This document discusses strategies for spreading quality improvement initiatives more widely and rapidly. It introduces AQuA, an organization that supports healthcare improvement in the North West of England. AQuA has developed several programs, including Advancing Quality (AQ), which uses bundled measures and data to drive improvements in key clinical areas. The document also discusses challenges to spreading innovations, drawing lessons from the slow adoption of scurvy treatments. It proposes focusing on engaging innovators, early adopters and using peer-to-peer learning. AQuA's model emphasizes using evidence, incentives and communities of practice to accelerate the spread of improvements. The document raises questions about priorities, engaging champions, and leveraging new contexts to advance the systematic spread of quality

1. Advancing Quality
David Fillingham
7th/8th March 2013
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2. 2

3. “Up and down the country there are brilliant
examples of pioneering work, great ideas and
fantastic improvements in service. But, so
often, these are isolated examples”
Sir David Nicolson, 2011
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4. 4

5. How can we get much better at spreading more widely
and more rapidly and what works?
• Evidence based care bundles
• Technological innovations
• Innovations in service design
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6. • A bit about AQuA
• The problem with Sauerkraut
• Lessons from experience (it’s the people, stupid)
• AQuA’s Model for Spread:
- Advancing Quality
- Discovery Community on Integration
• Some final thoughts and questions
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7. About AQuA
• A membership organisation – funded by 68 CCGs and providers in the
North West of England
• Our mission is to support our members to improve the quality of
healthcare
• All sectors, commissioners and providers – a whole system approach
• Firmly rooted in the North West but beginning to work more widely
• Encouraging radical service transformation
• Fully aligned with the North West’s two proposed Academic Health
Science Networks
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8. Industrial Age Information
Medicine Age Healthcare
• Infectious diseases • Chronic diseases
•Hospitals • Community based Services
predominate • Prevention and self care
• Acute intervention • Integrated delivery network
• Silo working • Smart use of technology
• Paper based • Shared Decision Making
• Doctor knows best
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9. 9

10. And new for 2013/14…
• First Do No Harm… AQuA’s Response to the Francis Report
• “Advancing Innovation” – in conjunction with the AHSNs
• AQuA Academy support for senior leaders and improvement
experts
• A strong focus on the needs of frail older people
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11. The Sauerkraut Problem
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12. How quickly does innovation spread? – the case of
Scurvy amongst Seafarers
1497 Vasco de Gamas voyage around the Cape of Good Hope – 100 of
160 men lost to scurvy
1601 Captain James Lancaster – controlled ‘trial’ with lemon juice
1747 Dr James Lind – confirms citrus as effective
1768-80 Captain James Cook – Sauerkraut as a cure
1865 British Board of Trade mandates a healthy diet on all marine
vessels
Time elapsed from definitive trial to full implementation = 264 years
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13. Some theoretical perspectives…
• Rogers E. – The Diffusion of Innovation, 1995
• IHI White Paper – A framework for Spread , 2006
• USAID Technical Report – Options for large scale spread of simple high impact
interventions, 2010
• Greater Manchester's CLAHRC – Spreading Improvement and Innovation, 2010
• Greenhalgh et al – Diffusion of Innovations in Service Organisations Mill Bank
Quarterly Vol. 82 No. 4, 2004
• Dixon-Woods et al – Quality Improvement Through Clinical Communities, Journal
of Health Organisation and Management, Vol 26, Issue 2, 2012
• Fraser S. – Accelerates the Spread of Good Practice, 2002
• Gladwell M. – The Tipping Point, 2000
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14. 3 interacting factors…
• The innovation itself (“stickiness”)
• The characteristics of the innovators
• The organisational context
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15. Source: Rogers, E.M.
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16. “Sauerkraut, Sobriety and the
Spread of Change”
1. Find sound innovations
2. Find and support innovators
3. Invest in early adopters
4. Make early adopters activity visible
5. Trust and enable re-invention
6. Create slack for change
7. Lead by example
Berwick: Escape Fire
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17. Lessons From Experience
(It’s the people, stupid)
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18. Fillingham’s Motivational Matrix
Positive Enthusiastic Naïve
Outlook on Life
Pragmatist Idealist
Disillusioned Embittered
Negative Sceptic Cynic
High Low
Grip on Reality
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19. Converting the Sceptics
• Tackle stress and burnout – develop resilience
• Make it specific to ‘my’ service
• Use rigorous improvement methods
• Robust and convincing data
• Hands on experience
• Reinforce through changed management system and
leadership style
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20. AQuA’s Model of Spread
Evidence and Intelligence
Change Champions
Robust Improvement Incentives
and Communities of
Methods Practice
Peer to Peer Learning
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21. Advancing Quality - AQ
• Programme established in 2007
• Adapted from Premier’s HQID programme in the US
• Now the dominant Regional CQUINS in the North West
• Has significantly improved reliability of evidence based
processes leading to improved outcomes and
productivity

22. Evidence Based Measures
Acute myocardial infarction (AMI) Community-acquired pneumonia (CAP)
1. Aspirin at arrival 1. Oxygenation assessment within 24 hours
2. Aspirin prescribed at discharge prior to or after hospital arrival
3. ACE or ARB for LVSD 2. Initial antibiotic selection
4. Smoking cessation advice/counseling 3. Blood culture collected prior to first
antibiotic administration
5. Beta blocker at arrival
4. Antibiotic timing, first dose of antibiotics
6. Beta blocker prescribed at discharge within six hours after hospital arrival
7. Thrombolytic received within 30 minutes of 5. Smoking cessation advice/counseling
hospital arrival
8. PCI received within 90 minutes of hospital
arrival
Coronary artery bypass graft (CABG)
1. Aspirin prescribed at discharge
2. Prophylactic antibiotic received within one
Hip and knee replacement hour prior to surgical incision
1. Prophylactic antibiotic received within one 3. Prophylactic antibiotic selection for surgical
hour prior to surgical incision patients
2. Prophylactic antibiotic selection for surgical 4. Prophylactic antibiotics discontinued within
patients 48 hours after surgery end time
3. Prophylactic antibiotics discontinued within
24 hours after surgery end time
4. Recommended Venous Thromboembolism Heart failure (HF)
prophylaxis ordered 1. Left Ventricular Systolic (LVS) assessment
5. Appropriate Venous Thromboembolism 2. Detailed discharge instructions
prophylaxis within 24 hours prior to surgery 3. ACEI or ARB for LVSD
to 24 hours after surgery 4. Smoking cessation advice/counseling

23. Robust data collection
Patient 1 Patient 2 Patient 3 Overall Trust Scores
Measure 1 robust
• Need  data   2 of 3 = 66.6%
Measure identify 
– to 2 opportunities to improve 3 = 100%
  3 of
Measure benchmark
– to 3    1 of 3 = 33.3%
Measure 4    3 of 3 = 100%
• Rules based / algorithmic approach
Measure 5    3 of 3 = 100%
– Identifyingof 5 5 of 5 3 of 5
Opportunities 4 patient cohorts – every
patient
12 of 15
– Data dictionary & reasons for exclusion from a
taken
Composite
measure 80%
Process Score
100% 60% 80%
Patient 0 of 1 1 of 1 0 of 1 1 of 3
• Web based measure data collection
Appropriate Care
(all or nothing)
– Utilise existing data where available
Appropriate Care    33.3% 23
Score

24. A culture of change & collaboration
• Regular collaborative learning events
• Involvement from all provider & commissioner
organisations
• Created networks of clinical and non clinical
communities
• A willingness to share and learn
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25. Incentives
• Additional financial rewards – first 18
months – top performers / top improvers
• Absorbed into CQUIN – regional scheme
(0.01%)
• Benchmarking and friendly
competition
• Public reporting
www.advancingqualitynw.nhs.uk
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26. Marathon Raised the bar
not a sprint! with a new
measure!
Rapid Steady
improvement, New
improvement, condition
sustained sustained

27. Reducing
variation
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29. Outcomes & cost
effectiveness
• Overall (3 conditions) statistically significant reductions
in mortality & LoS
• NW mortality gain greater than rest of England
– >1% point reduction in mortality rate (>5% relative
rate) = c890 deaths averted.
• >20,000 hospital days saved (~£5m)
• >6000 QALYs gained as result of mortality reductions
– based on healthy life expectancy of people in general population of
same age as the patient population.
– Health gain of c£120m (£20k threshold, c£180m @ £30k)
– 10 times more cost effective than break-even point

30. AQuA Discovery Community on Integration
• We don’t have one accepted “right” model we can copy
• We don’t even have a single definition of integration
• The aim is to:
-Steal with pride from elsewhere (creatively adapting)
- Stimulate invention
- Accelerate progress by mutual sharing and learning
• 8 Health Economies in cohort 1; 11 more in cohort 2
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31. Discovery Community Model
Learning from each
other
Emerging national
Faculty input Your policy context
Learning
National and
international case
studies
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32. The Framework
Service
Design Workforce
Leadership • Role design
• Skills
• Capacity
Integration to Improve
• Safety
Patient and
Carer
• Effectiveness Healthcare Infrastructure
• Population health value and IT
Engagement
• Use of resources
Financial and
Contractual
Governance mechanisms
Culture
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34. Richard Gleave
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35. AQuA’s Model of Spread
Evidence and Intelligence
Change Champions
Robust Improvement Incentives
and Communities of
Methods Practice
Peer to Peer Learning
AWR
“Accelerated Wheel Reinvention”
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36. A new ‘Context’ for Improvement and Spread
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37. Some Final Thoughts and Questions…
• What are the most important priorities for spread?
• Do we have enough “enthusiastic pragmatists”?
• Is it “hit and hope” or do we have an aligned, systematic
approach?
• How can we use the new improvement “context” to our
advantage?
• How we can counter pessimism and setbacks with resilience,
energy and hope?
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