Building Capacity & Capability for

Innovation & Improvement

Gerry Marr

Chief Executive

NHS Tayside

Carrie Marr

Director

TCOE

Scottish Parliament Finance

Committee

Report On Strategic Budget Scrutiny

June 2009

The Centre for Public Policy for Regions (CPPR) Risk Analysis

“By 2013-14 the (Scottish) Budget will be between roughly £2 billion and £4 billion lower in real terms than at its peak in 2009-10.

That represents a 7 to 13 per cent real terms cut over that four to five-year period.”

In the period forward to 2017-18 it expects “a return to positive, but very low, real-terms growth of perhaps around 1 per cent.”

This compares with its estimate of an average of 6 per cent per year growth in the Scottish budget over the first six or seven years of devolution.

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.

Clinically 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.

Quality & Efficiency = Value

Demographic change for population aged 65+ Scotland

Potential impact on emergency bed numbers 2007-2031

0

2000

4000

6000

8000

10000

12000

14000

16000

Y/E Mar 2007 Projected

2011

Projected

2016

Projected

2021

Projected

2026

Projected

2031

Year

Bed

s

9%24%

41%61%

84%

NHS Tayside

+148 beds 2016

+517 beds 2031

Healthcare demand is growing

A new Ninewells

Hospital by 2031!

Improving Quality and

Reducing Costs

Delivering Government Efficiency Targets 3-4%

Creating the time and the space to

transform and redesign the 97%

Change

the

world

Create the conditions

Make the improvement

Macro system –

Vision, aim and context.

Meso system –

Culture, capacity

And challenge.

How much and by

when?

Micro system –

Implementation,

measurement and

improvement

The 3-step Improvement Framework

for Scotland’s public services

TACTICAL STRATEGIC

DEALING WITH

THE 5%

SPENDING THE 95%

BETTER

PRODUCTIVITY &

EFFICIENCY

CRES

SERVICE

OPTIMISATION

TRANSFORMATION

TACTICAL STRATEGIC

DEALING WITH

THE 5%

SPENDING THE 95%

BETTER

PRODUCTIVITY &

EFFICIENCY

CRES

SERVICE

OPTIMISATION

TRANSFORMATION

Improving Care for Older People

TACTICAL STRATEGIC

DEALING WITH

THE 5%

SPENDING THE 95%

BETTER

Prevention of admissionImproved Day care

Improved service liason and discharge

Reduced hospital stays and bed days

Case management – improved pathways

Intermediate careCare home interfaceMedications reviews

Housing/home care supportTechnologies

Maximise health and social care services

Cost minimisationWorkforce efficiencies

Teleheath/telecare

Virtual wardsWorkforce redesign

Self care and enablementNew models of care in dementia, falls,

end of life careWorking with communities -

coproduction

PULL

PUSH

1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortable

Make the future attractive

3. Build Will• Plan for Improvement

• Set Aims/Allocate Resources

• Measure System Performance

• Provide Encouragement

• Make Financial Linkages

• Learn Subject Matter

5. Execute Change• Use Model for Improvement for

Design and Redesign

• Review and Guide Key Initiatives

• Spread Ideas

• Communicate results

• Sustain improved levels of

performance

4. Generate Ideas• Understand Organization as a

System

• Read and Scan Widely, Learning

from other Industries & Disciplines

• Benchmark to Find Ideas

• Listen to Patients

• Invest in Research & Development

• Manage Knowledge

Framework: Leadership for

Improvement

2. Establish the Foundation• Prepare Personally

• Choose and Align the Senior Team

• Build Relationships

• Develop Future Leaders

• Reframe Operating Values

• Build Improvement Capability

Our Journey So Far…..

Source: System thinking and spreading

knowledge, Bojestic M., Henriks, G., Provost

L. IHI European Forum, Prague 2006

Awareness• Safer Patient Initiative

• Change & Innovation Plan

Education• Learning from Qulturum and IHI

• Patient Safety Officer training

• Improvement experts and practitioners training

• Board Effectiveness Development Programme

Process

Thinking• Lean and Rapid Improvement work

• Real time data and measurement for improvement

Redesign• Improvement as a Systems Property

• Steps to Better Healthcare

• Triple Aim

Movement• Triple Aim

• System Infrastructure - TCOE

• Creating Breakthrough and Leverage

Scaling Up• Public Service

• Working with

Communities

• Mobilising and deploying

shared resources

2006 2007 2008 2009 2010 2011 Beyond

Inquiry

Should our ambition be everyone or a few

experts?

What could be the incremental steps in building

our capacity and capability?

How will we approach this journey and create

the right conditions for sustainability?

Attributes of High Performing Organizations

Safest

Most Effective

Most Personal

Source: Kaiser Permanente, 2008

Creating the Conditions

Build

Infrastructure

& Capacity

Formal programmes of QI education

Embed QI into all development work e.g.

leadership and management development

Enabling people to lead improvement in

their daily work processes

• Tools, techniques, support

“Data is our vision - we

must learn from it”

•Realtime measurement

and Information systems

Shaping the Culture:

• Will and commitment

• Quality reinforced at every

level by behaviour, action

and communication.

• The patient and the

family are the focus

of attention at all times

Ref: Staines 2009

Building System

Capacity & Capability

Building

Capacity

& Capability

Improvement Academy

eLearning Portal

Tools and Techniques

Clearing the way!!

Experiences of care, compassion and respect

Mobilising & deploying expert support “through the line” – 2 step challenge

• Real time information and

measurement systems

• Sharing evidence of

improvement

• Staff engagement

• Data for discussion not

judgement

Shaping the Culture

• Permission and space

• Evidence based approach

• Facing the Future – shared

ethical responsibility

• Board Effectiveness Programme

• User and community voice

Leadership and Management

Development

Virtual learning environment

Experts Senior

Leaders

& Boards

Change

Agents

(Middle

Managers,

project leads)

Everyone

Staff

Teams

Continuum of PI Knowledge and Skills

Deep

Knowledge

Many People Few People

What Skills Do We Need?

Source: Kaiser Permanente, 2008

Shared

Knowledge

A key operating

assumption of building

capacity is that different

groups of people will have

different levels of need for

QI knowledge and skill –

what will you need people

to have?

Our approach will be to

make sure that each

group receives the

knowledge and skill sets

they need when they need

them and in the

appropriate amounts.

What data do we need?

Board

ET

EMT

Directorate / CHP

Ward / Team Level

Patient / Practitioner Level

ASSURANCE

Validated Data for 6 domains:

Access, Efficiency, Infection & Prevention, Quality &

Patient Experience, Patient Safety and Data Quality

PERFORMANCE

Validated and un-validated data across 6 domains:

Clinical Excellence, Finance & Activity, Valuing Staff,

Capacity & Activity Planning, Patient Experience and

Patient Safety

Imp

rove

me

nt

“focusing on information and data to provide assurance on improvement and

quality to deliver better services”.

Pe

rfo

rma

nce

As

su

ran

ce

Data

an

d M

ea

su

rem

en

tfo

r

IMPROVEMENT

Un-validated data provided in real time through Unified

Patient Tracking, Clinical Portal and operational

dashboard with metrics covering Patient Flow, Inpatient

Activity, Out Patients, Waiting Times, Patient Safety,

Infection Control, Clinical Outcomes

What Knowledge Do We Need?The Shift to “All Learn : All Teach” as a Movement

Developing

local

improvement

stories

Widening our

improvement

conversations

and networks

Profound

Knowledge

&

Evidence of

Standards

Adopt & Adapt Improvement

Tools and Technology

Harvest and

share and

enable new

ideas

Sharing

experiences and

embedding the

improvement

cultureMeasuring the effectiveness

of improvement activities

Individual Microsystem

frontline

Mesosystem

Middle mgrs

Macrosystem Policy

Real time

tests of

change

Improvement

Evidence

• Workplace VLE

• Communities of

Practice

Developing

a culture of

improvement

Steps to Better Care

Mental

Health

Older

People

Planned

Care

Workforce Integrated

care

communities

Child

health

Optimisation

of Health

Facilities

across

Tayside

Prescribing

and

Medicines

Finance Support

Workforce Support

Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases

Workforce Modelling, Engagement & Communications with staff

Comms SupportCommunications with public and staff

Other

OE SupportImprovement & Development Support

Labs

Maternity

Transform

NHS Tayside

healthcare systems

though focused

expertise and

implementation of

Improvement

Science

Improvement science

expertise and application

drives improvement in all

services

Primary

Improvement Boards track and support progress remove

barriersCreate a reliable metric system

IT used to improve real time data

Harmonize our metrics Develop local improvement data repository

QoF driven By Improvement outcomes

Ownership of agreed upon set of outcomes from Triple Aim

Clear, shared measurement plans in all departments Macro Meso and Micro

level

Inventory of national programs and measurement

Secondary Drivers

Board uses Improvement science to delivery national

strategic prioritiesReview of outcomes at each meeting

Infrastructure supports improvement and measurement

Patients drive Improvement agenda

International expert faculty Alliance Board

Capacity Building Driver Diagram 5 year Plan

Organisational culture drives improvementAcademic Acceptance of pragmatic science - multidisciplinary education includes

improvement science

Educational infrastructure focused on capacity building in improvement skills

All staff development has elements of improvement goals

Faculty experts - improvement methods and coaching

Capacity Building Programme design and structure

Population QI improvement goals, %Cost reduction,%

Patient experience improvement

Improvement board dashboard of

measures

% involvement of patients and public in redesign

% of staff in training involved in improvement activity

% staff development has elements of improvement goals

Robust, evidence- based

proven clinical changes

NHS Tayside Board accepts

Improvement as key strategic

priority for effective

governance

50% of Board agenda

focused on

Improvement data

% movement to real time data

Heat target

achievement

•%Achievement of all

improvement local

Delivery plan goals

•% staff in training

using improvement

science within

curricula

•% staff using

improvement science

improved patient

outcomes

% of staff trained in improvement

science and supported to apply

the methodology – 2 step

challenge

Profound and basic levels

Key Components* Self-Assessment

Will (to change)

Ideas

Execution

Low Medium High

Low Medium High

Low Medium High

*All three components MUST be viewed together. Focusing on one or even two of the components will guarantee sub optimized performance. Systems thinking lies at the heart of CQI!

How prepared is your organisation?

Business Unit

Providing Support to Build Capability & Capacity to Use Information Intelligently

for Improvement, Performance & Assurance through a whole system approach with key

input from pharmacy, workforce information, e-health and finance.

Programme

Management

of

commissioned

projects from

EMT

Corporate

Programme Business Intelligence

Provision of high quality

information and health

intelligence to improve

patient experience,

quality of care, and

support improvement in

resource utilisation.

Predictive

Modelling

Provision of

prospective

capacity modelling

using information,

improvement

methodology and

simulation tools

Health

Records &

Clinical Coding

Provision of a

Health Records

Service to support

clinical care &

delivery of the

clinical coding and

data quality

improvement plan

Finance

Workforce

TCOE

Safety

Governance &

Risk

Organised for Quality

TCOE

Improvement and

development expert support

Education, training and

learning

BSU

Reporting

Data collection & analysis

Clinical team data support

Table Top Discussion

Where should our immediate, medium

and longer term focus be to create the

necessary capacity and capability

required to support our improvement

and innovation ambitions?