PDSA

NewcastleExperience

Level1Hospitals11th January2016

DrAngusVincentRegionalCLODNorthern

Plan-Do-Study-Act• Achievingchangeandgettingthingsdoneoncriticalcareunits

ishard.

“…delivering improvement inhealthcarerequiresthealterationofprocesseswithincomplexsocialsystemsthatchangeovertimeinpredictableandunpredictableways.”

• Hugeinfluenceoflocalcontext onsuccessofanintervention

Level1Meeting, January2016

Level1Meeting, January2016

Plan-Do-Study-Act

• Aqualityimprovementtool(toeffectchange ornewprocess)

• EndorsedbyNHSInstituteforInnovationandImprovement

• Longhistory,originatedinthebusinessworld

Level1Meeting, January2016

PDSA- Essence• Startsmallandsimple– e.g.1patient

• Iterative

• Effectiveinterventionsareusuallycomplexandmulti-facetedandadapttolocalcontextandallowforunforseencircumstance

Level1Meeting, January2016

Level1Meeting, January2016

EUwideproject– multipleworkstreams

Thus– pickaprojectandimplementbyPDSAmethodology

Level1Meeting, January2016

Phase1– IdentifyingtheProblem

DBDConsent

62%

DCDConsent

45%Level1Meeting, January2016

Phase1– IdentificationoftheProblem

SignificantdropinconsentratesMarch– August2013

CombinedDBD/DCD 55%ConsentWithSNOD 72% WithoutSNOD20%SNODUsed 54%

Despiteafullytrainedconsultantbody

ConcernsfromournursingstaffregardingtheSNODrolewereidentified

Level1Meeting, January2016

ModelforImprovement

Whatwerewetryingtoachieve?

IncreasedconsentratesbyincreasingSN-ODinvolvement

Howwouldweknowthechangewasanimprovement?

MeasureconsentratesandSN-ODinvolvementratesinPhase2datacollectionofACCORD,alongsideUKPDA

Level1Meeting, January2016

Plan- Do

1.Targetnursingstaff- specifictraininginterventionontheconsentprocess– valueaddedbySNOD

2.PeerReviewConsultantPerformance – ‘public’feedbackontheirconsentpracticeatmonthlyM+M

3.ClarifyourUnitExpectationandPractice – explicitstepbystepconsentpracticeoutlinedinourunitdonationdocumentation

Level1Meeting, January2016

Do– NurseMandatoryTraining

Time Subject Speaker

09:00-09:15 Introduction, NICE guidelines, Organ Donation as part of good end of life care.

Kate Dreyer (Specialist Nurse –Organ Donation)

09:15-09:45 Donation after Circulatory Death (DCD) Linda Wilson (Specialist Nurse –Organ Donation)

09:45-10:15 Donation after Brain Stem Death (DBD) Dr Phil Laws/Sue Lee (SN-OD)

10:15-10:30 Donor family experience of organ donation Lesley Kremer (Donor Family Member)

10:30-11:00 TEA/COFFEE & CAKES

11:00-11:30 Planning a collaborative approach & the role of the SNOD in the donation process.

Specialist Nurses –Organ Donation

11:30-12:30 Role play – approaching families about organ & tissue donation.

All

12:30-13:00 Discussion & debriefing – chance for the staff to discuss any issues, questions, previous experiences.

All

Level1Meeting, January2016

Do - M&MReportingTotal Deaths

Uncontrolled Deaths

BSD/WLST with contraindications

to donation

No. of Potential Donors

Referral Rate

No Families approached

SNOD involvement

rate

Consent Rate

8 2 1 5 100% 4 75% 50%

Initials Age Gender

Diagnosis BSD/WLST On ODR? SNOD used in approach

Consent?

Organs donated/Reason for refusal

JI 43 M TBI BSD Y Referred but coroner refused permission for donation due to circumstances surrounding death.

XS 48 F HBI following OOHCA

BSD N Y N Husband was not accepting of death, organ donation was brought up with SNOD present, husband didn’t realy answer the question but due to circumstances was not reapproached.

SB 17 F TBI BSD Y Y Y DBD donor – donated heart, liver to be split, kidneys, pancreas & small bowel. Lungs unsuitable due to consolidation.

KG 30 F ICH WLST Y Y Y DCD donor – donated liver, kidneys & pancreas. Lungs placed but unsuitable at retrieval. Family brought up donation when SNOD was present.

DH 70 F CVA WLST N N N Kidneys suitable for donation. Referred, on call SNOD was at Freeman & offered to come but consultant approached alone due to time pressures.

Level1Meeting, January2016

Study

• Phase2(Dec13– May14)

• Overallconsentrate- 76%

• UseofSNOD– 96%(27/28)

0

5

10

15

20

25

30

FamiliesApproached(N) SNODInvolved(N) Consents(N)

Phase1Phase2

Level1Meeting, January2016

Act Sustainability(April14– March15)

DBD Familiesapproached 27SNODused 27 =100%Consent 17/27 =63%

DCD Familiesapproached 25SNODused 24 =96%Consent 20/25 =80%

Level1Meeting, January2016

WasthistruePDSA?

• Inpart– Plannedafterdiscussion– Deliberateandmonitoredintervention– Impactassessedandpresented

• But,– Didn’tstartsmall– Didn’tanalyseandrepeatwithmodification

Level1Meeting, January2016

11th January 2016 Programme

Time Topic Speaker/s

1000-1030 RegistrationandCoffee

1030-1050 Level1nationalupdate DrDaleGardinerDeputyNationalCLOD

1050-1130 Sharingbestpracticesession Various

1130-1200 Results, neurological deathtestingaudit DrPaulMurphyNational CLOD

1200-1220 PDSA,howweusedthemethodology DrAngus VincentRegionalCLOD,Northern

1220-1250 PDSAExercise1 DrPaulMurphy (chair)

1250-1330 Lunch

1330-1400 PDSAExercise2 DrMalcolmWatters(chair)RegionalCLOD,SouthCentral

1400-1440 Group1Ante-morteminterventionworkshop andGroup2EDstrategyworkshop

1440-1500 Coffee

1500-1540 Group1EDstrategyworkshopandGroup2Ante-morteminterventionworkshop

1540-1600 Level1s andtheirimportancetoNHSBT Mr IanTrenholmChief Executive, NHSBT

The Wesley, 81 – 103 Euston Street, London NW1 2EZ.

Level 1 Meeting, January 2016

Improvement Model and PDSA Cycles

Overview

Understand the problem and its causes

Define aim and measures

Collect change ideas

Test change idea with PDSA cycles

Implement changes that are improvements

Work with colleagues and value different perspectivesLink frontline changes with strategic objectivesWork towards sustainability as part of implementation

Root cause analysis using the Ishikawa fishbone

example brain death testing

Brain Death (BD) tests are not always carried out when patient meets pre-conditions

Family have declinedResources

BD tests not a standard part of care

Donation will not happen

Lack of knowledge

Doubts/ concerns regarding the validity of testingNo clinical

interpretation of current BD testing policy

Can not/ will not test

Other patients considered to be higher priority for beds

Judicial/ Police refusal

Medical contra-indications

Patient choice not understood by family

Previous poor experience of care whilst in hospital

Approached prematurely Family refused

before a formal approach made

Biased due to adverse press/ TV

Poor approach from staff

Ancillary testing not available/ supported

Lack of suitable medical staff to perform tests

No transplant surgeon available

Lack of availability of expert opinion

Lack of available equipment for testing

Prevented by clinical condition (e.g. hypothermia)

Paediatric case

Doubts about time needed to wait

Lack of confidence / experience in performing tests

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

The aim should be clear, focussed and based upon real and important problems. It should measurable and, where relevant, in line with national targets.

Any intervention should be designed in such a way that its impact can be accurately measured. Monitoring arrangements need to be agreed before the change idea is introduced.

Change ideas may come from many sources, and are most likely when they concentrate on the patient rather than the various teams involved in the pathway.

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

The Model for Improvement

PDSA

Plan: we will do this, in this location, with this expectation

Do: we did this, we made these measurements and observed these unexpected occurrences

Study: our data from the pilot compare with baseline data in this way. We also had the

following problems

Act: as a result of our observations we will now extend the trial, adjust the change idea, trial more widely, implement into practice etc

What are we trying to achieve?

How will we know that change is an improvement?

What changes can we make that will result in improvement?

act plan

study do

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

The aim should be clear, focussed and based upon real and important problems. It should measurable and, where relevant, in line with national targets.

Any intervention should be designed in such a way that its impact can be accurately measured. Monitoring arrangements need to be agreed before the change idea is introduced.

Change ideas may come from many sources, and are most likely when they concentrate on the patient rather than the various teams involved in the pathway.

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

The aim should be clear, focussed and based upon real and important problems. It should measurable and, where relevant, in line with national targets.

Any intervention should be designed in such a way that its impact can be accurately measured. Monitoring arrangements need to be agreed before the change idea is introduced.

Change ideas may come from many sources, and are most likely when they concentrate on the patient rather than the various teams involved in the pathway.

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

Level 1 Meeting PDSA Exercise 1

Increase FICM/ICS form use (and thereforeapnoea compliance) in your hospital/s.How will you measure form use and apnoeacompliance?

PDSA Plan

Plan (anything else you need to do):

Do (when will you start):

Study (when will you assess):

Act:

11th January 2016 Programme

Time Topic Speaker/s

1000-1030 RegistrationandCoffee

1030-1050 Level1nationalupdate DrDaleGardinerDeputyNationalCLOD

1050-1130 Sharingbestpracticesession Various

1130-1200 Results, neurological deathtestingaudit DrPaulMurphyNational CLOD

1200-1220 PDSA,howweusedthemethodology DrAngus VincentRegionalCLOD,Northern

1220-1250 PDSAExercise1 DrPaulMurphy (chair)

1250-1330 Lunch

1330-1400 PDSAExercise2 DrMalcolmWatters(chair)RegionalCLOD,SouthCentral

1400-1440 Group1Ante-morteminterventionworkshop andGroup2EDstrategyworkshop

1440-1500 Coffee

1500-1540 Group1EDstrategyworkshopandGroup2Ante-morteminterventionworkshop

1540-1600 Level1s andtheirimportancetoNHSBT Mr IanTrenholmChief Executive, NHSBT

The Wesley, 81 – 103 Euston Street, London NW1 2EZ.

Level 1 Meeting, January 2016

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

The aim should be clear, focussed and based upon real and important problems. It should measurable and, where relevant, in line with national targets.

Any intervention should be designed in such a way that its impact can be accurately measured. Monitoring arrangements need to be agreed before the change idea is introduced.

Change ideas may come from many sources, and are most likely when they concentrate on the patient rather than the various teams involved in the pathway.

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

The aim should be clear, focussed and based upon real and important problems. It should measurable and, where relevant, in line with national targets.

Any intervention should be designed in such a way that its impact can be accurately measured. Monitoring arrangements need to be agreed before the change idea is introduced.

Change ideas may come from many sources, and are most likely when they concentrate on the patient rather than the various teams involved in the pathway.

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

Level 1 Meeting PDSA Exercise 2 Takeaperformanceratefromyour

hospital/sthatimpactsonconsent.Howwillyouimproveit?

PDSA Plan

Plan (anything else you need to do):

Do (when will you start):

Study (when will you assess):

Act: