Posted on: 8 April 2022
In this edition, our feature article will be an introduction to the Institute for Healthcare Improvement’s (IHI) Triple aim and the evolution of the Quadruple aim.
Our improvement story this month is from Sally Lydamore and the Camden School Nursing Service.
Each month we will be sharing great examples from across CNWL where individuals and teams are improving systems and processes to ensure that we deliver the best evidence-based service user and carer experience where ever teams are delivering care across the trust. We also have exciting updates from the Improvement Academy and share great educational opportunities that are coming up.
Image Source : https://www.steelcase.com/research/articles/topics/healthcare/designing-quadruple-aim
An introduction to the IHI triple aim and the evolution of the Quadruple aim
In this month’s newsletter we would like to explore the Institute for Healthcare Improvement (IHI) Triple aim, it’s origins and how it has evolved. This journey commenced in the late 1990’s with healthcare researchers in the US. This commenced with two seminal books: ‘To Err is Human’ & ‘Crossing the Quality Chasm’. The first of these ground-breaking books was ‘To Err is Human’ that broke the silence that surrounded medical errors and their consequence. The authors focus was not on pointing the fingers at caring healthcare professionals who make honest mistakes, as they state that to ‘err is human’. Instead this paper established a roadmap agenda for reducing medical errors and improving patient safety through the design of safer healthcare systems (Kohn, Corrigan & Donaldson, 2000). The second book, ‘Crossing the Quality Chasm’, identified and recommends six dimensions of quality healthcare where improvement efforts could be focused; These were patient safety, care effectiveness, patient/service user-centeredness, timeliness, care efficiency and equity of access (Institute of Medicine, 2001).
On the backdrop of this work and based on the collective healthcare experience at the IHI, the Triple AIM framework was conceived and describes an approach to optimising health system performance (Institute for Healthcare Improvement, 2006). At that time, it was the IHI’s belief that new strategies must be developed to simultaneously pursue three dimensions, which they called the “Triple Aim”:
- Improving the patient experience of care (including quality & satisfaction)
- Improving the health of our population
- Reducing the per capita cost of healthcare
(Institute for Healthcare Improvement, 2006)
Since Don Berwick and his colleagues at the IHI introduced the ‘Triple Aim’ to the language of Healthcare, it has become widely accepted as a guiding compass to optimise healthcare system performance and has spread to all four corners of the globe. This being said, Bodenheimer & Sinsky (2014) found that members of the healthcare workforce had reported widespread burnout and dissatisfaction. Burnout has been associated with lower patient satisfaction, reduced health outcomes and at times has also increased healthcare delivery costs (Bodenheimer & Sinsky, 2014). Burnout consequently jeopardises the Triple Aim. Bodenheimer & Sinsky (2014) recommended that the Triple Aim be expanded to a ‘Quadruple Aim’, adding the goal of improving the working life of our healthcare workforce.
This focus on the health and wellbeing of those providing care has been brought into even more acute focus in present day as we have seen and felt the impact of Covid both at work and at home. This combined with the public’s rising expectations of our National Health Service in general, it can be challenging for healthcare providers to meet the public need within the constraints of existing healthcare resourcing.
Perlo et al. (2017) found that unhappy healthcare workers are more likely to make mistakes in the workplace and have lower levels of empathy which can impact on safe patient-centered care. In addition, if staff choose to leave their profession for a change of career or early retirement, this can also put a significant financial burden on the healthcare system that is already struggling to recruit people into the training pipeline as our future healthcare workforce (Bodenheimer & Sinsky, 2014).
This being said, there are ways that we, as a healthcare organisation, can have a positive impact on this fourth aim to support the health and wellbeing of our teams and colleagues at CNWL. For additional information please click here to access the CNWL Staff health & wellbeing page.
Many teams across CNWL, including our practicum teams, are focusing on one or more of the ‘Quadruple Aim’, and these include:
- The health of our populations and health equity
- The use of resources
- Experience and outcomes for patients and service users
- The health and wellbeing of those who provide and support care
In future editions of our newsletter we will be sharing improvement stories from teams who are working to improve any of the Quadruple aim, prioritising the fourth aim, focusing on health and wellbeing of teams delivering and supporting care across the trust.
If you have an idea that you would like to explore that you think could improve any of the above aims then please do not hesitate to get in touch with a member of our team and we would be more than happy to help you at our QI clinic. To book a QI clinic slot, please email us at cnw-tr.improvementsupport@nhs.net and we look forward to hearing from you. Additional details re QI Clinic and other educational opportunities are below.
References:
Bodenheimer, T. & Sinsky, C. (2014) ‘From Triple to Quadruple Aim: Care of the patient requires care of the provider’, Annals of Family Medicine, 12 (6), pp.573-576. doi: https://doi.org/10.1370/afm.1713
Institute for Healthcare Improvement (2006) ‘IHI Triple Aim Initiative: Better care for Individuals, Better Health for Populations and lower per Capita Costs’. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
Institute of Medicine (U.S.). (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C., National Academy Press.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To Err is human: building a safer health system. Washington, D.C., National Academy Press.
Perlo, J. et al. (2017). IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. Available at: http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx
Improvement Stories: Camden School Nursing Service
This month’s improvement story focusses on the management of Asthma in the Camden School Nursing Service. Sally Lydamore and colleagues produced an excellent QI poster that received the Best Poster Award in the Safety Conversation 2022.
Safe Asthma Management for Camden Children Through Effective School Nursing Interventions
We know that poorly controlled and unmanaged asthma can result in a dangerous medical emergency with a high risk of death, children missing school, and can have an impact on their growth and development. Asthma is the most prevalent long-term medical condition affecting children and young people in the UK. It is estimated that it will affect 5,300 children in Camden by 2025. In Camden, stakeholders across the borough have produced a local strategy to operationalise and take forward some core priorities for asthmatic children - in line with the North Central London Partnership recommendations. School Nurses have a key role in supporting schools, families and children in the safe management of asthma and in supporting the Asthma Strategy.
Our improvement project set out with the following aims:
- For all Camden schools to be asthma friendly by 2023 (reducing stigma, promoting safe management, and community ownership)
- To keep children medically safe in school
- To reduce hospital admissions due to exacerbation of asthma
- For all children on our caseload to have a “My Asthma” care plan
We launched our project in January 2020 for School Nurses and GP’s to highlight vulnerable families through meetings. Link Nurses spoke to schools about the Asthma Standards promoting the “Ask Me About Asthma” Campaign as part of the partnership agreements.
Our methodology was driven by school Nurses, who identified asthmatic children, and offered all a health review and care plan. In doing this, the school nurses were able to ensure that medication to treat asthma was managed correctly in the school environment and that staff were appropriately trained. It was also important that School Nurses provided follow up support in school following hospital admissions and unscheduled Accident & Emergency (A&E) presentations and were able to facilitate safe school transfers. We felt that it was vital that we were able to promote children/young people’s autonomy in managing their medical condition.
We then collated and analysed data collected by Link Nurses and School Nursing Staff on SystmOne and this was used to inform service leads how effectively care was being provided. The service measured the numbers of clinical interventions and used data to analyse outcomes.
In parallel with our data analysis, we undertook a school feedback survey at the end of the academic year, asking school senior leadership team members to evaluate the service.
What we found was that the project had significant impact on the engagement of children in our service alongside a marked decrease in the numbers requiring an attendance at an A&E department:
- From the 612 children requiring initial intervention, 600 required 4-6 weekly follow up
- School Nurses have had a 75% increase in clinical activity managing medical conditions in schools from the previous year
- A&E attendances were reduced from 71 to 14 throughout 2020/2021
Lessons Learnt
The number of A&E admissions for exacerbation of asthma have reduced due to collaborative working, which is key to managing medical conditions.
Schools value the role of the School Nurse in supporting them to keep children with medical conditions such as asthma safe in school.
The profile of the School Nursing Service has been significantly raised with Camden GP’s and the partnership working around children's health needs has improved.
Effective partnership working between School Nurses and the Camden Asthma and Atopy (Asthma & Eczema Clinic) Nurse has provided a more accessible service for hard to reach families, keeping them safe.
Utilising the materials provided by the “Ask Me About Asthma” Campaign enables School Nurses to deliver public health promotion on asthma and deliver safety messages.
If you would like to know more specific details about this project then please click on the link HERE to see this team’s poster submission to the CNWL Safety Conversation Day 2021 or email us at cnw-tr.improvementsupport@nhs.net and we will be very happy to connect you with someone from the Camden School Nursing Service.
The Improvement Academy
This has been an exciting and busy time for the Improvement Academy this month. Please see our new Improvement Academy website with new updated resources www.cnwl.nhs.uk/ia and twitter handle @CNWLImprovement.
For your convenience we have also added QR codes to fast-track your access to both our platforms.
Twitter Improvement Academy Website
Executive QI Conversation with our CEO, Claire Murdoch
This month the Addictions Services QI team shared their improvement journey with our CEO, Claire Murdoch. As part of the CNWL Practicum, the team has been focusing on improving digital enablement with their service users and are having a positive impact on engagement and experience by providing multiple modes of access to a range of clinics and service, both virtually and in-person. This is an exemplar of co-production with improvement ideas conceived and designed with service users and supported by Senior Peer Support workers & Group facilitators.
Well done team!
Improvement Awards
We would like to congratulate all the teams that have submitted improvement posters for this month’s Improvement Academy Awards. Thank you for taking the time to create these together with your teams – All Teach, All Learn!!
We have received a total of 28 entries and the judges are very much looking forward to seeing your posters. All entries will receive an Improvement Academy Award certificate and the top five entries will receive an Improvement Award presented in person by one of our CNWL Executive Team. We will be announcing the winners shortly.
Thank you again and Good Luck!
News from the Practicum 2021/2022
#CNWLQIPracticum2021
The fourth learning session for project teams on the QI Practicum took place on 24 March with teams learning together about the lifecycle of an improvement project, sustainability models, scale-up, spread and change packages.
This was also an opportunity to sharing success and valuable learning and insights that teams have gained during the practicum so far.
More updates from our #CNWLQIPracticum2021 can be found by following us on twitter by clicking HERE @CNWLImprovement.
Upcoming education opportunities
The QI Clinic is here to support your improvement ideas:
** Session times increased for 2022!! **
Book time with us today to discuss
We are excited to announce that we have listened to your feedback and have increased our QI Clinic time slots from 20 to 30 minutes. So take the opportunity today to book a QI Clinic slot while they are still available!
We look forward to hearing about your improvement ideas and look forward to supporting you in bringing these improvement ideas to life in your workplace.
The QI Team have weekly 30 minute sessions that are bookable in advance to help staff with any questions or issues relating to your improvement work. You will have exclusive access to both an Improvement Advisor and an Improvement Coach to help you think through your messy problem. The QI Clinic runs every Friday with bookable slots at 12.00 noon & 12.30 pm.
To book, send a request stating your preferred date and time to cnw-tr.improvementsupport@nhs.net and we shall confirm back to you with a diary invite and link to your QI clinic slot.
We look forward to speaking with you!
Level 1: Bronze - Bitesize (Intro to QI) New dates for 2022!
Dates for the ever-popular monthly 3-hour virtual QI training on the model for improvement and how to set out on a QI project are bookable here direct on the Improvement Academy website.
Useful Links
Contact information for Improvement Advisors:
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Diggory Division |
Peter Toohey |
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Goodall Division and Corporate |
Peter Smith |
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Jameson Division |
Bridget Browne |
Life QI: www.lifeqisystem.com/
If you want to get in touch please contact us here:
cnw-tr.improvementsupport@nhs.net
and follow us on twitter by clicking @CNWLImprovement.