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Building capability in quality improvement to improve population health outcomes: UCL Partners working in partnership with Health Education England locally

Chris Caldwell

Dean of Healthcare Professions,

Health Education North Central & East London, England

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No conflicts of interest to declare

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Session Aims

• To explore a framework for building quality improvement capability within the workforce at scale

• To consider the potential of this approach for patients and population health outcomes

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Background

• Great Ormond Street Hospital in London• Health Education North Central & East London• UCL Partners

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Great Ormond Street Hospital for Children

Transformational Goal:

• Zero Harm

• No Waste

• No waits

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The Curriculum ‘model’

• Model of Improvement

• Project Identification and Planning

• Measurement

• Engagement; Human Factors;

Appreciative Inquiry

• Process Mapping, Lean and Value

• Evaluation and After Action Review

• Spread & Sustain

• Project support by expert “Buddy”

• Assessment with accreditation

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Programme Evolution: Continuous Quality ImprovementLeap Ahead Learning ProgrammeMini-Leap Ahead – Transforming Care on your WardIntroduction to Improvement MethodologyTransformation Improvement Methodology Programme (TIMP)Enabling Doctors in Quality Improvement & Patient Safety (EQuIP)Advanced & Bespoke ProgrammesLeadership & coaching

8South London LETB

Investment Plan

• Designated one of 15 Academic Health Science Networks in England in May 2013 - largest in UK

• Serving a diverse population of over six million people in London Hertfordshire Bedfordshire & Essex. 

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UCLP Mission

To translate research and innovation in care delivery into measurable health gain for patients and

populations through partnership across settings and sectors, and through excellence in education

10South London LETB

Investment Plan

Health Education North Central & East London

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Shared Values

Integrated

Compassionate

Knowledgeable

Rigorous

Collaborative

Improvement focussed

Innovation

Patient centred

Transparent

Inclusive

Multidisciplinary

Pan-organisation

Integrated

Partnership

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Transforming Health through Education

… Creating a learning culture where all want to learn and keep on learning....

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… enable people to gain the

skills and knowledge required

… to deliver measurable

health gains to people and populations

Vision

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Building Quality Improvement Capability within a wide Context

What the external world prioritises

Strategy

Leadership and alignment

Operating system

Outcomes

Leadership and alignment

• Measurement and reporting• Capability development• Learning

Individual action Institutional action

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Three Areas of work

• Deteriorating Patient Project

• UCLP Partners Academy (Frail Elderly)

• Educational Development & Fellowships

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We’ve built a community of practice withmaximum local pull around a common aim

Tight on …

• Aim of 50% reduction in cardiac arrests by end 2012

• All teach, all share, all learn

• All collecting and submitting data

Loose on …

• Locally determined priorities

• Tools used at each site

• Emphasis on particular interventions

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A local need

- A clear and urgent clinical need identified across partner Trusts

and an important problem

Of national relevance

- Cardiac arrests in hospitals• mostly predictable• often avoidable• usually fatal (13% survival)

NCEPOD (2012) ‘Cardiac Arrest Procedures: Time to Intervene?’

And addresses some big issues …

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1. Reliable recording of vital signs

2. Early identification of deterioration (timely referral)

3. Effective communication of deterioration (e.g., SBAR)

4. Escalation to higher level (timely response, timely transfer)

5. Treatment Escalation Planning

• and two additional learning and cultural aims

- Learning and applying Quality Improvement methods

- Working collaboratively across partner Trusts

We homed in on a few key measurements & interventions

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Local Pull• A bottom up approach…• …with trust sponsorship

Community of Practice

• Share unconditionally: “all teach, all learn”

• Secure network: Doccom.me

Learning

• Learn Quality Improvement• Apply PDSA small tests of change• Learning Sets

Performance information

• Open and transparent sharing of comparative data

Key elements of deteriorating patient

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Welcome

Abbott

Sepsis at Royal Free

Data

Trust Updates

SHMI :National Ranking Expected vs. Observed deaths UCLP Trusts: Apr 12– March 12

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Jan

-10

Fe

b-1

0

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0

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7

8

LCL

Royal Free Hospital

30 % down from 2010 to 2011, p = 0.053(20 % down in 2012 vs. 2010)

Cardiac arrests/1000 admissionsJa

n-1

0

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0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

LCL

Whittington HospitalCardiac arrests/1000 admissions

6 % reduction in absolute numbersfrom Year 1 to Year 2

Aiming to halve arrests: 2010 - 2012

And, 61 % reduction in variance of cardiac arrests

across original 6 hospitals from 2010 to 2012

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Approach to delivery

• Academy programme development commenced in October 2013• The Academy offers all staff the opportunity to develop

improvement, innovation and implementation skills for patient and population benefit.

• The Academy is being designed and applied alongside real time work programmes

• The first phase is working with Barking Havering and Redbridge to

reshape service provision for the frailty elderly • Engaging staff from health social care, voluntary sector

and patient groups

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Working in partnership as commissioner and provider

Educational Development & Fellowships

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NCEL Medical commissions 2014/15

24

Medicine1827

Psychiatry917

Clinical Oncology

424

Clinical Radiology

Obstetrics & Gynaecology

163

Paediatrics320

Sport & Exercise Medicine

74

145

GP 566

4,154Medical & Dental

Posts and supporting infrastructure

Pathology

Ophthalmology

Surgery379

9

Dentistry

472

49

30

Emergency Medicine

Foundation 800

Psychiatry311

Public Health Medicine

Dentistry

198

30

Medicine577

Anaesthetics / ICM314

ACCS

ACCS90

tbc

NIHR

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NCEL Non-Medical commissions 2014/15

25

Midwifery235

Mental health

126

2,306 university places and supporting

infrastructure

AHPs397

Nurses and midwives

1,613

25

Adult Nursing

690

Mental Health

209 Child Nursing

245

23

5

46 52

Clinical PsychologyImproving Access to Psychological Therapies (IAPT)

Mental Health Practitioner

Child Psychotherapy

15 Healthcare Scientist

Other170

21

11

72

57

Pharmacist

Dental Care Professions

Pharmacy Technician

Midwifery Support Workers

9Physician’s Assistant

8685

Physiotherapy

Occupational Therapy

65

29

Speech and Language Therapy

Dietetics

17

Operating Dept. Practitioner 14Podiatry

31Therapeutic Radiography

Learning Disability

60Health Visiting

38District Nursing

19School Nursing

65Practice Nursing

27 Emergency Nurse Practitioners

70Diagnostic Radiography

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• ‘Darzi’ Leadership Fellowships• Other Fellowships• Inter-professional learning opportunities

in leadership & quality improvement

Educational Development & Fellowships

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What works in changing a culture?

“A powerful person at the top, or a large enough group from anywhere in the organization, decides the old ways are not working, figures out a

change vision, starts acting differently, and enlists others to act differently. If the new actions produce better results, if the results are communicated and celebrated, and if they are not killed off by the old

culture fighting its rear-guard action, new norms will form and new shared values will grow”

“Some group decides what the new culture should be. It turns a list of values over to the communications or HR departments with the order that they tell people what the new culture is. They cascade the message down the hierarchy, and little to nothing changes”

And what doesn’t work?

John Kotter, Quoted in BMJ editorial March 2013

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But what else works?

Articulate shared vision

Harness existing skills/knowledge/research

Co-create Co-

design planact

measure

Evaluate/review

Identify success criteria

Identify priorities Engage others

Design curricula

Mobilise resources

LeadManage

Celebrate successShare

Connecting with Communities of Practice …

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Building Strategic Networks

Community of practice

Community of engagement

Community of interest

System

Bring people together…

… to bring about change

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Learning to share

• Cultural change takes time• Gently push but pull hard• Keep it simple • Just in time training backed up by expert

coaching• Measurement & analytical skills• Don't ignore the ‘middle’• Sometimes special things are needed for special

people• Don't over estimate the confidence of coaches• Where you start might not be important • Keep ‘rocking the boat’ but make sure you hold

your friends in there with you 

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