Counties Manukau Health Library Database & Resource Directory
Innovation and Improvement Spotlight: an archive of MUST reads
*The Innovation and Improvement Clearinghouse is a Ko Awatea resource supporting health system innovation and improvement.
In January 2017, a team from IHI argued that health care organizations must make health equity a strategic priority. The authors identified five key steps for health care organizations: make health equity a leader-driven priority, develop structures and processes that support equity, take specific actions that address the social determinants of health, confront institutional racism within the organization, and partner with community organizations.
Within our Implementation Science Group at PenCLAHRC, we’ve been exploring how evidence-based practices implemented in one hospital can be spread to other departments or hospitals in the South West of England. In theory, this sounds simple. Why wouldn’t other places make improvements to care found to work well elsewhere? In actual practice, as quite often can be the case, the experience was not quite so straightforward. So, we sought to study in real-time how context can critically influence the spread of practices – helping in some places and hindering in others.
Deprescribing is a practice that all clinicians and pharmacists understand, yet guidelines on how and when a patient should stop taking a medication remain rare. The focus of this practice is to reduce or stop medications that may harm or no longer benefit a patient. When physicians can discontinue or decrease the number of medications a patient is prescribed, it both decreases the likelihood of an adverse event, and reduces the financial burden of paying for a multitude of medications.
How can health care providers get back to basics to stop the medications that may be unnecessary or even harm patients?
An innovative program out of Ottawa, Canada demonstrates how simplifying deprescribing can help providers incorporate the basics back into their routine.
While there have been significant strides in providing frontline clinicians with quality information, these clinicians still lack the tools they need to play an active role in controlling the costs of the care they provide. To date, only small steps have been taken at most health care systems (for example, clarifying the costs of specific tests during the test-ordering process), and new clinical analytics systems that offer better insights into costs and efficiency often aren’t integrated into day-to-day clinical care. Worse, discussions at health care organizations about how to increase “overall value” too often degenerate into conversations about cost reduction, with participants forgetting that delivering value means both improving outcomes and lowering costs.
In 2016 the Scottish National Health Service (NHS Scotland) piloted an approach to value improvement that took both cost and quality into account and turned the management of value into the basic task of the point-of-care manager. Value ceased to be a side initiative or something driven solely by top-level finance and executive leaders.
The “lean accounting” method for measuring real, unallocated costs used came from the Institute for Healthcare Improvement and one of us (Brian). IHI had partnered with him to combine a version of lean accounting that had been used in manufacturing with a point-of-care management system.
Improvement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.
Agency for Healthcare Research and Quality (AHRQ)
Patient safety culture has a positive influence on the effectiveness of patient safety and quality improvement interventions. A study was conducted to gain knowledge about promising best practices used by hospitals to improve patient safety culture hospitalwide.
The Health Foundation
This report, written in partnership with the Health Foundation, calls for new approaches to scaling tried and tested health care innovations. It highlights the need to create the right conditions to spread these successfully across the NHS and identifies a shortlist of ten innovations that have successfully spread across the NHS in recent years.
“The report identifies additional implications of the new care models programme for local health and social care leaders embarking on cross-organisational change. Taking time to understand and adapt to the local context is essential for new care models. Sites should focus on care redesign and its intended aims, and reserve time for people to collaborate to support co-design. Finally, evaluation must be seen as a core component of any plan, and teams must be given the time and support to collect and analyse data.”
“The idea that the NHS is slow to adopt seemingly well-evidenced innovations is not new and, for the most part, is accepted as fact. The reasons for this have been extensively studied. Last year, the Accelerated Access Review set out the barriers once again – proposing a number of useful solutions that, if implemented as envisaged, could go a long way to improving the situation.”
Social Care Institute for Excellence
This briefing explains that innovative, often small-scale models of health, social care and support for adults could be scaled up to benefit as many people as possible. It argues that the challenge is to make scaling up successful.
This report covers the learning from 13 acute care collaborations that were established in September 2015 as part of the new care models programme. It highlights six common strategies that have emerged, including the way clinical practices are being standardised; how vanguards are making better use of clinical support services; and how the skills of health care professionals are being used more creatively and flexibly.
This article aims to make a pragmatic contribution to the discussion of how to speed up the adoption of service innovation in the NHS. It draws on eight examples of successful spread of innovation supported by academic health science networks (organisations set up by NHS England in 2013 to identify and spread health innovations, including through connecting the NHS with academic organisations, local authorities, the third sector and industry). We interviewed the originators of the innovations wherever possible and the AHSN staff responsible for supporting adoption and spread, to understand the approach they had taken and the challenges they had encountered.
Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies / by Trisha Greenhalgh et al
J Med Internet Res. 2017 Nov; 19(11): e367.
Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level.
Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program.
Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.
Additional comment from Dr Robyn Whittaker published in the latest NZ Digital Health Research Review
Comment (GH): This paper is an important piece in the ongoing discourse of health technology pilots presenting good evidence but still resulting in a lack of sustained uptake and adoption into business as usual. The authors have distilled a large amount of information through extensive methodology modes to create a framework (NASSS) that aims to help inform and evaluate the success of technology-supported health programmes. The paper lays out nicely questions to use to assess each of the seven domains. They place each response into a matrix of Simple, Complicated and Complex, which then helps set the tone for assessing the difficulty a health technology programme may have in becoming embedded and sustained into service delivery. The authors highlight that the framework could be used retrospectively and prospectively. However they advocate that prospectively using it can inform the implementation and help with lining up the wider system variables that would be needed to support success. However, it is not a deterministic or formulaic tool where if you tick all the boxes you will have success. The authors suggest that the framework is more iterative and should be used to help identify the challenging domains (which will be different depending on the implementation programme) at a (preferably) early stage and therefore set a realistic plan for adoption, spread and sustainability, or contrarily, whether to embark on the programme at all.
There is an overly supply-driven and top-down approach to innovation. Shifts towards the co-production of solutions between clinicians and industry are encouraging, but initiatives such as the Innovation and Technology Tariff (while useful in some regards) do little to move the NHS away from a supply-driven approach, which starts with products first.
Identifying the most pressing problems and looking for solutions is rarely built into anyone’s day job – least of all clinicians. This is further compounded by a lack of clarity around how far chief executives should be involved in adopting innovation. Chief innovation officers with board oversight of the innovation process could make a fundamental difference.
Evidence generation (and the bodies that support it such as NIHR) are often not conducive to assessing real-world innovations in a timely way – particularly where there is a focus on cost effectiveness (rather than cost benefit).
Too often procurement departments and organisations as a whole look to innovations to produce short-term cash-releasing savings, rather than identifying where innovations can transform care pathways and lead to more efficient services. This requires adaptive leadership that can work across boundaries.
There is a tension between the policy push towards large-scale organisations (such as accountable care systems) and the capacity of SMEs to fulfil the needs of large contracts.
Leading Large Scale Change: a practical guide has been produced by the NHS England Sustainable Improvement Team and the Horizons Team, NHS England, to help all those involved in seeking to achieve transformational change in complex health and care environments.
A comprehensive round-up is provided of all the latest thinking and practical approaches and tools that can be used in advancing large scale change. This publication refresh includes:
Updates on the leading transformational change models
The latest thinking from national and global improvement experts and change leaders
New tools, techniques and tips to help effectively progress large scale change programmes
Case studies and learning that will help leaders and change agents in health and care and across public services
Signposting to a host of new online resources including videos, presentations and digital media links.
Care Quality Commission
This report provides practical examples of positive action that some trusts are taking to help meet the challenges of managing capacity and demand. The examples cover a range of areas including ambulance arrivals, initial patient assessments, staffing, managing deteriorating patients and specialist referrals.
The Health Foundation has captured some of the experiences of those working on the vanguard sites of the new care models programme in England. Drawing on the experiences of those leading the vanguard sites of the new care models programme, this report sets out 10 lessons for those seeking to systematically make improvements across local health and care services for those patients who are in most need of joined up care.
It emphasises the value of local co-creation and testing of new care models, and offers useful learning for those seeking to drive the development of new models of care within sustainability and transformation partnerships and accountable care systems.
The report sets out 10 lessons for those seeking to systematically make changes across services in their area. These are based on first-hand accounts of clinicians and managers from the new care models programme’s vanguard sites. These sites have worked through the complexities of bringing together professions and organisations to develop place-based models of better coordinated care for people with complex health and social care needs.
The report finds that assessing and understanding what change efforts have come before, and what organisations and relationships currently exist is vital when developing new models of care. It emphasises the value of local co-creation and testing.
South West Science Academic Health Network
A paper published in the journal Health Research Policy and Systems, reports on an approach to improve health service delivery using a collaborative approach between researchers, health care organisations, commissioners, and patients and the public to introduce and evaluate innovative approaches to person-centred coordinated care (P3C).
Multi-faceted challenges within the care/health environment are the catalyst for new and sometimes radical thinking about how care is delivered. This has resulted in a move away from disease-based models to an effective and integrated person-centred approach – person-centred coordinated care.
For people with complex health needs, their experience is often of fragmented care which results in poor outcomes. P3C is seen as a potential solution, but the dilemma for care providers is there is an absence of accessible evidence or scalable guidance – resulting in services ‘experimenting’ with new models of care with little support on implementation or evaluation.
This collaborative action is being used to support and accelerate the spread and adoption of P3C in UK primary care environments, with a focus on closing the gap between research and practice.
This publication highlights examples of P3C service model innovations and organisational links.
Six Steps for Communications with Impact
Watch a short animated video from 1000 Lives Improvement in Wales that describes how to use communications strategies to meet your QI goals. see also http://www.tandfonline.com/doi/full/10.1179/1753807615Y.0000000006
This briefing examines how embedded behavioural design teams could help providers rethinking the delivery of care in their organisations. Using interviews with experts in clinical delivery innovation and members of behavioural design teams, it highlights best practice in embedded behavioural design teams within health care organisations.
BMJ Quality and Safety
Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.
QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.
Embedding a culture of quality improvement
Quality improvement refers to the use of systematic tools and methods to continuously improve the quality of care and outcomes for patients. This report explores the factors that have helped organisations to launch a quality improvement strategy and sustain a focus on quality improvement.
The report draws on a roundtable event attended by senior local and national NHS leaders, semi-structured interviews with NHS leaders and senior stakeholders involved in quality improvement initiatives, and a literature review.
We identified three common themes for successfully launching a quality improvement strategy: having a clear rationale; ensuring staff are ready for change; understanding the implications for the organisation’s leadership team in terms of style and role.
Key enablers for embedding a culture of quality improvement included: developing and maintaining a new approach to leadership; allocating adequate time and resources; ensuring there is effective patient engagement and co-production; maintaining staff engagement. Fidelity to a chosen approach is critical to sustaining and embedding quality improvement in an organisation’s culture.
The report finds that NHS leaders play a key role in creating the right conditions for quality improvement. Leaders need to engage with staff, empower frontline teams to develop solutions, and ensure that there is an appropriate infrastructure in place to support staff and spread learning.
About 10 years ago, IHI established a Research and Development team and a systematic process of 90-day innovation cycles to tackle some of the vexing issues in health care. A new publication, 10 IHI Innovations to Improve Health and Health Care, curates some key ideas that have emerged from this systematic approach, and reshaped how and what IHI has committed itself to over the years — including the Triple Aim, the concept of a health care Campaign, the Breakthrough Series Collaborative model, among others
The culmination of approximately two decades of IHI’s research, innovation, and learning about hospital-wide patient flow, this white paper guides leaders and quality improvement teams through an in-depth examination of a systems view of patient flow, theories for improvement, and high-leverage strategies and interventions to achieve hospital-wide patient flow.
This publication explores how five vanguards are implementing innovative digital technology solutions at the heart of a new approach to care. They are:
East and North Hertfordshire
Better Care Together Morecambe Bay
Better Together Mid Nottinghamshire
East Midlands Radiology Consortium
The report describes how the starting point for any project introducing new technology should be the perspective of the end users. Technological solutions should be co-produced with people who use services and clinicians to ensure that the solutions are anchored in their needs and experiences.
Engaging staff in the development process, understanding how they work and want to work in future, and providing ongoing support and training, is crucial to the successful implementation of new digital technologies.
The experiences of these vanguards demonstrate that it is possible to overcome the many challenges to adopting digital technology in health and care, and use it to enable more efficient, integrated, precise and personalised care.
In light of the national policy emphasis on enabling supported self-care and the shift towards out of hospital service provision, it is more important than ever before for health and care services to provide tools and information to support people and communities to have greater control over their own health and wellbeing.
Digital technologies can drive, and underpin, care that is truly integrated around the needs of people – breaking down the barriers that have historically existed between primary, secondary and social care services.
When it comes to harnessing technology, local areas should ‘steal with pride’ and make use of learning and evidence from other areas. However new technological solutions need to be considered in the context of local needs, and anchored to wider change programmes across organisations and whole health and care systems.
In isolation, small-scale technology projects will not bring about the fundamental shift envisioned in the Five year forward view. Teams should consider how they can make use of local place-based approaches that encourage collaboration across public services and capitalise on existing strengths and resources in the community.
This briefing makes the case for quality improvement to be at the heart of local plans for redesigning services. By quality improvement, we mean the use of methods and tools to try to continuously improve quality of care and outcomes for patients.
The briefing does this by drawing on existing literature and examples from within the NHS of where quality has been improved and describing how this was done. It describes the potential benefits from investing in quality improvement – including for patients, staff and the financial sustainability of the system.
Quality improvement – the use of methods and tools to continuously improve quality of care and outcomes for patients – should be at the heart of local plans for redesigning services. Leaders have a vital role to play in making this happen – leadership and management practices have a significant impact on quality. Studies have shown that board commitment to quality improvement is linked to higher-quality care, underlining the leadership role of boards in this area.
Improving quality and reducing costs are sometimes seen as conflicting aims when they are in fact often two sides of the same coin. There are many opportunities to deliver better outcomes at lower cost (improving value), for example by reducing unwarranted variations in care and addressing overuse, misuse and underuse of treatment. There are many examples across the NHS showing that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients and staff, while also delivering better value.
The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems. To deliver the changes that are needed to sustain and improve care, there needs to be a move from pockets of innovation and isolated examples of good practice to system-wide improvement.
This briefing looks at a range of current organisational partnerships. It focuses on five different partnering arrangements, as well as interviews with national leaders, and draws out learning to help inform and guide policymakers and providers.
National Quality Forum
The (US) National Quality Forum convened an expert Committee to develop a conceptual framework for measuring diagnostic quality and safety and to identify priorities for future measure development. The Committee’s seven themes and recommendations are intended to apply broadly to those researching or wishing to develop measures related to reducing diagnostic harm.
International Journal for Quality in Health Care
Healthcare reform typically involves orchestrating a policy change, mediated through some form of operational, systems, financial, process or practice intervention. The aim is to improve the ways in which care is delivered to patients. In our book ‘Health Systems Improvement Across the Globe: Success Stories from 60 Countries’, we gathered case-study accomplishments from 60 countries. Common factors linked to success included the ‘acorn-to-oak tree’ principle (a small scale initiative can lead to system-wide reforms); the ‘data-to-information-to-intelligence’ principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); the ‘many-hands’ principle (concerted action between stakeholders is key); and the ‘patient-as-the-pre-eminent-player’ principle (placing patients at the centre of reform designs is critical for success).
Another meta-message centers on the extent of the change people try to enable. With time and focused effort, small scale, purpose-designed, local initiatives can and often do lead to system-wide improvements. Another overarching lesson learned is that the method by which information is captured, analysed and communicated throughout a systems change is fundamental. No reform can stick unless stakeholders are informed, information is exchanged and communication occurs at the right time, in the right place, between the right people, through the right medium. The book also teaches that implementation predicated on relationships between key stakeholders, using evidence on which to base decisions, and adopting clear principles of reform design provide a strong opportunity to deliver system improvements.
A final meta-lesson is the most crucial of all: placing the patient, their experience and well-being, at the centre of an initiative, anchors it to the point of the whole reform enterprise, whichever country is involved. That is the obvious, bedrock test for any reform: does it make care better for patients?
These guides are for organisations seeking to begin or build on their improvement capacity and capability.
The guide builds on 2012 work from the NHS Institute of Innovation and Improvement and draws on the experience of healthcare providers. NHS Improvement has worked with the Institute for Healthcare Improvement (IHI) which have provided subject matter expertise in the development of this co-produced document.
It outlines the IHI ‘dosing’ approach to embedding quality improvement (QI) skills that several NHS trusts have found useful. It:
• outlines the scale of training and development required to embed quality improvement into the fabric of your organisation
• introduces some of the challenges leaders face around building capacity and capability
• introduces the concept of ‘dosing’
• makes recommendations on how to frame and plan the development of a system-wide strategy to build improvement capacity and capability.
Building capacity and capability for improvement is grounded in experiential learning and the application of the concepts, tools and methods to daily work. Both classroom and virtual learning are part of the design principles.
These guidelines and practical tools have been developed as a resource to support staff of Counties Manukau Health to consider ethical implications of quality improvement.
The tools (checklist and decision tree) are intended to:
build knowledge and awareness of potential ethical issues encountered in Quality Improvement
build knowledge to respond to ethical issues arising in Quality Improvement work
provide further resources to support ethical conduct of Quality Improvement.
This report explores how digital tools can help to address rising demand, constrained funding and workforce challenges, and it demonstrates how technology has the potential to revolutionise the way health and care is delivered. It focuses on how five vanguards are implementing innovative digital technology solutions at the heart of a new approach to care.
Rising demand for services, constrained funding and a multitude of workforce challenges require us to think differently about the way we deliver health and care services to meet people’s needs and expectations. Digital tools are key part of the answer to this set of challenges, and the NHS Five year forward view outlined ambitious plans to deliver a step-change in how health and care services use technology.
The report describes how the starting point for any project introducing new technology should be the perspective of the end users. Technological solutions should be co-produced with people who use services and clinicians to ensure that the solutions are anchored in their needs and experiences. Engaging staff in the development process, understanding how they work and want to work in future, and providing ongoing support and training, is crucial to the successful implementation of new digital technologies.
The refreshed guide provides a vital and comprehensive round-up of all the latest thinking and practical approaches and tools that can be used in advancing large scale change programmes.
Leading Large Scale Change: A Practical Guide brings you:
Updates on the leading models that will enable you to address the challenges in achieving transformational change;
The latest thinking from national and global improvement experts and change leaders;
New tools, techniques and tips to help you effectively progress large scale change programmes;
Evidence-based insights and learning that will help leaders and change agents in health and care and across public services;
Thought-provoking content that will help you successfully take forward your STP, vanguard, new care model, accountable care system or other large scale change programme;
Signposting to a host of new online resources including videos, presentations and digital media links.
We have collaborated with NHS Horizons Group and the Health Foundation to produce 8 interviews with key inspirational leaders about their experience of introducing quality improvement changes across health and care.
Our collaboration offers an inspirational insight into 8 leaders, each giving a detailed account on what enabled them to cope with highly stressful factors such as complexity, difficult relationships up and down the NHS and across other care providers, as well as unpredictability in policy shifts.
They provide an unparalleled opportunity to learn from a diverse group of people with diverse experiences. We find out about their successes, mistakes, and how they learnt to use improvement skills in their daily work.
In this paper the authors identify and describe eight different levers for change in healthcare that are each enabled by performance information. Their framework structures these levers in terms of the source of motivation (internal/external) and whether change is planned or emergent.
The eight levers identified are:
cognitive – a means to gauge one’s own performance
mimetic – inform about the performance of others
supportive – provide facilitation, implementation tools or models of care to actively support change
formative – develop capabilities and skills through teaching, mentoring and feedback
normative – set performance against guidelines, professional standards, norms, certification and accreditation processes
coercive – use policies, regulations incentives and disincentives to force change
structural – organisational constraints
competitive – attract patients or funders.
These have then been mapped in a matrix of quadrants each quadrant representing a different way in which change occurs (source of motivation and origin of change).
In any given context (and context matters) multiple levers may operate; but there are also instances whether different levers may act in different directions.
The authors make a number of apposite observations, including:
Measuring performance in healthcare is …about quantifying what healthcare systems, organisations and professionals are really achieving;
Routine release of information can guide planned efforts to improve and provide formative feedback according to agreed regular schedules. However, routine reporting can also lose salience if too many measures or too frequent reporting generates indicator chaos or fatigue;
Levers are the way to harness the power of data to secure improvement. However, a lever rarely operates in isolation—any system, organisation or healthcare professional is subject to multiple levers simultaneously; Meaningful and sustained change is more likely to be secured when different levers work in concert—aligning and reinforcing efforts to improve;
the efficacy of levers is context dependent… there is a need informed and often nuanced application
This is an evaluation report for the Primary Care Home (PCH) model – a way of organising care for groups of 30,000 to 50,000 patients. It was developed by the National Association of Primary Care (NAPC), which commissioned this report.
Established last year, the model seeks to link staff from general practice, community-based services, hospitals, mental health services, social care and voluntary organisations to deliver joined-up care. The model was piloted in 15 rapid test sites, each of which qualified for £40,000 of start-up funding from NHS England. Since then another 170 sites have signed up.
Our formative evaluation was based on reviews in 2016/17 of 13 rapid test sites’ plans and priorities for building the PCH model, and an in-depth look at the progress and early successes in three case study areas.
The report looks at how sites can make early progress with implementing and evaluating their local PCH models, examines what might stand in the way of change and offers a number of broader lessons for the NHS as a whole.
In October 2009, AHRQ launched the Patient Safety and Medical Liability (PSML) Initiative to address four goals: (1) putting patient safety first by reducing preventable injuries, (2) fostering better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries while reducing malpractice litigation, and (4) reducing liability premiums. Under the PSML initiative, AHRQ funded 13 planning grants and 7 demonstration grants; the goal was to help States and health systems seek comprehensive solutions that improve patient safety and address the underlying causes of the malpractice problem.
This publication, Advances in Patient Safety and Medical Liability, presents contributions and findings from the AHRQ-funded projects. In addition to a prologue, the volume includes two commentaries and nine papers, organized into two primary themes: improving communication and improving patient safety.
The health system in Canterbury, New Zealand, has undertaken a significant programme of transformation over the past decade. As a result of the changes, the health system is supporting more people in their homes and communities and has moderated demand for hospital care, particularly among older people.
Change was achieved through developing a number of new delivery models, which involve better integration of care across organisational and service boundaries, increased investment in community-based services, and strengthening primary care.
The experience in Canterbury offers useful lessons in terms of how to redesign care in this way. Key approaches include the development of a clear, unifying vision of ‘one system, one budget’; sustained investment in giving staff skills to support them to innovate and giving them permission to do so; and developing new models of integrated working and new forms of contracting to support this.
International Journal for Quality in Health Care
Paper reporting on a project undertaken in nine Australian hospitals seeking to improve the management of inadvertent peri-operative hypothermia. This paper focuses less on the intervention and more the approach or model adopted (or more accurately, adapted). The authors discuss taking the models developed by the Institute of Healthcare Improvement and the Johns Hopkins Quality and Safety Group and developing a ‘hybrid model’. This model focused on engaging those most affected by the intervention so as “to engage the hearts and minds of healthcare clinicians, and others in order to empower them to make the necessary improvements to enhance patient care quality and safety.” In a sense this is an example not so much of developing models but being aware of the importance of context. Transferability is often not so much a case of simply importing a solution but understanding the local context and making adjustments and modifications to suit the local setting.
Having witnessed tracking technology first hand in two American health care organisations, in a new long read Sophie Castle-Clarke sets out its strengths and how to implement it successfully.
Case studies: Focus on improving patient flow
This series of case studies explains how selected providers are delivering effectively against good practice priorities.
Even the most dedicated quality improvement champions get overwhelmed sometimes. How do we avoid wasting time and resources on improvement initiatives that don’t succeed or “stick”? How can we prevent overwork, resentment, and burnout related to QI? IHI faculty member Chris Hayes says one way to do this is to use the “Highly Adoptable Improvement” model that he helped develop. According to this model, change initiatives that don’t add to workload and have high perceived value are most likely to be adopted, cause less workplace burnout, and achieve their intended outcomes.
In IHI Framework for Improving Joy in Work
There are many ways to take a systems approach to improving joy in work. The aim is to make the change process rewarding and effective. Using principles of improvement science, organizations can determine if the changes they test are leading to improvement; if they are effective in different programs, departments, and clinics; and if they are sustainable. In IHI’s prototype initiative, teams used the Model for Improvement27 or another improvement method that was standard in their organization. In all cases, the teams set an aim for their work, decided on measures that would tell them if they were making progress, and selected components of the Framework for Improving Joy in Work as areas in which to test changes.
The full research report from the Institute's latest benchmarking study provides insights into trends in structure and practice, leadership and measurement and offers core considerations for organizations looking to lead in experience excellence. The largest research of its kind, the study engaged almost 1,700 respondents from 26 countries representing six continents sharing the challenges and opportunities they are facing and the steps they are taking to address the patient experience.
According to the research:
Experience efforts are expanding and are now an integral part of the fabric of our healthcare efforts.
Patient experience remains a top priority with a focus on employee engagement now seen as a central driver in experience efforts.
Leadership and culture are now the significant motivators versus the historic focus on mandates and requirements, and there is a recognition of the impact that patient/family voice and caregiver engagement has on the work of healthcare.
Patient experience itself continues to establish presence with the role of patient experience leaders, experience team size and the use of a formal definition on the rise.
Patient experience is now being recognized as an integrated effort touching on much of what we do in healthcare and one that drives clear and measurable outcomes
The guide outlines areas for providers to focus on to improve the safety, efficiency and effectiveness of their urgent and emergency care programmes. Each section contains links to supporting resources that provide further detail.
Good patient flow is central to patient experience, clinical safety and reducing the pressure on staff. It is also essential to the delivery of national emergency care access standards. Experts consistently advocate focussing on patient flow as a key factor in providing effective health care.
The good practice guide is also accompanied by a series of case studies that offer examples of how providers have implemented some of the principles in the guide.
National Institute for Health Research
The UK’s National Institute for Health Research (NIHR) have produced this themed review focusing on three themes relating to the care of older people in care homes
Living well – maintaining good health and quality of life
Ageing well – managing long term conditions associated with ageing (Noting that 70% of people in care homes have dementia or severe memory problems)
Dying well – ensuring a good quality end of life (Noting that 18% of the people who die in England each year die in a care home).
The King’s Fund
Quality improvement approaches – increasingly well-established in NHS acute hospitals – could play a key role in improving the quality of mental health care.
A growing number of mental health providers (in the UK and beyond) are beginning to embed quality improvement across their organisations, with some encouraging results. The approach is based on the concept that sustained improvement is best achieved by empowering frontline teams, service users and carers to design, implement and test changes to services.
This report describes the quality improvement journey of three mental health organisations (two in England and one in Singapore). It provides key insights and lessons for others considering embarking on a similar journey.
Sustaining change is one of the biggest challenges in quality improvement. Studies estimate that up to 70 per cent of change initiatives fail to stick.[
How, then, can you maximise the sustainability of your quality improvement project? This article shares eight tips for sustainability factors that are often overlooked.
The Folau I Lagi-Ma collaborative project brought together project manager and improvement advisor expertise from Ko Awatea with the clinical expertise of frontline healthcare staff. Together, they created an innovative new model of selfmanagement support that integrates occupational therapy and peer support into primary care to help people living with long-term conditions in Counties Manukau to manage their own health and achieve a better quality of life.
Perhaps the more difficult aspects of an intervention or innovation in health care are the implementation and evaluation. This short (29-page) guide offers some suggestions on possible project/research designs that permit clearer evaluation of the intervention. The guide includes flowcharts to suggest which designs are better suited to the question or intervention being studied.
The guide is aimed at program managers and other stakeholders implementing innovations in public health and community settings who are involved in evaluation but may not themselves be evaluators. The evaluation designs covered included a mix of experimental, quasi-experimental and observational designs. For each design there is an illustrated description, examples, discussion of strengths and weaknesses and more, including discussion of the compromises involved in design selection.
National Academy of Medicine
According to this report from the [US] National Academy of Medicine, “the top 1 percent of patients account for more than 20 percent of health care expenditures, and the top 5 percent account for nearly half of the nation’s spending on health care”. The National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops and summarizing the presentations, discussions, and the relevant literature. This resulting document, reports and reflects on the following issues:
Key characteristics of high-need patients
Use of a patient categorization scheme—or a taxonomy—as a tool to inform and target care
Promising care models and attributes to better serve this patient population, as well as insights on “matching” these models to specific patient groups
Areas of opportunity for policy-level action to support the spread and scale of evidence-based programs. The publication concludes by exploring common themes and opportunities for action in the field.
The Academy argues that “Improving care for high-need patients is not only possible–it also contributes to a more sustainable health system. But progress will take a coordinated effort from policy makers, payers, providers, and researchers, as well as patients and their loved ones.”
This report looks at Scotland’s unique health care system, and explores how other parts of the UK might be able to learn from it.
It looks at how health care in Scotland is different, where its approach seems to solve problems being faced elsewhere in the UK, and whether that approach could be transplanted to England, Wales and Northern Ireland. It also assesses whether there are areas where Scotland could learn from its peers.
Scotland has a unique system of improving the quality of health care. It focuses on engaging the altruistic professional motivations of frontline staff to do better, and building their skills to improve. Success is defined based on specific measurements of safety and effectiveness that make sense to clinicians.
Scotland’s smaller size as a country supports a more personalised, less formal approach than in England. The Scottish NHS has also benefited from a continuous focus on quality improvement over many years. It uses a consistent, coherent method where better ways of working are tested on a small scale, quickly changed, and then rolled out. This is overseen by a single organisation that both monitors the quality of care and also helps staff to improve it.
IHI’s QI Essentials Toolkit includes the tools and templates you need to launch and manage a successful improvement project. Each of the ten tools in the toolkit includes a short description, instructions, an example, and a blank template.
BMJ Quality & Safety
It is temptingly easy to treat improvement interventions as if they are drugs—technical, stable and uninfluenced by the environment in which they work. Doing so makes life so much easier for everyone. It allows improvement practitioners to plan their work with a high degree of certainty, funders to be confident that they know what they are buying and evaluators to focus on what really matters—whether or not ‘it’ works.
But of course most people know that life is not as simple as that. Experienced improvers have long recognised that interventions—the specific tools and activities introduced into a healthcare system with the aim of changing its performance for the better1—flex and morph. Clever improvers watch and describe how this happens. Even more clever improvers plan and actively manage the process in a way that optimises the impact of the improvement initiative.
The challenge is that while most improvers (the authors included) appreciate the importance of carefully designing an improvement intervention, they (we) rarely do so in a sufficiently clever way. In this article, we describe our attempts as an experienced team of practitioners, improvers, commissioners and evaluators to design an effective intervention to improve the safety of people living in care homes in England...
The Getting It Right First Time (GIRFT) programme aims to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices.
It uses national data to identify the variations and outcomes, shares that data with all those concerned with a service – not only clinicians, but also clinical and medical directors, managers and chief executives – and monitors the changes that are implemented.
The programme began with orthopaedics and is now being rolled out to 32 different surgical and medical specialisms across the English NHS. Through an informal assessment of the programme, this paper sets out what the programme is, why it is needed, what is different about it, what it has achieved, what challenges it faces and what potential it has. It also contains vignettes illustrating hospitals’ experiences of the programme.
In June 2014, National Voices set out to explore and test how communities of practice could facilitate the spread of large-scale change across England’s voluntary sector working for health and wellbeing.
This publication reflects on our experiences over the last 3 years, and in the spirit of communities of practice, aims to share reflections in order that others can use our learning.
In an era of digital business and rapid technology change, virtually no company can ignore the imperative to innovate. Failing to do so is an invitation to lose business.
To learn how companies are responding to this mandate, PwC conducted a major global study. We surveyed over 1,200 executives in 44 countries and spoke in depth with individuals charged with managing innovation initiatives at leading companies. Our goal was to understand how these leaders view innovation and what they are doing to better reap its rewards. We looked at innovation across a complex set of challenges, including innovation strategy, operating models, culture, metrics, and more to understand how innovating companies are seeking to create business value and financial returns on their efforts.
The latest snapshot of the quality of New Zealand’s health care shows continuing improvements, but also highlights ongoing inequity in treatment.
Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time.
The operating room is the single most important place in the hospital for surgeons. Despite enormous innovation in surgical practice, relatively fewer advances have been made to the actual operating room itself. New technology and devices have been introduced to crowd the space, but changes to the actual lay out and how to organize the room remains largely unchanged. Indeed, many of the design shortcoming described by surgeons 4 decades ago—“faults in equipment, inaccessibility of necessary items, problems in communication, inefficient handling of materials, unconscionable delays … that are an expression of a hazardous environment”1—could readily be identified by surgeons today.
The problem of building a better operating room is not new and arises largely from knowledge gaps between architects and users of the operating room. Many surgeons and nurses who have been involved in operating room planning and are around to occupy that space afterwards are often disheartened by the gap between their suggestions and the result. The architects, however, are faced with enormous constraints—budgets, regulatory codes, materials limitations—that they cannot or do not communicate well. Revisions made to accommodate these constraints can often make the initial plan unrecognizable leaving care providers wondering why they ever offered their input to begin with.
In this perspective, we take both an architectural and surgical view to outline current limitations of operating room design and emerging solutions to facilitate improvement
Care Quality commission
We spoke to staff, patients and local patient representative groups at eight trusts that have shown significant improvement.
We set out to explore what a selection of NHS trusts had done to become 'well-led'. We chose eight trusts that had shown significant improvement since a previous inspection.
We asked people in those trusts how they had achieved improvements, looking at the steps their leaders had taken and the effect of those actions on staff and patients.
We interviewed a range of people from each trust, including chief executives, medical and nursing directors, non-executives, heads of communications, frontline staff, patient representatives and external stakeholders.
BC Patient Safety & Quality Council
This resource is intended to facilitate working with groups to accelerate improvement through interactive team-building activities. It is designed to develop communication skills, model adaptive systems, shift culture, and foster innovation, creativity, and thought diversity.
For each of the activities in this resource, we outline the purpose, category, instructions, time commitment/range, number of participants, resources required, and debriefing notes.
Healthcare today is all about cooperation. Everywhere you look new networks, federations and communities of practice are emerging.
Acute providers that once had little inclination, or, they argued, the time to look beyond their own walls are forging ties with their primary and community care neighbours. Multi-professional working, once the exception, is now the norm in many parts of the NHS. And innovative ways of capturing and using data from multiple organisations are now being developed.
All of this activity is helping to improve the quality and safety of patient care. But there is still plenty of work to do.
Many of these fledging collaborations are still feeling their way and are a long way from being embedded into the healthcare landscape. Overcoming the legacy of 70 years of siloed working within the NHS and professional divides that often go back even further is far from easy. Nor are there any shortcuts or quick fixes: mandating collaborative working, or trying to force the issue through structural change, doesn’t work – this much we know from previous re-organisation attempts.
So what can we do to build on what’s been done to date and galvanise the rest of the healthcare system? One area of real potential is flow, or more specifically, the way in which patients, staff, information and resources flow between services and organisations. Read more …
As I qualified in 1989, my career has coincided with the growing evidence based medicine movement. It’s been a major advance in evaluating clinical interventions, defining best practice, and moving beyond a reliance on expert opinion or tradition. It’s given us methodologically consistent systematic reviews such as Cochrane, and evidence based guidelines such as those from NICE.123
Medics learn that good systematic reviews and meta-analyses top the evidence pyramid, then randomised controlled trials (RCTs).45 In conventional evidence based medicine, even good local observational and implementation data are ranked as less weighty evidence. This may skew our world view—making it harder for quality improvement (QI) work to find academic funding, prestige, or publication impact.
Shouldn’t we start giving QI work equal status to evidence based medicine, given its powerful ability to tackle pressing and relevant problems in individual systems and services in real time? Read more …
Health Quality and Safety Commission
Raising the Bar on the National Patient Experience Survey responds to the national inpatient experience survey results by investigating the lower scoring areas of the survey and recommending interventions to improve these results. Four DHBs participated and provided opportunities for staff and patients to explore the reasons behind the responses to information about medication side effects and discharge from hospital through interviews, observation and focus groups. The results suggest there are interventions that could improve the experience for patients and staff and lead to improved patient outcomes, reduced readmission rates, and reduced health care costs associated with these readmissions.
Since 2010 the Health Foundation has been investing in and promoting improvement research; the work they have supported has improved care and altered national policy. We are delighted that the Foundation is now investing around £40 million in the establishment of an improvement research institute. This new organisation is being set up and run by the University of Cambridge, working closely with a wide range of partners including the health service, university and charity sectors and from other sectors across the UK.
Our vision for the institute is bold and ambitious: we want to create the enabling infrastructure for the NHS to become the world’s largest producer of systematic learning about how to improve health care for patients. To do this, we will use innovative approaches ranging from citizen science through to large-scale research capacity building, and we will be working directly with patients themselves as partners.
The basic principle behind the institute is a simple but important one: we need to get better at getting better at delivering healthcare, and one way to make that happen is by creating a better evidence-base for improvement. Read more …
The Health Foundation is working with Dr Harry Rutter from the London School of Hygiene and Tropical Medicine to develop a new model of evidence that will inform the policy and action needed to make our population healthier. We spoke to Dr Rutter about the challenges inherent in generating and using evidence in new ways, and how traditional measures alone don’t capture the complexity of work in this area.
Ko Awatea has published a guide to enabling self-management support which describes programme options to deliver this type of support and the patient, clinician and service activators that enable these options.
The guide, Enabling self-management support, is based on learning from Ko Awatea’s Manaaki Hauora – Supporting Wellness campaign, which aimed to provide self-management support for people living with long-term conditions in Counties Manukau.
The Manaaki Hauora – Supporting Wellness campaign covered 16 collaborative teams in different settings and clinical contexts, each of which worked towards a unique aim that contributed to the overall campaign goal. Ten of the teams, whose projects demonstrated the greatest reach and impact, are featured in the guide.
Self-management support options that demonstrated reach and impact in the Manaaki Hauora – Supporting Wellness campaign include the use of peers to engage with and support patients, personalised self-management support, health passports, the use of health coaches, generic and condition-specific group-based self-management support, group care planning, and ongoing support.
These options work well when the patient, the clinician and the healthcare system are activated.
The campaign also identified six system-level enablers which must exist in complement with factors that activate patients and clinicians to establish and deliver self-management support services that work well and make a difference for people with long-term conditions.
“The support of senior managers to address barriers is important, as is making resources available. The use of co-design and collaborative methodology provides quality improvement teams with a framework for ensuring that services and resources meet the needs of patients and their families and putting improvement initiatives into practice. Quality improvement project teams also need passionate leadership, and they are more likely to succeed if staff turnover is low during the project period or succession planning is in place,” says Ms Dowdle.
Ko Awatea has published key learning from the 5th APAC Forum in The APAC Forum Report 2016. The report captures the highlights from the 5th APAC Forum to create a permanent, written record of the most valuable insights and ideas presented at the conference.
The APAC Forum Report 2016 covers:
15 in-depth, full-day intensives, covering topics from leadership to gamification, mindfulness to patient safety
four inspiring and diverse keynote addresses from world-renowned presenters
48 concurrent sessions that examined key issues in healthcare and provided practical examples of change in action
six short, powerful InSight talks designed to inspire and incite action to improve and transform health and care
winners in eight categories in the Ko Awatea International Excellence in Health Improvement Awards
winners in six categories in the Poster Awards.
A summary of the insights from each is presented in the report.
A paper published by Ko Awatea and the Ministry of Health in the New Zealand Medical Journal shows how 18 DHBs are implementing Enhanced Recovery after Surgery (ERAS) protocols in their orthopaedic services.
The paper, Implementation and effects of Enhanced Recovery After Surgery for hip and knee replacements and fractured neck of femur in New Zealand orthopaedic services describes the implementation of ERAS for elective hip and knee joint replacement and acute fractured neck of femur, and its effects.
ERAS comprises an evidence-based, multimodal, patient-centred rehabilitation programme for patients undergoing surgery. It is known to significantly improve surgical outcomes for patients and the cost-effectiveness of care.
The National Orthopaedic ERAS Collaborative, launched in 2013, implemented ERAS protocols using IHI Breakthrough Series (BTS) collaborative quality improvement methodology.
Compliance with the elements that make up ERAS increased from 33% to 75% for knee replacements, from 31% to 78% for hip replacements, and from 29% to 51% for fractured neck of femur. The length of time patients spent in hospital for knee joint replacement fell from 5.4 days to 4.5 days, and for hip replacement from 5.1 days to 4.3 days.
“ERAS can be difficult to implement because it requires all members of a multidisciplinary peri-operative team to work together to implement identified protocols. The National Orthopaedic ERAS Collaborative shows that BTS methodology works to implement ERAS on a large scale,” says Suzanne Proudfoot, Projects and Campaign Manager, Ko Awatea.
“When you look at the success we’ve had with this and our Target CLAB Zero collaborative, which reduced the national CLAB rate in intensive care units by 96%, you can see the potential of this methodology to address other problems in healthcare.”
Patient safety experts and researchers have increasingly pointed to the role of organizational culture in the success of patient and workforce safety initiatives. Yet, creating a culture of safety in healthcare settings has proven to be a challenging endeavor, and there is a lack of clear actions for organizational leaders to take in developing such a culture.
Leading a Culture of Safety: A Blueprint for Success was developed to bridge this gap in knowledge and resources by providing chief executive officers and other leaders with a useful tool for assessing and advancing their organization’s culture of safety. This guide can be used to help determine the current state of an organization’s journey, inform dialogue with the board and leadership team, and help leaders set priorities.
The high-level strategies and practical tactics in the guide are divided into two levels:
The foundational level provides basic tactics and strategies essential for the implementation of each domain.
The sustaining level provides strategies for spreading and embedding a culture of safety throughout the organization.
What role can open innovation play in addressing health challenges around the world? In this report, we explore the ways that companies, governments and researchers around the world are collaborating to improve the innovation process in health, from the way that problems are identified to how new products and services are created and then adopted by providers of healthcare.
The guide is the result of a collaboration with the State of São Paulo and the UK government and involved testing open innovation methods in Brazil through two pilot projects. It identifies open innovation approaches across the innovation cycle.
Institute of Healthcare Management
The report focuses on the processes and behaviours of the emergency teams that are managing to deliver outstanding results despite the ever increasing challenges. The report is a must for anyone that works in or interacts with A&E departments or is interested in how human factor changes can positively influence difficult situations.
This report highlights the importance of using data to identify and shape solutions to this challenge; listening to the people in the frontline, staff and patients; and of planning improvement as part of a whole system.
This paper looks at compassion – which involves attending, understanding, empathising and helping – as a core cultural value of the NHS and how compassionate leadership results in a working environment that encourages people to find new and improved ways of doing things.
It also describes four key elements of a culture for innovative, high-quality and continually improving care and what they mean for patients, staff and the wider organisation: inspiring vision and strategy positive inclusion and participation enthusiastic team and cross-boundary working support and autonomy for staff to innovate.
The paper also presents case studies of how compassionate leadership has led to innovation.
This report draws on interviews with Culture of Health stakeholders whose work focused on culture, incentives, or both to learn how organizations are addressing and leveraging culture and incentives to promote health and well-being.
Key findings include the following:
Equity is often addressed in silos, which impedes progress toward a unified goal of health equity for all;
members of specific cultural groups need to be given a voice in health-related activities;
systems are built around prevailing cultural norms, making it challenging for those working with specific cultures to make cultural adaptations; and not all incentives are monetary.
Recommendations include institutionalizing practices that ensure ongoing input from marginalized populations, identifying ways to help smaller organizations overcome structural inequalities, and institutionalizing health promotion efforts in sectors other than public health or health care to sustain collaborative efforts.
Patient Experience Journal
The Health & Quality Safety Commission New Zealand commissioned Ko Awatea, an innovation and improvement centre, to deliver a co-design programme to nine teams of healthcare providers. The co-design programme was part of Partners in Care, a broader programme developed in 2012 to support and enable patient engagement and participation across the health and disability sector. Health professionals identified key challenges to patient engagement as capturing diverse experiences, clear communication of project details and the availability and health of the patient. Patients advised the importance of improved communication, planning in advance and providing feedback and assurance about the value of their contribution. There are several important considerations to secure and maintain patient engagement in co-design. These include tailored strategies for approaching patients and capturing their experiences, pre-existing relationships and continued rapport building between patients and health professionals, good communication throughout the project, planning, and visibility of outcomes.
This briefing summarises the findings of a study which surveyed patient experience of care coordination in eleven high-income countries (incl. NZ). The dimensions of care coordination assessed for this study were: access to medical records or test results; receiving conflicting information; use of diagnostic tests that the patient felt was unnecessary; and dissemination of information between primary care doctor and specialist.
THE BOTTOM LINE
Adults with poor primary care coordination were more likely to be hospitalized and more likely to visit the emergency room for nonurgent and urgent care than people who did not report poor coordination. An established relationship with a regular physician was associated with better care coordination, indicating the ongoing benefits of strengthening primary care.
This compilation of best practices illustrates the global efforts to increase patient safety. Development and implementation of patient safety measures require continuous interaction of the three areas Policy, Evidence, and Implementation. Prerequisites of feasibility and the benefits of this interaction are a close collaboration and communication between lawmakers, scientists, stakeholders, healthcare professionals, and patients. The various examples in this best practice compilation provide a good insight in working cooperation, opportunities, and challenges when improving patient safety. All these examples have in common that the long-term success depends on the synergy of policy, evidence, and implementation: the most promising evidence-based approach is only sustainable if it can be successfully implemented in healthcare settings and is supported by governmental decisions. The topics in this compilation range from global issues on patient safety efficiency to preventions of patients harm caused by infections or specific antibiotics. This booklet can finally guide governments, scientists, stakeholders, healthcare professionals, and patients to contribute to the promotion of regional and global safety culture.
Over the past four years, the OECD has conducted a series of in-depth reviews of the policies and institutions that underpin the measurement and improvement of health care quality in 15 different health systems. This synthesis report draws on key lessons from the OECD Health Care Quality Review series. The objective is to summarise the main challenges and good practices to support improvements in health care quality, and to help ensure that the substantial resources devoted to health are being used effectively in supporting people to live healthier lives. The overarching conclusion emerging across the Health Care Quality Review series concerns transparency. Governments should encourage, and where appropriate require, health systems and health care providers to be open about the effectiveness, safety and patient-centredness of care they provide. More measures of patient outcomes are needed (especially those reported by patients themselves), and these should underpin standards, guidelines, incentives and innovations in service delivery. Greater transparency can lead to optimisation of both quality and efficiency – twin objectives which reinforce, rather than subvert, each other. In practical terms, greater transparency and better performance can be supported by changes in where and how care is delivered; changes in the roles of patients and professionals; and employing tools such as data and incentives more effectively. Key actions in these three areas are set out in the twelve lessons presented in this synthesis report
Clinical Interventions in Ageing
Objectives: The main objective was to investigate the applicability and effectiveness of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility (SNF)-to-hospital readmissions.
Problem: The rate of rehospitalizations from SNF within 30 days of original discharge has increased within the last decade.
Setting: The research team participants conducted a literature review via Cumulative Index of Nursing and Allied Health Literature and PubMed to collect data about quality improvement implemented in SNFs.
Results: The most common facilitator was the incorporation of specialized staff. The most cited barriers were quality improvement tracking and implementation.
Conclusion: These strategy examples can be useful to acute care hospitals attempting to lower bounce back from subacute care providers and long-term care facilities seeking quality improvement initiatives to reduce hospital readmissions.
Objective To examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care.
Conclusions Positive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of ‘good’ feedback. Relative scores are more easily interpretable when used to compare the performance of providers.
In patient-centred healthcare systems, patients should be enabled to reflect candidly on their experiences of care, and be certain that such experiences make a meaningful contribution to quality improvement.
This briefing summarises research that analysed data from over 230,000 anonymised patient records for older people aged 62–82 years. The research found that there were fewer hospital admissions for certain conditions when the patient saw the same GP more consistently. Patients who saw their usual GP two or more times out of every ten were associated with six per cent fewer avoidable hospital admissions.
Leading health systems have invested in substantial quality improvement (QI) capacity building, but little is known about the aggregate effect of these investments at the health system level. We conducted a systematic review to identify key steps and elements that should be considered for system-level evaluations of investment in QI capacity building.
This research draws on an extensive literature review to assess the realism of the narrative that moving care out of hospital will save money. It explores five key areas: elective care, urgent and emergency care, admission avoidance and easier discharge, at risk populations, and self-care.
Our research has shown that despite the potential of initiatives aimed at shifting the balance of care, it seems unlikely that falls in hospital activity will be realised unless significant additional investment is made in out-of-hospital alternatives.
Where schemes have been most successful, they have: targeted particular patient populations (such as those in nursing homes or the end of life); improved access to specialist expertise in the community; provided active support to patients including continuity of care; appropriately supported and trained staff; addressed a gap in services rather than duplicating existing work.
Implementation and contextual factors cannot be underestimated, and there needs to be realistic expectations, especially around the economic benefit of new care models. If STPs continue to work towards undeliverable expectations, there is a significant risk to staff morale, schemes may be stopped before they have had a chance to demonstrate success, and gains in other outcome measures such as patient experience may be lost.
A staggering 36,000 randomized controlled trials (RCTs) are published each year, on average, and it typically takes about 17 years for findings to reach clinical practice. Proposed changes in frontline care often originate with suggestions from clinicians, but evaluating their merit can be time-consuming and expensive. Focused evidence reviews may yield inconclusive results that don’t lend themselves to clear-cut decisions; pilot studies are vulnerable to poor design, less-than-rigorous evaluation, scant evidence, and other limitations. The result: a logjam of epic proportions that slows the real-world implementation of evidence-based practices. At Kaiser Permanente Southern California (KPSC), we aimed to find a quicker, more effective, more systematic way to break that logjam in a manner that is consistent with the Triple Aim.
The result was E-SCOPE — Evidence Scanning for Clinical, Operational, and Practice Efficiencies — a system for identifying and rapidly implementing clinical and operational practices that are supported by newly published, high-quality evidence.
Five years ago, Maureen Bisognano, IHI President Emerita and Senior Fellow, gave an influential keynote at IHI’s Summit. Her exhortation to ask not only “What's the matter?” but also “What matters to you?” is helping to fundamentally change the conversation between clinicians and patients. In a preview of her upcoming keynote at IHI’s April 20-22 Summit on Improving Patient Care in the Office Practice and the Community, Bisognano shares why “What matters to you?” has spread around the world. She also shares how this change in the balance of power increases patient engagement and has the potential to increase joy in work.
Every year, over 150 students submit their work in quality improvement, IHI Open School Chapter leadership, and community organizing. A group of interprofessional faculty review the submissions across the categories select three winners to present their storyboards at a special session.
This blog post highlights a few of the exceptional quality improvement projects IHI Open School learners are leading. Students and trainees tackled all types of projects in many settings — offering translation for patients with limited English proficiency, making more effective referrals from birth centers to acute care, and reducing patient wait times. They set clear aims appropriate to the context of their system, used specific improvement methods and tools, highlighted the data that demonstrated improvement, and shared a clear study of their results as they look toward future tests of change.
Stanford Social Innovation Review
All too often, nonprofits take a “build it and they will come” approach, focusing most of their efforts on creating services that they think are innovative or effective, and expressing surprise when those services go begging for participants. It’s time for nonprofits to develop a more sales-driven approach to social change...
There are three critical steps nonprofits need to take when creating and implementing solutions. In the sections that follow, each of these three steps will be explored in detail.
Recognize the limits of designing a service or program primarily for effectiveness and also design for “spreadability.”
Go beyond identifying a broad group of potential beneficiaries and focus first on a subgroup most likely to participate.
Develop and resource a sales and marketing capability from the outset, right alongside budgeting for program delivery.
This study looked at the level of influence the following factors have on each other:
And how they affect innovation capability and performance within organisations
As more and more health care organizations apply quality improvement (QI) methods to improve care processes, some common questions arise: What’s the difference between a QI approach and more traditional research and evidence-based medical practice? Is there “additive benefit” from bringing together these approaches? Dr. Amar Shah, Associate Medical Director and Consultant Forensic Psychiatrist at East London NHS Foundation Trust, and Dr. Robert Lloyd, IHI Vice President, make a case for bringing the best of quality improvement and traditional research together. They provide examples to illustrate how improvement-based testing of evidence-based interventions can lead to more efficient and effective implementation.
American Hospital Association
This report showcases how volunteer services support the Triple Aim, a framework developed by the Institute for Healthcare Improvement that outlines an approach for maximizing the performance of the health care system. This framework looks at improving the patient experience of care; improving the health of populations; and reducing the per-capita cost of health care.
The Joint Commission Journal on Quality and Patient Safety
One of the issues around discharge from hospital is the communication with the patient’s GP or other provider(s) about that hospitalisation. This paper describes the approach taken at a US academic children’s hospital. The quality improvement intervention used Lean methodology, engagement frontline provider s (usually residents), and redesigned workflow processes within the electronic health record to improve communication around discharge. The study reports that they achieved their goal communication with primary care physicians at discharge to 80%, and that this was then sustained for a 7-month period.
A new white paper from IHI and Safe & Reliable Healthcare presents a framework for achieving safe and reliable operational excellence in health care organizations and systems. The authors describe the key strategic, clinical, and operational components required to create a “system of safety” — not just a collection of stand-alone projects. The framework comprises two foundational domains — culture and the learning system — and provides definitions and implementation strategies for nine interrelated components, with patient and family engagement at the core. Organizations may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date.
This paper is a synthesis of findings from a three year research programme on “engaging with the ‘hard to reach’ to improve uptake of social and health service”. The researchers recognised that ‘hard to reach’ is a problematic way of thinking about potential clients of a service. The ‘hard to reach’ may not necessarily see themselves as ‘hard to reach’, and it may be services that are ‘hard to reach’. The project chose to focus on ‘making services reachable’. Following a typology published by Heatley (2016), the kind of programmes and agencies that have informed our findings, and for whom our findings are intended to be useful, are those that work with clients with complex needs (requiring multiple forms of support or intervention) and low capacity to “understand and manage their access to available services” (Heatley, 2016). Our data confirms that clients with complex needs tend to experience the services, rather than themselves, as being ‘hard to reach’. The research took an ecosystems approach, highlighting how uptake of service emerges from interaction between a social service, a client and the client’s family, plus the wider service ecosystem.
Six principles for designing social service engagement with those deemed hard to reach
1. Service is not a service product delivered. Service is an experience in which a service seeker benefits by accessing resources offered by another.
2. Service (co-)design is about reciprocal values of the parties involved, not merging or agreeing on values.
3. Structures and processes need to be (co-)designed to enable and support negotiated meaning and empowerment.
4. Capability and social, cultural and financial capital is needed from all parties – service needs to recognise, enhance and build capability and capital with clients.
5. Engagement with clients with complex needs is about negotiating core assumptions with them on the purpose, course and context of service offered.
6. Negotiation of core assumptions is needed in every key relationship in service provision, and is ongoing and dynamic.
In 2014, the Commonwealth Fund established the International Experts Working Group on Patients with Complex Needs to outline the prerequisites for a high-performing health system designed for high-need patients. This report outlines the working group's recommendations for tackling the challenges of delivering care that is more patient-centred, more collaborative and integrated.
Researchers at IHI have been working to identify and test the “active ingredients” that make for continuous improvement and quality control at the front line in health care. A new Healthcare Executive article describes six management principles, leadership practices, core competencies, and mental models that all play a role in generating and sustaining improvement. For example, shaping team culture and building team capability increase the capacity for and rate of improvement and reinforce the expectation that improvement is everyone’s job, every day.
OECD Health Care Quality Reviews provide a toolkit to improve the quality of health care.
Over the past four years, the OECD has conducted a series of in-depth reviews of the policies and institutions that underpin the measurement and improvement of health care quality in 15 different health systems. Caring for Quality in Health: Lessons learnt from 15 reviews of health care quality seeks to answer the question of what caring for quality means for a modern health care system by identifying what policies and approaches work best in improving quality of care.
Despite differences in health care system priorities, and in how quality-improvement tools are designed and applied, a number of common approaches and shared challenges emerged across the 15 OECD Reviews of Health Care Quality analysed. The most important of these concerns transparency. Governments should encourage, and where appropriate require, health systems and health care providers to be open about the effectiveness, safety and patient-centredness of care they provide.
More measures of patient outcomes are also needed - especially those reported by patients themselves. These should underpin standards, guidelines, incentives and innovations in service delivery. Greater transparency can lead to optimisation of both quality and efficiency – twin objectives which reinforce, rather than subvert, each other. In practical terms, greater transparency and better performance can be supported by changes in where and how care is delivered; changes in the roles of patients and professionals; and employing tools such as data and incentives more effectively. Key actions in these three areas are set out in the 12 lessons presented in this synthesis report.
Does quality improvement improve quality?
Future Hospital Journal
Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process. This article considers these challenges and proposes four key ways in which QI might itself be improved.
Innovation is vital to deliver higher quality and lower costs in the complex, rapidly changing environment of healthcare.
While innovation exists in healthcare, it is not systematically applied, and the current rate of innovation is unlikely to achieve the change we want and need. Efforts at innovation in healthcare will continue to move at the same slow pace and yield the same mixed results unless we explicitly address the organisational culture required to support innovation.
Leaders at every level have a disproportionately large effect on organisational culture. By their behaviours, leaders create the conditions that either aid or hinder innovation.
Literature on organisational transformation suggests that leaders can support innovation by paying attention to seven key dimensions of an innovation culture. Read more …
IHI White Paper
This white paper presents a framework that health care organizations can use to sustain improvements in the safety, effectiveness, and efficiency of patient care. The key to sustaining improvement is to focus on the daily work of frontline managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization.
To inform this work, we reviewed selected literature and interviewed leading organizations. The result presented in this white paper is a description of high-performance management in theory and practice, along with recommendations for organizations interested in pursuing these methods:
A theoretical context for high-performance management, grounded in the Juran Trilogy (Quality Planning, Quality Control, and Quality Improvement) and selected current literature;
An organizational framework for a high-performance management system (HPMS), illustrating standard work for each tier of management and the integrated organizational hierarchy that reinforces, supports, and improves work at all levels;
A driver diagram that summarizes our theory of the key factors for implementing a HPMS through standardized management tasks, pervasive Quality Control (as defined by Juran to mean monitoring the system and making necessary adjustments to ensure stability over time), coordinated Quality Improvement, and development of a culture of candid transparency that encourages and sustains these activities;
Case examples that describe three health care organizations’ approaches to testing and implementing management standard work; and
Appendices containing additional guidance for organizations seeking to implement these practices.
World Health Organization
The World Health Organization has produced the Technical Series on Safer Primary Care – a series of nine short monographs exploring the magnitude and nature of harm in the primary care setting from various perspective. Each monograph describes the scope, approach, potential solutions, practical next steps, concluding remarks, and then provides links to online toolkits and manuals to provide practical suggestions for countries and organizations that have committed to moving forward this agenda.
The nine monographs cover:
Education and training
Transitions of care
National Quality Board
This is an improvement resource to support nurse staffing in adult inpatient wards in acute hospitals which is aligned to Commitment 9 of Leading Change, Adding Value: a framework for nursing, midwifery and care staff (2016).1It is based on the National Quality Board’s expectations that to ensure safe, effective, caring, responsive and well-led care on a sustainable basis, trusts will employ the right staff with the right skills in the right place and at the right time. We have designed it to be used by all those involved in clinical establishment setting, approval and deployment– from the ward manager to the board of directors.
The resource outlines a systematic approach for identifying the organisational, managerial and ward factors that support safe staffing. It makes recommendations for monitoring and taking action if not enough staff are available on the ward to meet patients’ needs. It builds on NICE guidelines2 on safe and sustainable staffing for nursing in adult inpatient care in acute wards.
The challenge and potential of whole system flow
The Health Foundation
Whole system flow is the coordination of all systems and resources, across a health and social care economy, to deliver effective, efficient, person-centred care in the right setting at the right time and by the right person.
Improving flow is seen by both practice leaders and policymakers as having a crucial role to play in driving up service quality and productivity, as well as improving the experience of care for patients and service users.
The challenge and potential of whole system flow introduces methods that local health and social care leaders can use to improve whole system flow. It also describes steps policymakers and regulators can take to create an environment conducive to change at this scale.
We sat down with CFHI Faculty, Chris Hayes, to find out what it takes for quality improvement projects to succeed. Watch the video for some helpful tips.
Institute for Healthcare Improvement
Brief report from the (US) Institute for Healthcare Improvement describing how a UK health ‘system’ (the East London NHS Foundation Trust (ELFT) has been able to reduce incidents of inpatient violence, medication errors, waiting times for treatment in the community, and improved staff satisfaction and engagement, among other improvements.
The ELFT provides mental health and community services to a diverse and largely low-income population. Approximately 65,000 individuals come into contact with ELFT’s services each year at more than 100 community and inpatient sites.
According to the report, ELFT leaders and staff made a concerted effort to entrench a culture of continuous improvement in the organization, and they integrated quality improvement methodology and training into every level of work.
Institute for Healthcare Improvement
IHI developed Whole System Measures 2.0 (WSM 2.0) to provide specific guidance to health care system leaders and boards on how to measure current overall system performance and use this data to inform organizational strategy. WSM 2.0 is a set of 15 measures that help leaders better understand their organization’s current (and desired) state across three domains (the Triple Aim): population health, experience of care, and per capita cost.
This work builds on the original Whole System Measures IHI White Paper, published in 2007, and ongoing efforts to advance the Triple Aim. While directive, this small measure set creates the opportunity for health care system leaders, managers, clinicians, and staff to drill down further to understand specific performance challenges or successes, and to identify strategic opportunities for improvement.
Many efforts to develop core measures of quality have emerged in recent years. While these efforts are important and substantive in their own right, they also contribute to health care measurement complexity, highlighting the need for clarity and parsimony to enable senior leaders to understand the overall performance of their systems.
The individual measures that comprise WSM 2.0 are not new; pulling them together to gain the appropriate level of understanding of quality across the system is new. While we do need to reduce measurement burden, we also need to rationalize the measures that exist. WSM 2.0 is intended to provide specific guidance to health care system leaders and boards on how to do just that: measure overall system performance and use this data to inform organizational strategy.
Future Hospital Journal
With this provocative title the authors pick up some of the issues raised in John Øvretveit’s piece discussed in the last issue of On the Radar. This piece poses perhaps more fundamental questions about quality improvement (QI) in healthcare – as it has been practiced – and suggests ways in which QI may be improved.
The authors describe the issue thus “Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process.”
The proposals for improving the quality of quality improvement include:
Act like a sector – many of the quality challenges that confront healthcare need to be solved at the level of entire systems
Stop looking for magic bullets – focus on organisational strengthening and learn from positive deviance. …Too little has been spent on the organisational strengthening needed to make improvement. …much can be learned from the characteristics, practices and behaviours that are implicated in the performance of demonstrably safe and high-quality settings.
Build capacity for designing and testing solutions, and plan for replication and scaling from the start – Developing solutions to many quality and safety problems may require high-level skills and expertise from multiple disciplines, and highly sophisticated development processes. …we need to get better at developing or selecting interventions that have a high likelihood of success, testing them rigorously in different contexts, and offering organisations solutions
Think programmes and resources, not projects – QI projects are sometimes the right answer … but where they are undertaken it should be with a commitment to sharing. … Healthcare needs to do for QI what it has done for research: build an infrastructure that enables learning about successful and less successful efforts to be curated and searched by others.
Paper evaluating the NHS (England) large-scale two-phase quality improvement programme. The programme sought to
develop a shared national, regional and locally aligned safety focus for 4 high-cost, high volume harms (venous thromboembolism (VTE), pressure ulcers, urinary tract infection in patients with urinary catheters and falls)
establish a new measurement system based on a composite measure of ‘harm-free’ care and
deliver improved outcomes, with a specific objective of ensuring that 95% of patients would be harm-free.
These aims were only partially met or met in some places better than others. However, as the authors note external events, “A context of extreme policy-related structural turbulence impacted strongly”. Many participants “saw the principles underlying the programme as attractive, useful and innovative” but “they often struggled to convert enthusiasm into change.” The development of the measurement system was “arduous” and data submission rates were “patchy throughout phase I but improved in reach and consistency in phase II.” Also reported was “Some evidence of improvement in clinical outcomes over time could be detected but was hard to interpret”.
The authors conclude that there are “important lessons for large-scale improvement programmes, particularly when they seek to develop novel concepts and measures. External contexts may exert far-reaching influence. The challenges of developing measurement systems should not be underestimated.”
British Geriatrics Society
GPs and geriatricians are uniquely suited to lead the response to the challenges of caring for this group. As generalist disciplines, general practice and geriatrics look at the whole person and consider care within the context of the patient’s family, carers and the wider community. They take continuity of responsibility for care across many disease episodes and over time, and coordinate care across organisations. These shared holistic values provide opportunities for collaboration between the two specialisms, and this should be at the forefront of the future design and delivery of care for older people.
However, in the past, service development has all too often taken place in isolation, leading to the creation of services in silos. Not only does this fragmentation have a detrimental impact on patient experience and outcomes, there are also negative consequences for service efficiency and effectiveness. This has been particularly true at a national level and, in this respect at least, little has changed.
However, improvements are being made at a local level where GPs and geriatricians are providing clinical leadership in spite of the organisational barriers they face. This report has been designed to showcase examples of these new approaches that are putting the positive talk around integration of care into practice.
The case studies were all selected as examples of collaboration between GPs and geriatricians that provide innovative and interesting ideas about the care of older people. They were also chosen to cover a range of locations across the UK, including urban and rural populations, and a range of settings, including services based in the community, in GP practices, in care homes and in hospitals. While the majority are led by GPs or geriatricians, the initiatives were selected to illustrate the vital role that many other professionals play, including nurses, therapists, pharmacists and social workers.
The digital patient: transforming primary care? reviews the evidence that exists on digital technology and its impact on patients in primary care and the NHS. It explores the impact of seven types of digital services offered by the NHS:
1. Wearables and monitoring technology
2. Online triage tools
3. Online sources of health information and advice, targeted interventions and peer support
4. Online appointment booking and other transactional services
5. Remote consultations
6. Online access to records and care plans
The report finds that patient-facing technology is already showing promise that it can improve care for patients and reduce strain on the stretched health service – particularly for people with long-term conditions such as diabetes or COPD. However, this rapidly evolving market comes with risks. Many apps, tools and devices have not been officially evaluated, meaning that their effectiveness is unknown. In some cases, technology can increase demand for services, disengage staff and have the potential to disrupt the way that patients access care.
Moreover, the report warns that policy-makers and politicians should avoid assuming that self-care-enabling technology will produce significant savings, at least in the short term.
The report also presents a series of lessons and recommendations to NHS professionals, leaders and policy-makers about how best to harness the potential of technology and avoid the pitfalls.
The Health Foundation
This is the final report of the Realising the Value programme, an 18-month programme funded by NHS England and led by Nesta and the Health Foundation. The programme was set up to support the NHS Five Year Forward View vision to develop a new relationship with people and communities. The programme sought to enable the health and care system to support people to have the knowledge, skills and confidence to play an active role in managing their own health and to work with communities and their assets.
This report sets out the key learning and recommendations from the programme, based on what we think it means to realise fully the value of people and communities at the heart of health and wellbeing.
Our recommendations include both what should be done and how people need to work differently. We believe that significant progress can be made through the following 10 actions:
What needs to happen:
Implement person- and community-centred ways of working across the system, using the best available tools and evidence.
Develop a simplified outcomes framework, focused on what matters to people.
Continue to learn by doing, alongside further research.
Make better use of existing levers such as legislation, regulation and accountability.
Trial new outcomes-based payment mechanisms and implement them as part of wider national payment reform.
How people need to work differently
Enable health and care professionals and the wider workforce to understand and work in person- and community-centred ways.
Develop strong and sustained networks as an integral part of implementation.
Value the role of people and communities in their health and wellbeing, including through co-production, volunteering and social movements for health.
Make greater use of behavioural insights to increase effectiveness and uptake.
Support a thriving and sustainable voluntary, community and social enterprise sector, working alongside people, families, communities and the health and care system.
Royal College of General Practitioners
The prevalence and significance of multimorbidity – where patients have multiple conditions (usually chronic) – is gaining greater recognition. For example, the UK’s National Institute for Health and Care Excellence issued a Guideline on Multimorbidity: clinical assessment and management in September (available from https://www.nice.org.uk/guidance/ng56). Now the UK’s Royal College of General Practitioners has issued this document that starts by reviewing how effectively the current health system serves patients living with multiple long-term conditions before examining some innovative ways of working and the impact they have had on the quality of care received by patients with multiple long-term conditions, such as longer consultation times for those who need them, collaborative care and support planning and the role of multidisciplinary teams in caring for patients with complex needs. The report also recommends improving communication between primary and secondary care professionals, increasing exposure of delivering care to patients with multimorbidities in GP training, and the development of improved decision making tools.
Journal of Antimicrobial Chemotherapy
The text of Peter Davey’s 2015 Garrod Lecture. The Garrod Lecture is deliver by the recipient of the British Society for Antimicrobial Chemotherapy's Garrod Medal. The Medal is awarded to individuals who are an international authority in the field of antimicrobial chemotherapy. In 2015 Peter Davey spoke on the “urgent need to improve the design and reporting of interventions to change behaviour.”
Davey's noted that “achieving sustained improvement at scale will also require a more profound understanding of the role of context. What makes contexts receptive to change and which elements of context, under what circumstances, are important for human performance? Answering these questions will require interdisciplinary work with social scientists to integrate complementary approaches from human factors and ergonomics, improvement science and educational research. We need to rethink professional education to embrace complexity and enable teams to learn in practice. Workplace-based learning of improvement science will enable students and early-career professionals to become change agents and transform training from a burden on clinical teams into a driver for improvement. This will make better use of existing resources, which is the key to sustainability at scale.”
We explore five inspirational examples of innovation in health care.
Our series of five short films – the Power of people – is a unique and moving take on how the lives of people using health services and their families can be improved through the determined efforts of people working in health care.
Pills: Reviewing medication in care homes
Flo: Telehealth with a human touch
Bottoms up: Everyone can influence safety, quality and experience
Recovery college: From mental health patient to recovery student
Gold Line: Bringing health care home
The Power of people films present different perspectives on innovative ways to provide care, which have changed the lives of both people receiving care and the people caring for them.
The demands on our health service are growing – the ideas of the people working in the health service will be essential in meeting this challenge. Our short films show the power of what can be achieved when people are given the time and support to innovate. We hope they inspire those already doing great things in the health service to think about what else might be possible.
Dr Carl Horsley, Counties Manukau Health
Dr Carl Horsley is a dual trained intensivist who is the current clinical head of the Critical Care Complex at Middlemore Hospital. He is a member of the Resilient Healthcare Network and recently co-authored a chapter on a project he introduced to enhance the ability of staff to adapt to changing situations within the Complex. This approach sees people as the key resource required to deal with the complexity of modern healthcare and has led to improved staff engagement, improved quality care and a more patient centred view.
“The reality is that healthcare is a complex adaptive system which is constantly changing and thus requires constant adjustment and adaptation. In the real work environment, staff constantly have to make trade-offs between efficiency and thoroughness. This reality requires a different view of safety.
Safety-II: The new view
The ability to juggle complex dynamic situations is how we achieve normal success; it is also how things sometimes go wrong. Safety-II recognises that both good and bad outcomes stem from the same performance adjustments people make every day to get their jobs done. No action is intrinsically good or bad – the outcome depends on whether the action suits the context.
In this model of safety, the system only succeeds because people can adjust to meet the conditions of work. Complexity is the problem and people are the solution…”
International Journal for Quality in Health Care
Quality problem Many modern health systems strive for ‘Triple Aim’ (TA)—better health for populations, improved experience of care for patients and lower costs of the system, but note challenges in implementation. Outcomes of applying TA as a quality improvement framework (QI) have started to be realized with early lessons as to why some systems make progress while others do not.
Initial assessment Limited evidence is available as to how organizations create the capacity and infrastructure required to design, implement, evaluate and sustain TA systems.
Choice of solution To support embedding TA across Canada, the Canadian Foundation for Healthcare Improvement supported enrolment of nine Canadian teams to participate in the Institute for Healthcare Improvement's TA Improvement Community.
Implementation Structured support for TA design, implementation, evaluation and sustainability was addressed in a collaborative programme of webinars and action periods. Teams were coached to undertake and test small-scale improvements before attempting to scale.
Evaluation A summative evaluation of the Canadian cohort was undertaken to assess site progress in building TA infrastructure across various healthcare settings. The evaluation explored the process of change, experiences and challenges and strategies for continuous QI.
Lessons learned Delivering TA requires a sustained and coordinated effort supported by strong leadership and governance, continuous QI, engaged interdisciplinary teams and partnering within and beyond the healthcare sector.
This report illuminates the power of people in movements to improve health and proposes the need for new models of engagement between institutions and social movements.
People working together in social movements have changed how we experience health and the systems that shape it: reducing stigma around issues like breast cancer, improving end of life care, winning rights for those with disabilities, advancing clinical research and reframing health priorities.
The report identifies seven ways social movements impact health and care and illustrates the transformative potential of movements through over 20 national, international and historical examples.
Social movements put pressure on societal systems to accelerate transformation, respond directly to the experiences of people and can diffuse change widely across populations. Yet, they can be messy, turbulent and risky. They represent one approach to the transformation so urgently needed in health and care.
It is potentially unprecedented for a major public institution like the NHS - with clear hierarchies, rules and protocols - to actively call for and nurture social movements.
Effective encounters between institutions and movements will require new models of engagement that draw on the efficiency and scale of institutions and the dynamism and agility of movements. The report also stresses that understanding how social movements behave is critical to engaging with them.
The Royal College of Emergency Medicine
This guide is intended to assist Fellows and Members who are undertaking Quality Improvement (QI) work in their Emergency Departments. It is intended to help bridge the gap between improvement science and implementation.
This report describes the results of a pilot analysis of the effectiveness of using routine health care data to determine areas that have made quality improvements in the care of frail and older people over time. It focuses on a few indicators that were mainly derived from acute emergency hospital use and applies statistical analyses to them at the local authority area level.
International Journal for Quality in Health Care
The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions.
The complexity of health care requires a more rigorous approach to advance our understanding of methods for learning about improving health care. Additionally, the greater use of robust qualitative, quantitate and mixed methods is needed to assess effectiveness—not merely to demonstrate if an intervention works, but why and how it works—and to explore the factors underlying success or failure.
Many Ways to Many : A brief compendium of networked learning methods.
Stanford Social Innovation Review
Donors, governments, NGOs, and other stakeholders in the social sector are increasingly interested in how to spread effective solutions and innovations to everyone who can benefit from them. A growing literature on the topic is forming, as researchers and analysts describe general principles for building collective will and setting shared aims, designing scalable and charismatic interventions, and leveraging existing networks and institutions to have bigger impact.
In our view, however, there remains a crucial gap in this collected knowledge. While the attributes of effective learning networks (i.e. structured methods to support knowledge exchange and spread new behaviors) have been described in general terms, few attempts have been made to define and distinguish the approaches that have been applied to greatest effect. Building on our work in the last two decades, mainly in international health, we attempt to address that gap here by documenting ten approaches to orchestrating networked learning at various scales.
From knowledge to action: A framework for building quality and safety capability in the New Zealand health system is a high-level framework to guide the development of quality and safety capability across all levels in the health and disability sector, including consumers/patients.
It has been developed at the request of the sector and informed by international models with input from an expert advisory group.
Training healthcare professionals in quality improvement
Future Hospital Journal
The Academy of Medical Royal College's report Quality improvement – training for better outcomes sets a path for the normalisation of quality improvement as part of all health professionals’ jobs. This accompanies similar calls to action by the King's Fund and the Faculty of Medical Leadership and Management and is aligned with NHS Improvement and Health Education England future strategies. These exhortations to action come on the backdrop of increased fiscal constraints within the NHS, low morale, a burgeoning volume of research evidence and audit outputs and increasing complexity of how we deliver care in a bewildering NHS landscape. Asking the question ‘how can we do something better?’ or ‘do we really need to do this?’, and building our resilience and capability to respond effectively gives us new purpose, the right skills and a means to influence and make a difference to the safety, effectiveness and experience of patient care. Most importantly, we do this through harnessing the talents of multiprofessional teams – with meaningful patient involvement – to rediscover the joy and optimism in our work and what truly motivates us and to see this translated into improved sustainable outcomes for our patients and our working days.
World Health Innovation Network
The purpose of this paper is to propose a new strategy for addressing the seemingly intractable challenge of patient safety and the growing rates of death and injury associated with adverse events in healthcare systems. The paper examines the capacity to strengthen health system performance by improving visibility to create value for health systems, government, industry, and patients. WIN’s research has engaged four countries (Canada, US, UK and Australia), seven Canadian provinces, industry partners and leaders in the health sector. The paper’s recommendations have capacity to improve the delivery of safer, higher-quality, more efficient and sustainable health care by leveraging strategic supply chain innovation.
Objectives We aimed to evaluate whether a large-scale two-phase quality improvement programme achieved its aims and to characterise the influences on achievement.
Setting National Health Service (NHS) in England.
Participants NHS staff.
Interventions The programme sought to (1) develop a shared national, regional and locally aligned safety focus for 4 high-cost, high volume harms; (2) establish a new measurement system based on a composite measure of ‘harm-free’ care and (3) deliver improved outcomes. Phase I involved a quality improvement collaborative intended to involve 100 organisations; phase II used financial incentives for data collection.
Measures Multimethod evaluation of the programme. In phase I, analysis of regional plans and of rates of data submission and clinical outcomes reported to the programme. A concurrent process evaluation was conducted of phase I, but only data on submission rates and clinical outcomes were available for phase II.
Results A context of extreme policy-related structural turbulence impacted strongly on phase I. Most regions' plans did not demonstrate full alignment with the national programme; most fell short of recruitment targets and attrition in attendance at the collaborative meetings occurred over time. Though collaborative participants saw the principles underlying the programme as attractive, useful and innovative, they often struggled to convert enthusiasm into change. Developing the measurement system was arduous, yet continued to be met by controversy. Data submission rates remained patchy throughout phase I but improved in reach and consistency in phase II in response to financial incentives. Some evidence of improvement in clinical outcomes over time could be detected but was hard to interpret owing to variability in the denominators.
Conclusions These findings offer important lessons for large-scale improvement programmes, particularly when they seek to develop novel concepts and measures. External contexts may exert far-reaching influence. The challenges of developing measurement systems should not be underestimated.
Future Hospital Journal
Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process. This article considers these challenges and proposes four key ways in which QI might itself be improved.
The Academy of Medical Sciences
Over the coming decades, the UK population will face a wide range of complex health challenges and opportunities, many of which can only be fully addressed through strategies to secure and improve the health of the public as a whole. The Academy’s report, ‘Improving the health of the public by 2040’, explores how to organise our research environment to generate and translate the evidence needed to underpin such strategies.
The report concludes that while public health research has provided fundamental insights into human health, there remains much we do not know about the complex array of interlinking factors that influence the health of the public, and about how to prevent and solve the many health challenges we face as a population.
Solving these challenges will require shifting towards a ‘health of the public’ approach, involving disciplines that would not usually be considered to be within the public health field. This is turn requires six key developments:
Rebalancing and enhancing the coordination of research;
Harnessing new technologies and the digital revolution;
Developing transdisciplinary research capacity;
Aligning perspectives and approaches between clinical and public health practice;
Working with all sectors of society, including policymakers, practitioners, the commercial sector and the public;
Australian Healthcare and Hospitals Association
This evidence brief from the Deeble Institute examines how to include consumers in “value creation in health care planning and delivery”. The report refers to the growing literature on health value co-creation and its benefits in the health sector and how it suggests that value can be co-created for the individual consumer, clinical practices, health care organisations, and governments. The author offers some recommendations on how to increase the role of consumers in (co)designing healthcare services. The report includes examples of emerging models of community engagement in Primary Health Networks such as NSW’s WentWest, the Western Australia Primary Health Alliance, Capital Health Network in the ACT and North Brisbane PHN.
Kings Fund [blog]
I’ve been to many conferences on quality and safety in the NHS, and never cease to be frustrated by suggestions of creating yet another policy or checklist, or by people bemoaning the difficulty of implementing improvement measures with the common complaint ‘Why is it so hard for people just to do the right thing?’
Choosing the right method of implementation is vital. Those leading change need to ensure:
an easy method of implementation;
clear benefits – with numbers, feelings and experiences demonstrating that the change is better than status quo;
the message is delivered in person, using the right role model or opinion leader;
people are recognised and rewarded for their actions, and thanked for their contribution;
they adopt a coaching style of leadership; if leaders simply try to solve the problems themselves then people will not take ownership of the outcome.
Implementation is more often about making smaller changes that can incrementally make things easier, better, safer and more effective. And it requires ongoing maintenance. Read more …
A pair of Issues Briefs from the same team of authors published by (US) Commonwealth Fund that discuss the characteristics and experiences of heavy or ‘high need’ users of healthcare.
The first provides an analysis of the health care needs of patients in the USA with long-term conditions and argues that health care improvement efforts should focus on the needs of those with multiple chronic illnesses and who have limited ability to care for themselves. The high need patients have rates of hospital more than twice those for adults with multiple chronic conditions only; they also visited the doctor more frequently and used more home health care.
The second Issue Brief compared the health care experience of patients with co-morbidities and a functional limitation to those with multiple conditions but no functional limitations. The authors found that patients with higher levels of need were more likely to report having unmet medical needs and less likely to report experiences of good patient-provider communication. These findings highlight the importance of tailoring interventions to meet the needs of the highest-need, most complex patients.
The Action Guide is a framework to help multi-sector groups work together to improve population health by addressing 10 interrelated elements for success and using the related resources as needed. Like a “how-to” manual, the Action Guide is organized by these 10 elements and contains definitions, recommendations, practical examples, and a range of resources to help communities achieve their shared goals and make lasting improvements in population health.
The Action Guide’s 10 key elements are:
Leadership Across the Region and Within Organizations
Audience-Specific Strategic Communication
A Community Health Needs Assessment and Asset Mapping Process
An Organizational Planning and Priority-Setting Process
An Agreed-Upon, Prioritized Set of Health Improvement Activities
Selection and Use of Measures and Performance Targets
Joint Reporting on Progress Toward Achieving Intended Results
Indications of Scalability
A Plan for Sustainability
In the mid-1990s, the service improvement methodologies developed by Don Berwick at the Institute for Healthcare Improvement in Boston, US, were first used in the NHS. In 2001 the Department of Health established the Modernisation Agency to develop and spread service improvement skills more widely throughout the NHS. And yet there is still a mountain to climb in terms of both service improvement and productivity, and there is significant variation across the country. Why is it that the best ideas are so hard to spread?
Why the NHS needs a quality improvement strategy
Chris Ham in conversation with Don Berwick
Even simple improvements take intention and method. In complex systems such as health care, with high levels of interdependency, risk, and hard-to-see dynamics, without stewardship and active nurturance, things will decay.
A shared approach to improvement is essential. Exactly what that approach should be is open to debate, but, without a strategy, what would we expect to happen?
…Great innovation has bi-directional kinetic energy: ‘top-down’ and ‘bottom-up’ at the same time. From the ‘top’ can come resources, clarified aims, permission, and assets for collective learning. From the ‘bottom’ can come great ideas, tested, de-bugged and exciting. And local innovators can become teachers for others. Key to spreading innovation is a combination of (a) strong respect for and support of local improvement and (b) consistent, positive and generous leadership from executive and clinical leaders who believe that shared learning almost always beats central control.
The enemy of the spread of innovation is fear. Read more …
If you talk to enough people working in health care quality improvement, you sometimes get the impression there is a lot of confusion and misunderstanding about Lean and what we refer to in the white paper as “IHI-QI,” or IHI’s approach to improvement.
Traditionally, IHI has focused much attention on the Model for Improvement, developed by Associates in Process Improvement (API). IHI has worked closely with API for the last 25 years.
People working on quality improvement also hear about approaches like the Toyota Production System, or Lean. They hear about how Virginia Mason Medical Center in Seattle and ThedaCare in Wisconsin successfully apply Lean.
How do these approaches differ, and what do they have in common? How, if at all, can we use these approaches together?
What are some of the common misunderstandings about Lean and the IHI approach?
Many assume Lean is only about cutting costs or reducing waste, or that it’s basically just a set of tools. With IHI-QI, people sometimes think it only means the application of PDSA cycles or the Model for Improvement.
People sometimes see both Lean and IHI-QI as using dogmatic checklists that spell out every step, or as if you can magically fix a problem as long as you use the right tool from the toolbox.
These simplistic views ignore that — whichever approach you use — you need an organizational and leadership strategy that guides how to introduce these methods and apply them in practice.
Sue Desmond-Hellmann is using precision public health — an approach that incorporates big data, consumer monitoring, gene sequencing and other innovative tools — to solve the world's most difficult medical problems. It's already helped cut HIV transmission from mothers to babies by nearly half in sub-Saharan Africa, and now it's being used to address alarming infant mortality rates all over the world. The goal: to save lives by bringing the right interventions to the right populations at the right time.
This article has ideas on how to push your organisation, your people and yourself to stop talking and start innovation
1. Sharpen the (organizational) saw
2. Plant thought leaders in a room: just add coffee (and seed funding)
3. Don’t just stand there… partner, invest, accelerate and scratch your own itch along the way.
4. Steal the wheel, don’t reinvent it. You’d be surprised how open and willing other innovators are to sharing ideas, methods, and tools.
5. Create space for innovation to thrive
6. Free your “Radicals” to empower real change in your organization
7. Build diverse teams who focus on innovation (from incremental to disruption)
8. Get senior leaders actively involved in the innovation process
This article shares ten factors that are important in making a collaborative a success:
Considering population size and the structure of the health system;
Using Breakthrough Series methodology;
Proving international evidence in the national context;
A clear mandate for change;
Leveraging clinical expertise and professional respect;
Involving diverse stakeholders;
Sharing measurement data with teams promptly;
Being adaptable and responsive;
Setting clear roles and responsibilities;
Putting an effective communications plan in place.
Continuous learning is vital for those working in health and social care, but quality training resources and study time are hard to find. Is e-learning the answer?
Professional learning and development are essential parts of any career in health and social care, and leaders across both sectors want to create a culture of lifelong learning among their staff.
Despite this, 57% of health and social care staff don’t feel they have opportunities to take training to further their career and just over two-thirds (68%) don’t feel they have enough training to do their job, according to the results of a recent Guardian survey.
How can employers in health and social care improve access to training and development? What examples of innovative technologies are there and how can health and social care professionals fit training around work and other commitments?
In 2014, Ko Awatea was fortunate to have Joe McCannon visit and teach. Last week, delegates from Ko Awatea had the opportunity to visit Joe at the Skid Row School for Large-Scale Change. The school was run by Joe McCannon, Dan Heath and Becky Margiotta of the Billions Institute. This article summarises the key learnings.
Ideas that work often fail to spread to everyone who could benefit. We glorify discovering new ideas over implementing them and assume that change will diffuse as if by magic to the people who need it. In addition, a marketplace crowded with ideas, variation in values and beliefs, contextual differences, logistical barriers, fear and inertia make it difficult to create large-scale change.
However, large-scale change can and does happen. The Billions Institute shows us how. Their model has five features:
Set your vision and aims;
Design your intervention;
Choose your expansion method;
Run a ‘command centre’;
Manage fear and liberate creativity for the individual and the team
Like tackling any big problem, getting involved in reducing health disparities starts with small steps. As we like to say at IHI, “What can you do by next Tuesday?”
One small step could be to examine your own reactions to people who are different from you — in race, ethnicity, gender, country of origin, age, or many other dimensions of diversity.
If you are like most of us, you have some degree of implicit bias, the attitudes and stereotypes that unconsciously affect how we perceive, respond to, and interact with others.
see also the IHI's new guide 'Achieving Health Equity: A Guide for Health Care Organizations'
This Evidence Check sought to identify factors reported in primary research as relating to positive and negative experiences of patients in Australian hospitals. From the 39 studies reviewed, the researchers identified 7 themes: ‘The care environment’, ‘Reciprocal communication and information sharing’, ‘Correct treatment and physical outcomes’, ‘Emotional support’, ‘Comfort, pain and clinical care’, ‘Interpersonal skills and professionalism’, and ‘Discharge planning and process’.
The authors’ concluded that “Tangible opportunities to enhance the patient experience are apparent. Small changes to the way that the health system operates, is resourced, and the way that health professionals engage with patients could substantially improve care. Examples include inviting patients and carers to contribute to decision making and discussions about treatment options and care preferences.
“Payers for health care are pursuing a variety of policies as part of broader efforts to improve the quality and efficiency of care. Payment reform is but one policy tool to improve health system performance that requires supportive measures in place such as policies with well-developed stakeholder involvement, information on quality, clear criteria for tariff setting, and embedding evaluation as part of the policy process. Countries should not, however, underestimate the significant data challenges when looking at price setting processes. Data access and ways to overcome its fragmentation require well-developed infrastructures. Policy efforts highlight a trend towards aligning payer and provider incentives by using evidence-based clinical guidelines and outcomes to inform price setting. There are signs of increasing policy focus on outcomes to inform price setting. These efforts could bring about system-wide effects of using evidence along with a patient-centred focus to improve health care delivery and performance in the long-run
How health care providers are paid is one of the key policy levers that countries have to drive health system performance. However, health providers are still paid in traditional ways – through fee-for-service (FFS), capitation, salary, global budgets or more recently diagnosis-related groups (DRGs). These give incentives for undesirable behaviours, for instance over-provision of services or inattention to clinical needs. More should be done to align payer and provider incentives so that payment is based on delivering value to patients.
“The Institute of Public Health in Ireland partnered with the Centre for Effective Services to produce a volume linking research and practice relating to the early years. The early years have been increasingly recognised in research and policy as a pivotal time in the life course, providing the foundations for numerous health-related outcomes. The lifelong effects of the early years’ experience includes impacts across many aspects of health and wellbeing; including inter alia obesity, heart disease, mental health, educational achievement and economic status. This publication brings together academic authors to consider the rationale and evidence regarding early interventions, as well as practitioners providing on-the-ground examples of what can be achieved.” Source: Institute of Public Health in Ireland
“In this qualitative case study, decision-makers from 2 provinces -- British Columbia and Nova Scotia -- reflect on the main actions they have taken and the challenges they face in improving health system efficiency. This study builds on previous work from CIHI's health system efficiency project.”
Academic Health Science Networks
Patient Safety Collaboratives are led by Academic Health Science Networks and are made up of NHS, academic and health care experts. The aim of the collaboratives is to improve patient safety, spread examples of success and influence system leaderships. This report highlights the work of 15 teams of Patient Safety Collaboratives that aimed to improve patient safety and reduce avoidable harm in the NHS.
This report is an independent evaluation of a quality improvement initiative undertaken by Counties Manukau Health. The objectives of this report are to establish if improvement within the Counties Manukau healthcare system as a consequence of the initiative was evident, how any improvement was accomplished, and if any gaps remained. Three aspects of quality improvement were examined: Counties Manukau’s System Level Measures, the establishment of comparisons and gold standards for these measures; and a case study of healthcare organisations recognised for their work on quality improvement.
From online programmes to serious games, video teleconferencing and text counselling, digital platforms lend themselves to providing preventative and self-managed care options. Commonly cited benefits include consumer empowerment, scalability, possible efficiency gains, reduced burden and social cost, standardisation of programmes and access to usage data.
But how confident are we that such initiatives actually work?
The publication draws out high-level findings on the most established types of digital tools for delivering wellbeing support, then digs deeper to learn about good practices from particular cases.
It looks at:
· intended users
· questions of safety and support
· design forms and processes
· challenges in implementation, uptake, and quality assurance.
We conclude there is a lot of potential for going digital in delivering services, if done the right way.
Prepared by Ko Awatea for the NZ Health Quality & Safety Commission
These findings have highlighted a high level of passion and enthusiasm for the co-design approach across programme participants. Participant responses suggest that application of the co-design approach to future projects is the main avenue through which others, through observation and ‘doing’, learn about co-design and its role in health care transformation.
The lack of systemic or structural integration of the co-design approach into organisational training and development, policy or strategy leaves the co-design approach open to the risk of poor sustainability. This is compounded by competing organisational priorities and need for increased senior leadership or management knowledge of co-design and expected benefits of the approach. These findings suggest that knowledge about co-design needs to filter to higher organisational levels.
Future considerations for the Co-Design Programme
This report has identified a number of learnings. These offer potential future opportunities to increase the sustainability of co-design approaches through:
1. embedding co-design within existing organisational training at DHBs, for example, the improvement advisor programme, safety programmes and other general improvement training
2. delivering focused workshops on areas of the co-design process participants have found challenging, such as effectively engaging with consumers
3. identifying programme participants who may need additional support to train or teach colleagues and connect them to existing training or mentorship in their organisation that can assist in developing these skills
4. considering different modalities for the delivery of programme content which teams can access within timescales that suit their needs, for example, e-learning programmes
5. increasing support for senior leaders to understand co-design and expected benefits, and how co-design can fit within their organisational strategy, values and priorities, potentially through targeted training or communications to senior leaders
6. support senior leaders and sponsors to play a more active role in sharing the co-design methodology, in particular, advocating for co-design to be embedded within broader organisational policies or strategy.
BMC Health Services Research
Paper reporting on a review of the literature on clinical leadership, clinician involvement in governance and hospital performance that focused on ‘quantitatively-oriented studies’ or ‘scientific papers’ with a final selection of 19 papers published in English language journals. The authors report that “In general terms, the findings show a positive impact of clinical leadership on different types of outcome measures, with only a handful of studies highlighting a negative impact on financial and social performance. Therefore, this review lends support to the prevalent move across health systems towards increasing the presence of clinicians in leadership positions in healthcare organisations.”
Challenges, solutions and future directions in the evaluation of service innovations in health care and public health
Health Services and Delivery Research
Another substantial report (164 pages) in the NHS National Institute for Health Research’s Health Services and Delivery Research. Rather than being a single report this is a collection of essays from some of the ‘thought leaders’ that provide a ‘state of the art’ view of the evaluation of complex interventions. AsJennifer Dixon noted in one of the report’s forewords, “It is clear from the contributions in many essays that the task of evaluating complex interventions is almost as complex as the systems being evaluated.” In her Foreword, the English Chief Medical Officer, Sally Davies, observed that “The volume provides a clear and authoritative explanation for the range of methods that can now be brought to bear to evaluate services. A wide spectrum of methods are described from novel forms of randomised trials to innovative statistical techniques for analysing data about services, outcome measures focused on patients’ priorities, and new focuses of research such as how to implement best practice. An impressive range of experts were mobilised to contribute to the debates out of which the position papers emerged. As well as providing accessible state-of-the-art explanations of best methods for evaluative research, the volume contains other important messages. These messages are that evaluation involves partnership between health professionals, providers, commissioners and researchers; and that innovation will best emerge from early and close dialogue between these different partners.”
Health Quality & Safety Commission
The Health Quality & Safety Commission’s in-hospital patient experience survey was implemented on 1 July 2014.
Since the survey began, there are three questions which consistently rate lower than others. In early 2016, the Commission undertook qualitative analysis of comments in the quarterly survey results for August and November 2015, to get a better understanding of why those three questions continue to be the lowest rated.
To date quantitative data has formed the basis of results. Some district health board (DHBs) have analysed the patient experience survey comments to guide their own improvement initiatives, however, this is the first attempt to collate comments collectively from all 20 DHBs.
How can health care organizations sustain improvements in safety, effectiveness, and efficiency of patient care? According to the new IHI White Paper, Sustaining Improvement, the key is to focus on the daily work of frontline managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization. The white paper presents a theoretical context for high-performance management, grounded in the Juran Trilogy (Quality Planning, Quality Control, and Quality Improvement); a framework for high-performance management; a driver diagram for implementing the framework; and case examples describing three organizations’ approaches to testing and implementing management standard work.
Presentation by Helen Bevan
Lucian Leape Institute at the National Patient Safety Foundation
The Lucian Leape Institute of the [US] National Patient Safety Foundation have compiled this short (32 page) compendium of the executive summaries and recommendations from five of their reports as a resource for health care leaders. As is noted in the Introduction:
“The series of reports has revealed how much the issues overlap and intersect. It is difficult to imagine robust patient and family engagement without greater transparency, for example. Likewise, greater patient and family engagement is essential if we are to work together to improve care integration.
What has become particularly clear is the fact that strong leadership and a culture of safety are essential for lasting improvement in patient safety. But changing culture takes time, and not all leaders know where or how to begin. This compendium should be referenced to inform discussions, set work priorities, and make what may sometimes be difficult decisions.”
The five reports that are drawn together here include:
Shining a Light: Safer Health Care Through Transparency (2015)
Safety Is Personal: Partnering with Patients and Families for the Safest Care (2014)
Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care (2013)
Order from Chaos: Accelerating Care Integration (2012)
Unmet Needs: Teaching Physicians to Provide Safe Patient Care (2010)
The King’s Fund was commissioned by Oxleas NHS Foundation Trust to work with their Quality Board to facilitate an assessment of its existing approaches to quality improvement and to develop a strategy for future work. This case study details the approach and philosophy behind this work, which involved working with the trust’s five directorates to develop their ability to appraise their own approach to quality improvement with a view to improving performance, achieving better clinical outcomes and building further on the trust’s capacity as a learning organisation.
Australasian Medical Journal
The organisation of primary health care in Australia through supportive meso-level PCHOs, the PHNs, holds enormous potential, but a critical success factor will be the successful and appropriate engagement of frontline clinicians and GPs.
This requires a structured and systematic approach to developing an engagement plan. The evidence from the international experience and past Australian experience may inform what should be included in such a plan, but adaptation to the local context will be paramount. To successfully adapt it to the local context, PHNs should consider the level of engagement required from its membership, measure the level of engagement they have ,and then develop and implement a multi-faceted strategy to improve the degree of engagement. In doing so they will need to consider the heterogeneity of general practices and the four levels of quality improvement to produce an appropriately segmented engagement strategy. Co-designing the strategy with GPs will stack the deck of cards in their favour and to achieve all of this will require a vision, will ,and resources. However, in doing so they will achieve the collective and distributed leadership required for quality improvement to achieve their objectives of improving effectiveness and efficiency of health services.
“Disruptive innovation is a concept that has been developed for analysing ways to improve health outcomes and reduce costs in the US health care system. The Expert Panel on Effective ways of Investing in Health (EXPH) was requested to focus on the implications of disruptive innovation for health and health care in Europe. The Expert Panel understands “disruptive innovation” in health care as a type of innovation that creates new networks and new organisational cultures involving new players, and that has the potential to improve health outcomes and the value of health care. This innovation displaces older systems and ways of doing things.”
While communitywide efforts and coalitions are key to achieving health equity, health care organizations and systems have tremendous potential to directly influence numerous underlying societal inequities that contribute to health disparities and poor health. This article presents an overview of a framework developed by IHI to help guide leaders in improving health equity by making it a system-level priority for their organizations.
The Health Foundation
This report looks at the first year of the Q initiative and the extensive co-design process used to create it.
Q is a diverse and growing community of people, with experience and understanding of improvement, committed to improving the quality of health and care across the UK.
To ensure Q meets the needs of those in improvement, the Health Foundation worked in partnership with 48 organisations to recruit 231 founding members to help design and test Q during 2015. The Health Foundation believe the process to design Q is the largest collaborative design process of its type undertaken in improvement in health care.
The report identifies lessons for anyone seeking to support improvement work across organisations or through networks, as well as those engaged in designing initiatives with many diverse stakeholders. It draws on a variety of sources including the independent real-time evaluation of Q undertaken by RAND Europe.
· Q needs to be first and foremost about connecting people involved in improvement. During 2015, members were supported to build many new connections and relationships with people from other professional backgrounds and geographies. There are early signs to support the hypothesis that these connections can boost the effectiveness and confidence of those doing improvement, enable innovations to flow more easily across the system and allow new collaborations.
· Multiple enablers need to be in place for people to be able to design, implement and measure improvements effectively. These include time, access to information and resources, and support in a system that is often fragmented and turbulent. Members supported the idea that Q should provide a long-term infrastructure that will offer development opportunities and make members more visible to each other, encouraging connections and helping people work together to support each other.
· The scale of the co-design process enabled broad-based engagement in shaping Q. Collaboratively designing Q with such a large and diverse range of people was complex and challenging. Members were very engaged in debates around what Q should deliver, but with many divergent views synthesising and deciding how to move forward was often hard. However, the scale of the process enabled a broad-based community of improvers to be established. A significant majority of founding members report a positive attitude to Q, perceive the initiative as important and want to stay involved and shape the strategy further. Q is now broadly at the stage intended, with an agreed operating model that will now be tested in practice on a larger scale as the community grows.
Health Services Delivery and Research
This report sets out findings from a scoping review of the literature to update what we know about interventions designed to improve the effectiveness and efficiency of the outpatient referral system. We also provide substudies on a range of more recent innovations taking place in England, which are not yet adequately covered in the published literature. Finally, we include data on international experiences in this area, which may provide lessons for the UK.
Aims and objectives
Identify and review what is currently known about strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services.
Comment on the impact of such schemes on the organisation of primary care, the primary care workforce, access, clinical outcomes for patients and patient experience.
Identify and comment on the potential for innovative models of care to be replicated more widely.
Identify the needs for future research in this area in terms of both primary research and systematic reviews that might be needed.
Summarise the findings in a way that will be readily accessible to policy-makers and managers.
For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.
More organisations in and out of the health and care system are reconsidering their approach to improving employee engagement and performance. Organisational transformation is taking on a more employee-as-human focus. Underneath this trend is the realisation that traditional approaches have not worked to create healthy, high-functioning teams that deliver better care. While many attempts at organisational transformation are well-intentioned, they often lack a key ingredient that is necessary for success.
In this talk, Dr Irv Rubin and Matt Stone of Temenos outlined the key (and often missing) ingredient to realising meaningful, sustainable change. They also introduced a specific communication technique that illustrates the ‘secret ingredient’ in action and they discussed effective development interventions for improved performance, engagement and the quality and safety of patient care.
Maxine Power [blog]
This post follows Maxine’s first blog ‘Improvement is a contact sport’ packed with top tips when facing challenges as an aspiring improver.
Exploring the links between quality improvement strategies and organisational outcomes in four New Zealand district health boards
(2016). Ministry of Health, the Treasury, and the Health Quality & Safety Commission.
Participating DHBs provide real-life examples of what customer-centric models of care look like in practice. Elements that contributed to the success of programmes in these DHBs are relevant to other services delivered by the Government.
A number of New Zealand District Health Boards (DHBs) are using quality frameworks and concepts as core elements of their organisational strategies to improve patient outcomes and manage healthcare costs. The successes and challenges of these strategies can provide useful insights for other DHBs and the broader health system.
During 2015, the Ministry of Health (Ministry), the Treasury (Treasury) and the Health Quality & Safety Commission (the Commission) undertook a collaborative project with Auckland, Bay of Plenty, Canterbury and Whanganui DHBs to explore the links between quality improvement (QI) strategies and organisational outcomes.
The four participating DHBs were retrospectively evaluated using two frameworks. Their organisational strategy and overall approach to quality were summarised using a framework based on the Institute for Healthcare Improvement’s (IHI) Seven Leadership Leverage Points for Organization-Level Improvement in Health Care1 and the New Zealand Quality Guide2. Concurrently, their performance was measured against the dimensions of the Triple Aim. This approach provides a comprehensive overview of each DHB, both from the qualitative and quantitative perspectives.
Analysis carried out for the project found that all four case study DHBs showed clear improvements in some measures, and for some measures the improvement was greater than for non-case study DHBs. There is no evidence that a focus on specific outcomes had a negative impact on outcomes elsewhere. Rather, the general direction of QI in the studied DHBs in areas not covered by specific local initiatives was similar or better than the country as a whole.
QI programmes undertaken by the four DHBs were all significantly different in nature, approach and scale. However, there were common success factors across most or all of the case study DHBs including alignment to strategic goals, executive and clinical leadership, culture and capability, measurement and results, and consumer engagement and patient experience.
In addition to providing an overview of each DHB and their approach to QI, the case studies offered a number of useful lessons for DHBs seeking to include QI elements in their organisational strategy. The case studies also offer a number of valuable insights for the centre.
Lessons in Leadership for Improvement: Kaiser Permanente’s Improvement Journey Over 10 Years.
Institute for Healthcare Improvement
Over the past decade, Kaiser Permanente (KP) has achieved impressive improvements in quality of care — halving its hospital standardized mortality ratio and reducing hospital-acquired pressure ulcers by more than 80 percent, among other achievements. These accomplishments are all the more remarkable for the size and complexity of the organization in which they occurred, and a testament to what can be accomplished in health care with engaged and effective leadership and staff. Kaiser's achievements also owe a great deal to a unique 10-plus-year collaboration with IHI — a strategic partnership that accelerated improvement at KP, greatly informed IHI’s own learning, and helped KP build system-wide capacity for improvement.
International Journal for Quality in Health Care
Lean is a widely used quality improvement methodology initially developed and used in the automotive and manufacturing industries but recently expanded to the healthcare sector. This systematic literature review, published in the International Journal for Quality in Health Care, seeks to independently assess the effect of Lean or Lean interventions on worker and patient satisfaction, health and process outcomes, and financial costs.
Quality improvement (QI) activities occur widely across health care. Much of this activity goes unreported. There are a number of sites/repositories that do allow QI activities to be reported on and searched (such as BMJ Quality Improvement Reports at http://qir.bmj.com/). This article reports on a review of 13 publicly available, web-based QI repositories. The authors report that the 13 sites “used different terminology (eg, practices vs case studies) and approaches to content acquisition, and varied in terms of primary areas of focus. All provided some means for organising content according to categories or themes and most provided at least rudimentary keyword search functionality. Notably, none of the QI repositories included evaluations of their impact.”
This commentary, drawing on site visits to cancer care centres and interviews with cancer patients, family members, clinicians, and health care leaders in the USA, proposes six “essentials” for improving service quality in cancer care. The six factors are:
1. Embrace team-based care
2. Offer concurrent palliative care
3. Prepare family members for caregiving
4. Facilitate continuous connection
5. Broaden the geographic reach of clinical excellence
6. Adopt payment-system reforms.
This year, our APAC Forum attracted over 1,500 delegates from 30 countries. We heard from over 130 high-profile international change leaders, who helped to stimulate cross-sector and multidisciplinary dialogue, nurture ideas, share knowledge, and encourage each and every delegate to become a catalyst for change.
It was an explosive agenda, offering:
• 14 in-depth full day intensives, covering topics from patient safety to health equity, regeneration to mindfulness
• inspiring and diverse keynote addresses from world-renowned presenters
• 46 concurrent sessions that examined key issues in healthcare and provided practical examples of change in action
• eight short, powerful InSight talks designed to inspire and incite action to improve and transform health and care
• winners in nine categories at our first Ko Awatea International Excellence in Health Improvement Awards
• over 170 posters, displaying the depth and breadth of improvement work being undertaken throughout the world.
This report aims to capture the key insights from our 4th APAC Forum, allowing you to experience the highlights from the sessions you couldn’t attend. We invite you to use the report as a map on your journey to improvement – expand your universe, the possibilities are endless.
This guide will help district health boards (DHBs) put quality and safety at the centre of governance and drive improvement in their organisations. While the guide has been written with DHBs in mind, the principles and guidance are relevant and can be applied to all health care providers.
• an outline of the role of boards as agents for quality and safety improvement
• the seven essential steps boards can take to improve the quality and safety of health care services:
1. Lead and set clear goals
2. Gather information and seek out patient stories
3. Establish system-wide measures and monitor them
4. Put a high quality and safety culture in place
5. Ensure the right mix of people and encourage discussion
6. Commit to ongoing learning at all levels
7. Define roles and establish clear accountability at all levels
The Health of the Nation: Averting the demise of universal healthcare
London: Civitas; 2016
The UK think tank Civitas has published this collection of essays that examine that the background to the current pressures on the UK’s National Health Service and some of the ideas that have been proposed for reform. The publication features contributions from eleven authors from across the political spectrum and covers a wide range of suggestions covering public health and behaviour change; change management; technological innovations; and the future of commissioning.
Deeble Institute Issues Brief No 15
This issues brief offers an evaluation of current delivery models of after-hours primary health care nationally and internationally. It identifies a number of innovations and program elements that could be commonly applied by Primary Health Networks throughout Australia. Recognising that local setting is important and there is a need to tailor after-hours services appropriately, each model must be assessed in terms of suitability in the local context. As such, this Issues Brief describes individual program elements and options for innovations in after-hours service delivery which may be adaptable and transferrable across PHNs. Key principles common across the options proposed are:
- Services are flexible, responsive and tailored to regional circumstance
- Efficient and effective use is made of the broader health workforce
- Innovative service delivery is promoted
- Data is used to inform policy change
- Communication with patients and providers is key to success
London: Reform; 2016.
Primary care (or general practice) is often seen as the hope for reducing the pressures on hospitals. However, primary care faces its own challenges. This report form the UK’s Reform think tank reviews the current model of general practice in the UK and asserts that the model needs to change to address the future needs. The authors believe that British general practice would benefit from economies of scale and better integration. Creating such large practices will entail quite a different model of care, including much more multidisciplinary work in which “GPs could pass 50 per cent of appointments they currently conduct to other professionals. A more diverse workforce could, for instance, see pharmacists or nurses administering the estimated 57 million appointments (15 per cent of the total number of appointments) consumed by common conditions and medicines-related problems each year. This alone could deliver up to £727 million of savings per year.” The approach also calls for a significant change in commissioning of services.
Competencies for Patient Safety and Quality Improvement: A Synthesis of Recommendations in Influential Position Papers
Joint Commission Journal on Quality and Patient Safety
This paper reports on a study that examined 22 “position papers published by national and international professional associations, expert panels, consortia, centers and institutes, and convened committees, in the domain of patient safety and QI.” The list of bodies is heavily focused on North America and some of the sources are a tad dated. The authors reveal a concern about the breadth of competencies and “instead encourage development of an international consensus on the essential KSA [knowledge, skills and attitudes] for patient safety and QI [quality improvement] across all health professions and all levels of skill acquisition.”
Australian Health Review
In this article, the characteristics of success for transformational change in healthcare are explored through four case studies from the US, UK and Australia. Multiple sources of evidence were used to investigate each case study. Some common observations between case studies are:
- In most case studies, there was a clear case for change because the preceding health system was very poor
- A well-communicated narrative existed for each case study with evidence-based rationale for why change was needed
- In most cases, health professional and patient engagement and consultation was paramount
- A clear delineation of responsibility and appropriate performance measures and incentives were present
- System redesign was essential and was facilitated by sophisticated data management
Leadership focused on quality of care and the notion of health as a complex adaptive system.
Health Research & Educational Trust
This HPOE guide, a collaboration with the American Society for Healthcare Engineering, explores ways hospital and health system leaders can use the physical environment to improve the patient experience. The guide describes a "people, process, place" model that will help hospital and health system leaders identify people-centered ways to improve the patient experience of care through:
establishing a culture of caring; implementing process improvements, such as processes that support patients and staff; and making improvements to the place of care, including the hospital physical environment, technology and furniture.
By working with this model, hospitals and health systems can take a more holistic approach to improving the patient experience.
The guide includes case studies; a hospital leader checklist; a template for using the people, process and place model; a detailed table outlining eight domains of care measured by the HCAHPS survey with observed relationships to the physical environment; and additional resources list.
Background: This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.
Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation.
We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation.
Conclusions: This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.
Longwoods Healthcare Papers
Quality improvement collaboratives (QICs) are popular vehicles for supporting healthcare improvement; however, the effectiveness of these models and the factors associated with their success are not fully understood. This paper presents a QIC in the Canadian context, where provincial healthcare systems have historically faced difficulty in transcending their structural and political limitations as well as moving from reactive models of care (prioritizing illness treatment in a hospital-reliant system) to more proactive ones (prioritizing population health in a primary care-based system). In March 2012, in a move that has been described as "unprecedented," 17 health regions across four provinces in Atlantic Canada, together with the Canadian Foundation for Healthcare Improvement (CFHI), developed a collaborative to improve chronic disease prevention and management.
This paper introduces the Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC), reflecting on the experience of developing and implementing the model, which involved teams of front-line clinicians and managers working with CFHI faculty, coaches and staff to assess, design, implement, evaluate and share healthcare improvements for people living with chronic diseases. The paper shares key results and lessons learned from the AHC QIC experience, thus far, for improving chronic disease prevention and management in healthcare in Canada.
Royal College of General Practitioners and Royal College of Physicians
Integrated care and the coordination and continuity of care are all seen as desirable for improving the care patients receive. They all tend to place primary care as the key for achieving these improvements. This report from the UK’s Royal College of General Practitioners (RCGP) and Royal College of Physicians (RCP) presents a number of case studies “that exemplify how integration between GPs and physicians can be achieved. The case studies span a wide range of services in England and Wales, and cover a variety of learning points involving different specialties, different population groups and different ways of addressing complex issues. This report has been compiled to share learning from successful examples of integration, and to encourage GPs and physicians to reflect on their own practice. Many of the examples provided are disease specific, owing to the way in which secondary care is organised; however, around the country there are many innovative examples of more holistic treatment.
The sheer variety of integrative services show there is no ‘one size fits all’ approach, and the themes of the report include:
- the many approaches to integration, which will vary depending on the patient population
- improved communication and the establishment of an ongoing dialogue between GPs and physicians are vital to successful integration
- empowering the workforce to make change, and the importance of providing an educational environment that encourages innovation
- a supportive external environment, including commissioning and funding fit for purpose, and information and technology systems that support primary and secondary care working together
- the difference that can be made to patients if GPs and physicians are part of a multidisciplinary team (MDT) and work across the whole health economy
Physician Leadership Journal
Despite a vast amount of knowledge about the technical methods of improving quality and safety in health care, rates of success have been highly variable within and across organizations. In our work with many health care leaders and organizations, our observation has been that relational rather than technical issues are the most common barriers to improvement.
This may seem paradoxical in an industry devoted to healing relationships. But we have observed that the complexity and stress so prevalent in health care settings lead to frequent problems in working relationships at all levels of interaction: interpersonal, team, interdepartmental and inter-organizational.
Multiple research studies and analyses have suggested that contextual factors (such as quality of relationships, communication, leadership style, organizational culture, team process and behaviours, etc.) are critical facilitators or impediments for change…
Habits of thinking and action are not broken overnight. In health care, we have a long way to go to break our habit of marginalizing relational knowledge, skills and practice. The key ingredients are patience, persistence, courage and compassion for our innately human way of falling into counterproductive behaviour under stress.
Paradoxically, by recognizing this less rational side of our humanness and addressing it with compassion, we greatly enhance the chances for transformation.
Health Care Management Review
Despite broad agreement among researchers about the value of examining how context shapes implementation of improvement programs and projects, limited attention has been paid to contextual effects on implementation of Lean.
To help reduce gaps in knowledge of effects of intraorganizational context, we researched Lean implementation initiatives in five organizations and examined 12 of their Lean rapid improvement projects. All projects aimed at improving clinical care delivery.
On the basis of the literature on Lean , innovation, and quality improvement, we developed a framework of factors likely to affect Lean implementation and outcomes. Drawing on the framework, we conducted semi structured interviews and applied qualitative codes to the transcribed interviews. Available documents, data, and observations supplemented the interviews. We constructed case s studies of Lean implementation in each organization, compared implementation across organizations, and compared the 12 projects.
- Intra-organizational characteristics affecting organization-wide Lean initiatives and often also shaping project outcomes included CEO commitment to
- Lean and active support for it, prior organizational capacity for quality
- improvement-based performance improvement, alignment of the Lean initiative with the organizational mission, dedication of resources and experts to Lean, staff training before and during projects, establishment of measurable and
- relevant project targets, planning of project sequences that enhance staff
- capabilities and commitment without overburdening them, and ensuring communication between project members and other affected staff. Dependence of projects on inputs of new information technology was a barrier to project success. Incremental implementation of Lean produced reported improvements in operational efficiency and occasionally in care quality. However, even under the relatively favourable circumstances prevailing in our study sites, incremental implementation did not readily change organizational culture.
This study should alert researchers, managers, and teachers of management to ways that contexts shape Lean implementation and may affect other types of process redesign and quality improvement.
There have been repeated calls to better involve patients and the public and to place them at the centre of healthcare. Serious clinical and service failings in the UK and internationally increase the urgency and importance of addressing this problem. Despite this supportive policy context, progress to achieve greater involvement is patchy and slow and often concentrated at the lowest levels of involvement.
A selective narrative literature search was guided by the authors’ broad expertise, covering a range of disciplines across health and social care, policy and research. Published systematic literature reviews were used to identify relevant authors and publications. Google and hand searches of journal articles and reference lists and reports augmented identification of recent evidence.
Patients and the wider public can be involved at most stages of healthcare, and this can have a number of benefits. Uncertainty persists about why and how to do involvement well and evaluate its impact, how to involve and support a diversity of individuals, and in ways that allow them to work in partnership to genuinely influence decision-making. This exposes patient and public involvement (PPI) to criticisms of exclusivity and tokenism.
Current models of PPI are too narrow, and few organisations mention empowerment or address equality and diversity in their involvement strategies. These aspects of involvement should receive greater attention, as well as the adoption of models and frameworks that enable power and decision-making to be shared more equitably with patients and the public in designing, planning and co-producing healthcare.
Melbourne: Grattan Institute
This latest report from the Grattan Institute asserts that the Australian primary care is proving sub-optimal care for patients with chronic diseases. The report’s authors claim that ineffective management of chronic diseases costs the Australian health system more than $320 million each year in avoidable hospital admissions, that the primary care system provides only half the recommended care for many chronic conditions each year and that there are more than a quarter of a million admissions to hospital for health problems that potentially could have been prevented.
Chronic conditions affect many Australians and the numbers have been growing. To address these primary care needs to function well. This report argues, as have others, that the fee-for-service model is unsuited to managing and preventing chronic disease. The authors perceive a role for Primary Health Networks in helping patients receive better care for their chronic conditions.
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices
United States Government Accountability Office
It is no secret that implementation (and sustained implementation and impact) is where some of the biggest challenges lie in safety and quality interventions. This brief (34-page) report from the US U.S. Government Accountability Office (GAO) examined how six American hospitals tried to implement a number of evidence-based safety practices. Three key challenges affected the efforts to implement evidence-based patient safety practices, including:
- Obtaining data to identify adverse events in their own hospitals
- Determining which patient safety practices should be implemented
- Ensuring that staff consistently implement the practices over time.
At first glance it would seem that managing patient safety may be more straightforward in some settings than others. One setting that may seem more challenging is that of emergency care. This article reports on a systematic review that sought to focus on interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility. From, the 18 included studies that authors found "The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively".
In January 2015, the NHS invited individual organisations and partnerships to apply to become ‘vanguard’ sites for the new care models programme, one of the first steps towards delivering the Five Year Forward View and supporting improvement and integration of services.
In March, the first 29 vanguard sites were chosen. There were three vanguard types – integrated primary and acute care systems; enhanced health in care homes; and, multispecialty community provider vanguards.
In July, 8 urgent and emergency vanguards were announced.
In September a further 13 vanguards were announced – known as acute care collaborations, they aim to link local hospitals together to improve their clinical and financial viability.
The 50 vanguards were selected following a rigorous process, involving workshops and the engagement of key partners and patient representative groups.
Each vanguard site will take a lead on the development of new care models which will act as the blueprints for the NHS moving forward and the inspiration to the rest of the health and care system.
‘Behavioural insights’ has been described as the ‘application of behavioural science to policy and practice with a focus on (but not exclusively) “automatic” processes’. Nudges are a particular type of behaviour change intervention that might be considered an expression of behavioural insights. Nudge-type interventions – approaches that steer people in certain directions while maintaining their freedom of choice– recognise that many decisions – and ensuing behaviours – are automatic and not made consciously. Nudges have been proposed as an effective way to change behaviour and improve outcomes at lower cost than traditional tools across a range of policy areas.
There is much evidence that suggests the potential for all of these nudge-type interventions to be successful if suitably applied. However, the evidence available is highly variable in terms of quality, relevance to health care and behaviour change impact. Further, even for those interventions with the strongest evidence base – prompts, cues and reminders, and audit and feedback – there is much that is not yet known about how to enhance and optimise them. There is a clear need for more good quality evaluation and synthesised evidence of nudge-type interventions, their behaviour change potential and their impact on inefficiency and waste.
While nudge-type interventions hold much promise for reducing inefficiency and waste in health care it is important that intervention development clearly builds on existing research and theory. If this does not happen then nudging in health care is more likely to contribute to inefficiency and waste than reduce it.
Enabling Change in Health Care
Innovation centers such as the Penn Medicine Center for Health Care Innovation — an arm of the University of Pennsylvania Health System — are using rapid, low-cost experiments to explore new approaches to improving care.
Health care reforms and market trends are stimulating local health systems to seek better and more cost-efficient ways of meeting their patients’ needs. This case study is part of ongoing research by The Commonwealth Fund to track how health systems are transforming care delivery, particularly to meet the needs of high-needs, high-cost patients and vulnerable populations.
This report from the NIHR Patient Safety Translational Research Centre at Imperial College London and Imperial College Healthcare NHS Trust asserts that there is a need for a ‘toolbox’ for patient safety which includes using digital technology to improve safety; providing robust training and education, and strengthening leadership at the political, organisational, clinical and community levels. The report’s authors argue that interventions implemented to reduce avoidable patient harm must be engineered with the whole system in mind, and must empower patients and staff to become more involved in preventing harm and improving care.
Bringing together physical and mental health: A new frontier for integrated care
The King’s Fund in the UK have released this report claiming that the psychological problems associated with physical health conditions, and vice versa, are costing the NHS more than £11 billion a year and care is less effective than it could be. The report argues that by integrating physical and mental health care the NHS can improve health outcomes and save money.
The £11 billion a year is the collective cost of:
- high rates of mental health issues among those with long-term conditions such as cancer, diabetes or heart disease
- limited support for the psychological aspects of physical health, for example during and after pregnancy
- poor management of ‘medically unexplained symptoms’ such as persistent pain or tiredness.
The authors argue that the separation between physical and mental health has a high human cost: in the UK the life expectancy for people with severe mental illness is 15 to 20 years below that of the general population.
The report identifies 10 areas where there is particular scope for improvement across the system from enhancing mental health input in acute hospitals and assessing physical health problems in mental health inpatient facilities, to increased support for GPs in managing people with complex conditions. The ten priorities identified are:
1. Incorporating mental health into public health programmes
2. Promoting health among people with severe mental illnesses
3. Improving management of medically unexplained symptoms in primary care
4. Strengthening primary care for the physical health needs of people with severe mental illnesses
5. Supporting the mental health of people with long-term conditions
6. Supporting the mental health and wellbeing of carers
7. Supporting mental health in acute hospitals
8. Addressing physical health in mental health inpatient facilities
9. Providing integrated support for perinatal mental health
10. Supporting the mental health needs of people in residential homes.
This report from the UK’s King’s Fund argues that the NHS in England cannot meet the health care needs of the population without a sustained and comprehensive commitment to quality improvement as a principal strategy. The authors argue that the NHS in England has lacked a coherent approach to improving quality of care. They proceed to describe key features of a quality improvement strategy and the role of organisations at different levels in realising it, offering 10 design principles to guide its development. The design principles include:
- Expecting organisations to build in-house capacity for quality improvement
- Supporting organisations through shared learning and regional support
- Establishing a national centre of expertise
- Integrating quality improvement and leadership development
- Ensuring national bodies provide unified, co-ordinated support to the NHS as full participants in a single strategy
- Involving frontline clinical leaders and the leaders of organisations in developing the strategy
- Ensuring the voice of patients and the public is sought and heard in the design and implementation of the strategy
- Being open to learning from other organisations at home and abroad
- Working with organisations and experts outside the formal structures
- Reflecting, measuring and learning rapidly about what is and is not working to help implementation become more successful.
Safer Healthcare: Strategies for the Real World
In their new book, Safer Healthcare: Strategies for the Real World, Professors Vincent and Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system.
There have been many advances in patient safety but we now need a new and broader vision that encompasses care throughout the patient’s journey. We argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
Report of an Expert Panel Convened by the National Patient Safety Foundation.
Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.
With a grant from AIG, the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.
The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.
The report makes eight recommendations:
- Ensure that leaders establish and sustain a safety culture;
- Create centralized and coordinated oversight of patient safety;
- Create a common set of safety metrics that reflect meaningful outcomes;
- Increase funding for research in patient safety and implementation science;
- Address safety across the entire care continuum;
- Support the health care workforce;
- Partner with patients and families for the safest care
- Ensure that technology is safe and optimized to improve patient safety
The authors of this piece assert that “effective leaders in health care can have a stark consequence on the quality and outcomes of care. The delivery of safe, quality, compassionate health care is dependent on having effective clinical leaders at the frontline.” They proceed to explore ways of translating clinical leadership into health care quality improvement.
They argue that “Clinical leaders are effective in facilitating innovation and change through improvement. This is achieved by recognizing, influencing, and empowering individuals through effective communication in order to share and learn from and with each other in practice.” They recognise that health care organisations need to create cultures that encourage and develop clinical leaders. Openness and candour are key elements in their view.
Health is a complex human endeavour and the factors that contribute to high performance are complex. The objective of this review was to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement. The review screened more than 11,000 studies before focusing on 19. From the analysis the authors report that seven themes (and 25 sub-themes) representing factors associated with high performance emerged: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork.
The objective of this study, published in BMJ Open, was to systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.
This article details a sequence of four steps for taking a health intervention to full scale: 1. Set-up, 2. Develop the Scalable Unit, 3. Test of Scale-up, and 4. Go to Full Scale. The properties that facilitate adoption of the new ideas and the infrastructure required to support the scale-up are also described. Two case studies present national-scale initiatives in Ghana and South Africa that used early iterations of this framework to scale up evidence-based interventions to improve maternal and child health.
An inquiry into hospital productivity released this week claims that the NHS could save £5 billion a year through running costs and reducing the number of patients unable to leave wards. Our Chief Executive Nigel Edwards warns that the government should beware top-down approaches to reducing costs.
This Guide is a framework for use when developing or reviewing programmes set up to demonstrate the competence and performance of medical specialists. The Best Practice Guide was produced as a joint project Council of Medical Colleges (CMC) and Member Colleges, the Medical Council of New Zealand (MCNZ), the Ministry of Health (MoH) and District Health Board (DHB) Chief Medical Officers.
The Best Practice Guide is accompanied by a stock take of definitions, resources, tools and additional information to assist all to implement a best practice guide for continuous practice improvement.
Paper reporting on a systematic review examining economic analyses of interventions to prevent hospital-acquired infections. The review focused on 27 articles published in the period 2009 to 2014 The authors report finding highly positive cost–benefit ratios and conclude that preventing hospital-acquired infections is a cost-effective patient safety strategy.
Working Paper. Toronto: Institute of Health Policy, Management and Evaluation; 2015.
Poor quality of care places a heavy financial and human burden on health care systems worldwide.
Low quality care is widespread and persists despite the fact that more organizations than ever before are actively engaged in Quality Improvement (QI) efforts.
System level assessments of the impact of QI capacity building are essential to link investments to health system performance improvement and transformation.
The objectives of this study were to explore existing QI capacity building evaluations that allow assessment of the return on investments (ROI) or other types of economic evaluations, and to gather and review the literature on the current knowledge in QI capacity building evaluation.
BMJ Quality and Safety
Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers-particularly middle managers-also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions.
BMJ Quality and Safety
Quality improvement (QI) methods have been introduced to healthcare to support the delivery of care that is safe, timely, effective, efficient, equitable and cost effective. Of the many QI tools and methods, the Plan-Do-Study-Act (PDSA) cycle is one of the few that focuses on the crux of change, the translation of ideas and intentions into action. As such, the PDSA cycle and the concept of iterative tests of change are central to many QI approaches, including the model for improvement,1 lean,2 six sigma3 and total quality management.4
PDSA provides a structured experimental learning approach to testing changes. Previously, concerns have been raised regarding the fidelity of application of PDSA method, which may undermine learning efforts,5 the complexity of its use in practice5 ,6 and as to the appropriateness of the PDSA method to address the significant challenges of healthcare improvement.7
This article presents our reflections on the full potential of using PDSA in healthcare, but in doing so we explore the inherent complexity and multiple challenges of executing PDSA well. Ultimately, we argue that the problem with PDSA is the oversimplification of the method as it has been translated into healthcare and the failure to invest in a rigorous and tailored application of the approach.
Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.
We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010–2011 to 2011–2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.
When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.
Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations.
Measurement of performance in the healthcare sector is essential for transparency and accountability, and to support improvement. However, these improvements are undermined by weaknesses in the generation of data and metrics. This report outlines five steps that are not currently being addressed by policy but could significantly reduce data abuse and increase the benefit that can be gained through the use of performance dataQuality Improvement Essentials Toolkit
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This page was last updated at 12:46PM on March 21, 2018.