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1 This image cannot currently be displayed. WIRED 3 rd April 2014 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

2 Background The Institute of Healthcare Improvement Formed in the late 1980s 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

3 PLAN DO STUDY ACT

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

5 This image cannot currently be displayed. The Quality Journey Culture Comparison How we define good Source of motivation to deliver Duration Compliance To meet all required targets From outside Imposed To be better than others, locally or nationally From outside Top-down To be the best we can possibly be From inside Episodic Episodic Ongoing Internal, personal

6 Salford Royal s Quality & Safety Journey Source: Salford Royal Strategy

7 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 Strategy

8 This image cannot currently be displayed. 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) Identify deterioration Monitoring plan Standardise observation taking CEWS Charts close to child Reliable response to CEWS Respond to deterioration SBARD Simulation training Source: UCLPartners Education on deterioration

9 This image cannot currently be displayed. In great organisations, what sort of metrics are tracked and who chooses the measures? Intermountain example Source: Intermountain Healthcare

10 This image cannot currently be displayed. What matters to patients Brain Cancer example Experience of Time: Speed vs. Haste Mastery over Medical Language Re-instating and Re-creating Identity Scientific Rigour vs emotional empathy Source: London Cancer, 2011 Life Context: Patient defined outcomes Accountability Taken Together

11 This image cannot currently be displayed. 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 5. Follow-up/ secondary prevention and hospital readmissions Functional status Return to pre-stroke life role SF36 Secondary incidence Population mortality 6. Measurement of patient experience Source: UCLPartners Was care well-connected? Did you get understand care plan & have chance to make choices?

12 How you display and report data determines the conclusions you draw: rolling average of 12 months data 2.8 All England Acute Crude Mortality (All) by Rolling 12 Month Average p' chart Temporary: UCL = 1.84, CHART CTL = 1.76, LCL = 1.67 (Lloyd Nelson option) Inspected Mean = 11,388,218.15, Counts Mean = 199, Proportion of crude mortality (%) UCL CTL LCL /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/2013 Rolling 12 Months Source: NHS England, with thanks to Maxine Power

13 The same data again: by quarter 2.8 All England Acute Crude Mortality (All) by Quarter p' chart Temporary: UCL = 2.16, CHART CTL = 1.75, LCL = (Lloyd Nelson option) Inspected Mean = 3,084,820.86, Counts Mean = 54, Proportion of crude mortality (%) UCL CTL LCL 1.2 Q1 07 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 Q2 09 Q3 09 Q4 09 Q1 10 Q2 10 Q3 10 Q4 10 Q1 11 Q2 11 Q3 11 Q4 11 Q1 12 Q2 12 Q3 12 Q4 12 Financial Quarter Source: NHS England, with thanks to Maxine Power

14 The same data again: by month 2.8 All England Acute Crude Mortality (All) p' chart Temporary: UCL = CHART 2.08, CTL = 1.75, LCL 3 = 1.41 (Lloyd Nelson option) Inspected Mean = 1,030,245.99, Counts Mean = 18, Proportion of crude mortality (%) UCL CTL 1.4 LCL /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/ /04/ /07/ /10/ /01/2013 Month Source: NHS England, with thanks to Maxine Power

15 This image cannot currently be displayed. And finally, teasing apart two seasonal systems CHART 4 Source: NHS England, with thanks to Maxine Power

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

17 This image cannot currently be displayed. Major improvements are possible inputs/processes 100% 90% GRI VAP Prevention Bundle Sampled one day per week - varied day Aim >95% Reliability by May 2009 All 4 components of bundle 30 head up 80% DG sheet - reformatted, Prompts added Chlorhexidine used as part of daily mouth care 70% 60% 50% Daily Goals Sheet Script of questions to ask doctors Head-up redundancy Re-testing at daily goals: handing script, using script, change daily goals sheet responsive to command; had sedation hold; or described exclusion described weaning target or described exclusion 40% AIM - how much by when 30% Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Source: NHS Scotland.

18 This image cannot currently be displayed. And in outcomes that matter to patients 25 Script of questions to ask Drs GRI VAP Prevention Bundle Reliability and VAP rate per 1000 ventilator days Aim: > 95% reliability by March % DG sheet DG sheet change; prompts added Retesting at DG sheet; handling sript; change DG sheet 90% 80% 70% 60% Ventilator Associated Pneumonia rate per 1000 ventilator days Median over first 6 months 50% Aug-07 Oct-07 Source: NHS Scotland. Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Last VAP 02/01/2009 Dec-09 40% 30% 20% 10% 0% Ventilator Associated Pneumonia care bundle reliability (%) AIM

19 This image cannot currently be displayed. But measurement alone is not enough VAP Bundle Reliability (process) Feb 2012 VAP Incidence (outcome measure) Target 95% compliance with bundle HELICS surveillance (outcome measurement) begins 2005 VAP bundle prompts added to daily goals sheet. Continuous process measurement begins SPSP begins Twice daily wean screen sticker added to 24hr chart each change tested using MfI Move to new hospital & dept re-configured 100% 90% 80% 70% 60% 50% 40% 30% Bundle Reliability (process measure) 20% Days 147 Days 262 days 675+ Days Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May- Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May- Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May- Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May- Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May- Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 10% 0% Source: NHS Scotland.

20 35 Focus on prevention: improving vital sign monitoring 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 0 Number of Wards Compliant Number of Wards Participating Cardiac Arrest Rate Source: UCLH, with thanks to John Welch

21 Aim: to halve cardiac arrests by end 2012 Cardiac arrests/1000 admissions UCLH (3 hospitals) 44 % down from 2010 to 2012 p = 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 Year Cardiac arrests (8.92 / month) (7.00 / month) (5.42 / month) 2013 (to November) 61 (5.55 / month) Source: UCLH, with thanks to John Welch

22 This image cannot currently be displayed. 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

23 This image cannot currently be displayed. Building clinical leadership and enhancing professionalism Source: Bohmer (2011) The Instrumental Value of Medical Leadership, King s Fund

24 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

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