improving quality in primary care. leading with purpose and possibility
TRANSCRIPT
www.england.nhs.uk @robertvarnam @NHSEngland
Quality improvement
in general practice.
Leading through
purpose & possibility
Dr Robert Varnam MRCGP PhD MSc
Head of general practice development
@robertvarnam
28.04.15
www.england.nhs.uk @robertvarnam @NHSEngland
What do you want to achieve
for patients in your practice?
www.england.nhs.uk @robertvarnam @NHSEngland
Health & wellbeing-promoting care
Right access
Holistic, personalised, proactive
& coordinated care
Wider primary care at scale
www.england.nhs.uk @robertvarnam @NHSEngland
Leading with purpose.
Lashing with compliance or unleashing
commitment.
www.england.nhs.uk @robertvarnam @NHSEngland
Birth
Postnatal midwife
assesses risk
Midwife gives
Vitamin D
End
www.england.nhs.uk @robertvarnam @NHSEngland
Birth
Postnatal midwife
assesses risk
Midwife writes
to GP
End
www.england.nhs.uk @robertvarnam @NHSEngland
End
Discharge
Birth
Health visitor
assesses risk
Health visitor
gives Vitamin
D
www.england.nhs.uk @robertvarnam @NHSEngland
End
Discharge
Birth
Health visitor
assesses risk
Health visitor
writes to GP
GP issues
prescription
www.england.nhs.uk @robertvarnam @NHSEngland
End
Discharge
Birth
GP/PN assesses
risk in baby clinic
GP issues
prescription
www.england.nhs.uk @robertvarnam @NHSEngland
End
Discharge
Birth
GP assesses risk
at postnatal check
GP issues
prescription
www.england.nhs.uk @robertvarnam @NHSEngland
End
End
Discharge
Birth
Postnatal midwife
assesses risk
Midwife gives
Vitamin D
Midwife writes
to GP
GP assesses risk
at postnatal check
GP/PN assesses
risk in baby clinic
Health visitor
assesses risk
Health visitor
gives Vitamin
D
Health visitor
writes to GP
GP issues
prescription
End
www.england.nhs.uk @robertvarnam @NHSEngland
End
End
Discharge
Birth
Postnatal midwife
assesses risk
Midwife gives
Vitamin D
Midwife writes
to GP
GP assesses risk
at postnatal check
GP/PN assesses
risk in baby clinic
Health visitor
assesses risk
Health visitor
gives Vitamin
D
Health visitor
writes to GP
GP issues
prescription
End
www.england.nhs.uk @robertvarnam @NHSEngland
Vitamin D prophylaxis
Leading with purpose
vimeo.com/76794094
www.england.nhs.uk @robertvarnam @NHSEngland
Leading with possibility.
The problem
of human performance.
www.england.nhs.uk @robertvarnam @NHSEngland
How does good care happen?
Be a good person
Train well
Maintain good intentions
Work hard
www.england.nhs.uk @robertvarnam @NHSEngland
Please pay attention…
Watch the video
There is a team wearing white shirts and a team wearing
dark shirts
Count all passes made by the white team
www.england.nhs.uk @robertvarnam @NHSEngland
Remember …
Be a good person
Train well
Maintain good intentions
Work hard
www.england.nhs.uk @robertvarnam @NHSEngland
Remember …
Be a good person
Train well
Maintain good intentions
Work hard
www.england.nhs.uk @robertvarnam @NHSEngland
‘You can’t change the human condition,
but you can change the conditions
under which humans work’James Reason
Error is normal... what are you going to do
about it?
www.england.nhs.uk @robertvarnam @NHSEngland
OU
TP
UT
S
HUMAN
FACTORS
HUMAN
FACTORS
INTERNAL PROCESSES & PROCECEDURES
INP
UT
S
Success = systems x people
Whether I like it or not, it’s not just about me.
www.england.nhs.uk @robertvarnam @NHSEngland
Vincent, C. A. (2004). Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care, 13(4), 242–3.
What is ‘the system’?
www.england.nhs.uk @robertvarnam @NHSEngland
New improvement design principles
Be a good person
Train well
Maintain good intentions
Work hardMake it easier to do the right thing
Make it harder to do the wrong thing
Spot & stop inevitable errors
www.england.nhs.uk @robertvarnam @NHSEngland
Prototyping
• anything that tests an idea and answers a question
• helps test boundaries and manage risk
• is less about the actual ‘product’ and more about the
interaction it provokes
Start small
A prototype needs only to
be as good as it needs to
be in order to learn more
about the idea.
Peter Van Manen, MD McLaren Electronic Systems.
• Easy to simulate. ‘You can’t move for laptops.’
• Reliance on data. ‘Measurement is cheaper than mistakes.’
• Easy to mock-up. ‘Don’t pontificate, prototype.’
www.england.nhs.uk @robertvarnam @NHSEngland
Talk it or try it ?
This is my idea.
I’m right.
Do it!
We tried a couple of
ideas, and this
happened.
versus
www.england.nhs.uk @robertvarnam @NHSEngland
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994
www.england.nhs.uk @robertvarnam @NHSEngland
PDSA Cycles
SOMETHING
BIG!
A P
DS
How can we achieve this?
A P
DS
A P
DS
A P
DS
www.england.nhs.uk @robertvarnam @NHSEngland
Don Berwick myth-busting
livestream.com/IFQSH/ForumLIVE
What's wrong with audit?
bit.ly/WhatsWrongWithAudit1
Introduction to driver diagrams
bit.ly/DriverDiagramIntros1
The Productive General Practice
bit.ly/PGP2014
What next?
www.england.nhs.uk @robertvarnam @NHSEngland
Leading with purpose
vimeo.com/76794094
Burning platform or burning ambition
youtu.be/Tfn6vD4yyC4
These slides
What next?
www.england.nhs.uk @robertvarnam @NHSEngland
• Berwick, D.M., 1996. A primer on leading the improvement of
systems. BMJ : British Medical Journal, 312(7031), pp.619-622.
• Varnam, R.M., Dawda, P. & Jenkins, R., 2010. Quality
improvement in general practice. Discussion paper., London:
The King’s Fund.
www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_
of_care/quality_improvement.html
• Bendell, T., Penson, R. & Carr, S., 1995. The quality gurus –
their approaches described and considered. Managing Service
Quality, 5(6), pp.44-48.
www.emeraldinsight.com/10.1108/09604529510104383
• Langley, G. et al., 2009. The improvement guide : a practical
approach to enhancing organizational performance 2nd ed.,
San Francisco: Jossey-Bass. ISBN 978-0470192412
What next?