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					Promoting a Quality Improvement Culture in the
            Clinical Environment
Promoting a Quality Improvement Culture in the
            Clinical Environment


               Elizabeth Baines
          Patient Safety Coordinator
           Clinical Nurse Specialist

                 Cathy Howe
         Head of Clinical Governance

                  July 2007




                      2
Acknowledgments

We would like to thank all the people who made this study visit possible. The
Nuffield Trust, Royal College of Nursing and the Institute of Healthcare
Management for providing the Study Fellowship. Goran Henricks and
everyone at the Qulturum and Ryhov Hospital who made us welcome and
spent time with us.




                                     3
Contents
Acknowledgments ............................................................................................ 3
Contents .......................................................................................................... 4
Terms of Reference ......................................................................................... 5
Summary ......................................................................................................... 6
1.      Introduction ............................................................................................... 8
2.      Present Situation .................................................................................... 10
3.      Investigation............................................................................................ 11
        Figure 1 Programme for Visit to Qulturum .............................................. 11
     3.1 The Qulturm ......................................................................................... 12
        Figure 2 The Qulturum Building .............................................................. 12
        Figure 3 An Informal Meeting Area in the Qulturum ................................ 12
        Figure 4 Project Mapping Board ............................................................. 13
     3.2      History and Structure of the Qulturum (Rolf Bardon) ....................... 13
        Figure 5................................................................................................... 14
        Figure 6 The “Diamond Picture” a Model of the Qulturum‟s Approach ... 16
     3.3 Leadership and Staff Development (Ebbe Lindgen) ........................... 16
        Figure 8................................................................................................... 19
        Figure 9 Strategy for Transformation ...................................................... 19
     3.4 Microsystems (Joakim Edvirisson) ....................................................... 20
        Figure 11 Microsystem Model ................................................................. 21
        Figure 12................................................................................................. 22
     3.4 Concepts of Quality Improvement (Goran Henricks) .......................... 22
     3.5 Vision Esther – Coaches Training Programme..................................... 25
4.      Evaluation ............................................................................................... 28
        Table 1 Paired Comparison Analysis ...................................................... 30
        Table 2 Action Opportunities Ranked According to Achievement of
        Inclusion Criteria (weighted) ................................................................... 31
5.      Conclusions ............................................................................................ 34
6.      Recommendations .................................................................................. 35
7.      References ............................................................................................. 38
8.      Appendix ................................................................................................. 39



                                                          4
Terms of Reference

     To identify levels of clinical, and especially nursing, involvement in an
      organisation recognised as having a fully-embedded quality
      improvement culture – namely Jönköping County Council, Sweden.

     To identify the management and organisational support required in a
      multi-disciplinary quality culture with particular focus on nursing.

     To identify, evaluate and recommend practical methods of achieving
      this in Conwy and Denbighshire NHS trust.




                                      5
Summary
At present, for many healthcare professionals, involvement in quality
improvement work is target-led rather than routine practice. The purpose of
this study is to gain insights into how the transformation into a culture of
continuous quality management or improvement may be practically achieved
by seeing first-hand an organisation that is renowned for its success in
embedding quality improvement into the healthcare culture. A foremost
international example of this is Jönköping County Council in Sweden.

The visit to the Qulturum and Ryhov hospital provided a large range of ideas
and strategies to consider.

High clinical engagement was achieved through empowering clinicians to:
   • Focus on the patient (e.g. Esther).
   • Develop action focussed skills & leadership.
   • Work project by project within Microsystems.
   • Explicit recognition of the adoption curve accepting varying levels of
       take-up.
   • Advertising of the successes.

This requires large scale organisational support including:
   • Consistent message: Quality as a Strategy.
   • “To do the job and to improve the job” expectation.
   • Systematic (mandatory) skills & leadership programmes incorporating
       quality improvement tools & live projects.
   • Clarity of overview – totality of projects contributing to the corporate
       agenda (diamond) and system level measures.
   • CEO „Grand Round‟ with Top100 supervising progress.
   • Creating „Meeting places‟ and conducive environments.

It is recommended that in Conwy & Denbighshire NHS trust we should:
1. Developing a hypothetical patient such as Esther may be something that
     clinical staff and nurses in particular would relate to.

2. Use boards on walls to allow staff or patients to suggest areas for
   improvement. Progress on these also charted and displayed.

3. The use of mini nursing stations in the bays.

4. Phones answered by non-clinical member of the team.

5. Develop Microsystems work

6. To map the quality improvement approaches that have been implemented
   over the past 15 years at C&D Trust.




                                       6
7. The Trust Board to set up a „Grand Round‟ to be held once or more per
   year, where each Division can demonstrate its improvement work and
   associated results for shared learning and understanding

8. Explore the possibility of European or other funding sources to provide
   quality improvement training.




                                    7
1. Introduction
During the past few years quality improvement and clinical governance has
been high on the agenda at Conwy & Denbighshire NHS Trust. The
organisation‟s commitment to quality and safety has been recognised by its
selection as one of 4 pilot sites for the prestigious Health Foundation/Institute
for Healthcare Improvement “Safer Patients Initiative” (SPI). Through this
initiative further progress is being made in implementing interventions
designed to improve safety by reducing adverse events such as healthcare
acquired infections and medication errors. As the project manager for this
initiative I have become aware of the importance of two factors in the
implementation of change, these are spread and sustainability. If any
changes are going to succeed in the long term then an organisation needs to
have the environment or culture which will promote both spread and enable
sustainability of any improvements.

One way of achieving this would be to transform from a culture of project-style
quality and safety improvement work, to a fully-embedded quality culture such
as Total Quality Management (TQM). At present, for many healthcare
professionals, involvement in quality improvement work is target-led rather
than routine practice. The purpose of this study is to gain insights into how
the transformation into a culture of continuous quality management or
improvement may be practically achieved by seeing first-hand an organisation
that is renowned for its success in embedding quality improvement into the
healthcare culture. A foremost international example of this is Jönköping
County Council in Sweden.

Jönköping County Council has been building a Total Quality Management
approach for many years. They have achieved sustained improvements
(Overtveit J, Satines A.) that have been spread throughout Sweden (Strindhall
M, Henricks G). Further their reputation is international with other countries
keen to follow their lead (Bodhenheimer T, Bojestig M, henricks G). In 2003
they had over 800 quality improvement „projects‟ in progress. This clearly
demonstrates a huge scale of dedication and commitment. This suggests a
true quality improvement culture, and not just a target-driven approach. At the
centre of this improvement work is the Qulturum, an innovation and learning
centre within the healthcare system.            However Qulturum has no
responsibilities for clinical or administrative functions; its sole mission is
improvement work. Qulturum's improvement strategy is based on 3 principles:
(1) Learning is key to improvement, (2) Improvement needs to be broad and
deep, and (3) Improvement must be both bottom-up and top-down. Based on
these principles, Jönköping County has achieved timely access to primary and
specialty care, has improved the care of a number of chronic conditions, and
has accomplished these goals without increases in expenditures
(Bodenheimer T. Bojestig M. Henriks G.)




                                       8
In January 2007 I had the opportunity to travel to Jönköping through the
Nuffield Trust Joint Travel Award. Through this annual travel fellowship The
Nuffield Trust, the Institiute of Healthcare Management (IHM) and the Royal
College of Nursing (RCN) provide the opportunity for a healthcare manager
and nurse to undertake a joint study tour, within the UK or overseas, with the
aim of “jointly improving the patient experience”.

The two key objectives my colleague and I wished to achieve by undertaking
this visit were as follows:
1. Identification of levels of clinical, and especially nursing, involvement in
    culture-embedded quality improvement and practical methods of achieving
    this,
    and
2. Identification of management and organisation support required in a multi-
    disciplinary quality culture, with particular focus on the nursing element,
    due to current time-related challenges.

These objectives are about the integration of the management and nursing
agendas, with a clear focus on quality improvement and the safety and care of
the patient. Our aim is that our observations and reflection on practice will be
reported back to the Conwy & Denbighshire Trust with a view to designing
system changes to begin the process of embedding a more comprehensive
quality culture, focussing on measuring the success in quantitative and
qualitative ways.




                                       9
2. Present Situation

One of the key challenges that faces the NHS as an organisation is the need
to improve the quality and safety of healthcare that is currently being provided.
Nurses are front line staff who are responsible for providing a significant
proportion of the total healthcare that is delivered. Whilst it is recognised as
unacceptable to fail to invest in this area, it is nonetheless an enormous
challenge.

Personal experience from implementing the Safer Patients Initiative has
shown that knowledge of quality improvement tools and techniques amongst
nurses in Conwy & Denbighshire Trust is low and further that resistance to the
implementation of change is perceived, by those trying to implement change,
as high. Some of the reasons for this perceived resistance amongst nursing
staff could be due to lack of time, lack of knowledge regarding change
management or implementing change, fear of change or that they are simply
“weary of change”.

Further, following the development of the consultant contract and the
associated plans for other medics, nursing is one of the few professions
without contractual protected time for professional and service development.
Considerable work is being undertaken internationally to determine how to
„engage doctors‟ in improvement work, but very little focus has been paid to
the nursing profession.




                                       10
3. Investigation
The focus of the investigation was a four day visit to the Qulturum, sited at
Ryhov Hospital in Jönköping, Sweden. In Sweden secondary care is provided
by the County Councils.

The programme for the week (Figure 1) consisted of meetings with members
of the team and visits to specific areas of the hospital to meet with frontline
staff who have been involved in improvement work.

Figure 1 Programme for Visit to Qulturum

    Monday              Tuesday                Wednesday           Thursday
    12.3.07              13.3.07                 14.3.07            15.3.07
                    Passion for Life        Esther Coach       Root Cause
                    Annette Neilson         course             Analysis workshop
                                            Nassjo (highlands) Eva Johnsson
                                            FULL DAY

                    Microsystems            Nicoline          Two front line staff
                    Joakim Edvinson         Wackerberg        members – Stroke
                                            Eva Johnasson     Unit nurse &
                                            Joakim Edvinson   Midwife

Overview Swedish    Qulturum and                              TCAB
health care         principles, history,                      Anette Peterson
system, Jonkoping   structure,                                Visit to Medical
County Council &    processes and                             Rehab Ward
Qulturum            philosophy                                Christina
Rolf Bardon         Goran Henricks                            Gustavson -

Leadership                                                    Federation of
Ebbe Lindgen                                                  Pharmacists
                                                              Karin Svensson

                                                              TCAB progress/
                                                              Ward visit and e-
                                                              IR1 system
                                                              Henrik Hjortsjo
                                                              Head of Nursing,
                                                              Medicine




                                           11
3.1 The Qulturm
The Qulturum building is a conversion from a military Officers Mess remaining
from a previous use of the site.

Figure 2 The Qulturum Building




A first impression when entering the Qulturum building is that it is strikingly
different from the offices and buildings we are accustomed to in the NHS. It
was very light and airy with wooden flooring (Figure 3). It was neat, clean tidy
and uncluttered. Throughout the building the walls carry a variety of works of
art, display pieces and inspirational quotations from Gurus. This provides an
atmosphere of creativity and innovation. A bookcase containing international
tomes on the latest quality improvement tools, techniques and innovations
was available for all to browse.


Figure 3 An Informal Meeting Area in the Qulturum




                                      12
Displays provide clear open communication and demonstrate the results of
quality improvement work. A large white board showed progress with a range
of projects with associated indicators, timescales and progress markers
currently (Figure 4).

Figure 4 Project Mapping Board




The building also contains a number of more formal spaces including a
meeting hall and a number of smaller meeting rooms are scattered throughout
the building.

Action Opportunity: Creation of an environment that is conducive for learning,
creativity and innovation


3.2 History and Structure of the Qulturum (Rolf Bardon)

Figure 5 describes the journey that the Jönköping County Council, latterly
supported by the Qulturum, has taken in developing and embedding “Quality
as a Strategy” over the past 15 years. The journey started with awareness
through Medical Audit and Leadership Development that stressed dialogue as
important, through TQM and process thinking through to the current situation
described as „Full Scale‟. The Qulturum was established in its current form in
1999.




                                      13
Figure 5
    A history of Quality as Business Strategy in the County Council of Jönköping, Sweden


                                                                                                   Full Scale

                                                                       Movement
                                                                                                   • Pursing Perfection
                                                                                                   • Swedish Malcolm Baldridge
                                                                       • Big Group Healthcare      Award to Internal
                                                        Redesign       •The Diamond picture        Medicine,Eksjö and special
                                                        • Balanced     • System thinking           gratuity to Ryhov County
                              Process thinking          scorecard
                                                                       • Quantum leaps in          Hospital
                              • Patient Need            • Qulturum                                 • Medication
                                Related Groups                          Patient Safety
                                                        established
                              • Main processes                          •ATP – Brent James         • Inventory of Learning
                                                        • Access/Break                             • System measurements
                                defined                 through         • Environment work
                              • Accreditations                          becomes a part of
                                                        • Quality Award Business strategy
                                                                        to
                                of laboratories          Occupational
                              • Esther –                therapists      •Clinical Improvements –
                              Seamless care for elderly • The Child     new approach
                 Education • Special programmes         Dialogue
                              for physicians            • IT = improvement
                              • Healthcare Process       engine
  Awareness                   Redesign                  • Medication
                                                        Dialogue
                 • Common Values & Improvement tools
                 (Education for many)
                 • Process Leader Education
  •Leadership development that stress dialogue
  •Total Quality Management
  • Swedish Malcolm Baldridge Award (QUL): Hospitals (Varnamo, Ryhov) and clinics write QUL
  •Organization Evaluation, (in Swe: OG)
  • A new type of Development Dialogue = Annual report
  • Audit Group for Medical Evaluation
  1992                 1995                    1998                   2000                 2001             2002          2005




Action Opportunity: To map the quality improvement approaches that have
been implemented and when over the past 15 years at C&D Trust.

Rolf presented an overview of the Units that occupy the space in the Qulturum
building. These include:
 Qulturum – this area covers leadership courses, coaching, mentorship,
 collaborative organisation and facilitation, Microsystems support, Passion for
 Life, Transforming Care at the Bedside (TCAB), Project support including
 Extranet development and maintenance, Root Cause Analysis, support to
 the Esther programme etc.
 Research for Primary care – this covers some service provision as well as
 research into this care area.
 Child Health Unit – this looks at national level developments and adapts
 and implements locally including the education of all health care
 professional‟s who come into contact with children.
 Federation of Pharmacists – Pharmacy services are provided in Sweden by
 a private company who currently have a monopoly. The Federation
 supports pharmacists working in health care and provide a best practice
 review service similar to NICE.



                                                        14
  Futurum – this Academy for health care focuses on clinical research,
  epidemiology and outcomes research.
  Conference Centre.

Action Opportunity: To identify and create closer links and working
relationships with bodies and groups involved in quality improvement in
healthcare.

The Qulturum describes itself as a center for developing the knowledge of
improvement and renewal in healthcare. They deal with development and
improvement concerning patients journey, co-operation, inter-professional
teams, management and the organization of healthcare. They focus especially
on these strategic areas that they in Jönköping county believe are the most
important to improve in health care. Figure 6 illustrates the diagram known as
the „Diamond‟ picture, this is the model staff at the Qulturum feel best
represents the approach and role of the Qulturum.

The areas identified as the priorities are:

      Learning and innovation (including leading and leadership)
      Access and how patients are treated with respect and caring
      Prevention and Self-care
      Cooperation and flow
      Clinical improvement
      Patient safety
      Medication
      Good Finances and Reliability

Projects are monitored and reported using a balanced score card across the
four areas of Customer, Process, Learning and Innovation and Economic.


The Qulturum is described as a system rather than an organisation and when
illustrating it system or process maps are used rather than hierarchical maps




                                        15
Figure 6 The “Diamond Picture” a Model of the Qulturum’s
Approach


                                                      Learning and
                                                       Innovation




 IT
 ENVIROMENT    Access                Flow                 Clinical            Patient   Medication
 ADMIN                           Co-operation          Improvements           Safety

                317 teams          21 teams         47 teams + 43 teams        26         20
                                   Big Group        in National Quality        teams      teams
Number of teams that have          Healthcare       registers
participated in Collaboratives

                                                          Good
Totally educated 2002 – 2005:                           Finances
Approx 3550 employees                                  Reliability




                                                Value for patient increases




3.3 Leadership and Staff Development (Ebbe Lindgen)

Jönköping County Council puts a great deal into ensuring that its leaders are
appropriately equipped for the role they have to undertake in this system that
aims to improve and innovate. Therefore, senior staff including various
grades of doctors, ward leaders and Heads of Departments engage in
leadership development activities and programmes.

This process aims to develop leaders and decision makers in the county,
develop leadership competencies, and to support systematic improvement
work and service development.

It is assumed that the future will demand these skills and service performance
levels. It will provide senior staff with the ability to prioritise, be flexible whilst
maintaining an awareness of patient values. They also provide a networking
opportunity which is seen to build ongoing relationships and knowledge
sharing within the organisation. They aim to deliver a balance between hard
and soft processes i.e. a balance between systems, processes,
methodologies, technology and people, culture, and environment.

Approximately 150-200 leaders are trained each year and all programmes
contain the 3 corner stones of Personal Development, Management and
Improvement work.



                                                        16
  Personal Development training – working with groups, co-operation,
   management, improvement knowledge.
  Management Training – encompassing Organisation, laws and
   regulation, media, structure and planning.
  Improvement knowledge – variation, personal development training,
   taking action, change management.

All new leaders have to attend within 1 year. This includes mandatory
attendance for Junior Doctors and the equivalent of Specialist Registrars.
Inter-professional courses are attended by those identifying this as part of
their personal development.

The following Programs are run and all have service improvement skills
inbuilt:
    Heads of Department – 20 to 25 places on 1 course per year.
    Inter-professional groups – ward heads, first line managers,
         development leads (course run twice per year).
    Leaders for Pairs – could be ward manager with a head of department.
    Collaborative/Development programmes on a consultation basis,
         mentorship.
    Education for Improvement Leaders – coaching.
    Leadership development for professional groups not leaders in system
         but active leaders.
    Junior doctors – general (2-3 days).
    Specialist registrars compulsory (20 per group x 2 yr) (7 days-duration).
    Masters education – linked to the university.

Action Opportunity: Incorporation of quality improvement methodologies into
all training courses with associated live projects.

The system goals identified through these development programmes are:
  Patient Focus
  Economy & Balance
  Access
  System Focus
  Leadership
  Responsibility for Health
  Focus on Result




                                     17
Their model of leadership / management competency is as follows:




                 Leadership                      Strategic
                 Energy                          competence
                 Motivation
                 Team Formation




                                   Management




These competencies aim to support the Systematic improvement work. They
require their staff to combine professional knowledge and improvement
knowledge (Batalden and Stolz) stating that staff need both these to do their
jobs.

Action Opportunity: Set an expectation that all staff will „do their job‟ and
„improve their job‟ within their normal remit.

Their model of the leadership process is that leadership starts with the individual
and this individual needs to be comfortable, safe, confident and secure and have
clear aims of what they want, why they want to be a leader and an ability to
undertake reflective thinking. The organisation sets clear expectations that
leaders will demonstrate maturity, self-awareness, will network and provide others
with support, and will engage in a constant learning process. Leaders are
required to demonstrate a curiosity for the unknown.

Courses are based in Kolbs learning cycle using what they term as a
leadership and staff development “mixer” as illustrated in Figure 8.

Action Opportunity: To identify and assess leadership development
provision available to different levels of staff in the organisation.

The Strategy for Transformation includes both leadership development and
budgetary arms. A key contributor is deemed to be the Annual Meeting the
CEO holds with up to 100 Heads of Department. At this session Leads are
expected to present the results of their improvement work. The implication
was that no improvement work was unacceptable, whereas it seemed to be




                                        18
accepted that sometimes positive results would not be evident. This strategy
is demonstrated schematically in Figure 9.


Figure 8

       Action
       Learning

       Lectures
       (theory)
                                  Reflection             Apply
       Cases                                             learning
       Scenarios

       Everyday
       experience




Figure 9 Strategy for Transformation
                                                Strategy for
                                               Transformation




                                     Leadership              Budget Strategy
                                    Development




     Meetings          Personnel / HR             Qulturum             Annual Meeting with
                                                                              CEO




Action Opportunity: The Trust Board to set up a „Grand Round‟ to be held
once or more per year, where each Division can demonstrate its improvement
work and associated results for shared learning and understanding.

Ebbe also referred to the Diamond picture (Figure 6) explaining how
leadership will impact on Learning and Innovation. Often the process starts
with a need and ends in the development of a new working process,




                                        19
Action Opportunity: Map all improvement projects and plot against the
“Diamond picture” to demonstrate totality of project work over 10 years.


3.4 Microsystems (Joakim Edvirisson)

A microsystem is defined as “Where healthcare improves”. It is a small
frontline unit where group of patients & families meet with the healthcare
team. Patients, families and healthcare professionals are part of same team,
the patients need is in the centre and the healthcare professional is
considered a guest in the patients system.

The concept was developed in the United States and adapted in Jönköping.
In 2003 a European network started involving the UK, US, Norway, Sweden,
France. In March 2007 a Microsystem Festival was held involving 13
countries.

A Microsystem has to have common values and information systems are
crucial – right information, right time, right format. One area of success has
been in relation to Doctors ward rounds. On the Medical wards the patient is
taken to a meeting room for a multi-disciplinary consultation rather than being
seen in bed. Case notes and test results are available for all to see including
the patient. This approach avoids the issues of breaches of confidentiality
that may take place on a ward round; patients are empowered and can ask
questions in private.

Introducing the Microsystem approach can be challenging. Their may be
conflicts between ideas and practice. For example in theory the patient
decides who their family is but then visiting hours or the numbers of visitors
may be restricted.

Microsystems need to build from the inside out starting from a self care
system as illustrated in Figure 11.

There are considered to be Five P‟s of the microsystem - Purpose, Patients,
People or Professionals, Processes and Patterns. The patterns aspect is
important in evaluation of clinical outcomes, variation and working with
variation. Some consider that there is an additional P for Passion.

Courses on improvement work are included in pre-registration nurse
education. Students assist qualified staff with projects, they are included in
the study cycle. Students are seen as resource in the ideas or experiences
they can bring into a microsystem.

Action Opportunity: Training on improvement methodology could be
incorporated into Student education.

In some units students “do” 5P when they visit a unit, they are also
encouraged to translate work into “what value it is to a unit” and focus on a
customers needs rather task orientation.


                                      20
Action Opportunity: Students could be considered a pair of fresh eyes when
coming on to a unit and asked to consider the Microsystems they encounter in
terms of the 5 P‟s



Figure 11 Microsystem Model
                                                                 Community,
                                                                 market, social
                                                                 policy



                                                                      Macro-
                                                                      organization
                                                                      system

                               Self-care
                               System




                                                                    Microsystem
                                                                    (clinical,
                                                                    education etc.)



                                                               Individual
                                                               professional &
                                                               beneficiary system




Since 2005 in Sweden it has been statutory for nurses that as well as
professional knowledge they need to have improvement knowledge. The
professional knowledge is important in leading to improvement of diagnosis
and treatment. Improvement knowledge will lead to improvements of process
and healthcare systems. In conjunction these will lead to an overall
improvement for patients (Figure 12).




                                    21
Figure 12
      Professional knowledge                   Improvement knowledge –
      – medicine, nursing,                     system variation, psychology
      economic, individual                     of changes, action based
      skills, values, & ethics                 learning + improving.



         Improvement of                        Improvement of process
         diagnosis & treatment       +         & system in healthcare




                    Improvement For Patients



Action Opportunity: Explore Microsystems work www.clinicalmicrosystem.org


3.4 Concepts of Quality Improvement (Goran Henricks)

Goran Henricks is the Director of the Qulturum. He explained the thinking that
is behind the approach at the Qulturum.
         “Act into new thinking – don’t talk about it.
         Creativity – look at new landscape with new eyes.
         The future is now - Focus on what we are doing now.”

Goran also explained the systems approach. The Qulturum is considered a
system not a hierarchy, level or organisation. Further he stressed that it is
important to change system or circumstances not the people and that patients
depend on the system not the person.

The main cornerstone of Qulturum thinking is that everyone has two jobs – to
do the job and improve the job. However the incentives to do this may vary
between systems. Clinical staff have a budget and are expected to use
budget in service delivery and service improvement.

The quality improvement work began in 1997 through to 1999 with education
following Malcolm Bladridge‟s basic volumes. Approximately 4500 staff were
given this training. From 2001-2004 approximately 4500 were educated in
methods and models to improve work in 5 areas, Access, Flow, Safety,
Medication, Clinical Improvement


                                      22
In contrast to our approach in Conwy & Denbighshire the Qulturum has
pursued very few patient safety improvement initiatives. Their reasoning for
this is that most of the work is evidence based and therefore prescriptive
which means the creativity aspect may be lost. Staff may be more resistant to
introducing prescriptive changes rather than being allowed to identify their
own problems and develop their solutions. However projects must fit into 6
areas - Access, Prevention, Flow, Safety, Medication, Clinical Improvement
and the change transformation should be evidence based.

Motivational factors appear to be varied. Everything in Qulturum is free,
additional factors may be the environment of the Qulturum, the food,
continuing feedback, action learning, mentorship and monitoring of results by
CEO. It is not compulsory to participate in the improvement process however
it is compulsory to participate in the results.

The budget for the Qulturum is 0.003% of total council budget but it is
estimated that they have saved over a 100 million Swedish crowns in falls
prevention and improved nutrition in patients.

The system level measures for the health care in Jönköping are mortality, life
quality, financial outcomes, adverse event rates, staff turnover, access
(waiting times) and sick leave. Additional Measures in terms of work
satisfaction have indicated an improvement. Unfortunately up to date system
level measure were not available either during or since our visit however
some are details in figure 13.




                                     23
Figure 13 System Measures
3.5 Vision Esther – Coaches Training Programme

Esther is a hypothetical patient. Through this scheme health care staff are
encouraged to consider the impact of their care or service on Esther in
addition there are some ideals for Esther‟s care. Esther‟s should have:
    One care giver – not disjointed,
    Care near home,
    Care plan,
    Know who to turn to.

Action Opportunity: Developing a hypothetical patient such as Esther may
be something that clinical staff and nurses in particular would relate to

The purpose of the Esther coaching project was train multidisciplinary
coaches who then go into the clinical areas train their colleagues. The
programme is 15 days overall covering 12 sessions, some events are 2 days
e.g. communication. The programme covers lots of tools/methods and a
formal presentation is required at the end of course. An issue that has not yet
been covered by this programme is the issue of self–sustaining network of
coaches. Candidates are selected through a training needs analysis. Those
with identified needs can volunteer for programme, taking volunteers ensures
that candidates early adopters. The Coaching programme was funded from
European Objective 1 funding.

Action Opportunity: Explore the possibility of European or other funding
sources to provide quality improvement training.

The impact of process or system working on Esther is highlighted. Healthcare
workers often work in silos, these can be positive, i.e. specialist or
microsystem thinking however, Esther moves between systems/silos and it is
not her responsibility to monitor/track where she is in the system.

      Traditional way
                                                             The patients
      Process are described
                                                             Journey



        Manager                                                Manager




                                          Patient
Issues relating to total quality management are raised on the training course,
and clear analogies were used to explain difficult or contentious issues. For
example the issues of “how do you work with continuous quality
improvement?” and “how do you manage day work and quality
improvement?”. An example was given of a wood cutter. Would you like me
to help you by sharpening your axe? “No I don‟t have time for you to sharpen
my axe”.

Having Esther as a hypothetical patient ensures that the there is “customer”
focus at all stages of the process and decisions are made on facts.


3.6 Meeting with Front Line Staff

There were three opportunities for us to meet with front line staff. These
included visits to brain injury rehabilitation unit and an acute medical ward.

Nurses in Sweden undertake a three year training programme leading to
registration. Once a nurse is registered there is no need to re-register and
therefore no requirements for continual professional development to stay
registered. The nurses we met claimed they study in their own time.

Shift patterns also facilitate quality improvement work with a two hour shift
overlaps in the afternoon for reflection and/or special care activities. Other
activities observed that facilitated or indicated nurses‟ involvement in quality
improvement work were:
   Two away days a year to discuss ideas, half the team go to each.
   White boards on the wards listing staff/patient ideas and progress with
    their implementation.
   Phone calls are answered by non-nursing staff; studies have shown that
    85% of calls do not need to be dealt with by a qualified nurse.
   No phones on the nursing station leads to a quieter environment.
   Split ward to bring identified nurses closer to fewer patients
   Mini-nursing stations in the bays allowing the nurses to spend more time in
    the vicinity of their patients.
   Local measures displayed on wards for local demonstration of success.
   Standard of dress and jewellery in Hand Hygiene audit tool


Action Opportunity: Use boards on walls to allow staff or patients to
suggest areas for improvement. Progress on these also charted and
displayed.


Action Opportunity: The use of mini nursing stations in the bays


Action Opportunity: Phones answered by non-clinical member of the team.




                                      26
This study visit provided us with an opportunity to collect a substantial amount
of information. A significant amount of this information is qualitative in the
form of the thoughts, opinions and experiences of staff at the Qulturum. The
constraint of this type of information is that it can not be statistically analysed
in the same way as data or quantitative information and may be subjective or
biased. However there is data available in terms of system level measures
(mortality, life quality, financial outcomes, adverse event rates, staff turnover,
waiting times and sick leave) from Jönköping and also published articles that
demonstrate significant improvements have been made in areas they have
targeted in their improvement work.

Unfortunately the system level measures database was not entirely up to
date, apparently due to staffing problems, so it was not possible to validate all
of these measures at the time of our visits. We will however continue to
monitor the progress of work of this organisation to identify whether the
improvements that have been reported to date are sustained.




                                        27
4. Evaluation
The visit to the Qulturum and Ryhov hospital provided a large range of ideas
and strategies to consider. From 2002 to 2006 more than 500 teams + 3550
participants have participated in programmes that include quality improvement
methodology. All these programmes include a practical aspect as well as
theory which alone generates a significant number of quality improvement
projects.

In addition to the learning and application of quality improvement techniques
there is recognition of the importance of creating arenas or meeting places
where conversations can take place and work can be identified and
progressed and also the importance of quality as a strategy.

High clinical engagement is achieved through empowering clinicians to:
           – Focus on the patient (e.g. Esther).
           – Develop action focussed skills & leadership.
           – Work project by project within Microsystems.
           – Advertising of the successes.

This requires large scale organisational support including:
          – Consistent message: Quality as a Strategy.
          – “To do the job and to improve the job” expectation.
          – Systematic (mandatory) skills & leadership programmes
              incorporating quality improvement tools & live projects.
          – Clarity of overview – totality of projects contributing to the
              corporate agenda (diamond) and system level measures.
          – CEO „Grand Round‟ with Top100 supervising progress.
          – Creating „Meeting places‟ and conducive environments.

These approaches have been in contrast to those in the UK which made
continuous professional development a mandatory requirement for continued
registration for nurses. Many of the quality improvement initiatives developed
in the UK have had patient safety as a focus or patient or public involvement
as a priority. This has not been the focus with the work from the Qulturum.
There has been much more focus on identification of changes to be made by
nurses at a local level (Microsystems) with the focus on a hypothetical patient.

As a result of this study visit the following action opportunities were identified:

   •   Creation of an environment that is conducive for learning, creativity and
       innovation.
   •   To identify and create closer links and working relationships with
       bodies and groups involved in quality improvement in healthcare.
   •   To map the quality improvement approaches that have been
       implemented and when over the past 15 years at C&D Trust.
   •   Incorporation of quality improvement methodologies into all training
       courses with associated live projects.


                                        28
   •   Set an expectation that all staff will „do their job‟ and „improve their job‟
       within their normal remit.
   •   To identify and assess leadership development provision available to
       different levels of staff in the organisation.
   •   The Trust Board to set up a „Grand Round‟ to be held once or more per
       year, where each Division can demonstrate its improvement work and
       associated results for shared learning and understanding.
   •   Training on improvement methodology could be incorporated into
       Student education.
   •   Students could be considered a pair of fresh eyes when coming on to a
       unit and asked to consider the Microsystems they encounter in terms of
       the 5 P‟s.
   •   Develop Microsystems work.
   •   Developing a hypothetical patient such as Esther may be something
       that clinical staff and nurses in particular would relate to.
   •   Explore the possibility of European or other funding sources to provide
       quality improvement training.
   •   Use boards on walls to allow staff or patients to suggest areas for
       improvement. Progress on these also charted and displayed.
   •   The use of mini nursing stations in the bays
   •   Phones answered by non-clinical member of the team.

Other observations that may have potential applications are:
   • The use of system maps.
   • Implementing evidence based changes may not be the best way to
      engage and empower staff.
   • Staff need to have knowledge to change their attitudes.
   • As an organisation we need to map existing processes and projects.
   • Most improvement work in the organisation is identified by external
      sources (often national). It is not in reaction to information generated
      locally in the trust.

In practice it will be difficult to implement all these ideas and strategies. Using
the Pareto principle some interventions will provide much greater returns than
others. Also some interventions will have greater costs in terms of an impact
financially or on human resources than others. Therefore in deciding which
interventions we should recommend the following factors can be used as
inclusion criteria:

       A. There are demonstrable positive outcomes from the approach used.
       B. Low human resource costs in terms of time commitments for clinical
          staff – minimum impact on clinical time.
       C. Have been shown to have a positive impact on promoting clinical
          engagement.
       D. Requires a low financial input.

Paired Comparison Analysis can be used to identify the order of priority for
these factors as shown in Table 1.




                                        29
Table 1 Paired Comparison Analysis

                             A.           B.          C.       D.
                         Demonstrable Minimum     Promotes    Low
                          Outcomes    Impact on    Clinical Financial
                                      Clinicians Engagement Impact
A. Demonstrable
   Outcomes                                        A2              A1                 A2

B. Minimum
   Impact on                                                       C2                 B1
   Clinicians
C. Promotes
   Clinical                                                                           C1
    Engagement
D. Low
    Financial
    Impact
Score = the difference in importance from 0 (no difference) to 3 (major difference)

These scores can be summarised as follows:
      A=5
      B=1
      C=3
      D=0
This analysis shows that inclusion criteria can be prioritised as follows:

        1. There are demonstrable positive outcomes from the approach used.
        2. Have been shown to have a positive impact on promoting clinical
           engagement.
        3. Low human resource costs in terms of time commitments for clinical
           staff – minimum impact on clinical time.
        4. Requires a low financial input.

These criteria can then be used in a Grid Analysis (Decision Matrix Analysis)
can be used to asses action opportunities that have been identified. See
Table 3 & 4 in Appendix for details. Ranking these results according to the
whether or not they achieve the inclusion criteria and multiplying them
according to the weighting gives the results as seen in Tables 2 and 4.

One option is always to do nothing however, as already discussed; it is
recognised as unacceptable to fail to invest in engaging in clinicians especially
nurses in quality improvement as this group provides a significant proportion
of the total healthcare provided. Failure to invest in nurses will lead to
decreasing standards of patient care resulting in increased harm to patients,
increased stress to staff as they struggle to maintain standards, decreased
moral and ultimately problems with recruitment and retention nurses.




                                              30
Table 2 Action Opportunities Ranked According to Achievement of
Inclusion Criteria (weighted)

1. Developing a hypothetical patient such as Esther may be                     30
   something that clinical staff and nurses in particular would relate to.

2. Use boards on walls to allow staff or patients to suggest areas for         30
   improvement. Progress on these also charted and displayed.

3. The use of mini nursing stations in the bays                                30

4. Phones answered by non-clinical member of the team.                         30

5. Develop Microsystems work                                                   28

6. To map the quality improvement approaches that have been                    27
   implemented over the past 15 years at C&D Trust.

7. The Trust Board to set up a „Grand Round‟ to be held once or more           25
   per year, where each Division can demonstrate its improvement
   work and associated results for shared learning and understanding.

8. Explore the possibility of European or other funding sources to             25
   provide quality improvement training.

9. Incorporation of quality improvement methodologies into all training        20
   courses with associated live projects.

10. To identify and assess leadership development provision available          20
    to different levels of staff in the organisation.

11. Training on improvement methodology could be incorporated into             19
    Student education.

12. Students could be considered a pair of fresh eyes when coming on           19
    to a unit and asked to consider the Microsystems they encounter in
    terms of the 5 P‟s.

13. Set an expectation that all staff will „do their job‟ and „improve their   18
    job‟ within their normal remit.

14. Creation of an environment that is conducive for learning, creativity      17
    and innovation.

15. To identify and create closer links and working relationships with         17
    bodies and groups involved in quality improvement in healthcare.
Weighting A = 5 B = 1 C = 3 D = 0




                                        31
The following 8 actions had the highest scores:

1. Developing a hypothetical patient such as Esther may be something that
   clinical staff and nurses in particular would relate to.

2. Use boards on walls to allow staff or patients to suggest areas for
   improvement. Progress on these also charted and displayed.

3. The use of mini nursing stations in the bays.

4. Phones answered by non-clinical member of the team.

5. Develop Microsystems work

6. To map the quality improvement approaches that have been implemented
   over the past 15 years at C&D Trust.

7. The Trust Board to set up a „Grand Round‟ to be held once or more per
   year, where each Division can demonstrate its improvement work and
   associated results for shared learning and understanding

8. Explore the possibility of European or other funding sources to provide
   quality improvement training.


Developing a hypothetical patient (Action 1) is an option that has minimal
financial costs however has been shown to be significant in promoting clinical
engagement as it encourages staff to consider the impact of the services they
are providing or developing on the potential user. This idea was originally an
elderly female patient but has now been adapted for other services such as
children‟s services.

Many of the actions we have identified could also be linked to provide greater
benefits than if they were introduced alone. For example as we found in
Jönköping European funding was obtained (Action 8) and used to provide
quality improvement training into live projects (Action 9), such as Esther
(Action 1), in an environment that was conducive to learning (Action 14) and
away from the distractions and interruptions of the clinical area.

Another possibility is the introduction of mini nursing stations in the bays
(Action 3). This allows the nurses to complete the necessary documentation
close to the patient‟s bed side whilst still being able to observe the patients but
without the interruptions of phone calls. This promotes improved patent care
by freeing nurses up to do their job and decreases the risk of for example drug
administration errors that are known to result from interruptions or distractions
and improving job satisfaction. Management support would be required to
facilitate this change by providing clerical support to deal with the majority of
phone calls (Action 4) that do not require a nurse.




                                        32
Another action that has minimal financial implications but has been shown to
facilitate and promote not just staff engagement but also that of service users
in terms of patients and their relatives or visitors is the use boards on walls
(Action 2). Boards used in this way also have the advantage of providing
feedback to those who make the suggestions by charting and displaying
progress.

Mapping the quality improvement (Action 5) approaches that have been
implemented over the past 15 years at C&D Trust would again have minimal
financial implications however it would have several benefits. By this
approach management could support the clinicians by putting a structure in
place which provides recognition of the work that has been done in the past
but also promotes sharing and prevents duplication. Although this is a
retrospective approach it could also be prospective so that opportunities are
made to acknowledge and share improvement work that is being done in the
organisation. This prospective approach could include a “Grand Round”
(Action 7). This advertising of success could be motivational for staff as well
as promoting spread and sustainability of improvement work.

The concept of Microsystems (Action 5) is an important tool in empowering
and motivating clinical staff to improve services at the front line by increasing
their awareness of what is within their scope to achieve by identifying and
changing what is within their power to improve and seeing the positive impact
on the patient rather than trying to change the whole system. This approach
requires a change in thinking which may initially difficult to achieve but is
supported by the Model for Improvement and PDSA change methodology
which is currently being used in the organisation.




                                       33
5. Conclusions
The visit to Jönköping showed that high levels of clinical involvement,
especially nursing, are an important factor in achieving a fully-embedded
quality improvement culture. Several practical methods of starting to develop
a quality improvement culture were identified. In total 15 actions were
identified. From these 8 actions were prioritised as having demonstrated a
positive influence on clinician engagement with a low impact financially and on
human resources.


1. Developing a hypothetical patient such as Esther may be something that
   clinical staff and nurses in particular would relate to.

2. Use boards on walls to allow staff or patients to suggest areas for
   improvement. Progress on these also charted and displayed.

3. The use of mini nursing stations in the bays.

4. Phones answered by non-clinical member of the team.

5. Develop Microsystems work

6. To map the quality improvement approaches that have been implemented
   over the past 15 years at C&D Trust.

7. The Trust Board to set up a „Grand Round‟ to be held once or more per
   year, where each Division can demonstrate its improvement work and
   associated results for shared learning and understanding

8. Explore the possibility of European or other funding sources to provide
   quality improvement training.


Further these actions may well provide additional benefits such as improved
patient safety, increased patient and public engagement, increased job
satisfaction, improved motivation and increased availability of resources.




                                      34
6. Recommendations
The terms of reference of this report were as follows:

      To identify levels of clinical, and especially nursing, involvement in an
       organisation recognised as having a fully-embedded quality
       improvement culture – namely Jönköping County Council, Sweden.

      To identify the management and organisational support required in a
       multi-disciplinary quality culture with particular focus on nursing.

      To identify, evaluate and recommend practical methods of achieving
       this in Conwy and Denbighshire NHS trust.


One option is to do nothing however, as already discussed; this is not a viable
option. A total of 16 possible actions were identified. To evaluate these
inclusion criteria were identified including the above terms of reference.

Paired comparison analysis showed that inclusion criteria can be prioritised as
follows:

1. There are demonstrable positive outcomes from the approach used.
2. Have been shown to have a positive impact on promoting clinical
   engagement.
3. Low human resource costs in terms of time commitments for clinical staff –
   minimum impact on clinical time.
4. Requires a low financial input.

Therefore the actions were prioritised and those with a score over 20 were
identified. This identified 8 of the 15 actions as follows:

9. Developing a hypothetical patient such as Esther may be something that
   clinical staff and nurses in particular would relate to.

10. Use boards on walls to allow staff or patients to suggest areas for
    improvement. Progress on these also charted and displayed.

11. The use of mini nursing stations in the bays.

12. Phones answered by non-clinical member of the team.

13. Develop Microsystems work

14. To map the quality improvement approaches that have been implemented
    over the past 15 years at C&D Trust.




                                       35
15. The Trust Board to set up a „Grand Round‟ to be held once or more per
    year, where each Division can demonstrate its improvement work and
    associated results for shared learning and understanding

16. Explore the possibility of European or other funding sources to provide
    quality improvement training.


The following implementation plan has been devised:

ACTION        IMPLEMENTATION PLAN                RESOURCE IMPLICATIONS

    1      Through the Safer Patients            This will have minimal financial
           Initiative Ward Team it would be      and       human      resources
           possible to invite ward staff to      implication but will promote
           develop a hypothetical patient        clinical    engagement      and
           and test the use this approach.       improve service development.

    2      Through the Safer          Patients   This action has minimal
           Initiative Ward Team     identify a   financial     implications   but
           ward to pilot the idea   of having    should facilitate and promote
           a suggestion and          feedback    staff     patient    &     public
           boards.                               involvement.

    3      The introduction of mini nursing      This option has minimal
           stations in the bays is currently     financial implications as it
           being tested on a medical ward.       should be able to use a small
           This allows the nurses to             table as a mini nursing station.
           complete       the    necessary       There are no human resource
           documentation close to the            implications.
           patient‟s bed side whilst still
           being able to observe the
           patients.

    4      Having clerical support to deal       There are human resource and
           with the majority of phone calls      financial implications for this
           that do not require a nurse           option as a clerk would need to
           needs management support to           be recruited to answer the
           facilitate this change. This          calls. At the present time this
           change        would       promote     recommendation is unlikely to
           improved patent care by freeing       be taken forwards due to the
           nurses up to do their job and         cost saving targets on admin
           decreases the risk of for             and clerical staffing.
           example drug administration
           errors that are known to result
           from        interruptions      or
           distractions.




                                      36
    5       Microsystems thinking can be         This will have minimal financial
            introduced   through   PDSA          and       human      resources
            methodology and improvement          implication but will promote
            programmes that are currently        clinical    engagement      and
            in progress or about to be           improve service development.
            introduced       such     as
            “transforming care at the
            Bedside”

  6&7       By      mapping     the    quality   This will have minimal financial
            improvement approaches that          and       human      resources
            have been implemented over           implication but will promote
            the past 15 years at C&D Trust       clinical    engagement      and
            management could support the         improve service development.
            clinicians by putting a structure    Benefits include promotion of
            in     place    which    provides    sharing and prevention of
            recognition of the work that has     duplication. This advertising of
            been done in the past. Although      success could be motivational
            this is a retrospective approach     for staff as well as promoting
            it could also be prospective so      spread and sustainability of
            that opportunities are made to       improvement work.
            acknowledge        and      share
            improvement work that is being
            done in the organisation. It has
            been agreed that this is to be
            taken forwards by the Clinical
            Governance department.

    8       This final recommendation has        The       human       resource
            the potential to benefit the         implications of this are time
            organisation in many ways as         knowledge and skills required
            the financial backing would          to    apply    for   European
            facilitate many of the other         Objective     One      Funding
            actions.                             however the financial rewards
                                                 could be considerable. The
                                                 human resource issue may be
                                                 addressed     by    partnership
                                                 working with other areas that
                                                 have experience such as
                                                 County Councils.


In order to facilitate implementation of these recommendations a presentation
of the results of this study have been made to the trust executive directors
who agree and plan to support the recommendations.




                                      37
7. References
Batalden P B, Stolz P K. A framework for the continuous improvement of
health care, building and applying professional and improvement knowledge
to test changes in daily work. Joint Commission Journal on Quality
Improvement 1993;19:424-47.

Bodenheimer T. Bojestig M. Henriks G. Making systemwide improvements
in health care: Lessons from Jonkoping County, Sweden.        Quality
Management in Health Care. 16(1):10-5, 2007 Jan-Mar.

Davenport, Thomas H., Thinking for a living: How to get better performance
and results from knowledge

Overtveit J, Satines A. Sustained improvement? Findings from an
independent case study of the Jonkoping quality program. Quality
Management in Health Care. 16(1):68-83, 2007 Jan-Mar.

Strindhall M. Henriks G.     How improved access to healthcare was
successfully spread across Sweden. Quality Management in Health Care.
16(1):16-24, 2007 Jan-Mar.




                                    38
8. Appendix




              39
Table 3 Grid Analysis Showing Un-weighted Assessment

Achievement of criteria score = 0 (poor) to 3 (very good) .


              CRITERIA                             A.                B.              C.         D.
                                               Demonstrable       Minimum        Promotes      Low       TOTAL
                                                Outcomes         Impact on        Clinical   Financial
                                                              Clinicians Time   Engagement    Impact

Creation of an environment that is                     1            3               3           0          7
conducive for learning, creativity
and innovation.

To identify and create closer links                    1            1               3           2          7
and working relationships with
bodies and groups involved in
quality improvement in healthcare.

To map the quality improvement                         3            3               2           3         11
approaches that have been
implemented over the past 15
years at C&D Trust.

Incorporation of quality                               2            2               2           2          8
improvement methodologies into
all training courses with
associated live projects.
             CRITERIA                        A.                B.              C.         D.
                                         Demonstrable       Minimum        Promotes      Low       TOTAL
                                          Outcomes         Impact on        Clinical   Financial
                                                        Clinicians Time   Engagement    Impact

Set an expectation that all staff             1               1               3           3          8
will „do their job‟ and „improve their
job‟ within their normal remit.

To identify and assess leadership             2               2               2           2          8
development provision available
to different levels of staff in the
organisation.

The Trust Board to set up a                   3               2               2           2          9
„Grand Round‟ to be held once or
more per year, where each
Division can demonstrate its
improvement work and associated
results for shared learning and
understanding.

Training on improvement                       2               2               2           1          7
methodology could be
incorporated into Student
education.




                                                              41
            CRITERIA                      A.                B.              C.         D.
                                      Demonstrable       Minimum        Promotes      Low       TOTAL
                                       Outcomes         Impact on        Clinical   Financial
                                                     Clinicians Time   Engagement    Impact

Students could be considered a             1               2               3           3          9
pair of fresh eyes when coming on
to a unit and asked to consider the
Microsystems they encounter in
terms of the 5 P‟s.

Develop Microsystems work                  3               2               3           2         10

Developing a hypothetical patient          3               3               3           3         12
such as Esther may be something
that clinical staff and nurses in
particular would relate to.

Explore the possibility of                 2               3               3           3         11
European or other funding
sources to provide quality
improvement training.

Use boards on walls to allow staff         3               3               3           3         12
or patients to suggest areas for
improvement. Progress on these
also charted and displayed.

The use of mini nursing stations in        3               3               3           3         12
the bays




                                                           42
           CRITERIA                   A.                B.              C.         D.
                                  Demonstrable       Minimum        Promotes      Low       TOTAL
                                   Outcomes         Impact on        Clinical   Financial
                                                 Clinicians Time   Engagement    Impact

Phones answered by non-clinical        3               3               3           3         12
member of the team.




                                                       43
Table Grid Analysis Showing Weighted Assessment

Achievement of criteria score = 0 (poor) to 3 (very good) .

Weighting A = 5 B = 1 C = 3 D = 0

            CRITERIA                       A.                    B.              C.         D.
                                       Demonstrable           Minimum        Promotes      Low       TOTAL
                                        Outcomes             Impact on        Clinical   Financial
                                                          Clinicians Time   Engagement    Impact

Creation of an environment that is            5                 3               9           0         17
conducive for learning, creativity
and innovation.

To identify and create closer links           5                 1               9           2         17
and working relationships with
bodies and groups involved in
quality improvement in healthcare.

To map the quality improvement               15                 3               6           3         27
approaches that have been
implemented over the past 15
years at C&D Trust.

Incorporation of quality                     10                 2               6           2         20
improvement methodologies into
all training courses with
associated live projects.




                                                                44
             CRITERIA                        A.                B.              C.         D.
                                         Demonstrable       Minimum        Promotes      Low       TOTAL
                                          Outcomes         Impact on        Clinical   Financial
                                                        Clinicians Time   Engagement    Impact

Set an expectation that all staff             5               1               9           3         18
will „do their job‟ and „improve their
job‟ within their normal remit.

To identify and assess leadership            10               2               6           2         20
development provision available
to different levels of staff in the
organisation.

The Trust Board to set up a                  15               2               6           2         25
„Grand Round‟ to be held once or
more per year, where each
Division can demonstrate its
improvement work and associated
results for shared learning and
understanding.

Training on improvement                      10               2               6           1         19
methodology could be
incorporated into Student
education.




                                                              45
            CRITERIA                      A.                B.              C.         D.
                                      Demonstrable       Minimum        Promotes      Low       TOTAL
                                       Outcomes         Impact on        Clinical   Financial
                                                     Clinicians Time   Engagement    Impact

Students could be considered a             5               2               9           3         19
pair of fresh eyes when coming on
to a unit and asked to consider the
Microsystems they encounter in
terms of the 5 P‟s.

Develop Microsystems work                 15               2               9           2         28

Developing a hypothetical patient         15               3               9           3         30
such as Esther may be something
that clinical staff and nurses in
particular would relate to.

Explore the possibility of                10               3               9           3         25
European or other funding
sources to provide quality
improvement training.

Use boards on walls to allow staff        15               3               9           3         30
or patients to suggest areas for
improvement. Progress on these
also charted and displayed.

The use of mini nursing stations in       15               3               9           3         30
the bays




                                                           46
           CRITERIA                   A.                B.              C.         D.
                                  Demonstrable       Minimum        Promotes      Low       TOTAL
                                   Outcomes         Impact on        Clinical   Financial
                                                 Clinicians Time   Engagement    Impact

Phones answered by non-clinical       15               3               9           3         30
member of the team.




                                                       47

				
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