building capacity and capability: the really big...
TRANSCRIPT
11/22/2016
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Building Capacity and Capability: The REALLY BIG Challenge
Faculty
Robert Lloyd, PhD
Rebecca Steinfield
Amar Shah, MD
6 December 2016
Workshop A3 & B3
The presenters have nothing to declare
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Faculty(bios at the end of this presentation)
Dr. Robert Lloyd
Vice President
Institute for
Healthcare
Improvement
Dr. Amar ShahAssociate Medical
Director & Consultant
Forensic Psychiatrist
East London NHS
Foundation Trust
@DrAmarShah
Rebecca SteinfieldDirector IHI Improvement
Advisor Program
Institute for Healthcare
Improvement
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Discussion Topics
• Capacity versus Capability
• Who needs to be developed?
• What do they need to know?
• How do you evaluate your own efforts
for capacity and capability building?
4
To build a renewable infrastructure that produces
highly reliable quality and safety by (fill in the date).
The Aim
How good? By when?
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5
The Journey To Organizational Excellence
Excellence
Sustainability
Capability
Capacity
“We are what we repeatedly do.Excellence then, is not an act but a habit!
Aristotle (384 – 322 BC)
The Primary Drivers of Capacity & Capability Building
Will
IdeasExecution
QI
Having the Will (desire) to change the current state
to one that is better
Developing Ideasthat will contribute
to making processes and outcome better
Having the capacity and capability to
apply CQI theories, tools and
techniques that enable the
Execution of the ideas
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Key Components* Self-Assessment
• Will (to change)
• Ideas
• Execution
• Low Medium High
• Low Medium High
• Low Medium High
*All three components MUST be viewed together. Focusing on one or even two of the components will guarantee sub optimized
performance. Systems thinking lies at the heart of CQI!
How prepared is your organization?(your team, your department or your organization?)
Exercise #1
How prepared is your organization?(your team, your department or your organization?)
Capacity Building Issue Current Status Future Priority
C IP NS H M L
1. Evaluating your organization's mission,
vision and values to make sure that they
are consistent with QI principles.
2. Educating the following groups in the
theory and tools of QI:
• The Board
• Senior leaders
• Managers
• Physicians
• Staff
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3. Restructuring your performance evaluation
system so that it supports your efforts in
quality improvement.
4. Working with suppliers to establish long-
term partnerships that are based on
collaborative efforts to improve quality.
5. Providing employees with the support and
resources they need to participate in QI teams
and work.
6. Setting up process improvement teams.
7. Creating a process to set priorities for
selecting quality improvement initiatives.
8. Developing performance indicators of
quality improvement initiatives.
9. Preparing communication tools that share
information on quality goals and initiatives
with all associates.
For each item, you should make two responses. First, indicate the Current Status of each item within your organization by marking one of the following responses:
• Completed (C)• In Process (IP)• Not Started (NS)
Then, assign what you believe will be your Priority for each item over the coming twelve months by marking one of the following responses:
• High (H)• Moderate (M)• Low Priority (L)
Source: R. Lloyd. Quality Health Care: A Guide to
Developing and Using Indicators. Jones & Bartlett
Publishers, Sudbury, MA, 2004.
Exercise #2Building Capacity Self-Assessment©
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Capability• The power or ability to generate an outcome• The ability to execute a specified course of action• The sum of expertise and capacity• Knowledge, skill, ability, or characteristic associated with desirable
performance on a job, such as problem solving, analytical thinking, or leadership
• Some definitions of capability include motives, beliefs, and values
Capacity • The ability to receive, hold or absorb • The maximum or optimum amount of production • The ability to learn or retain information.” • The power, ability, or possibility of doing something or performing• A measure of volume; the maximum amount that can be held
0
1
2
3
Jan-0
8
May-0
8
Sep-0
8
Jan-0
9
May-0
9
Sep-0
9
Jan-1
0
May-1
0
SPSP c. Diff Rate (c. Diff s per 1000 patient days)
Capacity versus Capability
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“A focus on building capacity
and capability for improvement
is a key strategy.
Global analysis of healthcare
systems that deliver
outstanding performance in
cost and quality shows their
most common characteristic is
a systematic approach to
capability building for
improvement.”
Helen BevenJournal of Research in Nursing
15(2) 139-148, 2010.
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Key Terms: Helen Bevan
Capacity – having the right number and
level of people who are actively engaged
and able to take action.
Capability – the people have the
confidence and the knowledge and
skills to lead the change. Helen Beven, “How can we build skills to transform the healthcare system?”
Journal of Research in Nursing
15(2) 139-148, 2010.
Key Questions for Building Capacity and Capability
1. Will you involve everyone or just a few targeted groups?
2. Who needs to know what? (the dosing formula)
3. What methods do you plan to use to build capacity and capability?
4. Do you have a model or framework to guide your journey?
5. How will you make sure the learning system can be sustained?
Adapted and expanded from a conversation with Tom Nolan, Associates in Process
Improvement on material he presented at the IHI Strategic Partners Roundtable,
April 17-18, 2006.
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Key Questions for Building Capacity and Capability
1. Will you involve everyone or just a few targeted groups?
2. Who needs to know what? (the dosing formula)
3. What methods do you plan to use to build capacity and capability?
4. Do you have a model or framework to guide your journey?
5. How will you make sure the learning system can be sustained?
Adapted and expanded from a conversation with Tom Nolan, Associates in Process
Improvement on material he presented at the IHI Strategic Partners Roundtable,
April 17-18, 2006.
Key Question #1Will you involve everyone or just a few targeted groups?
Governance?Executives?Managers?
Supervisors?Front Line Workers?
Improvement Advisors (IAs)?Adapted and expanded from a conversation with Tom Nolan, Associates in Process
Improvement on material he presented at the IHI Strategic Partners Roundtable,
April 17-18, 2006.
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Improvement concepts, methods and
applications must be woven into the fabric of daily life and at all levels of the organization.
─ From point where care is delivered,
─ To management meetings and strategy sessions
─ And, in the board and governance level decisions
Therefore, a
cascading
system to
is needed!
build capacity
and capability
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Many organizations
start the cascade at the top…
and,trickle
downward!
While others believe that the cascade should start at the staff
level…
upward!percolate
and,
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But successful organizations cascade up and down throughout the organization
Top Down?
Bottom Up?
Spread from
the Middle?Mesosystem
Macrosystem
Microsystem
Details on the Microsystem
can be found in:
Quality by Design: A
Microsystems Approach. By
E. Nelson, P. Batalden and M.
Godfrey.
Jossey-Bass, 2007.
Key Question #2Who needs to know what? (the Dosing Formula)
Different levels of knowledge and skill in the Science of Improvement are required at different levels f the
organization.
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Organizations that have been successful at building capacity and capability recognize that people have different abilities,
skills and talents.
They have figured out who has what knowledge and skills and work from there.
Therefore, a one size fits all approach will not work
Organizational Levels and QI Science in Saskatchewan Province
Who What WhyPoint of Service
Teams
Model for
Improvement Basics
To realize
improvement can
happen.
Team leaders How to support teams To help teams use
new tools
QI Experts Theory of Profound
Knowledge
To reveal system
barriers to
improvement
Senior Execs,
Governors
How to set and
monitor system aims
To drive improvement
and learn
Source: Mary Smillie, Senior QI Consultant, Saskatchewan Health Quality Council
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Experts(Improvement
Advisors)
OperationalLeaders (Executives)
Change
Agents
(Middle
Managers,
Stewards,
Project
leads)
Everyone
(Staff, Supervisors,UBT lead triad)
Unit Based Teams
Continuum of PI Knowledge and Skills
Deep
Knowledge
Many People Few People
Our approach will be to make sure that each
group receives the knowledge and skill sets they need when
they need them and in the appropriate
amounts.
A key operating assumption of building
capacity is that different groups of
people will have different levels of need for PI knowledge and
skill.
Who needs to know what?
Source: Kaiser Permanente & IHI, 2008
Shared
Knowledge
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This Exercise is designed to create a dialogue on what we call the “dosing
formula.” That is, which groups of individuals within your organization need to
have what levels of knowledge and skill to successfully build a sustainable
infrastructure that produces highly reliable QI excellence?
The worksheet on the next page provides a list of Skills & Knowledge (the rows)
associated with organizations that have demonstrated QI excellence. For each of
the listed Skills & Knowledge items indicate the level or “dose” of Skill &
Knowledge you think each group (the columns) needs using the following
response scale:
1 = They need to know the basic terms, concepts and methods when they hear them2 = They need to be able to explain the terms, concepts and methods to others3 = They need to be able to teach the terms, concepts and methods to others4 = They need to be seen as an organizational lead and champion for the terms,
concepts and methods
Exercise #3Who needs what? (The Dosing Formula)
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Skills & Knowledge
Hospital Governance, Non-Execs, Board of
Directors
Senior Management (corporate)
Clinical Leadership (physicians
and nursing)
Middle Management, Directors & Supervisors
Frontline Staff
QI Experts
(IAs)
Models for QI (theory & concepts)
Leadership for improvement & cultural transformation
Teamwork and Facilitation
Gathering information
Analyzing and interpreting data
Presentation skills
Understanding variation
QI tools and methods
Change management
Patient-centered care
Exercise #3Who needs what? (The Dosing Formula)
Users GuideHospital leaders and staff can use the IHI Improvement Capability Self-Assessment Tool in several ways:- To better understand your hospital’s improvement capability;- To stimulate discussion about areas of strength and weakness; and-To help you reflect on and evaluate specific improvement efforts.
Note that this tool is not intended for performance management, judgment, or blame if you determine that your hospital’s improvement capability is less than you would like it to be.
You can use the tool to assess your hospital’s capability in six key areas: 1) Leadership for Improvement, 2) Results, 3) Resources, 4) Workforce and Human Resources, 5) Data Infrastructure and Management, and 6) Improvement Knowledge and Competence.
For each of these six areas, the tool provides a brief description of levels of capability, ranging from Just Beginning, to Developing, to Making Progress, to Significant Impact, to Exemplary. For each of the six areas, select and record below the level of capability that you think best fits your hospital’s current improvement capability – and briefly describe the data/evidence you used to inform your choice.
Exercise #4IHI Improvement Capability Self-Assessment Tool
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DIRECTIONS FOR USE
1. For each of the six areas, select and record below the level of capability that you
think best fits your hospital’s current improvement capability – and briefly
describe the data/evidence you used to inform your choice.
2. Reflect on the results of your assessment:- Does your assessment suggest one or more specific actions you can take
soon to increase your hospital’s capability? Note these
actions and who you would need to collaborate with to move ahead.
- Does your assessment suggest a need for more information to help you
determine specific actions to increase your hospital’s
capability? Note these needs.
Exercise #4IHI Improvement Capability Self-Assessment Tool
Just
Be
gin
nin
g
De
ve
lop
ing
Ma
kin
g P
rog
ress
Sig
nif
ica
nt
Imp
act
Exe
mp
lary Please provide a brief description
of the type of data or other
evidence you used to inform your
choice.
1. Leadership for Improvement
2. Results
3. Resources
4. Workforce and Human
Resources
5. Data Infrastructure and
Management
6. Improvement Knowledge and
Competence
Exercise #4IHI Improvement Capability Self-Assessment Tool
Summary Worksheet
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IHI IMPROVEMENT CAPABILITY SELF-ASSESSMENT TOOL:The levels below are intended to provide a basic indication of the improvement capability of your hospital in a number of domains that are
associated with overall improvement success. This information is confidential; the more honest the assessment, the more likely the initiatives
selected will be aligned with current ability and probability of success.
Just Beginning Developing Making Progress Significant Impact Exemplary
Leadership for Improvement: The capability of the leadership of the hospital to set clear improvement goals, expectations, priorities, and
accountability and to integrate and support the necessary improvement activities within the organizationThere are no clear
organizational level
improvement goals,
expectations, and priorities.
Improvement is seen as a
department or service
responsibility rather than
requiring overall organizational
leadership.
Leadership for improvement is
not coordinated across
departments or services. Very
little, if any learning from
improvement activities is
shared across the hospital.
The hospital leadership has set
clear improvement goals,
expectations, and priorities
through discussions with
department and service
leadership. Department or local
leaders are held accountable for
achieving the established goals
without the support required for
them to bring about
improvement.
Hospital leadership does not
fully facilitate improvement
activities across departments.
Some learning from
improvement activities is shared
across the hospital.
Hospital leadership has
prioritized some
organizational level
improvement goals to
actively monitor and support.
Hospital leadership focuses
on the system of care and
supports some local leaders
to facilitate coordination of
improvement activities
across the services involved.
Hospital leadership has
established a system for
sharing the learning from
some improvement activities
across the hospital.
Hospital leadership is actively
engaged in monitoring and
supporting most
organizational level
improvement goals. Hospital
leadership focuses on the
system of care and supports
most local leaders in
integrating and supporting
improvement activities across
the hospital. Hospital
leadership has established a
system for sharing the
learning from most
improvement activities across
the hospital.
Hospital leadership is actively
engaged in monitoring and
supporting all improvement goals.
Hospital leadership focuses on the
system of care and supports all local
leaders in integrating and supporting
improvement activities across the
hospital. Hospital leadership has
established a system for sharing the
learning from all improvement
activities across the hospital. Hospital
leadership continually sets clear
improvement goals, expectations,
priorities, and accountability.
Results: The capability of a hospital to demonstrate measureable improvement across all departments and areasSome programs or services in
the hospital can demonstrate
measureable improvement, but
this is not sustained over time
and no sustained improvement
can be demonstrated in any
whole system organization-level
measures.*
Although some programs or
services in the hospital can
demonstrate sustained and
measureable improvement over
time, very few if any of the
whole system organization-wide
measures can demonstrate
improvement over time.
The hospital has
demonstrated sustained
improvement over time for a
few whole system
organization-wide measures.
The hospital has
demonstrated sustained
improvement over time for
most whole system
organization-wide measures.
The hospital can demonstrate
sustained improvement over time for
all whole system organization-wide
measures.
IHI IMPROVEMENT CAPABILITY SELF-ASSESSMENT TOOL
Just Beginning Developing Making Progress Significant Impact Exemplary
Resources: The capability of a hospital to provide sufficient resources to establish improvement teams and to support their ongoing work
and success
Resources are available within
only a few services or
programs to support the work
of improvement teams in
these areas. There is no
hospital-wide coordination of
resource allocation.
Resources are available within
most programs or services to
provide adequate support to
improvement activities focused
in these areas. Some processes
for allocating resources within
programs or services have been
established, but these are not
coordinated across the hospital.
Resources are available to
support a coordinated
approach to improvement
across a number of services
or programs. Some
processes for allocating
resources across the hospital
are in place, but these are
not fully coordinated across
the hospital.
Resources are available to
support improvement
activities coordinated across
most of the hospital. Some
processes are in place to
review and coordinate the
allocation of resources for
improvement across the
hospital.
Resources are available to support
and promote improvement activities
coordinated across the whole
hospital. Clear processes are in place
to regularly review, prioritize, and
coordinate the allocation of
resources for improvement across
the hospital.
Workforce and Human Resources: The capability of a hospital to organize its workforce to encourage and reward active participation in
improvement work, clearly define and establish improvement leadership roles, and ensure that job descriptions include a component related
to improvement work
A few services or programs
have identified a person who is
responsible for improvement
work.
Most services and departments
have identified improvement
personnel, but they do not
report directly to senior
hospital leadership.
A plan for a clear chain of
improvement accountability,
responsibility, and
leadership across the
hospital has been
developed.
All services and departments
have a access to personnel
who are responsible for
improvement activities. The
personnel have sufficient
seniority to facilitate the
changes required for
improvement.
The hospital has established clearly
defined improvement leadership
roles. All staff see quality
improvement as an integral part of
their everyday work. The hospital
encourages and rewards active
participation in improvement work,
and job descriptions include a
component related to improvement
work.
30
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IHI IMPROVEMENT CAPABILITY SELF-ASSESSMENT TOOL
31
Just Beginning Developing Making Progress Significant Impact Exemplary
Data Infrastructure and Management: The capability of a hospital to establish, manage, and analyze data for improvement in a timely and
routine manner to meet the objectives and expected results of the hospital’s improvement plan
The hospital uses data to
measure performance, but
only a few places use data to
support and inform
improvement activities. There
is limited ability to
communicate information
across systems.
The hospital uses data to
measure performance and to
support some improvement
work. The hospital is aware of
a need to establish effective
data systems to communicate
across key stakeholders and
partners.
The hospital uses data to
measure performance and
to support most
improvement projects. The
hospital has established a
number of data systems to
allow for some cross-
system measures.
The hospital uses data to
measure performance and to
support almost all
improvement projects. The
hospital has established a
number of data systems
which it uses routinely to
share system-of-care
performance information
across key partners and
stakeholders.
The hospital uses data to drive all
improvement measures at both the
whole system and sub-system level.
Data systems allow for highly
effective communication within and
across departments and with key
stakeholders in a manner that
informs the knowledge and actions
required to meet the objectives of
improvement teams.
Improvement Knowledge and Competence: The capability of a hospital to obtain and execute on the skills and competencies required to
undertake improvement throughout the hospital
Few if any quality
improvement projects are
under way that are guided by
an organization-wide
improvement framework and
model. The hospital provides
training in improvement
methods to staff in a limited
fashion.
A number of quality
improvement projects are
underway. Multidisciplinary
teams are formed and actively
engaged.
A number of quality
improvement projects have
achieved measureable
improvements.
A number of quality
improvement projects have
achieved sustained
improvement. The hospital
spreads learning from quality
improvement projects
systematically across the
organization.
The hospital has embedded quality
improvement in all areas of the
organization. Teams have achieved
and sustained measureable
improvements. The hospital
consistently shares and spreads
improvements across all
departments and with key
stakeholders.
qi.elft.nhs.uk
@ELFT_QI
Building Capacity and
Capability for QI at ELFT
Amar Shah
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Mental health servicesNewham, Tower Hamlets, City & Hackney, Luton & Bedfordshire
Forensic servicesAll above & Waltham Forest, Redbridge, Barking, Dagenham,
Havering
Child & Adolescent services, including tier 4 inpatient
service
Regional Mother & Baby unit
Community health services Newham & Tower Hamlets
IAPTNewham, Richmond and Luton
Speech & LanguageBarnet
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Make it feel meaningful
Make it feel possible
Make it feel valued and permanent
Provide skills and support
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Build the will
Build
improvement
capability
Alignment
QI Projects
1. Newsletters (paper and electronic)
2. Stories from QI projects - at Trust Board, newsletters
3. Annual conference
4. Celebrate successes – support submissions for awards
5. Share externally – social media, Open mornings, visits,
microsite, engage key influencers and stakeholders
1. Build and develop central QI team capability
2. Online learning options
3. Pocket QI for those interested in QI
4. Improvement Science in Action waves
5. Develop cohort and pipeline of QI coaches
6. Bespoke learning, including Board sessions & commissioners
1. Embed local directorate structures & processes to support
QI
2. Align projects with directorate and Trust-wide priorities
3. Support staff to find time and space for QI work
4. Support deeper service user and carer involvement
5. Support team managers and leaders to champion QI
6. Align research, innovation, improvement and operations
Reducing Harm by 30% every year
1. Reduce harm from inpatient violence
2. Reduce harm from pressure ulcers
3. Other harm reduction projects (not priority areas)
Right care, right place, right time
1. Improving access to services
2. Improving physical health
3. Other right care projects (not priority areas)
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Bu
ild
ing
ca
pa
bil
ity
&
cap
aci
ty
Train all levels and across disciplines
Realign existing resources
Stop lower value work
Don’t just train people up – need to work on all four drivers at the
same time
Just-in-time: skill up as you scale up
Experts by experience
All staff
Staff involved in or leading QI
projects
QI coaches
Board
Internal experts
(QI team)
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Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Estimated number needed to train = 5000
Needs = introduction to quality
improvement, identifying problems, change
ideas, testing and measuring change
Estimated number needed to train = 1000
Needs = deeper understanding of
improvement methodology, measurement
and using data, leading teams in QI
Estimated number needed to train = 45
Needs = deeper understanding of
improvement methodology, understanding
variation, coaching teams and individuals
Needs = setting direction and big goals,
executive leadership, oversight of
improvement, being a champion,
understanding variation to lead
Estimated number needed to train = 11
Needs = deep statistical process control,
deep improvement methods, effective plans
for implementation & spread
Pocket QI commenced in October
2015. Aim to reach 200 people by
Dec 2016.
All staff receive intro to QI at
induction
500 people have undertaken the
ISIA so far. Wave 5 = Luton/Beds
(Sept 2016 – Feb 2017)
29 QI coaches graduated in
January 2016. Second cohort of 25
to be trained July-November 2016
Most Executives will have
undertaken the ISIA.
Annual Board session with IHI &
regular Board development
discussions on QI
Currently have 6 improvement
advisors, with 4 wte deployed to QI.
To increase to 8 IA’s in 2016/17 (6
wte).
Internal
experts (QI
team)
Bespoke QI learning sessions for
service users and carers. Over 50
attended in 2015. Build into recovery
college syllabus, along with
confidence-building, presentation
skills etc.
Needs = introduction to quality
improvement, how to get involved in
improving a service, practical skills in
confidence-building, presentation,
contributing ideas, support structure for
service user involvement
QI capability building
• In-depth training
• Course length is 6
months.
• 3days intensive
training; 4 WebEx
teleconferences;
2 full day learning
sets
• Applying learning
to their QI
projects in
‘action periods’
• Flexible, online training resource available to the whole Trust.
• Essential skills to support in leading QI
• Certificate which can be added to CPD portfolio.
• Apps for phone or tablet, or use browser
• Brand new modular
introduction to QI
• For anyone involved in
QI or wanting to learn
core QI skills
• Overview to using QI,
PDSAs and testing,
Using measurement &
data for improvement,
QI Tools
• One-stop shop• Learning resources
• Seminal papers, guidelines, whitepapers
• Videos• QI tools
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Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Estimated number needed to
train = 1000
Needs = deeper understanding
of improvement methodology,
measurement and using data,
leading teams in QI
700 people have
undertaken the ISIA
so far
Internal
experts (QI
team)
Workshop
(3 days)
Webex #2Webex #1
• Faculty consults
• Webex calls
• Coaching calls
Webex #3 Learning Set
2 &
graduation
AP-5AP-4
The two learning sets will be focused on sharing the
participants’ work on their projects and learning from each
other. These sessions also will reinforce the content from the
Webex calls and the ISIA workshop.
Improvement Science in Action Improvement Science in Action Improvement Science in Action Improvement Science in Action ---- 6 month learning path6 month learning path6 month learning path6 month learning path
Learning
set 1
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Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Estimated number needed
to train = 5000
Needs = introduction to
quality improvement,
identifying problems,
change ideas, testing and
measuring change
Pocket QI commenced in
October 2015. Aim to
reach 200 people by Dec
2016.
All new staff have
received intro to QI at
induction since 2003
Internal
experts (QI
team)
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Workshop 1
Overview to
using QI
PDSA & testing
Both workshops are between 3.5 hours in a classroom
format and rotate in location throughout the
geography of the Trust.
Group size approx. 30
Workshop 2
Using
measurement for
improvement
Tools
Pocket Pocket Pocket Pocket QI QI QI QI ---- 1 1 1 1 month learning pathmonth learning pathmonth learning pathmonth learning path
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QI ResourcesService User Input
Support around every team
Project Sponsor QI Coach
QI Forums
QI Team
Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Estimated number needed
to train = 45
Needs = deeper
understanding of
improvement
methodology,
understanding variation,
coaching teams and
individuals
29 QI coaches
graduated in January
2016. Second cohort of
25 to be trained July-
November 2016Internal
experts (QI
team)
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QI CoachesQI CoachesQI CoachesQI Coaches
Governance Improvement
Little i Big I
Surveys
Focus
groupsCommunity
meetings
Service
user
forum
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Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Internal
experts (QI
team)
Bespoke QI learning
sessions for service users
and carers. Over 50
attended in 2015. Build
into recovery college
syllabus, along with
confidence-building,
presentation skills etc.
Needs = introduction to
quality improvement, how
to get involved in
improving a service,
practical skills in
confidence-building,
presentation, contributing
ideas, support structure for
service user involvement
Intro to QI Intro to QI Intro to QI Intro to QI ---- for service users & for service users & for service users & for service users & carerscarerscarerscarers
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Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Estimated number needed
to train = 11
Needs = deep statistical
process control, deep
improvement methods,
effective plans for
implementation & spread
Currently have 6
improvement advisors,
with 4 wte deployed to
QI. To increase to 8 IA’s
in 2016/17 (6 wte).
Internal
experts (QI
team)
11/22/2016
28
Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Board
Needs = setting direction
and big goals, executive
leadership, oversight of
improvement, being a
champion,
understanding variation
to lead
All Executives will
have undertaken the
ISIA.
Annual Board session
with IHI & regular
Board development
discussions on QI
Internal
experts (QI
team)
PR
OJE
CT
SC
APA
BIL
ITY
& C
APA
CIT
YY
EA
R
2013 2014 2015 2016
4
prototype
sites
Grow from 4
to 60
Grow from
60 to 120
Grow from
120 to 200
Central
team of 2
Identified 3
people to
start IA
training
Stopping work
of lower value
Reduced audit
standards
Central team of
6, including 2
IA’s
First wave of
ISIA training
for 80 staff
Send three
more people to
IA training
Identify & train
1st cohort of
QI coaches
Central team
grows to 9
2nd and 3rd
waves of ISIA –
another 230
staff
Five more
people to IA
training
2nd cohort of
QI coaches –
45 in total
Central team
grows to 18
4th, 5th and 6th
waves of ISIA –
another 330
staff
First Board
sessions on
QI
11/22/2016
29
Key principles for capacity & capability building
11/22/2016
30
Make it feel meaningful
Make it feel possible
Make it feel valued and permanent
Provide skills and support
11/22/2016
31
Our QI Projects
0
50
100
150
200
250
Nu
mb
er
of
act
ive
pro
ject
s
Month
11/22/2016
32
225Active
Projects
REDUCE HARM BY
30% EVERY YEAR
14
PHYSICAL
HEALTHACCESS TO
SERVICES
PRESSURE
ULCERS
VIOLENCE
REDUCTION
2 18 83
29
RIGHT CARE, RIGHT
PLACE, RIGHT TIME
158
Our QI Projects
Is it making a
difference?
11/22/2016
33
Violence reduction
150
200
250
300
350
400
450
500
550
2013 2014 2015
No
. o
f In
cid
en
ts
Physical violence to patients (per 100,000
occupied bed days)
300
400
500
600
700
800
900
2013 2014 2015
Physical violence to staff (per 100,000
occupied bed days)
Over three years,
physical violence has
reduced compared to
other mental health
providers
Impact across all 35
East London wards =
25% reduction
60% reduction across 3 older adult
wards with highest level of violence
40% reduction across all six
wards in Tower Hamlets
50% reduction in Forensic
learning disability service
UCL
67.79
51.13LCL
20
30
40
50
60
70
80
90
100
06
-Ja
n-1
4
03
-Fe
b-1
4
03
-Ma
r-1
4
31
-Ma
r-1
4
28
-Ap
r-1
4
26
-Ma
y-1
4
23
-Ju
n-1
4
21
-Ju
l-1
4
18
-Au
g-1
4
15
-Se
p-1
4
13
-Oct
-14
10
-No
v-1
4
08
-De
c-1
4
05
-Ja
n-1
5
02
-Fe
b-1
5
02
-Ma
r-1
5
30
-Ma
r-1
5
27
-Ap
r-1
5
25
-Ma
y-1
5
22
-Ju
n-1
5
20
-Ju
l-1
5
17
-Au
g-1
5
14
-Se
p-1
5
12
-Oct
-15
09
-No
v-1
5
07
-De
c-1
5
04
-Ja
n-1
6
01
-Fe
b-1
6
29
-Fe
b-1
6
28
-Ma
r-1
6
25
-Ap
r-1
6
23
-Ma
y-1
6
20
-Ju
n-1
6
No
. o
f In
cid
en
ts
Incidents resulting in physical violence (Trust-wide, excluding Luton and
Beds) - C Chart
Improving access to services
32.21%
25.23%
26.30%
UCL
LCL
20%
25%
30%
35%
40%
Jan
-14
Fe
b-1
4
Ma
r-1
4
Ap
r-1
4
Ma
y-1
4
Jun
-14
Jul-
14
Au
g-1
4
Se
p-1
4
Oct-
14
No
v-1
4
De
c-1
4
Jan
-15
Fe
b-1
5
Ma
r-1
5
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Se
p-1
5
Oct-
15
No
v-1
5
De
c-1
5
Jan
-16
Fe
b-1
6
Ma
r-1
6
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Se
p-1
6
DN
A /
%
% of 1st face to face appts DNAs (Collaborative, 10/12 teams) - P Chart
UCL
1,021.711,213.13
1,331.17
LCL700
900
1100
1300
1500
1700
Jan
-14
Fe
b-1
4
Ma
r-1
4
Ap
r-1
4
Ma
y-1
4
Jun
-14
Jul-
14
Au
g-1
4
Se
p-1
4
Oct-
14
No
v-1
4
De
c-1
4
Jan
-15
Fe
b-1
5
Ma
r-1
5
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Se
p-1
5
Oct-
15
No
v-1
5
De
c-1
5
Jan
-16
Fe
b-1
6
Ma
r-1
6
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Se
p-1
6
No
. o
f R
efe
rra
ls
No. of referrals received (Collaborative, 10/12 teams) - I Chart
30% increase in referrals across
10 community services
20% reduction in non-
attendance at first appointment
across 10 community services
33% reduction in waiting time
from referral to first appointment
across City & Hackney community
mental health teams
60.77
40.05
UCL
LCL
20
30
40
50
60
70
80
90
Jan-1
4
Feb-1
4
Ma
r-14
Ap
r-14
Ma
y-1
4
Jun-1
4
Jul-14
Au
g-1
4
Se
p-1
4
Oct-
14
Nov-1
4
Dec-1
4
Jan-1
5
Feb-1
5
Ma
r-15
Ap
r-15
Ma
y-1
5
Jun-1
5
Jul-15
Au
g-1
5
Se
p-1
5
Oct-
15
Nov-1
5
Dec-1
5
Jan-1
6
Feb-1
6
Ma
r-16
Ap
r-16
Ma
y-1
6
Jun-1
6
Jul-16
Au
g-1
6
Se
p-1
6
Av
era
ge W
ait
ing
Tim
e / D
ays
Average waiting time from referral to 1st face to face appt (City and
Hackney CMHTs) - X-bar Chart
11/22/2016
35
The Formula for Improvement
Structure
+ Process
+ Culture*=Outcome
Donabedian, A. (1966). "Evaluating the quality of medical care." Milbank Memorial Fund Quarterly44(3): Suppl:166-206.
*Added to Donabedian’s original formulation by R. Lloyd and R. Scoville.
Senior Leadership Attention“Constancy of Purpose”
• Setting clear improvement goals,
expectations, priorities, and accountability
• Monitoring and supporting all improvement
goals.
• Establishing a system for sharing the learning
• Maintaining focus on the system of care:
integrating improvement activities across the
organization.
70
11/22/2016
36
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Improvement Guide, p 24
71
The Sequence of Improvement
Sustaining improvements and Spreading changes to other locations
Developing a change
Implementing a change
Testing a change
Theory and Prediction
Test under a variety of conditions
Make part of routine operations
11/22/2016
37
Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Execs/Board
All Staff Need to Know:
• Model for Improvement (or any improvement
model)
• Identifying problems and testing ideas to learn the
way to a solution
Need to Know:
• How to charter and execute a microsystem-level results-oriented
improvement project using the Model for Improvement
• Basic improvement tools
Need to Know:
• How to execute the Model for Improvement to get results
• Facilitation
• The human side of change
Need to Know:
• Model for Improvement
• High Impact Leadership Behaviours
Need to Know:
Deming’s System of Profound Knowledge
• Systems thinking
• Understanding variation
• Human behaviour
• Theory of knowledge
Internal
experts (QI
team)20-50% of their time dedicated
to coaching teams
50 - 100% of their time
dedicated to organizational
improvement
Experts by experience
All staff
Staff involved in
or leading QI
projects
QI coaches
Execs/Board
Need to Know:
• Model for Improvement (or any improvement model)
• Identifying problems and testing ideas to learn the way to a solution
QI Project Leaders and Teams Need to Know:
• How to charter and execute a microsystem-
level results-oriented improvement project
• Basic improvement tools
Need to Know:
• How to execute the Model for Improvement to get results
• Facilitation
• The human side of change
Need to Know:
• Model for Improvement
• High Impact Leadership Behaviours
Need to Know:
Deming’s System of Profound Knowledge
• Systems thinking
• Understanding variation
• Human behaviour
• Theory of knowledge
Internal
experts (QI
team)20-50% of their time dedicated
to coaching teams
50 - 100% of their time
dedicated to organizational
improvement
11/22/2016
38
75
Methods and Tools for ImprovementCategory Method or Tool Typical Use of Method or Tool
ViewingSystemsand Processes
1. Flow Diagram Develop a picture of a process. Communicate and standardize processes.
2. Linkage of Processes (LOP) Map
Develop a picture of a system composed of processes linked together.
GatheringInformation
3. Form for Collecting Data Plan and organize a data collection effort.
4. Surveys Obtain information from people.
5. Benchmarking Obtain information on performance and approaches from other organizations.
6. Creativity Methods Develop new ideas and fresh thinking.
OrganizingInformation
7. Affinity Diagram Organize and summarize qualitative information.
8. Force Field Analysis Summarize forces supporting and hindering change.
9. Cause and Effect Diagram Collect and organize current knowledge about potential causes of problems or variation.
10. Matrix Diagram Arrange information to understand relationships and make decisions.
11.Tree Diagram Visualize the structure of a problem, plan, or any other opportunity of interest.
12. Quality Function Deployment (QFD)
Communicate customer needs and requirements through the design and production processes.
UnderstandingVariation
13. Run Chart Study variation in data over time; understand the impact of changes on measures.
14. Control Chart Distinguish between special and common causes of variation.
15. Pareto Chart Focus on areas of improvement with greatest impact.
16. Frequency Plot Understand location, spread, shape, and patterns of data.
UnderstandingRelationships
17. Scatterplot Analyze the associations or relationship between two variables; test for possible cause-and-effect.
18. Two-Way Table Understand cause-and-effect for qualitative variables.
19. Planned Experimentation Design studies to evaluate cause-and-effect relationships and test changes.
Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Execs/Board
Need to Know:
• Model for Improvement (or any improvement model)
• Identifying problems and testing ideas to learn the way to a solution
Need to Know:
• How to charter and execute a microsystem-level results-oriented improvement
project using the Model for Improvement
• Basic improvement tools
QI Coaches Need to Know:
• How to execute the Model for Improvement to get
results
• Facilitation
• The human side of change
Need to Know:
• Model for Improvement
• High Impact Leadership Behaviours
Need to Know:
Deming’s System of Profound Knowledge
• Systems thinking
• Understanding variation
• Human behaviour
• Theory of knowledge
Internal
experts (QI
team)
20-50% of their time
dedicated to
coaching teams
50 - 100% of their time
dedicated to organizational
improvement
11/22/2016
39
Experts by experience
All staff
Staff involved in or
leading QI projects
QI coaches
Execs/Board
Need to Know:
• Model for Improvement (or any improvement model)
• Identifying problems and testing ideas to learn the way to a solution
Need to Know:
• How to charter and execute a microsystem-level results-oriented improvement
project using the Model for Improvement
• Basic improvement tools
Need to Know:
• How to execute the Model for Improvement to get results
• Facilitation
• The human side of change
Need to Know:
• Model for Improvement
• High Impact Leadership Behaviours
Improvement Advisors Need to Know:
Deming’s System of Profound Knowledge
• Systems thinking
• Understanding variation
• Human behaviour
• Theory of knowledge
Internal
experts (QI
team)
50 - 100% of their time
dedicated to
organizational
improvement
78
Program Name(s) Description Duration Target Audience
Program 0
IHI Open
School
Courses
Essential training and tools in an
online, educational community.
Eight improvement capability
courses are available.
1-2 hours
per course,
8 courses
total
Beginning medical students and allied
health professionals
Program 1
Science of
Improvement
(SOI)
IHI’s introduction to improvement
program. Ideal minicourse to offer
during conferences (ours or others)
or in conjunction with learning
sessions to build capability.
1-2 days Beginners to improvement
Program 2
Improvement
Science in
Action (ISIA)
IHI’s introduction to improvement
program plus application to team
projects
3-5 months Beginning improvement teams
Program 3
Improvement
Coach
Program
A 12-week experiential program for
those already familiar with
improvement to further develop
your improvement knowledge and
skill so you can coach and facilitate
improvement teams as well as
support the implementation of
improvement strategies within your
organization
3-5 months
Those with improvement experience
who want to coach and facilitate
improvement teams
Program 4
Improvement
Advisor
Professional
Development
Program
A professional development
program designed to develop health
care Improvement Advisors (IAs) to
be effective facilitators to
accomplish the improvement
strategies of their organizations
11 months
Specialists in QI and future QI
leaders; health care professionals
who expect to have a major portion
of their future work focused on
improvement
11/22/2016
40
79
What driving forces are compelling you to move forward with building capacity and capability for QI?
What restraining forces (or barriers) are holding you back from building capacity and capability for QI?
• Use the Force Field Analysis Worksheet on the next page
to identify these two sets of forces.
• Then take your list of Restraining Forces and identify, in
the box at the bottom of the Worksheet, the actions you
plan to take to reduce these Restraining Forces.
Exercise #5Force Field Analysis
Driving Forces (+) Restraining Forces (-)
Actions to reduce the Restraining Forces:
•
•
•
Issue or Project:
Exercise #5: Force Field Analysis Worksheet
11/22/2016
41
The Primary Drivers of Capacity & Capability Building
Will
IdeasExecution
QI
Having the Will (desire) to change the current state
to one that is better
Developing Ideasthat will contribute
to making processes and outcome better
Having the capacity and capability to
apply CQI theories, tools and
techniques that enable the
Execution of the ideas
Key Components* Self-Assessment
• Will (to change)
• Ideas
• Execution
• Low Medium High
• Low Medium High
• Low Medium High
*All three components MUST be viewed together. Focusing on one or even two of the components will guarantee sub optimized
performance. Systems thinking lies at the heart of CQI!
How prepared is your organization?(your team, your department or your organization?)
In light of what we have covered in this workshop do you
think any adjustments in your assessment of Will, Ideas and
Execution need to be made?
11/22/2016
42
83
Thanks for joining us today
Good luck with your Quality Journey!Good luck with your Quality Journey!Good luck with your Quality Journey!Good luck with your Quality Journey!
Please contact us with any questions.Please contact us with any questions.Please contact us with any questions.Please contact us with any questions.
Robert [email protected]
@rlloyd66
Rebecca [email protected]
Amar Shah [email protected]
@DrAmarShah
Robert Lloyd, PhD is Vice President at the Institute for Healthcare Improvement (IHI).
Dr. Lloyd provides leadership in the areas of performance improvement strategies,
statistical process control methods, development of strategic dashboards and building
capacity and capability for quality improvement. He also serves as lead faculty for
various IHI initiatives and demonstration projects in the US, the UK, Sweden, Denmark,
New Zealand and Africa.
Before joining the IHI, Dr. Lloyd served as the Corporate Director of Quality Resource
Services for Advocate Health Care (Oak Brook, IL). He also served as Senior Director of
Quality Measurement for Lutheran General Health System (Park Ridge, IL), directed the
American Hospital Association's Quality Measurement and Management Project
(QMMP) and served in various leadership roles at the Hospital Association of
Pennsylvania. The Pennsylvania State University awarded all three of Dr. Lloyd’s
degrees. His doctorate is in agricultural economics and rural sociology.
FacultyRobert Lloyd
Dr. Lloyd has written many articles and chapters in books. He is also the co-author of the internationally
acclaimed book, Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control
Applications (American Society for Quality Press, 2001, 5th printing) and the author of Quality Health Care: A
Guide to Developing and Using Indicators, 2004 by Jones and Bartlett (Sudbury, MA).
@rlloyd66
11/22/2016
43
IHI Faculty
Rebecca Steinfield
Rebecca Steinfield, MA, has been with IHI since 1996. She
currently serves as Director of IHI’s Improvement Advisor
Professional Development Program, teaches IHI courses on
improvement methods, and mentors “improvers-in-training.”
Rebecca sits on IHI’s Improvement Capability Focus Area.
Past IHI work includes serving as an Improvement Advisor on
IHI’s programming for reducing unnecessary re-hospitalizations
and primary care transformation in academic settings. Rebecca
received her MA in Applied Psychology from Boston University.
85
FacultyAmar Shah
Amar Shah, MD is a forensic psychiatrist at East London NHS
Foundation Trust (ELFT) and leads the organisation-wide QI
program aimed at supporting the Trust to provide the highest
quality mental health and community care in the country.
As part of the program, ELFT is building the will and alignment
for improvement at scale. They have partnered with the IHI in
this work, who support with building capability at scale and
providing strategic guidance.
@DrAmarShah
Dr Shah has experience of providing local quality improvement support within a number
of NHS providers, and national improvement work while seconded to the National
Patient Safety Agency in 2009-10. He is an IHI Improvement Advisor and faculty
member, and has completed an executive MBA in healthcare management, a masters in
mental health law and a postgraduate certificate in medical education.