change

change is hard

the world’s biggest change…

Changes we have seen in theatres

in the last couple of years…

• WHO Surgical Safety Checklist

• Reconfiguration of services

• Patients escort from TAU to reception

• Re-organisation of anaesthetic rooms

Surgical Patient Safety Incidents

No harm Low harm Moderate

harm

Severe

harm

Death

94,306 31,108 8331 1,206 296

Total: 135,247

Patients with a surgical site infection require on

average an additional hospital stay of 6.5 days

“This extraordinary coalition of United Kingdom’s

leading organisations for surgeons, anaesthesia

professionals and nurses has endorsed a seemingly

mundane but revolutionary idea: that a simple

operating room checklist could save lives in surgery

the same way that pilots’ checklists have saved lives in

aviation for the last half century.”

Atul Galwande

To energise you to go back and look at

your own work environment differently

AIM OF TODAY

change

??

What does it take to make

change happen?

Somebody challenging the current state of things...

the Sunday roast story

outpatients booking rulesNEW F UP

08:30 1

08:40 1

08:50 1

09:00 1

09:15 1

09:20 1

09:30 1

09:45 1

10:00 1

10:10 1

10:20 1

10:30 1

10:40 1

10:50 1

11:00 1

TOTAL 5 10

NEW F UP

08:30 1

08:40 1

08:50 1

09:00 1

09:15 1

09:30 2

09:45 1

10:00 1

10:10 1

10:15 1

10:20 1

10:30 1

10:40 1

11:00 1

TOTAL 6 9

?

The 5 WHYs analysis

The 5 WHYs example:The list did not start on time

The surgeon was late

They were marking and consenting

the patient

They had to wait for a bed space/room

to be available

There aren’t enough bed spaces or rooms

to mark and consent the patient in privacy

Because all the patients arrive

at the same time

WHY?

WHY?

WHY?

WHY?

WHY?

Renal list storyWHY?

Patients

aren’t

ready on

TAU

Problem:

late starts

WHY?

Blood results

not ready,

notes missing

WHY?

Patients have dialysis

on Sundays and

bloods are not taken

WHY?

Dialysis unit wasn’t

aware this was

important and

caused problems

What does it take to make

change happen?

Somebody seeing things differently….

Join all the dots with 4 straight lines and

without allowing your pen to leave the paper

Commodes are situated at the far end of the sluice room where

commodes and other stock items are randomly places in the sluice

How many steps in the process does it take to collect a

commode for a patient on the ward returning it back to the

sluice?

Waste Spotting!

Change?

Defects and

Rework

Motion

Over

production

Trans-portation

Over

processing

Waiting

Inventory

Equipment not returned

to the correct place so

the next person spends

time walking around the

department looking for

it

Waiting for a

member of the

team to arrive so

can do team brief

Repeatedly asking

patients the same

questions

Item not stocked in the

anaesthetic room, staff

walking to the main stock

room to collect item every

time required

Lost of copies of the

theatre list.

Excess stock with no

place to keep it,

potential for low use

items to go out of

date.

Duplication of

information at the

handover stages of

the patient journey

What does it take to make

change happen?

Somebody making it happen…

The Invisible

Bicycle Helmet

http://www.youtube.com/watch?feature=player_embedded&v=CMAhptqk-4Q

A local change idea

BeforeAnaesthetic Rooms. NGH Theatres

- Items overstocked, drawers full

- Key items out of stock.

- Out of date stock

- Items hard to find.

- Items left on the surface

The Stock

-125

-105

-85

-65

-45

-25

-5

15

35

55

Product

Nu

mb

er D

iffe

ren

ce

Difference Between Planned and Actual Stock Levels

-10

-5

0

5

10

15

20

25

30

35

40

Product

Nu

mb

er D

iffe

ren

ce

Mismatch between maximum stock needed and actual stock held.

Result:

- Staff frustration finding products not in stock.

- Theatre funding held in stock that would go out of date.

AfterAnaesthetic Rooms. NGH Theatres

- Items used together are kept together

- Clear coloured labelling system.

- New stock levels agreed

- Low usage cabinet introduced.

Colour Code

Category

Blue Intravenous

Yellow Warming

Red Invasive

Green Airway

Black Spinal/Epidural

White Miscellaneous

Staff Time to Find Temperature Probe in Anaesthethic Room

0

20

40

60

80

100

120

140

OD

P 5

OD

P 4

OD

P 3

OD

P 2

Student O

DP

Nurse

OD

P 1

Lead Practitioner

Anaesthetist

Anaesthetist

Support W

orker

OD

P 6

Nurse

Individual Member of Staff

Tim

e (s

eco

nd

s)

Before reorganisation

After Reorganisation

**

Measuring the Impact of the Change

• Somebody challenging the current state

of things…

• Somebody seeing things differently…

• Somebody making it happen…

What does it take to make

change happen?

change

??

‘We must redesign services.

Decisions about service redesign must

be clinically led and clinicians must be

prepared to challenge the way services -

including their own service – are

organised.’

Hospitals on the Edge – The time for action

Royal College of Physicians, 13th September 2012

When system improvement is needed, there are

different options we can choose from…

Focus on blame Focus on shared learning

Focus on individuals Focus on teams

Emphasis on symptoms Emphasis on diagnosis

External pressure Internal drive

Top down Bottom up

‘One offs’ Continuous Improvement

VS

System Levels

Patients who need some help and care

Teams helping patients -microsystem

Support structures to help the teams be effective –mesosystem

Corporate functions to help the support structures be effective -macrosystem

Directorate Admin and Clerical structures, kit and

equipment, training and education

Estates, IT, Human Resources, Finance, Executive Team

What is a Clinical Microsystem?

“The Place where Patients,

Families and Clinical

Teams meet.

It’s where everything

happens with, for and to

the patient and family.”

Just like a patient…

To improve a patient’s health status

A clinician:

• Assesses

• Diagnoses

• Treats

• Follows-up

based on biomedical science, patient preferences, and their outcomes.

Just like a patient…

To improve a microsystem’s “health” status

An interdisciplinary group:

• Assesses

• Diagnoses

• Treats

• Follows-up

based on improvement scienceand performance feedback.

The methodology uses 3 main approaches

1. Finding ways to do better at meeting each patient’s

needs.

2. Making the work experience for every staff person

meaningful and enjoyable.

3. Increasing each person’s ability to improve his/her

own work and contribute to the betterment of the

system.

Microsystem Improvement

Assessment

Diagnose

Treat -‘PDSA’ & ‘SDSA’

What is the purpose of this team?

What do staff think?What do patients think?

What does the data tell us?Define the high-level process

Microsystem Improvement

Assessment

Diagnose

Treat -‘PDSA’ & ‘SDSA’

Define themes, Set aimsDeeply understand a processExplore the reasons for what

we think are the issues

Microsystem Improvement

Assessment

Diagnose

Treat -‘PDSA’ & ‘SDSA’

Plan – Do – Study – ActPlan a small test of changeAgree balanced measures

Is the change an improvement?

What do staff involved

in improvement work think?

a story told by your colleagues…

What were your initial feelings?

“I must say initially I did just think:

‘oh, this is just more work for us

to do on top of…’ We haven’t got

enough hours in the day...”

“When I first when I must

all this before’…”

“When I first when I must

say I did sort of sit there

and think: ‘oh, I’ve heard

all this before’…”

Why did you start the work?

“I think we are all just very aware that for

things to change, we all have to get

involved. We can’t just sit there and say:

’this needs to be done…’

We have realised that nothing actually gets

done unless we actually get involved…”

“We got to the point, when you

to get involved…”

“We got to the point, when you

can’t just carry on and let other

people just decide for us. If we

want something doing, we’ve got

to get involved…”

How does it feel now?

“We do a superhuman effort to meet; because I think what

the team really see is that it’s not a waste of time, that we

are actually moving forward. It might only be small steps,

but you can see the enthusiasm that we’ve got as a team…”

“We know it’s taking a long time, we appreciate that, but

we all know now that it is a positive move; that the backing

is going to be there; that at last somebody’s listening to us.

I think it just makes you feel better to come to work…”

“At last things have started to improve, we

can now see that we are driving forward and

feeling more positive”

What was important?

“Data is extremely important, if we

haven’t got data, we can’t prove where

we are, what we actually need, what we

get, it just underpins everything…”

“Team is very dedicated. They go above and

beyond and desire to improve is great.”

“Clinical leadership is crucial, we

medical director.”

“Clinical leadership is crucial, we

need consultant backing and the

support and the ear of the

medical director.”

What was important?

“It’s not all about throwing money

and getting more staff, it’s not

always the answer and that’s not

always what we are asking for, it’s

just streamlining the processes,

the education and some of the

staff to support the capacity issues

we’ve got…. but nothing’s ever

going to improve unless we get

this external support…”

Where next?

http://www.sheffieldmca.org.uk/

• Information about

microsystems work

in Sheffield

• Case studies

• Principles of

microsystems

approach

• 2 days

Introduction to QI

course

http://www.youtube.com/watch?v=S_6y1CieJHo

The story of

Jonny the Bagger