1. Changing the World
…..in 3 steps?

2. The next hour (or so…)
• What‟s the problem we were trying to
solve?
• How did we tackle it?
• What has been achieved so far?
• How are we expanding the approach?
• Why might this matter to you?

3. The 3-step Improvement Framework for
Scotland’s public services
Vision, aim and context.
1) Change
the
world
Culture, capacity
And challenge.
How much and by
2) Create the conditions when?
3) Make the improvement
Implementation, measur
ement and improvement

4. Q?
In your pack
The six questions to be asked of EVERY change programme:
1) Does everyone in the system know what we are trying to
achieve?
2) Are we prioritising the improvements likely to have the biggest
impact on the aim and stopping those that have little impact?
3) Is everyone clear about the means of securing improvement
towards our aim?
4) Are we able to measure and report progress on our aim?
5) Do we know how and where to deploy resources when
improvement is slower than required?
6) Do we have a way of testing and innovating and then spreading
new learning?

5. JL

6. NHS improvement language
Reliability Bundles
Collaboratives

7. Which HC professional would you
want to go to?
96
94
92
90
88 Patient
Satisfaction
86
84
82
Practice Practice Practice
A B C

8. Which HC professional would you
want to go to?
96
94
92
90
Patient
88
Satisfaction
86
Accommodated
84
Appointments
82
80
Practice Practice Practice
A B C

9. Which HC professional would you
want to go to?
96
94
92
Patient
90
Satisfaction
88
Accommodated
86
Appointments
84
% of people back
82
to full functioning
80
Practice Practice Practice
A B C

10. Which HC professional would you
want to go to?
95
90 Patient
Satisfaction
85
Accommodated
80
Appointments
% of people back
75 to full functioning
Harm-free care
70
Practice Practice Practice
A B C

11. DF

12. What challenge are we trying to solve?

13. Current level of Harm
USA 3.7% of admissions
44-98,000 deaths
Australia 16% of admissions
250,000 adverse events
50,000 permanent disability
10,000 deaths
Denmark 9% of admissions
N.Z. 10% of admissions
UK 11% of admissions
850,000 adverse events
DoH ECRI 2002 Knox K et al

14. Q1
25.1 harms per 100 admissions

15. Global Trigger Tool Reviews
3 Exemplar 40 Bed rural 10 Hospital 7 Hospital Multi-state
Hospitals Hospital (300 Research System Tertiary
(900 notes) notes) Project (240 (3000 notes) System
notes) (2000 notes)
Events/1000 83 90 NA 119 86
Days
Events/100 45 40 37 41 38
admissions
Admissions 32% 30% 30% 29% 30%
with
adverse
events

16. Mid-Staffs
Families have described “Third World”
conditions at the trust, with some patients
drinking water from vases because they were
so thirsty and others screaming in pain.
The Healthcare Commission launched an
inquiry after concerns were raised about
higher-than-normal death rates in emergency
care, in particular at Stafford Hospital.
The trust argued that the anomalies were due
to problems with its recording of data rather
than the quality of care for patients, the report
said.
Times online March 2009

17. Q1

18. Q1
Evidence based medicine 
Evidence based care delivery
17 years to get 14% of evidence
into practice

19. How did we set out to solve it?

20. “quality improvement”
The combined and unceasing efforts of
everyone – health care
professionals, patients and their
families, researchers, payers, planners,
administrators, educators – to make
changes that will lead to
better patient outcome, better system
performance, and better professional
development.
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

21. Policy Options
• Do what we‟ve always done
• Let‟s get more data
• Run a pilot project
• Run a campaign
• Let Boards and hospitals decide what to
do
• Run a mandatory national improvement
programme

22. So why did Scotland go
national?
• The context was right
• Our size helped
• Clinicians and managers were receptive
• A good match with „values‟
• The evidence was good enough – the
Tayside effect
• It felt like the right thing to do

23. Q1-6
Our response to the 6 Questions
The six questions to be asked of EVERY change programme:
1) Does everyone in the system know what we are trying to
achieve?
2) Are we prioritising the improvements likely to have the biggest
impact on the aim and stopping those that have little impact?
3) Is everyone clear about the means of securing improvement
towards our aim?
4) Are we able to measure and report progress on our aim?
5) Do we know how and where to deploy resources when
improvement is slower than required?
6) Do we have a way of testing and innovating and then spreading
new learning?

24. It‟s complicated….
Too bad all the people who know how to run
the country are busy driving cabs and
cutting hair.
-- George Burns

25. “Conquering the world on horseback is easy: it
is dismounting and governing that is hard”
Genghis Khan

26. JL

28. Q3
IHI Breakthrough Series Collaborative
Q6
Select Participants (10-100 teams)
Topic
(develop
mission) Prework
Develop Dissemination
P P P
Framework A D A D Publications,
A D
& Changes Congress. etc.
Expert S S S
Meeting LS 1 LS 2 Holding
Planning LS 3
Group AP1 AP2 AP3* the Gains
Supports *AP3 –continue
reporting data as
LS – Learning Session Email (listserv) Phone Conferences needed to
document success
AP – Action Period Visits Assessments
Monthly Team Reports

29. Aim
Measures
Changes
Execution
The Improvement Guide, API

30. Q2
Q3 How has the frontline done it?
• Get goals. • Get the facts.
• Get bold. • Get to the field.
• Get together. • Get a clock.
• Get a model (and • Get the numbers.
stick with it) • Get the stories.
• Get patients and
families

31. Q2
Outcome Aims
Q3
• Mortality: 15% reduction
• Adverse Events: 30% reduction
• Ventilator Associated Pneumonia: 0 or 300 days
between
• Central Line Bloodstream Infection: 0 or 300 days
between
• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in
range
• MRSA Bloodstream Infection: 30% reduction
• Crash Calls: 30% reduction

32. What can be achieved?

33. HSMR
Hospital Standardised Mortality Ratio

34. Q4
Scotland – 7% reduction in HSMR
1.5
1.3
Standardised Mortality Ratio
1.0
0.8
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p

35. Q4
1.5 1.5
1.3
Standardised Mortality Ratio
1.3
Standardised Mortality Ratio
1.0
1.0
0.8
0.8
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
1.5
1.5
Standardised Mortality Ratio
1.3
1.3
Standardised Mortality Ratio
1.0
1.0
0.8
0.8
0.5
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- 0.5
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
1.5 1.5
1.3
Q5 Standardised Mortality Ratio
1.3
Standardised Mortality Ratio
1.0
1.0
0.8
0.8
0.5
0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
HSMR results
2008-2011

36. Scotland level results

37. Q4
Central line infection rate
(per thousand line days)
12
10 March 2011:
zero central line infections
8
in whole country
6
4
2
0
08
09
10
11
8
9
0
1
8
9
0
1
8
9
0
l-0
l-0
l-1
l-1
r- 0
r- 0
r- 1
r- 1
-0
-0
-1
n-
n-
n-
n-
ct
ct
ct
Ju
Ju
Ju
Ju
Ap
Ap
Ap
Ap
Ja
Ja
Ja
Ja
O
O
O

38. Q4
0
2
4
6
8
10
12
14
16
18
20
Jan-08
Mar-08
May-08
Jul-08
9.11
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
VAP rate
Jan-10
Mar-10
May-10
(per thousand ventilator days)
Jul-10
Sep-10
62% reduction
Nov-10
Jan-11
Mar-11
May-11
3.49
Jul-11

39. Q4
10
12
14
16
18
20
22
24
26
28
Jan-08
Mar-08
May-08
Jul-08
Sep-08
Nov-08 18.2%
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
% ICU mortality
Jul-10
14% improvement
Sep-10
Nov-10
Jan-11
Mar-11
May-11
15.7%
Jul-11

40. 0.5
1.5
2.5
0
1
2
Jan-08
Q4 Q5
Mar-08
May-08
1.18
Jul-08
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
(per thousand patient days)
Jul-10
Sep-10
88% reduction
Nov-10
General ward C.Difficile rate
Jan-11
Mar-11
0.14
May-11
Jul-11

41. How has NHSScotland done it?
Policy Leadership Execution
Structure Process Outcome
Donabedian, A.
Explorations in Quality Assessment and
Monitoring. Volume I: The Definition of Quality
and Approaches to its Assessment.1980.

42. Having the best
professionals in the world
is no longer enough

43. Q4
The Capacity and Capability Aim
To build a sustainable
infrastructure that produces
highly reliable QI excellence
by (fill in the date).
How good? By when?
© 2010 Institute for Healthcare Improvement

44. Q4
Who needs to be developed?
Governance?
Executives?
Managers?
Supervisors?
Front Line Workers?
Improvement Advisors (IAs)?
Adapted from Tom Nolan, Associates in Process Improvement presented at the
IHI Strategic Partners Roundtable, April 17-18, 2006
© 2010 Institute for Healthcare Improvement

45. Q4 How many quality experts
do we need?
Two suggestions for determining this number:
√
Number of
employees
Or…consider that no employee should
be more than 2 steps (individuals)
away from a QI expert.
© 2010 Institute for Healthcare Improvement

46. DF

47. Q6
Moving beyond safety

48. What patients see as high quality
healthcare?
• caring and compassionate health
services;
• collaborating effectively with
clinicians, patients and others;
• confidence and trust in health services;
• providing a clean care environment;
• improving access and the continuity of
care;
• delivering clinical excellence

50. Q2
The Healthcare Quality Strategy for Scotland
• Person-Centred - Mutually beneficial partnerships between
patients, their families, and those delivering healthcare services
which respect individual needs and values, and which demonstrate
compassion, continuity, clear communication, and shared decision
making.
• Effective - The most appropriate
treatments, interventions, support, and services will be provided at
the right time to everyone who will benefit, and wasteful or harmful
variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients from
healthcare they receive, and an appropriate clean and safe
environment will be provided for the delivery of healthcare services
at all times.

51. The 3-step improvement
framework for
Scotland’s public services
“Do not be content with mediocrity.
Do your job so well that nobody could do it better.”
Martin Luther king Jr.

52. The 3-step Improvement Framework for
Scotland’s public services
Macro system –
1) Change Vision, aim and context.
the
world
Meso system –
Culture, capacity
And challenge.
How much and by
2) Create the conditions
when?
Micro system –
Implementation, measur
3) Make the improvement ement and improvement

53. Step 1; Changing the world – an evidence base
•This is the macro-system‟s role: vision, strategy and building coalitions. “Aims
create systems” – W. Edwards Deming
•It must establish a vision, a theory of reform, an engagement strategy and an
understanding of context both of people and places – then improvement is likely.
Kotter‟s eight steps for change offers a framework for work at this level

54. Step 1; (in our context) – 7 points to change the world
• A compelling vision
• A story
• Actions/ Stepping stones
• Securing the improvement
• Engaging the workforce
• Making the change work locally (everywhere)
• Resilience and authorisation provided by a
guiding coalition

55. Step 2; Creating the conditions
•This is the meso-system‟s role: Capacity and capability building,
•It must communicate the changes, empower the citizens and
workforce, model and change the culture.
The six questions to be asked of EVERY change programme:
1) Does everyone in the system know what we are trying to
achieve?
2) Are we prioritising the improvements likely to have the biggest
impact on the aim and stopping those that have little impact?
3) Is everyone clear about the means of securing improvement
towards our aim?
4) Are we able to measure and report progress on our aim?
5) Do we know how and where to deploy resources when
improvement is slower than required?
6) Do we have a way of testing and innovating and then spreading
new learning?

56. Step 2; Creating the conditions
The public services improvement bundle
The six questions to be asked of EVERY change
programme:
1) Aim? yes/no
2) Correct changes? yes/no
3) Clear change theory? yes/no
4) Measurement? yes/no
5) Capability? yes/no
6) Spread plan? yes/no
Only proceed if all six are yes – all-or-none measurement.

57. Step 3; Executing the change
•This is the micro-system‟s role: all improvement is local.
•Will and ideas are not enough at this level – we need execution. We need
a theory of change and the ability to test and implement the changes.
• There are many change theories
and models. We must choose a
small number of improvement
methods and stick with them for
the long haul.
• They must all be based on the
simple formula of aims/measures
and changes.
• Our selection may be;
 Collaboratives
 Benchmarking and
competition
 User/ Community
empowerment
 Performance management
• The choice must be explicit and
evidenced.

58. How prepared is your organization?
Key Components Self-Assessment
• Will (to change) • Low Medium High
• Ideas • Low Medium High
• Execution • Low Medium High
© 2010 Institute for Healthcare Improvement

59. "Quality is never an accident;
it is always the result of high
intention, sincere
effort, intelligent direction and
skillful execution; it
represents the wise choice of
many alternatives.”
1941, William A. Foster

61. 3 lessons in 3 minutes
• Pay attention to culture
– Changing „our‟ world
– Inclusive – workforce
– Various approaches available
• Leadership attention – walkarounds
• Improvement vs performance
– Organising for quality
– Data
– Can we test the approach elsewhere?