TRUST QUALITY IMPROVEMENT (QI)

Transcription

1 BOARD OF DIRECTORS 21 st DECEMBER 2017 TRUST QUALITY IMPROVEMENT (QI) 1 INTRODUCTION The purpose of this paper is to provide an update to the Board on the progress of the quality improvement agenda since its launch at Leadership Council on the 21 st September This will include detail on the strategic direction, QI framework and methodology, governance and forward view. Quality Improvement in health care is based on a principle of the staff and organisation continuously striving to improve how they work. The approach puts significant emphasis on the role of frontline teams in consistently applying an agreed set of tools and techniques to test, measure and learn. There is no single definition, but it is generally understood to be a systematic approach based on specific methodologies for improving care - enhancing patients safety, outcomes and experiences. The Berwick Report on patient safety A promise to learn a commitment to act (2013) argued that the NHS should become more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. (p5) The report set out ten recommendations as to how this might be realised, including simplifying and clarifying supervisory and regulatory systems, and fostering a culture more focused on learning and improvement and less on scrutiny, rewards and punishments. Nottinghamshire Healthcare NHS Foundation Trust has committed to this Quality Improvement (QI) agenda and sets out the detail of that commitment below. 2 VISION AND PRINCIPLES 2.1 Vision Nottinghamshire Healthcare NHS Foundation Trust will have an embedded culture of continuous quality improvement. To achieve this vision, we will: Engage with patients, carers, staff, stakeholders. Build improvement capability. Support teams to deliver Quality Improvement. Embed the QI methodology. Page 1 of 11

2 2.2 Key Principles Staff Led - Staff will be trained, empowered, enabled and supported to design and implement QI activity in their workplace. Managers will create the right opportunity and support for quality improvement to prosper. Patient Centred - Engagement with patients, service users and carers and involving them in quality improvement. All quality improvements should be felt by patients. Focus on Measurement - This is the evidence that change is an improvement. Data will be shared as a driver for staff and organisational engagement. Consistent Methodology - Adopting a modern, relevant and scientifically grounded QI methodology is essential to achieving evidenced and sustainable improvements. 3 ALIGNMENT TO TRUST STRATEGY The Trust s strategy contains 4 priority Strategic Objectives. QI sits clearly under Strategic Objective 1: Provide Best Possible Care and Support. However, it is also very relevant in Strategic Objective 4: Make the Trust a Great Place to Work. Strategic Objective 1: Provide Best Possible Care and Support: This alignment ensures that the Quality Improvement is focused on improving care, maximising patient safety, outcomes and experience. Strategic Objective 4: Make the Trust a Great Place to Work The Quality Improvement work has direct links to this strategic objective with the Trust s People and Culture strategy. Achievement of the QI vision requires a cultural shift to one of continuous quality improvement. This will only be achieved through an engaged, empowered and enabled workforce who enjoy coming to work. The Trust Quality Strategy ( ) was launched this year and set out a number of quality priorities along with the associated governance and monitoring arrangements. The Trust s QI approach will support and augment the existing and new work aimed to impact on these priorities. The QI team will work with the Quality Governance team to ensure that the QI methodology, tools and techniques are utilised to ensure that improvement projects designed to address the quality priorities, clearly evidence measured improvement that is sustained. Page 2 of 11

3 4 QI FRAMEWORK The following graphic illustrates the sources of input into Quality Improvement activity. The Trust has a rich source of learning drawn from the elements listed below (Figure i). Whilst the learning and action plans are individually tracked, the QI projects will ensure that they will inform quality improvement activity with a standardised methodology. Figure i 5 THE TRUST S QI METHODOLOGY A strong theme for success through all of the QI literature is the need for a consistent methodology. This consistency ensures a standardised approach for staff, patients, carers and stakeholders. There are many QI methodologies available, many of which have been proven to be applicable in the Health sector and have been tried and tested in the NHS. In determining our approach in NHCFT, it has been prudent to assess the context for QI within the Trust but also within local health and social care systems and in the national NHS context. The NHCFT QI methodology is based on The Model for Improvement (Figure ii). This is a global QI methodology that is utilised by health providers around the world and particularly in the NHS. It provides a simple and accessible framework for accelerating improvement through small scale testing. This model currently underpins the national NHS Improvement Quality, Service Improvement and Redesign programme. NHCFT will play a key role in supporting this programme as part of delivery priority for the Nottinghamshire Sustainability Transformation Partnership (STP). The Model for Improvement is at the centre of the approach taken by the Institute of Healthcare Improvement (IHI) who along with NHS Improvement, offer a wealth of online resources, tools and techniques, training and learning. This has been particularly well utilised by our colleagues in East London NHS Foundation Trust in reaching their CQC Outstanding rating. Page 3 of 11

4 Figure ii Ref: Figure iii The graphic above (figure iii) illustrates the 5 step approach for designing and implementing quality improvement. This is a simple project management approach but will provide an accessible model for staff to follow. This will avoid the kneejerk implementation of ill-considered solutions that often do not address the quality issue, and seldom sustain. Human Factors - The NHCFT QI methodology will also incorporate the Human Factors theory around individual characteristics which influence behaviour. Quality Improvement changes will therefore be informed by the Human Factors theory in order to design out error and design in effectiveness. This is based on the premise that no-one sets out to do harm, humans are fallible and errors are common. Blame is therefore not appropriate in a wider system Page 4 of 11

5 problem and we must seek to manage the vulnerability of error in order to achieve a true safety culture. Measurement is an essential part of evidencing and sustaining quality improvement. Statistical Process Charts (SPCs) will be used to track and illustrate the extent of process stability prior to, during and following a quality improvement intervention. Below is an example of QI intervention in DNA rates for a muscular skeletal service. Figure iv 6 LIFE QI Our Quality Improvement projects will be managed though Life QI. Life QI is a web software platform built to support and manage quality improvement work in health and social care. This has been developed by the Allied Health Science Network and is currently available, at no cost, and is being used by many NHS Trusts across the country. It makes it easy for teams to run QI projects and organisations to report on QI activity. The Trust now has an account on this platform and can therefore run and manage all QI activity from this platform. A significant benefit is that all QI projects across the network can be shared and viewed easily, making shared learning very accessible across the NHS. Page 5 of 11

6 7 QUALITY, SERVICE IMPROVEMENT AND REDESIGN (QSIR) The last five years has seen a number of NHS Trusts form partnerships with QI organisations. This has produced a wealth of learning, material and shared experience across the system. It has also produced a considerable network of QI knowledge that is readily available. NHSI also offer a number of support functions for Trusts to call upon in support of their QI activity, least of all the QSIR programme, within the ACT (Advancing Change and Transformation) academy. The QSIR programmes are the latest iteration of a highly successful service improvement programme that has been delivered over many years to hundreds of staff involved in healthcare. Page 6 of 11

7 Quality, Service Improvement and Redesign (QSIR) Modular Programme Figure v Delivered in a variety of formats to suit different levels of improvement experience, the QSIR programmes (figure v) are supported by publications that guide participants in the use of tried and tested improvement tools and featured approaches and encourage reflective learning. The QSIR programmes suit clinical and non-clinical staff involved in service improvement within their organisation and/or system. There are a small number of NHCFT staff who have already undertaken the QSIR practitioner training on the journey to accreditation. This programme will form the modular framework to underpin QI training across the Trust. Page 7 of 11

8 8 RESOURCES What does the Trust need to effectively rollout a Quality Improvement methodology? The ultimate aim is for QI to be an embedded culture where every staff member has QI at the heart of their behaviour. This will be a project managed process with an initial investment in resource in order to grow improvement capability within the organisation. Two key activities will dominate: Supporting projects QI resource will be required to support teams to set up and manage QI projects at a local level. This will begin with a heavier commitment of time from QI staff, then as capability increases, the QI team will support and guide. Training A suite of QI training will be designed and delivered with varying degrees of intensity and complexity. The proposed structure for the QI team is the Trust Head of Quality Improvement supported by Project Support Officer, data analyst and 6 QI leads. The administration and project support of a vast spread of project activity will be essential, as will the data analysis to interrogate areas for QI priority work, the measurement required for outcome success, and evaluation. The QI leads will be a flexible resource with a mixed skills set around improvement science, operational and clinical knowledge and experience, as well as training and people skills. The QI leads will be allocated Trust wide across QI projects as well a leading on the QI training programme. They will be drawn from existing resource and will be recruited gradually through 2018 through expressions of interest, line manager and directorate/divisional support. 9 GOVERNANCE The Trust Service Improvement Group has been set up and the first meeting took place on 3 rd November The key premise for this group is to provide Trust wide oversight of Quality Improvement activity within a standardised methodology and project framework. Quality Committee Patient Experience and Service Improvement Sub committee Trust Service Improvement Group The Trust has the internal capability to rollout QI tools and techniques, QI project management, develop the QI framework and QI Hub. This work will be supported by local partnerships in the STP, as well as with ELFT and a wealth of online material and guidance from IHI and NHS Improvement. NHSCT has the internal Page 8 of 11

9 capability to design and rollout a QI training programme with the following dimensions: QI for all staff. QI for patients/carers/volunteers. QI for QI leads. QI for coaches. QI for leaders. Additional trainers can be spot purchased if required. The Organisational Development requirements to support a cultural shift that will embed and sustain a Quality Improvement culture is rich in complexity. The tools, techniques and training represent an essential good start to the practicalities of QI, but these must be supported and underpinned by a set of organisational values and principles that are modelled and lived throughout the Trust. This fundamental element of QI sits within the broader context of the Trust s People and Culture strategy and must therefore not sit as an isolated piece of work. This work will be progressed in the context of the NHS Improvement framework below: Developing People Improving Care. A national framework for action on improvement and leadership development in NHS-funded services (NHSI, Dec CURRENT AND NEXT STEPS A high level QI project plan is in place with timeframes and milestone for delivery throughout 2018 and beyond. The main headings are as follows: Strategic Direction. Methodology. Engagement. Human Resource. Communications Plan. Governance. Training Plan. Organisational Development. Immediate next steps focus on supporting QI projects emerging from teams, Vision 21 candidates and Trust Quality Priorities, particularly around restrictive practice and violence reduction and observation and engagement. The development of QI training packages will also occupy the following months, including intervention into the Medical Education programme. A Quality Improvement pamphlet will be produced for distribution that outlines the organisation s commitment and plans for QI. 10 PRIORITY PROJECTS Whilst the Trust s QI approach will be focussed on staff led improvements, there are clearly Trust quality priorities that must be progressed. The QI methodology with therefore be used to support these priorities. Page 9 of 11

10 Restrictive practice and violence reduction is a project that is being relaunched in January This will create a Trust wide approach with a specific project aim and set of measures. The implementation of the VIPS project (Values, Individual s Perspective, Support) on the MHSOP dementia wards has begun but is in the early stages. This is a Person Centred Care approach that will be supported by the QI team. The Observation and Engagement Collaborative is a project designed to improve and enhance engagement in mental health observations. With a particular focus on co-production and co-design, the QI team will support this work and guide progress using the QI methodology. 11 QI FORWARD VIEW 11.1 By the end of Year 1 (Oct 2018) Engagement with patients, carers, staff and stakeholders. A programme of engagement events will have been undertaken in order to listen to those closest to the care, and learn about the need for quality improvement. Learning from Trusts who have/are making considerable quality improvement. This will include visits and engagement in local and national QI networks. Quality Improvement Framework will be in place having been set out in the Quality Improvement Strategy. This will include a consistent methodology for QI across the Trust with clear governance and performance measurement. The framework will allow all QI activity to be properly benchmarked and measured in order to provide, share, scale out and celebrate Trust wide quality improvement. It will also include the programme and project management structures for the QI rollout, as well as the framework for patient and staff engagement and involvement. Quality Improvement Hub will be in place as a physical space and base for the QI team, but the hub will also include an online space. This will accommodate open access to QI tools, techniques, active and past projects database, staff learning, QI events etc, as well as provide a key space to promote and celebrate quality improvement across the organisation, with a clear QI communications strategy. Quality Improvement Training Programme will have been developed in order for staff, patients, carers, volunteers and leaders to gain knowledge and skills in QI methods. This will include a programme of introduction to QI for all staff, specific QI project lead skills, QI team coaches, QI for patients and carers, QI for leaders. This training programme will be designed in conjunction with Learning and Organisational Development team, as well as in the context of the People and Culture strategy. This will be aligned with the NSH Improvement Developing People Improving Care framework. A small team of NHCFT staff will have been trained in Quality, Service Improvement & Redesign (QSIR). The QSIR College programme offers NHS Page 10 of 11

11 organisations and health systems a unique opportunity to develop quality and efficiency improvement capability within their organisation or across their system, enabling them to rapidly build up a sustainable local skills base across the local STP Years 2 and 3 Building improvement capability through the relentless momentum of QI activity, projects, training and successful outcomes. Continued development of the QI Hub and QI training programme. Continued support to teams to deliver Quality Improvement. This will include the coaching model of having QI coaches in teams who are trained to support QI activity. Embed QI methodology throughout the organisation Years 4 and 5 A culture of continuous quality improvement is embedded as business as usual. 12 BOARD INVOLVEMENT There is a wealth of literature about the importance of Board level support for Quality Improvement and what that support should look like in order to sustain the shift to a learning improving organisation. Project Sponsorship All effective QI models highlight the need for senior leader sponsorship for substantial QI projects. This will ensure oversight and accountability, but will also provide an important organisational overview that helps safeguard against project isolation and silo. Board QI development session Some dedicated time is proposed for the Board to focus on QI, understand the methodology and agree leadership behaviours that will drive and support quality improvement in a learning organisation. Interestingly, ELFT board QI sessions regularly included reflection on the extent to which those agreed behaviours were established, just beginning or not in place. 13 CONCLUSION In summary, the Board is asked to note this report and consider the level of frequency and detail required for further QI updates. Luke Baumber Trust Head of Quality Improvement 11 th December 2017 Page 11 of 11