1 consumer experience systems and outcomes tools and skills governance and accountability CREATE A GREAT UALITY SYSTEM IN SIX MONTHS measures and reporting consumer partnerships compliance and standards A blueprint for building the foundations of a great consumer experience. effective implementation plans and goals great care staff ownership and leadership Redesign CATHY BALDING quality system maturity
2 'With grateful thanks to my family and friends who support, indulge and humour my pursuit of all things healthcare quality.'
3 Published by Cathy Balding / Qualityworks P/L Cathy Balding 2013 All rights reserved. Apart from any fair dealing for the purpose of private study, research, criticism or review, as permitted under the Copyright Act, no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means electronic, mechanical, photocopying, recording or otherwise without the prior consent of the publisher. ISBN: Editing: Jessica Cotter Design: Michael Brady Business Management and Support: Kerri Martin, Gemma Cameron and Joy Schaffer Cathy Balding / Qualityworks PL
4 consumer experience systems and outcomes tools and skills governance and accountability CREATE A GREAT QUALITY SYSTEM IN SIX MONTHS measures and reporting consumer partnerships compliance and standards A blueprint for building the foundations of a great consumer experience. plans and goals effective implementation great care staff ownership and leadership Redesign CATHY BALDING quality system maturity
5 CONTENTS Why Create a Great Quality System in Six Months? OVERVIEW 1 Six Months to Creating a Great Quality System: BLUEPRINT SUMMARY 5 MONTH ONE: Why Have a Quality System? 7 Begin with the end in mind 7 Define the purpose and key components of your quality system 11 MONTH TWO: Start Where You Are 21 Quality systems vs governance systems 22 Time for a stocktake 22 How is your quality system really working and what is it achieving? 23 Beg for or buy a database 28 MONTH THREE: Develop the Great Consumer Experience Plan 31 Develop the high level plan to achieve the great consumer experience 33 Develop the governance roles and accountabilities 38 Get the committee structure, process and reporting right 42 Start developing the quality system tools for organising and reporting on your quality plan 45 MONTH FOUR: Prepare to Implement 49 Operationalise the plan 49 Develop the leadership group 51 Start Where They Are 53 MONTH FIVE: Prepare to Launch 65 Reviewing results: reporting on the plan and 'care index' 66 Get the quality system story straight 73 Build your improvement toolkit 74 A change model is a key improvement tool 76
6 MONTH SIX: Launch (or Re-Launch) the New, Improved, Quality System 83 Review and finalise the local consumer experience plans for rollout 83 Finalise the organisation-wide consumer experience plan 84 Develop the roll out program 87 Celebrate and recalibrate 90 The end of the beginning 91 The last word 94 Appendices 97 A: Great resources 97 B: The great consumer experience quality house framework 101 C: Quality system checklist and optimisation plan 102 D: Model for implementing change 109 E: Consumer experience reporting structure and example report 112 F: Example local quality planning to meet an organisational goal and objective; and an improvement initiative concept workup template 119 G: Quality improvement cycle and tools 122 H: Quality system manager role description 123 I: High level quality plan contents page 128 J: The 3PQ Quality System Model 129 About the Author 130
7 OVERVIEW Why Create a Great Quality System in Six Months? great care consumer partnerships effective implementation staff ownership and leadership Redesign quality system maturity
8 This is not a book for quality system managers. And it s not a book for executive teams. Wait! I don t mean it s not for either of you. I m saying it s for both of you. It s a resource for quality system managers and operational executives who want more from their quality system and are prepared to work together on implementing a blueprint for creating a truly great system; one that addresses traditional problems with lack of purpose, ineffectiveness, staff and consumer engagement and rescuing and re-work. This is also the book for those who say: Just tell me what to do! Good care is more than the absence of bad. Transforming the quality of your organisation s care and services to create a great experience for every consumer, every time, requires more than a functioning quality system it takes a great quality system. A great quality system is based on a vision of great care in your organisation that is driven by the governing body and executive team and operationalised through line management; with technical improvement and co-ordination support supplied by the quality system manager/team. Achieving something great requires both the executive team and the quality system manager to play their roles each working by themselves can only do half the job. Of course, quality system managers and executives can use this book in isolation, and still achieve significant change. But the best results will be achieved by implementing this blueprint in partnership. This is essential if organisations are to move beyond staff doing quality and quality being seen as the quality system manager s problem, to something that is all about transforming the consumer experience. So, where to start? Despite the explosion of the quality improvement industry over the past few decades, there is no standard, tried and tested, best practice approach to the structure and implementation of quality systems in health and aged care - as there is for accounting, for example. In over 20 years of working in quality systems management in healthcare, I ve never seen two systems that looked alike. Or that worked the same way. We know more about how to improve than we ever have, with a wealth of literature available on change, improvement, measurement and tools, but these are components of a quality system, not the system itself. The lack of an agreed and accepted quality system blueprint can make it difficult to know where to start and how to continue. As a result, healthcare quality systems are often not designed so much as grown - and many are not systems at all.
9 2 CATHY BALDING / Create A Great Quality System In Six Months Why create a great quality system in six months? In my experience, that s about the time it takes to get the infrastructure established if staff ownership and effective implementation are built into the process. I don t believe there s any point developing a quality system and plan as a desktop exercise and then thinking about implementation and selling participation to executives and staff. It could be the greatest quality plan and system in the world but it belongs to those who developed it, not to those who must work with it every day. It is well worth well investing time and effort at the front end of planning and development to build in the implementation methods used by high performing organisations. This increases the likelihood that the system will achieve concrete results, be owned by the governing body, executive team, clinicians and staff, evolve with the organisation, and be robust and self-sustaining. Of course, six months is an estimate. How long this really takes depends on many factors: the quality maturity of your organisation, where you re starting from, the size and type of your facility, the current level of knowledge and understanding of quality systems across the organisation, access to resources, the size of the quality system support team, the degree of executive support and the related infrastructure in place. If you re starting from scratch in a medium to large size organisation, it may take 12 months. If you re overhauling an existing system, the time period will depend on the maturity of your current system, and each month of the blueprint may, in reality, take two. Or you may just be planning to take three months to refresh and refocus an already effective quality system to achieve something more for consumers than it already does. Whether it s three, six or 12 months, the steps are the same; the important thing is to tailor them to your organisation s needs. Creating a great consumer experience within the complexity of healthcare is not always easy. It s a jungle in there! Competing priorities, clashing sub cultures, unlimited demand for services with limited resources to provide them and dealing with people s lives; these all play out in an incredibly busy and high risk environment. Very little is written specifically for those charged with developing the infrastructure to pull all this together into a coordinated, dynamic and effective system that makes a real difference at point of care. As a result, many health services work with inefficient, resource-intensive processes for monitoring, improving and reporting on the quality of their care and services. Some quality systems are limited to incident reporting, auditing and meeting mandatory requirements, resulting in passive approaches that are a series of activities, rather than an active and coordinated organisational journey towards creating great consumer experiences. Little wonder that many quality system managers find their role more than challenging, executives become frustrated and staff are not always exactly enthusiastic about participating. Having seen too many of these situations, I decided to develop a step by step or month by month blueprint for building a dynamic quality system. Based on the literature, research and practical experience, Create a Great Quality System is essentially a manual for executives, managers and quality system managers who want to design, redesign or review a quality system to have
10 3 greater purpose and effectiveness. The great quality system laid out in this book is based on a simple '3PQ' model, built on robust governance and change management foundations, designed to deliver on compliance requirements and go beyond that to engage staff in creating consistently great care for every consumer. It contains Quality Guru tips that emphasise need to know points, and is packed with checklists, templates, examples and my favourite resources for continued learning and professional development. Create a Great Quality System Blueprint is also the perfect implementation partner to The Strategic Quality Manager Handbook (SQM, 2011), which provides much of the theoretical and practical knowledge base for Create a Great Quality System. SQM covers key issues of change, influence, complexity, data, planning and the quality system manager role in greater depth than you will find here. Create a Great Quality System is the manual that applies this information in a step by step blueprint for developing the mechanics and mindset to transform the consumer experience. SQM is the What and Why; CGQS is the How. If you want the effort and resources invested in your current quality system to achieve more for your organisation s consumers and staff, this book is for you. It is primarily written within the health and aged care context, but the principles, tools and steps are generic and can be adapted to apply in any service industry that is charged with providing a great experience for their consumers. The way we describe the experience in healthcare may be different, but the blueprint for achieving it is basically the same. However you choose to use Create a Great Quality System, I hope it makes your role easier, your quality system more effective, and helps you and your staff to create great experiences for, and with, your consumers. The research on high performing health services tells us that providing consistently good care for all, across the organisation, takes laser-like focus, commitment, planning and hard work over time to create the purpose, people and pillars that support great consumer experiences. It's time to stop re-discovering fire every time a new quality fad comes along, and build solid, sustainable platforms for improvement. The research also reveals that there is a point at which all the work launches its own momentum and takes off. This is the moment you are aiming for: when creating a great consumer experience becomes the way that the organisation - and the people in it - define themselves. And that s what I d like Create a Great Quality System to help you achieve. Dr Cathy Balding 2013.
11 Six Months to Creating a Great Quality System BLUEPRINT SUMMARY great care consumer partnerships effective implementation staff ownership and leadership Redesign quality system maturity
12 TO CREATE YOUR GREAT QUALITY SYSTEM: WHERE DO YOU WANT YOUR QUALITY SYSTEM TO TAKE YOU? In Month 1, you will: Engage with your staff and consumers to define the great consumer experience your organisation wants to achieve for - and with - every consumer, every time, and the behaviours, processes and governance systems required to support it. Identify the purpose, people and pillars of a great quality system. WHERE ARE YOU STARTING? In Month 2, you will: Perform a quality system stocktake on your current system to see what it comprises and how it s working. Draft your quality system development plan. HOW WILL YOU GET THERE? In Month 3, you will: Develop the high level plan to achieve the great consumer experience. Develop the governance accountability system and committee structure Start developing the quality system tools for organising, coordinating and reporting on your quality plan. HOW WILL YOU MAKE IT REAL FOR CONSUMERS AND STAFF? In Month 4, you will: Operationalise the plan for creating the great consumer experience. Develop the formal and informal leadership group. Develop local consumer experience plans and identify the governance supports and behaviour and ownership drivers. HOW WILL YOU GUIDE AND TRACK PROGRESS? In Month 5, you will: Develop the consumer experience plan reporting system. Link the activities of the quality system to the activities of creating a great consumer experience. Build your improvement toolkit. ARE YOU READY FOR ACTION? In Month 6, you will: Finalise the consumer experience organisational and local plans for roll out. Develop the rollout program. Prepare the training and support schedule and content. Plan to celebrate and recalibrate. Plan to develop the quality systems manager role. LET S GET STARTED!
13 MONTH ONE Why Have a Quality System? great care consumer partnerships effective implementation staff ownership and leadership Redesign quality system maturity
14 WHERE DO YOU WANT YOUR QUALITY SYSTEM TO TAKE YOU? To create your Great Quality System in Month 1, you will: Engage with your staff and consumers to define the great consumer experience your organisation wants to achieve for and with every consumer, every time, and the behaviours and governance systems required to support it Identify the purpose, people and pillars of a great quality system The point of a quality system is point of care. Why start with such an obvious statement? This is self-evident, right? Wrong. Many organisations don't question the purpose of their quality system. They ve been a part of healthcare for so long that we all assume that everyone knows why they exist. I rarely see a quality system purpose articulated, however, which is one of the reasons there are so many quality systems taking their organisations on journeys to nowhere. And it s difficult to gain staff commitment to achieving a vague and jargonistic concept of improvement, person-centred care, or worse, accreditation. Being clear and concrete about the point of your quality system will help you achieve tangible results. And this, in turn, attracts support and buy-in from your executive team and staff. Begin with the end in mind Stephen Covey said begin with the end in mind 1 and he was right! Clarity about the purpose of your quality system and absolute commitment to achieving it are the basis for a great quality system. You can t create a great quality system unless you can articulate exactly why you need it. Research into high performing healthcare organisations shows that those that demonstrate consistently good care over extended periods something that is difficult to achieve in the complexity of healthcare are crystal clear about what they re trying to achieve and laser like in their focus on achieving it. 2 Table 1.1 gives an overview of the key purpose of a quality system and the corresponding quality system components. But you need more than this if you want to create a quality system that drives transformation, staff engagement and achieves requisite compliance requirements; you need a clear picture of exactly what the quality system is built to achieve. Your quality system needs a purpose, people focusing their energies on the purpose and pillars to support them (see Appendix J for the '3P' quality system model.) A quality system is made up of hundreds of jigsaw pieces and to put it together you need the picture on the box top. As the picture of a great consumer experience is a complex 3D puzzle, you ll need some tools and instructions as well. But the pieces, tools and instructions are meaningless without a clear picture of what you re trying to build so that everything can be directed at achieving it. They are not ends in themselves. That s why the first month is dedicated to creating exactly that.
15 8 CATHY BALDING / Create A Great Quality System In Six Months What is a quality system? I m defining it as: A systematic, coordinated, organisationwide program of planning, governance, mindset, behaviours, tools, change, measurement, evaluation and action to achieve and maintain the organisation s vision of a great experience for each consumer. Effective organisational quality systems share a number of characteristics: A description of the purpose of the quality system, and the characteristics of the people and governance pillars that will make it happen (see Appendix J). A vision and goals for the quality consumer experience to be achieved. Robust planning that translates the goals into measurable objectives and describes feasible strategies for achieving them across the organisation. Consistent and committed leadership that embraces the goals and aligns improvement activities throughout the organisation to achieve them. Clear and specific roles at each level of the organisation for achieving the goals and objectives. Robust care teams, skilled and supported to achieve the objectives locally and create the consumer experience at point of care. Information and measurement as a platform for monitoring progress and guiding improvement. All staff with improvement roles working in partnership, contributing their different skills and tools to support staff to achieve the goals. Without a vision of what is possible, your quality system is likely to be perceived by staff as just a collection of mechanics : the projects and tools and monitoring activities they have to do. Your quality plan then becomes a long to do list of when these have to be done and by whom. I can t count the number of times I ve heard quality managers complain that no one in their organisation is interested in their quality system; that it s hard to get executive support and even harder to get engagement from clinicians and other staff. This is more likely to happen in organisations with quality systems that are heavy on task - and light on purpose. Lack of purpose is also the cause of quality being seen as the quality system manager s issue because all the staff see when they talk about quality is the quality system (and even then, usually just the dull bits.) They don t see the amazing things that the quality system can achieve for them and for their consumers because we don t define what those amazing things are, and therefore it s hard to see how to make them happen. And the executive team may not understand that these things can t happen without them - not the quality system manager - operationalising the quality plan through line management. Here s the thing: everyone working in healthcare is really busy and/or thinks they re really busy which is essentially the same thing. Perception is reality! No-one thinks they have time to be involved in anything they see as outside of getting their job done or unrelated to the things they value. Doing quality or everyone has to be involved or accreditation is coming up are just not going
16 9 MONTH ONE: Why have a Quality System? to cut it as motivators. Operational quality tasks without a link to a corresponding purpose and strategy can end up being seen as busywork. Staff who see the quality system as a series of tasks will resist engagement, and getting them involved can then become a power struggle where no one wins: a dance between staff and stuff. This is not productive or fun. And it definitely doesn t significantly and sustainably transform the quality of care and services. Your quality system is a means to an end. Is your organisation clear about what that end is? Or is the doing of the quality system an end in itself? Is it about people? Or paperwork? Without a clear picture of what can be achieved, and a motivating and strategic purpose, your executive team might support the quality system to achieve accreditation, or to meet other external and corporate requirements, but they won t make it their business to drive and lead and resource creating a great consumer experience. And without that ownership and leadership, creating a dynamic, effective quality system that engages staff across the health service is just about impossible. That s why this book is for both quality system managers and executives. To be effective, your quality system must cover the same key components required to effect large scale change as seen in Figure because you can t create the great consumer experience without effective change. VISION + SKILLS + INCENTIVES + RESOURCES + ACTION PLAN = CHANGE NO VISION + SKILLS + INCENTIVES + RESOURCES + ACTION PLAN = CONFUSION VISION + NO SKILLS + INCENTIVES + RESOURCES + ACTION PLAN = ANXIETY VISION + SKILLS + NO INCENTIVES + RESOURCES + ACTION PLAN = GRADUAL CHANGE VISION + SKILLS + INCENTIVES + NO RESOURCES + ACTION PLAN = FRUSTRATION VISION + SKILLS + INCENTIVES + RESOURCES + NO ACTION PLAN = FALSE STARTS Figure 1.1 Conditions for effective change 3 Operational executives and quality system managers have critical and interdependent roles Table 1.1 expands the key change components in Figure 1.1 and translates them into quality system components. What I usually see when someone shows me their quality system is points 2-5 in the right hand column. This is not wrong but it s also not purposeful. If your quality system doesn t also have a corresponding left hand column, it s likely that no-one in your organisation - governing body, executive, managers, clinicians, staff - is going to be very excited about the possibilities of the quality system for consumers and staff. And if people can t see the possibility of achieving something of value, they are unlikely to
17 10 CATHY BALDING / Create A Great Quality System In Six Months PURPOSE We need a quality system to: MECHANICS The corresponding components of our quality system are: 1. Define the great consumer experience : the level of care the service will provide for every consumer, every time 1. Defined vision for the great care experience we want our consumers to have, and corresponding goals, objectives, priorities and targets across the dimensions of quality care, linked to the organisational strategic plan 2. Determine the people and systems that must be in place to make the vision a reality: Structure: what you need Process: what you do Outcome: what you expect 3. Ensure people are supported and systems are implemented to achieve the desired quality of care 2. Governance to support quality care: leadership, accountability, culture, resourcing, legislation, standards, policy, protocols, systems and external evaluation to support achievement of quality goals 3. Implementation of systems and governance to support quality care: including clear and supported staff roles, training, resilience development, change models, and sustainability methods and mechanisms 4. Monitor whether practice and systems are achieving the experience we have defined 5. Improve systems and practice if the desired quality of consumer experience is not where it should be and to improve standards over time 4. Monitoring and Evaluation : data collection, analysis and benchmarking across each dimension of quality to track progress with creating the great consumer experience for every consumer, every time 5. Applying continuous improvement science : planning, methods such as PDSA, systems redesign, lean, bundling, learning from other organizations and industries, use of policy, protocols, guidelines, prompts and reminders, monitoring and evaluation of process and outcomes 6. Manage and respond to the risk of things going wrong 6. Proactive and reactive risk management: risk planning and register, controls, reporting, response, and resilience and safety culture Table 1.1: Overview of great quality system components
18 11 MONTH ONE: Why have a Quality System? put any effort into participating. The quality system manager provides many of the elements in the right hand column of Table 1.1: tools and instructions and some of the jigsaw pieces. The operational executive team must supply the box top rationale in the left hand column: the purpose, leadership, commitment and support, for managers and staff to put those pieces together to create great consumer experiences. Define the purpose and key components of your quality system It s important to take the generic components that we ll discuss in this chapter and localise them for your specific organisation, so they make sense to staff at all levels. This is where the executive leader (as they will be called throughout the book), be it the Chief Executive or one of the executives that has this portfolio, takes on their quality system leadership role. They will work with the quality system manager to help plan and operationalize the policy, systems and line management aspects of the quality system, as a quality system manager alone is generally unable to achieve the modifications and transformations required to achieve the great consumer experience. In some cases, of course, the quality system manager will be an executive team member. In this case, it is still important that carriage of the quality system be shared with another, preferably operational, executive member; both for support, because two heads are better than one, and because an operational view of the process will help guide effective implementation, so the quality system is seen as a credible support for operational staff, and not owned by the quality system manager. The first thing to do is define the purpose of your quality system. This does take effort and focus but it s worth it! So for this month, to define a great consumer experience, the executive leader will work with the quality systems manager to canvass the views of the governing body, executive and staff across the organisation. Health and aged care are an interesting mix of technical quality quality control; and service quality improvement and transformation. These components are interdependent either on their own will provide only part of a quality consumer experience. Defining can be done in groups, meetings, or workshops; or if you can t get people together, go to them - move around your organisation and visit the executive team, managers and their staff in their environment for a brief discussion. This exercise is not about teaching or convincing people to be involved in the quality system or berating them for not delivering on something. It s a consultation - a conversation about what they do every day what they d like to fix if they could, what they do well and are proud of and how good they d like to make their day and their consumers days, every day. You should also have these conversations with your consumers. You will have consumer feedback information via satisfaction surveys and other feedback mechanisms but these are often static guides based on the issues you ve asked them to rate. You must find out what s really important to them. You may use a consumer group or the consumers on your health service committees. If you don t have access to these formal mechanisms, that s OK. You re literally
19 12 CATHY BALDING / Create A Great Quality System In Six Months surrounded by consumers and their carers - in waiting rooms, chairs and beds. You have the information you need sitting in front of you! Of course, you must use an ethical approach: seek their (verbal or written) consent to be asked these questions; and explain exactly why you re asking, that their answers will be anonymous and what you intend to do with the information. And, of course, that they can opt out at any time. (Depending on your organisation s policy, this process may require ethics approval.) THERE ARE TWO KEY STEPS TO PURPOSE BUILDING: 1. Create a rich picture of the great consumer experience your organisation wants to provide for, and with, your consumers (what does success look like?) the What we want to achieve. (Purpose) 2. Identify the key strategies, systems and behaviours required to create the great consumer experience the How we can make it happen. (People and Pillars) STEP 1: Create a rich picture: define the quality of experience, care and services your organisation wants to provide for every consumer, every time. Staff need a rich, colourful picture of the end result to buy in to the process of improvement. No-one would agree to pay for a house to be built based solely on a set of blueprints and a project plan. We need to have a clear idea of what the finished product will look like. What will we have at the end of all the work and expense? Are we excited by it? Will it meet our needs? Is it what we want? Did we have a say? Will we be better off? Without a picture of what great care looks like as the guiding purpose, and something that the organisation and its consumers can get excited about, frameworks and plans (and new initiatives, requirements and measures) can become ends in themselves - drivers of doing, rather than achieving. Quality plans can then turn into quality manager to do lists, rather than an organisation s strategic pursuit of great care and experiences for consumers. Brainstorm the characteristics of a great experience for your consumers with the governing body, executive team, managers and staff using questions such as: How would we like to describe our care and services? How would we like our consumers to describe their experience with us? What would we like to be known for? What would we not like to be known for? What does a good day on this ward/in this service look like for: - Our consumers? - Our staff? What aspects of this are we already doing and are proud of? What does it take to create a great day? What gets in the way of us creating a great day every day? How does the current quality system help us to create a great day? What do we believe about our ability to create a great day, every day?
20 13 MONTH ONE: Why have a Quality System? What are the 5 things that must happen for every consumer in our health service to create a quality experience for them and with them? Discuss and define the characteristics of a great consumer experience with your consumers and carers, using questions such as: What things are important to you when you come to our health service? If you had a good experience with us today, how would you describe this to your family and friends? What could we do to make you feel more welcome and important? How could we make your experience in our health service less worrying? These discussions form the basis for creating your organisation s definition of the great consumer experience: What are the components of a great consumer experience from a consumer (subjective) perspective? What are the (objective) components of a great consumer experience, from a staff, or technical, perspective? As well as gathering information from your staff and consumers, you can also use what we know about creating a great consumer experience from the literature and research. For example, The Picker Institute has identified eight domains of patient priority and concern 4 : 1. Respect for patient centred values, preferences and expressed needs 2. Emotional support and alleviation of fear and anxiety 3. Access to care 4. Information, communication and education on clinical status and progress 5. Coordination and integration of care 6. Physical comfort, including pain management, help with activities of daily living and clean and comfortable surroundings 7. Involvement of family and friends 8. Continuity and transition across organisations. On the technical side of healthcare, we know that clinicians and managers value: 1. Providing the right care at the right time 2. Achieving the desired outcomes 3. Prevention of harm and complications 4. Avoiding over and under servicing, treatment delays and wastage. Staff are also likely to want a quality system that addresses key problems for them and their consumers, so it s important to also scan monitoring data and information you have that identifies these, and add this to the mix. When you put that together with the information you ve collected from your discussions with the governing body, managers, staff and consumers, you ll see that you