 2 1. 5 10 1 0. 5 0

Aim: to halve cardiac arrests by end 2012 44 % down from 2010 to 2012 p = 0. 017 Source: UCLH, with thanks to John Welch Year Cardiac arrests 2010 107(8. 92 / month) 2011 84 (7. 00 / month) 2012 65 (5. 42 / month) 2013 (to November) 61 (5. 55 / month)

Quality Measurement & Improvement within a wider context What the external world prioritises Leadership and alignment Strategy Operating system Individual action Institutional action • Measurement and reporting • Capability development • Learning Outcomes

Building clinical leadership and enhancing professionalism Source: Bohmer (2011) The Instrumental Value of Medical Leadership, King’s Fund

To close, two clinicians’ views “We aren’t trying to control the clinicians. Rather, we are trying to equip clinicians and managers to control the system in which they work” Terry Clemmer, Chief of Intensive Care, Intermountain Healthcare “Ah, I see what you’re saying: I really have two jobs: first, to do my job; second, to improve how we do our jobs every day” Nurse on Deteriorating Patient Collaborative