Question

Case study 10 Establishing a capability for continuous quality improvement in the NHS BACKGROUND AND HISTORY In March 2009 County Durham and Darlington Community Health Services (CDDCHS) formu- lated a strategy to improve patient outcomes, safety and service efficiency by developing and implementing a large-scale quality improvement programme across the organization. CDDCHS was the primary care provider for a large, semi-rural area around Durham and Darlington, serving a diverse community of around 600,000 people across the region. The CD&DPCT employed approximately 3,000 staff and had an annual budget of £1.1 billion to spend on services. They provided over 50 services, such as community nursing, speech and language therapy, podiatry, school nursing and the provision of out-of-hours services. CDDCHS had recently formed from six previous Primary Care Services covering the County Durham and Darlington operational region. The programme and its supporting infrastructure would also play a key role in helping CDDCHS with their journey towards a culture of continuous quality improvement. depth knowledge about the DRIVER improveme methodology - a proven approach to continuous improvement (Figure C10.3). Part of this training involved mentoring the participants as they tackled a key project in their directorate so that they could learn from experience and start to quickly reap the benefits of the training. This created a community of people who could share experiences and best practices and actively coach others. They also provided for training for second and third level managers across all directorates to provide them with quality tools and techniques and a robust approach to implementing continu ous quality improvement (CRI) projects. Managers were also provided with CQI toolkits to enable them to introduce the methods to their teams and encourage a continuous improvement mindset. Breakthrough Wins in Service - CDDCHS developed the criteria and process for selecting priority areas to reengineer and designed stan dardized materials and guidelines to ensure a consistent approach to process improvement across the organization in line with the local Primary Care Trust's existing policies and frameworks. They also identified and delivered breakthrough wins in service that improved patient pathways and created exemplars for the approach. Quality Infrastructure - the approach was underpinned by the deployment of a culture assess ment to evaluate the extent to which the culture of the organization supported a continuous improve ment orientation, development and deployment of an integrated communications programme to engage the wider PCT community, the establish ment of a measurement system to monitor progress and the development of a governance process to ensure that the programme continued to maintain momentum APPROACH CDDCHS developed a simple and pragmatic approach to the improvement programme, based on the quality journey' that organizations typically progress on (Figure C10.1). The approach was highly customised to meet their service needs (Figure C10.2) which involved the following Executive Engagement - they developed a clear vision for quality, created executive buy-in through two-way interviews and workshops and developed guidelines to clarify the role of leader ship in driving the programme. The Executive team also received training to ensure that they were well versed in the concepts and methodolo- gies associated with the improvement programme. Quality Improvement Training -representa- tives from each of their directorates were trained as 'improvement leaders, providing them with in- PROGRAMME DELIVERABLES The Executive team in CDDCHS identified common view of the 'vision' for quality 516 Quality Leadership Review programmes and processes continuously Quality becomes cost efficient Continuous Improvement Quality drives efficiency and is a means of competitive advantage Structure quality improvement programme, elicit staff feedback and communicate SUCCESSES Increasing Involvement Total staff involvement, engage external stakeholders (e.g. partners and patients) Signalling Commitment Develop Strategy Set up quality philosophy. define patient expectations, and current experiences, determine critical quality gaps Figure C10.1 Organizations progress on a 'quality journey' Fully aligned leadership with clarity of expectations Clearly defined vision, objectives and KPIs "Leading the journey Different levels of customized performance improvement training Structured qualifications system Sustainability for future Skills improvement initiatives Development & Knowledge Transfer Executive Engagement & Sponsorship Programme support structures & communications Infrastructure for Sustainable Change Clinical & Organisational Breakthrough improvements Pathway in service/patient pathways Redesign Direct impact on patient experience and operational performance Foundational quality system Performance measurement systems in the key service areas Standardized, agreed approach Figure C10.2 Addressing four areas helps create a sustained culture of continuous improvement Case 10 Capability for continuous quality improvement in the NHS 517 DRIVER is a proven approach for improving the efficiency and effectiveness of healthcare services: • DEFINE - the scope and goals of the patient process to be redesigned • REVIEW - understand the current processes and measure performance • INVESTIGATE - analyse the gap between the current and desired performance • VERIFY-generate the improvement solutions • EXECUTE - implement the improved processes in the pathway • REINFORCE - capitalize the improvement by learning the lessons "I've seen many different improvement methodologies come and go in my 33 years working in the NHS, For me, DRIVER is an approach that makes good practical sense and stops you jumping from the problem to the solution without considering the improvement options. My team are using DRIVER to make our work more efficient, more effective and ultimately to get more children into our improved services. Head of Children's Services, PCT Figure C10.3 DRIVER structured approach for improvement business through process improvement. A number of initiatives were put in place to help the PCT to start to establish this foundation and continue to be a main area of focus for the programme as it developed into maturity. improvement and this provided the basis for developing a PCT wide approach to quality improvement. They also determined pre-requisites for the achievement of that vision and aligned quality improvement initiatives to the PCT's Strategic agenda. All of the executives and senior management team were trained in the DRIVER improvement methodology and were actively involved in supporting quality improvement projects. Over 130 people were trained in the PCT's highly customized quality improvement approach and were actively involved in improvement projects and over 75 DRIVER continuous improve- ment projects were in progress across all direc- torates delivering significant benefits to patients, staff and the organization. Four major breakthrough projects were delivered with significant improvements to waiting times, non-attendance rates, wound care manage- ment costs, resource utilization and access for patients. They were widely perceived to have not only delivered real insight to the business but they have provided a meaningful example of the way the DRIVER methodology can provide benefits to a primary care environment in the NHS (Figure EVALUATION OF THE PROGRAMME In order to measure the programme a dashboard was developed to enable the team to monitor progress and take action quickly if any aspect of the programme fell behind the agreed timelines. The dashboard featured activity measures and outcome measures for each element of the pro- gramme and was reviewed regularly by the project team. Executive Engagement - activity measures comprised availability of the executive training and vision workshops within agreed timescales, proportion of the executive team that attended and quality of the training as perceived by the participants. Outcome measures were concerned with the extent that Executives became actively engaged as sponsors on key quality improvement projects and the extent to which they provided active support to the programme. Quality Improvement Training - activity measures included timely development of courses, numbers of participants on courses, distribution of participants across the directorates and quality of C104) The programme team were conscious of the need to build a solid foundation for the PCT by creating a critical mass of employees that were engaged, inspired and enabled to transform the Case studies Booking of 350K AHP appointments/yr . 18 different referral methods . 1 in 5 appointment slots were unfilled • 1 in 3 referrals had errors requiring rework • A single, harmonised referral method · Significant reductions in wait - Reduced cost per referral Retinal Screening • 70 sessions a week wasted due to inefficiencies in process and method of data capture with likely increase in demand of 4% YoY • An increase in screening capacity for 2,000 3,000 additional appointments a year more than meeting additional demand • Improved patient and staff satisfaction Speech & Language Therapy . 35% children over 18 week wait and trend increasing · Significant variation in processes - 95% referrel to initial assessment in 18 weeks - 'Smart' referral form reduces error rates - Removal of non value adding admin from Therapists creates sufficient appointments to meet demand with lass staff Figure C10.4 DRIVER in Primary Care Investment Return — Savings plus an improved patient and staff experience) Investment/Savings Pay Back Benefits begin to accrue from day 1 but really accelerate as more people become capable and motivated to make Improvements Launch DRIVER Immediate benefits driven by process standardization E stablish DRIVER Embed DRIVER in a culture of 'Total Quality' (TQ) i Breakthrough i Significant benefits realised through multiple DRIVER Improvements projects and an organization that is moving towards a accelerate benefits culture of 'Total Quality 2-4 months 4-8 months 8-12 months to payback, 1-3 years to embed TO Figure C10.5 Typical profile for Rol Case 10 Capability for continuous quality improvement in the NHS 519 ACKNOWLEDGMENT The author would like to thank the team from CDDCHS for their agreement to publish this case study. courses as perceived by participants. Outcome measures were focused on the proportion of trained employees involved in and completing improvement projects and proportions by directorate (Figure C10.5). Breakthrough Wins in Service - activity measures included the number of breakthroughs, the value of the improvement as perceived by the leadership team and satisfaction with the support provided by Oakland Consulting on the breakthrough. Outcome measures were concerned with the benefits realized by the breakthroughs in terms of efficiency gains and patient experience. Quality Infrastructure - measures on the culture assessment related to timeliness and response rates and measures on the commu- nications programme related to coverage and quality of the communications. DISCUSSION QUESTIONS 1. Discuss different possible approaches to establishing a CQI capability in an organization. In your opinion, which parts of the CDDCHS approach had the greatest impact on sustainable improvement and why? 2. Review the measures CDDCHS used to evalu- ate their programme. Why is it important to have both activity and outcome measures for such a programme? 3. Discuss how the approach to CQI might need to vary between a service based organiza tion such as CDDCHS and a manufacturing organization. 520 Case studies

Answer 1

1. From the above case study the type of approaches to establish the Continuous quality Improvements in an organization

• Quality improvement Training : This is a sort of mentor training where the representative of director will be the leader who have in depth knowledge about the drivers. This type of training will have a practical approach as the key project will be handled by the participants.Not only front line manager instead second and third level managers were also trained with quality tools.In addition to that there is involvement of quality tool kit with the managers so that the team will improve the quality.
• Executive Engagement : Under this approach there was involvement of executives in every level to over shadow the negative outcome in quality. The executives have developed the vision and standard for quality and the interviews and workshops with developed guideline clearly explains the role of leaders. This help the organization to main the quality of the organization.
• Quality Infrastructure : This approach helps to identify the cultures and how it is going to affect the improvement in quality . The system has been built to monitor the progress and development of program. Moreover keeping the check on the program will help to know the lacking area thus improving the quality.
• Breakthrough Wins in Services : In this approach the key areas are prioritized and redesigning and reengineering the standard guidelines to improve the quality in an organization. Creating the breakthrough pathway was considered as the quality improvement service

All the above mentioned approach were adopted to make continuous improvement in the quality of the organization.

According to me the part of approach having sustainable development is Quality Improvement Training as under this the executives are trained for DRIVERS methodology. This is best of sustainability and for future initiatives as it helps is delivering benefits to the organization.

The DRIVER stands for :

Define : The vision and mission

Review: the process and performance

Investigate : the deviation between performance accessed using the reviews

Verify: th optimum solutions

Execute : The solutions for eliminating the deviations and

Reinforce: Use this process as the improve technique to be used in future

The combination of all these will build the room for sustainable development

2. The measure to evaluate their programs were :

The dashboard was set up for surveillance to keep the track on the progress and also to take prompt action incase of any deviation. The measure of above approaches were

• Quality Improvement training measure : development courses, accumulating the participants , quality course for the participants , outcome check. The outcome measure focused on the employee completing the training and the key projects
• Executive Engagement : Vision workshop, quality assessment, executive training, quality training. The outcome measures focus on the involvement of executive in the organization.
• Quality infrastructure : Culture assessment, communication assessment . The outcome measure the proportion of culture affecting the overall organization and how will the people of different culture will communicate
• Breakthrough Wins in Service : Having breakthrough pathways, prioritizing the areas . The outcome measures the efficiency of quality improvement and the patient experience.

To have both the activity and outcome measure is must for the program as the progress of these approaches are calculated by the outcome only. Whether the approach is beneficial or not will required the outcome as it is the base which helps to decide the correct method for improving the quality.

Hence the measures are use to demonstrate the approach and outcome are used to monitor the progress derived by using those measures.

3. The approaches are designed as a whole to improve the quality. These approaches will be modified depending upon the industry the organization belongs to.

Like in the service industry the human resource are trained about the services to be rendered and mostly are of first and second level whereas in Manufacturing industry the quality is depended upon the production produced using machinery and mostly the second and third level are trained

In service industry the quality improvement approach is used on human resource to train them whereas in manufacturing industry the quality improvement is used on machinery and goods to reduce the cost of production.

In service industry focus on personnel is there whereas in manufacturing industry focus on production is given.

The approach will be same but the people using these approach will be different. For the service sector we have already discussed above . Now for manufacturing industry

• Quality improvement training : In this the mentor is appointed to make the participants clear about how the machines and other equipment functions.
• Executive Engagement : In this the executive has set the vision about the total number of production along with the standard quality
• Quality Infrastructure : In this the diversity of person is measured whether he or she is able to do multi tasking
• Breakthrough Win in service : To prioritize the level of production.