Intro to methodology12 July

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Coronary Heart Disease Collaborative Introduction to the Programme and Methodology Julie Harries National Collaborative Leader (South and West) 12 July 2002

Goal of the CHD Collaborative: 

Goal of the CHD Collaborative ‘To improve experience and outcomes for patients with suspected or diagnosed CHD by optimising care delivery systems across the whole integrated pathway of care’

The Northern Zone: 

The Northern Zone Phase 1 programmes East Riding and Hull Greater Manchester and Cheshire North Trent Phase 2 programmes Northern Network Tees Valley, Durham and North Cumbria Heart of North Cheshire Lancashire and South Cumbria West Yorkshire National Collaborative Leader - Ian Golton National Collaborative Managers - Carolyn Heyes, Kate Mudge

The Midlands Zone: 

The Midlands Zone Phase 1 programmes Black Country Essex Phase 2 programmes Anglia Birmingham, Solihull and Sandwell Staffordshire and Shropshire West Midlands South East Midlands National Collaborative Leader - Kate Gill National Collaborative Managers - Wendy Rushton, Sandie Manser, Fiona Mackie

The South and West Zone: 

The South and West Zone Phase 1 programmes South West Peninsula Dorset and Somerset Central South Coast Phase 2 programmes Five Counties Sussex West Country West Surrey Berkshire National Collaborative Leader - Julie Harries National Collaborative Managers - Linder Binder, Carol Siddle, Sue Hall

The South East and London Zone: 

The South East and London Zone Phase 1 programmes North West London North East London Phase 2 programmes Bedfordshire and Hertfordshire Kent North Central London South West London South East London National Collaborative Leader - Jim Heys National Collaborative Managers - Vanessa Lodge

Slide8: 

Local Programme Six projects Acute myocardial infarction / acute coronary syndrome Secondary prevention Patients with angina Management of heart failure Cardiac revascularisation Cardiac rehabilitation

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Three fundamental questions for improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement?

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What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements that we seek ? Model for improvement * Copyright IHI 2000

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goal for the national programme objectives for the 30 programmes aims for the 180 projects A clear aim

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Aim statement Our overall aim is to improve the delivery of care for patients with suspected and diagnosed heart failure within the network. This will be achieved by ongoing improvements, i.e. timely recognition and diagnosis of these patients, development of care pathways across the primary and secondary care interface ensuring a trouble free transition, and development of palliative care strategies for heart failure patients and their carers Targets include 90% patients are able to choose and book their review date 90% patients in established heart failure are on ace inhibitors 90% patients involved in the management of their own condition and that this is recorded in individualised patient records

Measurement for improvement: 

Measurement for improvement Q. How do we know when a change is an improvement??? A: We MEASURE it A common set of measures nationally. Monthly reports to track progress. Documentation of changes and sharing of progress nationally.

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Categories of measures 1. Access 2. Patient flow 3. Patient and carer experience 4. Clinical effectiveness 5. Capacity and demand Demand system

Measurement: 

Measurement

Changes and improvements: 

Changes and improvements What changes can we make that will deliver the improvement we seek? Not every change is an improvement Several tools and techniques to help change ideas emerge and be implemented

Change principles: 

Change principles D: enable people to see themselves as part of the same system B: Improve patient/carer experience C: optimise care delivery E: match capacity and demand A: co-ordinate the patient journey

PDSA Cycleplan, do, study and act to test, adapt and implement changes: 

PDSA Cycle plan, do, study and act to test, adapt and implement changes

Mapping the process: 

Mapping the process

Slide20: 

An elephant is like a brush An elephant is like a rope An elephant is like a snake An elephant is soft and mushy An elephant is like a tree trunk

Task: Map a process you know really well: going to work each morning : 

Task: Map a process you know really well: going to work each morning where does it start ? where are the main bottle necks? how do you manage the bottlenecks? what are the 5 - 10 high level process steps?

Processes can be mapped into more and more detail: 

woken by alarm wash dress break fast prepare for work leave house travel arrive set alarm select prepare put on think iron clean shoes Processes can be mapped into more and more detail

High medium and detailed process maps: 

High medium and detailed process maps High level Medium level Detailed

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A Diagnostic process B Patient processes cross many boundaries C D E 30 - 70% of work doesn’t add value for patient up to 50% of process steps involve a “handoff”, leading to error, duplication or delay no one is accountable for the patient’s “end to end” experience job roles tend to be narrow and fragmented organisational/departmental boundaries Acute M. I. Treatment process

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A B Patient processes cross many boundaries C D E organisational/departmental/professional boundaries output Acute M. I.

Analysing a process map: 

Analysing a process map How many steps in your process? How many hand-offs? What is the approx. time of or between each step? Where are possible delays and why? Where are major queues and why? How many steps do not “add value” for patient? Where are the problems for patients and staff? ……… ………

Slide30: 

An elephant is like a brush An elephant is like a rope An elephant is like a snake An elephant is soft and mushy An elephant is like a tree trunk

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What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements that we seek ? Model for improvement * Copyright IHI 2000

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Any questions?

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DISCOVERY INTERVIEWS Semi-structured interviews of patients and their carers Based on key stages of their journey through their illness

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DISCOVERY INTERVIEWS Trigger memories not constrained by thinking ‘in the box’ of their care experience Do not ask them to make value judgments about the services they have received

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When you look back to the beginning of your illness what has it been like for you and your family? Describe specific incidents that stick in your mind using the following steps as a guide

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CHD DISCOVERY INTERVIEW SPINE Thinking something was wrong Seeing someone in the NHS Having tests to find out what was wrong Being told what was wrong Receiving treatment Getting better Living with your condition Being followed up

Key messages : 

Key messages Overwhelmingly positive about services Patients’ inability to recognise the symptoms Information was given to patients at the wrong time Lack of support / information for the carers

Messages: 

Messages “My father died of a heart attack – so did my sister – I never knew you should go and be checked out if it’s in your family. Now we’ve all been to be tested – my husband, brother and even the kids.”

Messages: 

Messages “The doctor came at about seven and told me they couldn’t do me that day – he said to tell the nurse I could have some supper. Someone from Bournemouth came in and was more urgent than me – I do understand – these things happen – the really urgent people need to go first.”

Carers messages: 

Carers messages “It was like taking a new born baby home” “I woke at night to check he was still breathing” “I didn’t like to ask the nurses – they were so busy” I was frightened in case I upset him and brought on an attack”

Using the messages: 

Using the messages Main themes Identifying change ideas (what changes can we make to improve things) PDSA cycles Measuring improvements in patient and carer experience

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Any questions?