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QUALITY IMPROVEMENT
Improving care for the deteriorating child Alice Roueché,1 Jane Runnacles2 1
Department of Paediatrics, Royal Alexandra Children’s Hospital, Brighton, UK 2 Department of Paediatrics, Royal Free Hospital, London, UK Correspondence to Dr Jane Runnacles, Department of Paediatrics, Royal Free Hospital, Pond St, London, NW3 2QG, UK; [email protected] Received 20 September 2013 Accepted 7 October 2013 Published Online First 12 November 2013
To cite: Roueché A, Runnacles J. Arch Dis Child Educ Pract Ed 2014;99: 61–66.
INTRODUCTION To deliver safe care for children we need to be able to correctly identify clinical deterioration and appropriately respond to it. The evidence suggests we do not do this consistently and this should be a prime focus for improvement efforts. Yet, the systems in which we work are complex and change is often daunting. In this article we will look at how a quality improvement approach, using wellestablished methodologies, can be used to try to address a problem such as identifying the deteriorating child. It will look at large- and small-scale examples and will explore some of the approaches that can make a challenging task into a measurable improvement in care for children and young people (boxes 1 and 2).
SETTING THE SCENE Despite significant advances in medical science, children are still dying in hospitals with an even greater number suffering some form of harm.1 Harm may be defined as ‘Anything that one would not like to happen to oneself, one’s own child or a member of one’s family’.2 All children should be entitled to high quality healthcare, which, by definition, includes care that is safe and free from harm. Paediatric patient safety should therefore be at the forefront of everything we do and an important focus for improvement of work in our departments. Paediatric patient safety is an international issue. Recent publications from both the USA and Canada support the need for intervention to protect children from healthcare related harm.3 4 Only 10%–20% of medical errors are reported using voluntary reporting systems.5 However, using more robust systems such as the paediatric trigger tool, harm rates of up to 30% have been
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
detected.6 The trigger tool is a structured case note review by medical and nursing teams on a regular basis to help identify unintended harm within a service. It is crucial that our paediatric patients are prospectively protected against harm. This requires active prediction of what can go wrong before it does, and learning from harm when harm occurs. In 2006, the UK government report ‘Why Children Die’ found preventable factors in 26% of reviewed cases, predominantly related to recognition of the deteriorating child and poor communication.7 An NPSA review in the UK also identified difficulty in recognising deterioration as a key safety issue, as well as a high rate of reported medication errors.8 Many of the challenges we face in detecting deterioration are because ‘children are not little adults’; their vital signs, for example, are age and weight dependent as they move through different physiological stages, and they can deteriorate rapidly after a period of unrecognised compensated shock.9 Evidence has shown that children who have died showed signs of physiological or behavioural disturbance in the period prior to collapse. Recognition of the deteriorating child is therefore an important area for improvement relevant to all aspects of paediatrics and primary care. It is everyone’s responsibility to ensure children reliably receive consistently safe and effective assessments and interventions to avoid preventable deaths in hospital. AIM HIGH! SETTING AN AIM Moving from a great idea about improving care to a practical project and, ultimately, a measurable improvement is a real challenge. Many of the good ideas discussed at the end of a meeting or over coffee are never put into practice because the enormity of the change
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Quality improvement seems insurmountable. Beckhard’s change equation can help to express this: DVFR where D=Dissatisfaction with how things are now; V=Vision of what is possible; F=First, concrete steps that can be taken towards the vision; and R=Resistance to change.10 There will always be resistance to change but without a clear vision and some concrete steps to change, mere dissatisfaction will never be enough to overcome this. In the USA, The Institute for Healthcare Improvement has proposed an approach to change called the Model for Improvement.11 The first question asked is ‘What are we trying to accomplish?’ (figure 1). Setting a clear aim is part of communicating the vision for the change and is crucial to the success of the project. Therefore, a SMART approach may be helpful. This means ensuring that the aim is specific, measurable (how will we know that a change is an improvement?), achievable, relevant and time bound (see table 1). An example of a SMART aim is: ‘To reduce respiratory and/or cardiac arrests on all children’s wards (excluding ICU) at our hospital by 50% by end of December 2013’. There are clearly many factors that
Figure 1 Model for improvement (Adapted from the Institute for Healthcare Improvement11).
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Box 1 Quality improvement (QI) in practice: identifying the deteriorating child ▸ From the driver diagram in figure 2, we can see that there are multiple factors involved in reducing inpatient cardiorespiratory arrest. One important area to look at is the use of early warning scores to identify deterioration. ▸ One of the UK CEMACH recommendations for hospital paediatric care was a ‘standardised and rational monitoring system with embedded early identification systems for children developing critical illness’.7 The exact nature of the chart used should depend on local context but it is clear that a means of documenting and flagging up signs of clinical deterioration is important. ▸ In order to introduce a PEWS (Paediatric Early Warning Score) chart, a QI approach, using plan-so-study-act (PDSA) cycles, can be helpful: – Plan: Meet with colleagues and brainstorm ideas for implementing PEWS on your ward. Choose an idea that the team can support, for example, trialling a new observations chart. – Do: Trial chart for 10 patients. – Study: Look at chart completion rates and get feedback from nurses about ease of use, look at clinical outcomes, for example, escalation to medical team or paediatric intensive care unit (PICU) referrals. – Act: Ensure staff have access to results of the study phase. Consider next steps, for example, further training for nursing staff, redesign of charts if needed, posters and staff awareness activities. Each of these could form a new PDSA cycle. ▸ Despite the recommendations, use of PEWS charts is as low as 24% across UK hospitals.13 The validity and impact of early warning scores is difficult to show due to confounding factors such as rising standards of care and medical emergency response teams. Staff engagement is particularly important for interventions involving the deteriorating child as early warning systems are everyone’s concern. However good the nursing staff maybe at completing an early warning score, if the doctors do not believe they are valuable, information will not cascade. It may be important to measure the improvement in early detection of deterioration to demonstrate its value. ▸ Early warning scores may facilitate escalation of concerns to senior colleagues. Tibballs14 reviewed systems to prevent in-hospital arrest and found that the key feature is empowerment of any staff, however junior, and parents to summon help without deferring to senior colleagues or medical staff. Therefore, early warning scores should improve the response to the deteriorating child by empowering staff to speak up.
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Quality improvement Box 2 Quality improvement (QI) in practice: seeing things through families’ eyes Whenever a paediatric round starts, family members sit at the bedside of their children. They notice when things are not going according to plan and worry about complications that may potentially harm their children. We know that mistakes happen everywhere and a recent North American report suggests that 25.8% of children experience some sort of adverse events in hospital.6 Current under-reporting of adverse events leads to lost learning opportunities and may compromise patient safety. As part of the Deteriorating Child Project at Great Ormond Street Hospital for Children, London, UK (in cooperation with the BC Children’s Hospital in Canada), a project has started to improve the identification of previously unrecognised adverse events using electronic family reporting tools.15 16 PDSA cycles allow systematic and rapid tracking of change. To sustain improvement efforts, the strategy has been limited to a single ward at the time of discharge from hospital before spreading the idea to other wards or implementing real-time reporting systems. This gives clinical staff and families the chance to actively engage in the process and take personal ownership. Listening to safety concerns raised by families should lead to new improvement opportunities, enrich personal development of healthcare professionals and ultimately embrace patients as equal partners in care. PDSA, plan-do-study-act.
need to be considered in this very broad statement, and at first it may seem rather daunting, so it is important to break the problem down and decide which factor(s) you can address. Table 1 Specific
BREAKING THE PROBLEM DOWN The Model for Improvement asks: ‘What changes can we make that will result in an improvement?’ A driver diagram can be a helpful way of identifying potential areas for change by breaking down a large problem into manageable tasks. It looks at what you hope to achieve and then the different factors involved in getting there. Driver diagrams are a structured logic chart describing a theory of change. They may include the following levels: Level 1: Your ‘SMART’ aim or goal. Level 2: ‘Primary drivers’—what needs to be done to achieve the aim. Level 3: ‘Secondary drivers’—specific projects and activities that enable the primary drivers to happen. More complex goals may have more levels or ‘drivers’.
An example of a driver diagram for a deteriorating child project is shown in figure 2. It demonstrates how a complex and seemingly unachievable aim can be broken down into more manageable projects. Where possible, the drivers in a driver diagram should be made measurable so that a driver diagram can become a measurement framework for tracking progress. It is also useful as a communication tool for explaining a strategy for change. A team approach is important to ensure all factors are considered, allowing a shared mental model of the situation, and to encourage stakeholder engagement. The whole process of change may take some time but it is possible to break down the secondary drivers even further. A doctor in training, with the support of the supervising physician and nursing staff, could choose to engage in an awareness campaign of observations on children. The measurement could be ensuring 95% of observations are completed on all patients and the trainee could use
SMART aim Well-defined and clear aim
▸ What is the context and the target population? ▸ What is the improvement activity?
Measurable Include the benchmark and target for your objective (eg, improve from ×% to 100%) ▸ How much change are you expecting to see?
▸ How can you measure it? ▸ Will there be an increase or decrease? Achievable
Aim is something that can actually be reached
Relevant
Aim is relevant to your department or organisation’s objectives and vision, and agreed ▸ Does the activity relate to what you want to upon by stakeholders
▸ Can it be done? Is it realistic? ▸ Can it be accomplished in your time frame? ▸ Do you have the necessary resources? accomplish? ▸ Is it important and meaningful? ▸ Does it relate to broader organisational goals?
Time bound
Aim has a set time frame to be met
▸ What is the timeline for change? ▸ When will this be accomplished (days, weeks or months)?
Adapted from Minnesota Department of Health.17
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Quality improvement
Figure 2 Driver diagram for reducing cardiac arrests (adapted from Great Ormond Street Hospital, London, 2012/3). *SBAR communication tool is used to structure a conversation, especially a critical one, requiring a clinician’s immediate attention. SBAR, situation, background, assessment and recommendation.
a variety of implementation strategies. For example, reviews on ward rounds, requests for observations at handover, celebrating compliance with rewards or by displaying achievements. This is something that can be achieved during a typical paediatric attachment. GETTING PEOPLE ON BOARD At the heart of any sustainable change is the need to engage all the people involved. Anyone who has ever tried to effect any change in healthcare will be all too aware of this. Even the simplest change will elicit a wide range of responses. ‘We’ve tried this before’, ‘This isn’t your role’ and ‘Why don’t we do this instead’ are all common refrains. Taking time to
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engage each and every person who may be involved in or affected by your changes is vital. Communicating the need for change, canvassing for suggestions, pre-empting conflict and thinking about unintended consequences should be a key part of any change strategy. A multi-professional approach is always required and the local context must be taken into account. A driver diagram may have identified areas for change across many different clinical areas and roles. A doctor leading alone on a change in nursing practice (such as PEWS recording) is unlikely to be successful, just as a nurse-led change in junior doctor handover will need a very careful approach (see box 3 for resources around stakeholder engagement).
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Quality improvement Table 2
Overcoming barriers and key learning points
Barrier
Learning point
Unrealistic project
Ensure individual aims are achievable within a time frame (SMART approach) Resistance from colleagues Stakeholder engagement is crucial, make this a trust priority. Use data and patient stories to win hearts and minds, use patient feedback and serious untoward incidents to make the chief executive listen, and enlist ‘early adopters’ Measurement does not Valuable learning, think about why. May show improvement need to try another approach. Fundamental to the concept of PDSA—‘testing’ change Do not know where to Start small and try for easy wins to get begin people interested PDSA, plan-do-study-act; SMART, specific, measurable, achievable, relevant and time bound.
SMALL-SCALE CHANGE You have identified a problem, you have set an aim, you have got the clinical and non-clinical teams on board and you have identified areas for change and what to measure. What next? Learning from experience is the basis of quality improvement; failed changes are as important as successful changes as long as we study to understand why the change was unsuccessful. Using the Model for Improvement, small tests of change can be carried out through plan-do-study-act (PDSA) cycles. Using this approach, a theory or ‘hunch’ can be tested out safely and, if successful, that change can then be scaled up (figure 3). PDSA is simply a structured approach to planning a change, trying it out (usually on a small, easily accessible sample), establishing whether that change was successful and then acting accordingly. The same steps are seen in Kolb’s Cycle of Experiential Learning,12 which is what makes PDSA such a powerful tool. To study the effect of change, effective measurement is vital. Outcome measures, process measures and balancing measures (unintended consequences elsewhere in the system) can all be looked at—the exact nature of the data collected will depend on the process being
Figure 3 Using multiple plan-do-study-act (PDSA) cycles to test out small changes (Adapted from Langley et al IHI11).
Box 3 Further reading and resources ▸ Stakeholder mapping – http://www.kidneycare.nhs.uk/howto_guides1/ stakeholder_mapping_and_engagement/ – http://www.institute.nhs.uk/quality_and_service_ improvement_tools/quality_and_service_ improvement_tools/stakeholder_analysis.htmlin ▸ Driver diagrams – http://www.institute.nhs.uk/quality_and_service_ improvement_tools/quality_and_service_ improvement_tools/driver_diagrams.html – http://www.scottishpatientsafetyprogramme.scot. nhs.uk/programme/toolkit/patient-safety-tools/ spsp-driver-diagrams-and-change-packages ▸ Data collection and measurement – http://www.qihub.scot.nhs.uk/knowledge-centre/ quality-improvement-topics/ measurement-for-improvement.aspx – http://www.institute.nhs.uk/quality_and_service_ improvement_tools/quality_and_service_ improvement_tools/statistical_process_control.html
studied. Each PDSA cycle needs to collect ‘just enough’ data to establish whether the change was effective and worth trying on a larger scale. If the data are collected and recorded continuously as different cycles are performed, improvement (if present) can be demonstrated clearly. Run charts are a very helpful tool that can be used to plot data over time and help communicate the outcome of changes to the whole team. More information about data collection and measurement can be found in box 3. Table 2 outlines potential barriers to quality improvement and how these may be overcome. CONCLUSIONS We are increasingly aware that children and young people are experiencing harm in healthcare settings and that we are missing preventable causes of death. The extent of the problem is shocking to any clinician (and indeed any parent) and calls for urgent intervention on the part of all healthcare workers to make improvements for the better. Improving recognition of the deteriorating child is one such way to reduce preventable deaths, yet the factors involved are multiple and complex. The Model for Improvement is a useful approach to tackling a large project such as this. It can help to ensure that a clear aim is identified and ideas for improvement tested on a small scale with measurement of data to demonstrate change. We are all too aware of the problems within the healthcare that we provide but may not feel empowered or informed enough to address them. A structured approach such as the Model for Improvement can be used to help
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Quality improvement really understand the problem and start to put improvement strategies into action. PDSA cycles, driver diagrams and stakeholder engagement are all strategies that can be employed. In this article, we have shown examples of these methods and have given links to relevant resources. We hope that readers will see that implementing and improving any of the primary and secondary drivers mentioned in figure 2 could start to be put into motion tomorrow with these approaches. Clinicians of any grade or background can be at the forefront of planning and driving change and we hope that this will inspire other clinicians to take a lead in improving care for children and young people. Acknowledgements We thank Damian Roland for sharing his expertise and advising on the content of this article. Thank you to Henning Clausen, Peter Lachman and the Quality, Safety and Transformation team at Great Ormond Street hospital for providing the information on the improvement project mentioned in box 2.
4
5
6
7
8
9
10
Contributors This article was commissioned as part of the ADC Equipped series. AR and JR worked closely together on the planning, design, drafting and final approval of this article.
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Funding The authors did not receive any funding for this work. The quality improvement project outlined in box 2 is supported by The Health Foundation’s SHINE programme (UK charity number: 286967).
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Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
13 14 15
REFERENCES 1 Pearson GA, Ward-Platt M, Harnden A, et al. Why children die: avoidable factors associated with child deaths. Arch Dis in Child 2011;96:927–31. 2 NHS Institute for Innovation and Improvement. Paediatric trigger tool. http://www.institute.nhs.uk/safer_care/paediatric_ safer_care/the_paediatric_trigger_tool.html (accessed Feb 2013). 3 Steering Committee on Quality Improvement and Management and Committee on Hospital Care. Principles of pediatric
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patient safety: reducing harm due to medical care. Pediatrics 2011;127:1199. Matlow AG, Baker GR, Flintoft V, et al. Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study. CMAJ 2012;184:E709–18. Sari A, Sheldon TA, Cracknell A, et al. Sensitivity of routine system for reporting safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;334:79. Kirkendall ES, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Pediatrics 2012;130:e1206–14. Pearson G. Why Children die: a pilot Study, England (South West, North East and West midlands), Wales and Northern Ireland. London: CEMACH, 2006. National Patient Safety Agency. Review of patient safety for children and young people. London: NPSA, 2009. http://www. nrls.npsa.nhs.uk/resources/?entryid45=59864 Tume L, Bullock I. Early warning tools to identify children at risk of deterioration: a discussion. Paediatr Nurs 2004; 16:8. Beckhard R. Organization development: strategies and models. Reading, MA: Addison-Wesley, 1969. Langley GL, Nolan KM, Nolan TW, et al. The improvement guide: a practical approach to enhancing organizational performance. 2nd edn. San Francisco: Jossey-Bass Publishers, 2009. Kolb DA. Experiential Learning experience as a source of learning and development. New Jersey: Prentice Hall, 1984. Roland D. Paediatric early warning scores: holy Grail and Achilles’ heel. Arch Dis Child Educ Pract Ed 2012;97:208–15. Tibballs J. Systems to prevent in-hospital cardiac arrest. Paediatr Child Health 2011;21:322–8. Daniels JP, Hunc K, Cochrane DD, et al. Identification by families of pediatric adverse events and near misses overlooked by health care providers. CMAJ 2012;184:29–34. Daniels JP, King AD, Cochrane DD, et al. A human factors and survey methodology-based design of a web-based adverse event reporting system for families. Int J Med Inform 2010;79:339–48. Minnesota Department of Health. Developing a SMART Aim Statement. October 2012. http://www.health.state.mn.us/divs/ cfh/ophp/consultation/qi/resources/toolbox/smartobjectives.html (accessed 21 Mar 2013).
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Improving care for the deteriorating child Alice Roueché and Jane Runnacles Arch Dis Child Educ Pract Ed 2014 99: 61-66 originally published online November 12, 2013
doi: 10.1136/archdischild-2013-304326 Updated information and services can be found at: http://ep.bmj.com/content/99/2/61
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QUALITY IMPROVEMENT
Improving care for the deteriorating child Alice Roueché,1 Jane Runnacles2 1
Department of Paediatrics, Royal Alexandra Children’s Hospital, Brighton, UK 2 Department of Paediatrics, Royal Free Hospital, London, UK Correspondence to Dr Jane Runnacles, Department of Paediatrics, Royal Free Hospital, Pond St, London, NW3 2QG, UK; [email protected] Received 20 September 2013 Accepted 7 October 2013 Published Online First 12 November 2013
To cite: Roueché A, Runnacles J. Arch Dis Child Educ Pract Ed 2014;99: 61–66.
INTRODUCTION To deliver safe care for children we need to be able to correctly identify clinical deterioration and appropriately respond to it. The evidence suggests we do not do this consistently and this should be a prime focus for improvement efforts. Yet, the systems in which we work are complex and change is often daunting. In this article we will look at how a quality improvement approach, using wellestablished methodologies, can be used to try to address a problem such as identifying the deteriorating child. It will look at large- and small-scale examples and will explore some of the approaches that can make a challenging task into a measurable improvement in care for children and young people (boxes 1 and 2).
SETTING THE SCENE Despite significant advances in medical science, children are still dying in hospitals with an even greater number suffering some form of harm.1 Harm may be defined as ‘Anything that one would not like to happen to oneself, one’s own child or a member of one’s family’.2 All children should be entitled to high quality healthcare, which, by definition, includes care that is safe and free from harm. Paediatric patient safety should therefore be at the forefront of everything we do and an important focus for improvement of work in our departments. Paediatric patient safety is an international issue. Recent publications from both the USA and Canada support the need for intervention to protect children from healthcare related harm.3 4 Only 10%–20% of medical errors are reported using voluntary reporting systems.5 However, using more robust systems such as the paediatric trigger tool, harm rates of up to 30% have been
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
detected.6 The trigger tool is a structured case note review by medical and nursing teams on a regular basis to help identify unintended harm within a service. It is crucial that our paediatric patients are prospectively protected against harm. This requires active prediction of what can go wrong before it does, and learning from harm when harm occurs. In 2006, the UK government report ‘Why Children Die’ found preventable factors in 26% of reviewed cases, predominantly related to recognition of the deteriorating child and poor communication.7 An NPSA review in the UK also identified difficulty in recognising deterioration as a key safety issue, as well as a high rate of reported medication errors.8 Many of the challenges we face in detecting deterioration are because ‘children are not little adults’; their vital signs, for example, are age and weight dependent as they move through different physiological stages, and they can deteriorate rapidly after a period of unrecognised compensated shock.9 Evidence has shown that children who have died showed signs of physiological or behavioural disturbance in the period prior to collapse. Recognition of the deteriorating child is therefore an important area for improvement relevant to all aspects of paediatrics and primary care. It is everyone’s responsibility to ensure children reliably receive consistently safe and effective assessments and interventions to avoid preventable deaths in hospital. AIM HIGH! SETTING AN AIM Moving from a great idea about improving care to a practical project and, ultimately, a measurable improvement is a real challenge. Many of the good ideas discussed at the end of a meeting or over coffee are never put into practice because the enormity of the change
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Quality improvement seems insurmountable. Beckhard’s change equation can help to express this: DVFR where D=Dissatisfaction with how things are now; V=Vision of what is possible; F=First, concrete steps that can be taken towards the vision; and R=Resistance to change.10 There will always be resistance to change but without a clear vision and some concrete steps to change, mere dissatisfaction will never be enough to overcome this. In the USA, The Institute for Healthcare Improvement has proposed an approach to change called the Model for Improvement.11 The first question asked is ‘What are we trying to accomplish?’ (figure 1). Setting a clear aim is part of communicating the vision for the change and is crucial to the success of the project. Therefore, a SMART approach may be helpful. This means ensuring that the aim is specific, measurable (how will we know that a change is an improvement?), achievable, relevant and time bound (see table 1). An example of a SMART aim is: ‘To reduce respiratory and/or cardiac arrests on all children’s wards (excluding ICU) at our hospital by 50% by end of December 2013’. There are clearly many factors that
Figure 1 Model for improvement (Adapted from the Institute for Healthcare Improvement11).
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Box 1 Quality improvement (QI) in practice: identifying the deteriorating child ▸ From the driver diagram in figure 2, we can see that there are multiple factors involved in reducing inpatient cardiorespiratory arrest. One important area to look at is the use of early warning scores to identify deterioration. ▸ One of the UK CEMACH recommendations for hospital paediatric care was a ‘standardised and rational monitoring system with embedded early identification systems for children developing critical illness’.7 The exact nature of the chart used should depend on local context but it is clear that a means of documenting and flagging up signs of clinical deterioration is important. ▸ In order to introduce a PEWS (Paediatric Early Warning Score) chart, a QI approach, using plan-so-study-act (PDSA) cycles, can be helpful: – Plan: Meet with colleagues and brainstorm ideas for implementing PEWS on your ward. Choose an idea that the team can support, for example, trialling a new observations chart. – Do: Trial chart for 10 patients. – Study: Look at chart completion rates and get feedback from nurses about ease of use, look at clinical outcomes, for example, escalation to medical team or paediatric intensive care unit (PICU) referrals. – Act: Ensure staff have access to results of the study phase. Consider next steps, for example, further training for nursing staff, redesign of charts if needed, posters and staff awareness activities. Each of these could form a new PDSA cycle. ▸ Despite the recommendations, use of PEWS charts is as low as 24% across UK hospitals.13 The validity and impact of early warning scores is difficult to show due to confounding factors such as rising standards of care and medical emergency response teams. Staff engagement is particularly important for interventions involving the deteriorating child as early warning systems are everyone’s concern. However good the nursing staff maybe at completing an early warning score, if the doctors do not believe they are valuable, information will not cascade. It may be important to measure the improvement in early detection of deterioration to demonstrate its value. ▸ Early warning scores may facilitate escalation of concerns to senior colleagues. Tibballs14 reviewed systems to prevent in-hospital arrest and found that the key feature is empowerment of any staff, however junior, and parents to summon help without deferring to senior colleagues or medical staff. Therefore, early warning scores should improve the response to the deteriorating child by empowering staff to speak up.
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
Downloaded from http://ep.bmj.com/ on June 16, 2015 - Published by group.bmj.com
Quality improvement Box 2 Quality improvement (QI) in practice: seeing things through families’ eyes Whenever a paediatric round starts, family members sit at the bedside of their children. They notice when things are not going according to plan and worry about complications that may potentially harm their children. We know that mistakes happen everywhere and a recent North American report suggests that 25.8% of children experience some sort of adverse events in hospital.6 Current under-reporting of adverse events leads to lost learning opportunities and may compromise patient safety. As part of the Deteriorating Child Project at Great Ormond Street Hospital for Children, London, UK (in cooperation with the BC Children’s Hospital in Canada), a project has started to improve the identification of previously unrecognised adverse events using electronic family reporting tools.15 16 PDSA cycles allow systematic and rapid tracking of change. To sustain improvement efforts, the strategy has been limited to a single ward at the time of discharge from hospital before spreading the idea to other wards or implementing real-time reporting systems. This gives clinical staff and families the chance to actively engage in the process and take personal ownership. Listening to safety concerns raised by families should lead to new improvement opportunities, enrich personal development of healthcare professionals and ultimately embrace patients as equal partners in care. PDSA, plan-do-study-act.
need to be considered in this very broad statement, and at first it may seem rather daunting, so it is important to break the problem down and decide which factor(s) you can address. Table 1 Specific
BREAKING THE PROBLEM DOWN The Model for Improvement asks: ‘What changes can we make that will result in an improvement?’ A driver diagram can be a helpful way of identifying potential areas for change by breaking down a large problem into manageable tasks. It looks at what you hope to achieve and then the different factors involved in getting there. Driver diagrams are a structured logic chart describing a theory of change. They may include the following levels: Level 1: Your ‘SMART’ aim or goal. Level 2: ‘Primary drivers’—what needs to be done to achieve the aim. Level 3: ‘Secondary drivers’—specific projects and activities that enable the primary drivers to happen. More complex goals may have more levels or ‘drivers’.
An example of a driver diagram for a deteriorating child project is shown in figure 2. It demonstrates how a complex and seemingly unachievable aim can be broken down into more manageable projects. Where possible, the drivers in a driver diagram should be made measurable so that a driver diagram can become a measurement framework for tracking progress. It is also useful as a communication tool for explaining a strategy for change. A team approach is important to ensure all factors are considered, allowing a shared mental model of the situation, and to encourage stakeholder engagement. The whole process of change may take some time but it is possible to break down the secondary drivers even further. A doctor in training, with the support of the supervising physician and nursing staff, could choose to engage in an awareness campaign of observations on children. The measurement could be ensuring 95% of observations are completed on all patients and the trainee could use
SMART aim Well-defined and clear aim
▸ What is the context and the target population? ▸ What is the improvement activity?
Measurable Include the benchmark and target for your objective (eg, improve from ×% to 100%) ▸ How much change are you expecting to see?
▸ How can you measure it? ▸ Will there be an increase or decrease? Achievable
Aim is something that can actually be reached
Relevant
Aim is relevant to your department or organisation’s objectives and vision, and agreed ▸ Does the activity relate to what you want to upon by stakeholders
▸ Can it be done? Is it realistic? ▸ Can it be accomplished in your time frame? ▸ Do you have the necessary resources? accomplish? ▸ Is it important and meaningful? ▸ Does it relate to broader organisational goals?
Time bound
Aim has a set time frame to be met
▸ What is the timeline for change? ▸ When will this be accomplished (days, weeks or months)?
Adapted from Minnesota Department of Health.17
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Quality improvement
Figure 2 Driver diagram for reducing cardiac arrests (adapted from Great Ormond Street Hospital, London, 2012/3). *SBAR communication tool is used to structure a conversation, especially a critical one, requiring a clinician’s immediate attention. SBAR, situation, background, assessment and recommendation.
a variety of implementation strategies. For example, reviews on ward rounds, requests for observations at handover, celebrating compliance with rewards or by displaying achievements. This is something that can be achieved during a typical paediatric attachment. GETTING PEOPLE ON BOARD At the heart of any sustainable change is the need to engage all the people involved. Anyone who has ever tried to effect any change in healthcare will be all too aware of this. Even the simplest change will elicit a wide range of responses. ‘We’ve tried this before’, ‘This isn’t your role’ and ‘Why don’t we do this instead’ are all common refrains. Taking time to
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engage each and every person who may be involved in or affected by your changes is vital. Communicating the need for change, canvassing for suggestions, pre-empting conflict and thinking about unintended consequences should be a key part of any change strategy. A multi-professional approach is always required and the local context must be taken into account. A driver diagram may have identified areas for change across many different clinical areas and roles. A doctor leading alone on a change in nursing practice (such as PEWS recording) is unlikely to be successful, just as a nurse-led change in junior doctor handover will need a very careful approach (see box 3 for resources around stakeholder engagement).
Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Quality improvement Table 2
Overcoming barriers and key learning points
Barrier
Learning point
Unrealistic project
Ensure individual aims are achievable within a time frame (SMART approach) Resistance from colleagues Stakeholder engagement is crucial, make this a trust priority. Use data and patient stories to win hearts and minds, use patient feedback and serious untoward incidents to make the chief executive listen, and enlist ‘early adopters’ Measurement does not Valuable learning, think about why. May show improvement need to try another approach. Fundamental to the concept of PDSA—‘testing’ change Do not know where to Start small and try for easy wins to get begin people interested PDSA, plan-do-study-act; SMART, specific, measurable, achievable, relevant and time bound.
SMALL-SCALE CHANGE You have identified a problem, you have set an aim, you have got the clinical and non-clinical teams on board and you have identified areas for change and what to measure. What next? Learning from experience is the basis of quality improvement; failed changes are as important as successful changes as long as we study to understand why the change was unsuccessful. Using the Model for Improvement, small tests of change can be carried out through plan-do-study-act (PDSA) cycles. Using this approach, a theory or ‘hunch’ can be tested out safely and, if successful, that change can then be scaled up (figure 3). PDSA is simply a structured approach to planning a change, trying it out (usually on a small, easily accessible sample), establishing whether that change was successful and then acting accordingly. The same steps are seen in Kolb’s Cycle of Experiential Learning,12 which is what makes PDSA such a powerful tool. To study the effect of change, effective measurement is vital. Outcome measures, process measures and balancing measures (unintended consequences elsewhere in the system) can all be looked at—the exact nature of the data collected will depend on the process being
Figure 3 Using multiple plan-do-study-act (PDSA) cycles to test out small changes (Adapted from Langley et al IHI11).
Box 3 Further reading and resources ▸ Stakeholder mapping – http://www.kidneycare.nhs.uk/howto_guides1/ stakeholder_mapping_and_engagement/ – http://www.institute.nhs.uk/quality_and_service_ improvement_tools/quality_and_service_ improvement_tools/stakeholder_analysis.htmlin ▸ Driver diagrams – http://www.institute.nhs.uk/quality_and_service_ improvement_tools/quality_and_service_ improvement_tools/driver_diagrams.html – http://www.scottishpatientsafetyprogramme.scot. nhs.uk/programme/toolkit/patient-safety-tools/ spsp-driver-diagrams-and-change-packages ▸ Data collection and measurement – http://www.qihub.scot.nhs.uk/knowledge-centre/ quality-improvement-topics/ measurement-for-improvement.aspx – http://www.institute.nhs.uk/quality_and_service_ improvement_tools/quality_and_service_ improvement_tools/statistical_process_control.html
studied. Each PDSA cycle needs to collect ‘just enough’ data to establish whether the change was effective and worth trying on a larger scale. If the data are collected and recorded continuously as different cycles are performed, improvement (if present) can be demonstrated clearly. Run charts are a very helpful tool that can be used to plot data over time and help communicate the outcome of changes to the whole team. More information about data collection and measurement can be found in box 3. Table 2 outlines potential barriers to quality improvement and how these may be overcome. CONCLUSIONS We are increasingly aware that children and young people are experiencing harm in healthcare settings and that we are missing preventable causes of death. The extent of the problem is shocking to any clinician (and indeed any parent) and calls for urgent intervention on the part of all healthcare workers to make improvements for the better. Improving recognition of the deteriorating child is one such way to reduce preventable deaths, yet the factors involved are multiple and complex. The Model for Improvement is a useful approach to tackling a large project such as this. It can help to ensure that a clear aim is identified and ideas for improvement tested on a small scale with measurement of data to demonstrate change. We are all too aware of the problems within the healthcare that we provide but may not feel empowered or informed enough to address them. A structured approach such as the Model for Improvement can be used to help
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Quality improvement really understand the problem and start to put improvement strategies into action. PDSA cycles, driver diagrams and stakeholder engagement are all strategies that can be employed. In this article, we have shown examples of these methods and have given links to relevant resources. We hope that readers will see that implementing and improving any of the primary and secondary drivers mentioned in figure 2 could start to be put into motion tomorrow with these approaches. Clinicians of any grade or background can be at the forefront of planning and driving change and we hope that this will inspire other clinicians to take a lead in improving care for children and young people. Acknowledgements We thank Damian Roland for sharing his expertise and advising on the content of this article. Thank you to Henning Clausen, Peter Lachman and the Quality, Safety and Transformation team at Great Ormond Street hospital for providing the information on the improvement project mentioned in box 2.
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Contributors This article was commissioned as part of the ADC Equipped series. AR and JR worked closely together on the planning, design, drafting and final approval of this article.
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Funding The authors did not receive any funding for this work. The quality improvement project outlined in box 2 is supported by The Health Foundation’s SHINE programme (UK charity number: 286967).
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Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
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REFERENCES 1 Pearson GA, Ward-Platt M, Harnden A, et al. Why children die: avoidable factors associated with child deaths. Arch Dis in Child 2011;96:927–31. 2 NHS Institute for Innovation and Improvement. Paediatric trigger tool. http://www.institute.nhs.uk/safer_care/paediatric_ safer_care/the_paediatric_trigger_tool.html (accessed Feb 2013). 3 Steering Committee on Quality Improvement and Management and Committee on Hospital Care. Principles of pediatric
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Roueché A, et al. Arch Dis Child Educ Pract Ed 2014;99:61–66. doi:10.1136/archdischild-2013-304326
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Improving care for the deteriorating child Alice Roueché and Jane Runnacles Arch Dis Child Educ Pract Ed 2014 99: 61-66 originally published online November 12, 2013
doi: 10.1136/archdischild-2013-304326 Updated information and services can be found at: http://ep.bmj.com/content/99/2/61
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