The Quality MK story
A whole system approach to quality improvement
In 2006, Milton Keynes PCT joined with health:mk (the Milton Keynes practice-based commissioning collaborative), the Joint PPI (LINk:MK) and the Centre for Evidence-Based Medicine, University of Oxford, to respond to a call for proposals from The Health Foundation around Engaging with Quality in Primary Care.
The bid was selected from among 170 applicants to benefit from funding from The Foundation over three years, 2007-10. The programme quickly became known as ’Quality:MK’ and much of the work and learning had been around getting research into practice, stakeholder engagement and developing system and process to achieve quality improvement.
Our mantra: three values
Recognising the challenge of implementing and spreading quality improvement initiatives across the system, the programme aimed to improve patient outcomes by shaping a whole system approach to quality improvement, making a reality of three widely used slogans:
- Public and patient engagement - meaningful channels of communication and interaction
- Evidence-based decision making – in general practice, in commissioning
- Primary care led – clinical engagement; clinical leadership
It aimed to contribute to health improvement by empowering colleagues to apply these principles, building capability, enabling access to the knowledge base and putting in place efficient processes to drive quality improvements across the system, in a coordinated way.
Sue Lacey-Bryant, Programme Manager, Quality:MK, June 2010
The programme
In 2007 the steering group deliberately took an ambitious approach, with multiple projects and work-streams - a mix of innovation driven from the coal-face of primary care, initiatives drilling down from the top, and enabling work to underpin the two. This allowed Quality:MK to observe progress, behaviours and hurdles across multiple projects.
Using a transparent process of priority setting, the project Steering Group chose to support work on six clinical pathways and two ‘bright ideas’ in practice and to initiate and lead an innovative programme to get evidence into practice via journal clubs, which became known as IMPACTE (Improving Medical Practice by Assessing CurrenT Evidence) groups.
The project team
Quality:MK assembled a small, part-time team which drew on the support of the programme Board and the steering group. Eight people from the latter completed leadership development training funded by The Foundation as part of the award, and joint staff team/ ‘award development’ meetings became a key problem-solving group for programme.
The team supported project leads across all the workstreams. Those setting out on large-scale pathway reviews, for example, were leading this work as part of their day job - and indeed a number of staff changes significantly slowed progress in the first 18 months of the programme. Other leads were taking forward pilot projects or developments initiated through Quality:MK. The programme looked to find flexible approaches to contribute to each project.
Three members of the team stayed with Quality:MK throughout the three years: a GP, a librarian and the progamme manager. A project information specialist was quickly recruited, and in all four GP champions worked with Quality:MK. The team itself led on the evidence-based work-stream, and on embedding the learning and new ways of working.
The project approach
The Quality:MK programme worked through:
- supporting project leads by piloting tools, techniques and approaches; allowing a small fund of £1000 - £1100 to support practice involvement; offering a wide ranging programme of continuing professional development; encouraging participants to reflect on their experience and learning
- bringing in temporary staff to support the changing needs of specific projects and to test approaches: a LEAN-trained Quality Improvement facilitator assisted the strategic development of smoking cessation services, a Clinical Effectiveness Pharmacist worked with IMPACTE to support evidence-based prescribing, a data specialist worked on a dyspepsia project
- observing enablers and barriers to quality improvement across a tranche of projects
- shaping the system, and criteria for decision making, to support the values
- translating lessons learned into explicit, systematic, streamlined guidance and processes
Building a self-improving system: the approach
Working through this portfolio of projects, an ongoing process of continual self-conscious change was applied to build the infrastructure of a self-improving system within which:
- there are multiple points through which to initiate and progress quality improvement - evidence-based discussion; supporting and spreading a ‘bright idea’ in and from one practice; pathway review and service redesign; public and patient involvement and engagement
- enabling workstreams are identified and addressed strengthening public and patient involvement; early adoption of the Map of Medicine; continuing professional development; programme and project management
- learning is made explicit and transferred; articulating and sharing lessons learned
- Knowledge is managed to improve systems and processes - Production of a suite of products to build capability; Commissioning and Contracting Manual –setting out a systematic approach, streamlining processes and providing templates to boost efficiency; NHS Milton Keynes Model of Quality Improvement supported via action learning sets; Guidance on stakeholder engagement; www.qualitymk.nhs.uk supporting quality improvement
Evaluation
Reporting on outcomes
Project leads were supported in setting performance indicators and evaluating their work. The outcome data below report on five component projects. The final project reports a are in no sense “victory narratives”. They identify challenges and what has not worked well as well as recording progress. For many projects the results cannot be attributed to any one intervention; many activities have had an impact. Hence project leads were asked to comment on how participation in Quality:MK made a difference.
1 Brief interventions in alcohol pilot
“The ability to involve the GP within the TAF group through the availability of funding ... made a significant contribution to the development of the pilot LES. Quality: MK has changed mind sets, with the main winner being public and patient involvement .. right from the beginning... we have talked about it for years but probably never got this embedded in our thinking. Coming in second would be the requirement for good evidence underpinning the service. Third and much more problematic... as I think it is difficult to find interested GPs (even with a little funding). ..“I ..found the requirement for ... reporting difficult especially where this project was so impacted on by external factors, such as the surprise introduction of a national DES at the same time as the new LES was planned..."
- Total number of referrals Feb 09/Feb 10: 150
- 96% had more than one appointment and reduced alcohol consumption by 20% or more.
- Of these 33% reduced alcohol consumption to within sensible recommended alcohol limits (with a score of 0 to 8 on the Full AUDIT assessment), as set by the government guidelines
- 63% reduced their alcohol consumption by more than 20% and to an increased risk level (with a score of 9 to 15 on the Full AUDIT assessment), as set by the guidelines
- 4% showed no significant change
- 79% (n=119) also referred on to other agencies for further assistance
“funding was secured for 2 years from Quality: MK ........Benefits of participation ... also included ... Primary Care Trust stakeholders, who provided support and frameworks to complete project data and documentation which contributed to the project’s success ... Quality: MK enabled wider promotion of the work locally which has led to changes in practice in other surgeries and PCT staff ....”
- 40 patients in the study; positive measurable outcomes were achieved in all reviews
- £24,500 saved in prescribing costs over one year period, and costs to provide the multi-disciplinary reviews cost £3000.
- OOH presentations reduced from 95 to 2; hospital admissions reduced from 34 to 2
- All patients had changes made to medication
- The same multidisciplinary review framework used successfully in two other surgeries.
- PCT decided to fund a fulltime pharmacist to work with other health care professionals to review all patients in nursing homes.
- Community matrons changed their referral criteria as a result of the project’s outcomes
- Due to staff changes, lessons learnt will not be integrated in the pilot surgery as planned.
“The overarching themes and joint project group with regular updates required added rigour and a supportive framework to the project. Learning from other projects and the finding that some areas of concern particularly around roll-out and contracting were shared with others. Already the lessons learned from this project have proven invaluable for other long term conditions care pathways such as Stroke and COPD. ... We are considering how we might apply for an innovation fund to take forward complex patients’ medicine management (from another Quality:MK project) for COPD patients”
- QOF diabetes monitoring indicators have improved on average since 2007/8 for testing for microalbuminurea (by 1.7%) and retinal screening recorded (by 1.1%)
- Recording of HbA1c has remained constant at its high level of 96.8%
- All of the QOF diabetes management indicators have improved for patients
- Reduction in exception reporting;
- Hospital Ketoacidosis admissions have fallen from 1 admission for every 100 registered patients 2007/8, to 1 admission for every 150 registered patients 2009/10, despite the increase in the number of people registered with diabetes. Cost savings to be calculated.
- Over 1000 patiints have received an annual review with care planning since April 2009 in the first three practices of the pilot studies
- The number of practices initiating insulin has increased from 5 to 14.
- Intermediate service to provide direct clinical care outside hospital yet to be procured
- Number of 4 week quitters:
- 07/08 Target 1425; actual achieved 1337;
- 08/09 Target 1610 and actual achieved 1597;
- 09/10 Target 1700 and actual achieved 2678 (58% over target)
- Quit rate per 100,000 population: 09/10 Target 620 and actual achieved 970 (56% over target). This is the highest across South Central Region.
5 Weight management
- An increase of 70 referrals to new weight management services,2008/09 to 2009/10 (up 47%) “evidences the effect of this project”
- The levels of obese children in Reception as measured by the national child measurement programme decreased from 13.9% in 2007/08 down to 9.4% in 2008/09. These levels are now in line with the national average, and much lower for year 6.
- Many activities will have had an impact on this and the differences will have been made in the early years which have been a focus for work over the last year.
The journey so far...
MK Commissioning
MK Commissioning
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