Pennine acute trust and aqua celebration event fiona thow

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NHS Improving Quality was invited to take part in a recently held event that celebrated the work that is being done in partnership between the Pennine Acute Hospitals NHS Trust and AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP). Gillian Phazey, Learning and Organisational Development Manager at Pennine Acute Hospitals NHS Trust explains: 'The Learning and Organisational Development and Governance teams at the Pennine Acute Hospitals NHS Trust have been working collaboratively with AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP) to support staff in developing knowledge and skills in this topic. The programme has been specifically designed to support colleagues wanting to gain an introduction to the fundamentals and concepts of quality improvement. So far, two cohorts of staff, from clinical and non-clinical areas of the Trust have completed the programme, and have completed quality improvement projects in their own work area to apply their knowledge. On 17th July a celebration event was held for cohort 2 where staff presented their work in poster or presentation form, the aim of which is to share and spread learning across the Trust. Projects were wide ranging, from introducing new processes to reduce complaints and drug errors, to improving patient experience by implementing new tools and techniques. The day was a great success with the Chief Executive and Chief Nurse in attendance. The Trust is highly supportive of this approach in equipping staff with these important techniques, and the programme supports not only our internal quality agenda and objectives, but more widely responds to the recommendations of the Berwick report. The next cohort is starting in September this year.' Fiona Thow, Patient Safety Collaborative Delivery Lead at NHS Improving Quality delivered a keynote speech, (link to presentation slides) providing a national perspective on the plans for improving patient safety and took the opportunity to introduce the national safety collaboratives. She also highlighted the need for organisations and individuals to think differently about safety for both patients and staff.

Text of Pennine acute trust and aqua celebration event fiona thow

  • Building the will for a safer culture in the NHS - thinking differently about Patient Safety Creating a system devoted to continual learning and improvement
  • Todays session: Set out the emerging plans for improving patient safety in England Look at some theory around large scale change Consider the issues and challenges in designing a national improvement programme, if change happens at the microsystem level Please ask questions or make your point at any time lets have a discussion not a lecture! 2
  • Mid Staffordshire NHS Trust Public Inquiry report published Feb 13 Julie Bailey of Cure the NHS Campaign stands outside Stafford Civic Centre
  • Key messages from the Francis Inquiry 290 recommendations, 4,000 pages This was a system failure as well as failure of an individual organisation No single recommendation should be regarded as the solution to the many concerns identified A fundamental change in culture is required across the NHS We need to secure the engagement of every single person serving patients in the change that needs to happen
  • QualityBetter Old Way (Quality Assurance) QualityBetter Worse New Way (Quality Improvement) Action taken on all occurrences Reject defectives Old Way, New Way Source: Robert Lloyd, Ph.D. Requirement, Specification or Threshold No action taken here Worse
  • The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. Our most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following: Placing the quality of patient care, especially patient safety, above all other aims: Engaging, empowering, and hearing patients and carers throughout the entire system and at all times: Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work: Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge. Don Berwick Findings A system devoted to continual learning and improvement
  • Design Rules some examples from the Design Day event A system devoted to continual learning and improvement National v local building the learning system to support a safety culture & continuous improvement. Building networks that align to local clinical communities Transparent sensible measurement - : If youre not measuring youre not improving, if you are measuring stupidly you are not improving, and if you are only measuring you are not improving Mary Dixon Woods. Inclusion patients equity partnership Preparedness work before the work dont start too soon. Prepare staff, communicate, build in evaluation from the start. Build in capability and embed as part of the day job Leadership, sustainability what does success look like? Align system drivers
  • 8 The Patient Safety Collaborative for England A system devoted to continual learning and improvement Key features: Learning from the past, adapting what works in improvement Systematic application across England with widespread engagement Positioned as transformational not transactional change Set within the context of NHS Englands Patient Safety Plan Locally led; across all healthcare organisations and all sectors providers and commissioners Patient centred Engaged with clinical staff at all levels Focused on fewer priorities but at scale to demonstrate results in year one Using a range of improvement tools, techniques, social movement approaches and capability building
  • 9 AHSN footprint 2-5m population Central and local funding allocated for patient safety Quality Improvement expertise and support form NHS IQ available Linking good practice and sharing learning widely Shared purpose A system devoted to continual learning and improvement Patient safety collaboratives
  • Patient safety improvement 3 strands 10
  • Patient safety collaboratives core priorities outlined by NHS England A system devoted to continual learning and improvement Topic area Patient Safety Topic The essentials Leadership Measurement NHS Outcomes Framework improvement areas VTE HCAI Pressure Ulcers Maternity Medication Errors Deterioration in children Other major sources of death and severe harm Falls Handover and Discharge Nutrition and hydration AKI Deterioration in adults Sepsis Medical Device Errors Vulnerable groups for whom improving safety is a priority People with Mental Health needs People with Learning Disabilities Children Offenders Acutely ill older people Transition between paediatric and adult care
  • @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore Creating a patient safety movement: four things we can learn from the great social movements (Helen Bevans Slides)
  • Emerging themes in large scale change Foundation Emerging direction Organisation Community Power through hierarchy Power through connection Mission and vision Shared purpose Making sense through rational argument Making sense through emotional connection Leadership-driven (top down) innovation Viral (grass-roots driven) creativity Led by expert opinion Allow all talent Engaged patients Passionate users Clinical networks Mass communities Tried and tested, based on experience Net Generation principles Transactions Relationships
  • What are the implications for improvement leaders? From doing improvement to connecting for improvement at scale Rethinking: whos in the improvement community How we lead change Metrics of success New roles Curators Relationship leaders Storytellers Co-creators New mechanisms for connecting: Social media Web seminars Tweet chats New methods for leading improvement open innovation hacks/hackathons crowdsourcing Ideas channels
  • @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
  • Most large scale change fails to achieve its objectives Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey 70% 25% 5%
  • @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore Factor 1: Focus on the physiology of change as much as the anatomy
  • Anatomy of change Physiology of change Definition The shape and processes of the system; detailed analysis; how the components fit together. The vitality and life-giving forces that enable the system and its people to develop, grow and change. Focus Processes and structures to deliver health and healthcare Energy/fuel for change Leadership activities measurement and evidence improving clinical systems reducing waste and variation in healthcare processes redesigning pathways creating a higher purpose and deeper meaning for the change process building commitment to change connecting with values creating hope and optimism about the future calling to actionSource: Crump and Bevan
  • Anatomy of change Physiology of change Definition The shape and processes of the system; detailed analysis; how the components fit together. The vitality and life-giving forces that enable the system and its people to develop, grow and change. Focus Processes and structures to deliver health and healthcare Energy/fuel for change Leadership activities measurement and evidence improving clinical systems reducing waste and variation in healthcare processes redesigning pathways creating a higher purpose and deeper meaning for the change process building commitment to change connecting with values creating hope and optimism about the future calling to actionSource: Crump and Bevan
  • Anatomy of change Physiology of change Definition The shape and processes of the system; detailed analysis; how the components fit together. The vitality and life-giving forces that enable the system and its people to develop, grow and change. Focus Processes and structures to deliver health and healthcare Energy/fuel for change Leadership activities measurement and evidence improving clinical systems reducing waste and variation in healthcare processes redesigning pathways creating a higher purpose and deeper meaning for the change process building commitment to change connecting with values creating hope and optimism about the future calling to action
  • Intrinsic motivators build energy and creativity
  • Intrinsic motivators connecting to shared purpose engaging, mobilising and calling to action motivational leadership build energy and creativity
  • Int