The Early Years Collaborative

1. Components of a Learning SystemDavid M. Williams, Ph.D.Improvement AdvisorInstitute for Healthcare Improvement

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5. The Early Years Collaborative “Scotland will be the best place to grow up.” Draws upon existing community infrastructure across the country Focused on age-based workstreams: 15% reduction in the rates of still-births and infant mortality by 2015. 85% of all children within each CPP will reached all of the expected developmental milestones at the time of the child’s 27-30 month child health review, by end-2016. 90% of all children within each CPP have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017.

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7. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

8. Workstream 1 Aim To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015).

9. Workstream 2 Aim To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child’s 27‐30 month child health review, by end‐2016.

10. Workstream 3 Aim To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time the child starts primary school, by end‐2017.

11. Big Aims We are here! Source: Brandon Bennett, IA

12. Overall Project Measures vs. PDSA Cycle Measures Data for Project Measures: - Overall results related to the project aim (outcome, process, and balancing measures) for the life of the project Achieving Aim Data for PDSA Measures: - Just enough data - Quantitative data on the impact of a particular change - Qualitative data to help refine the change - Subsets or stratification of project measures for particular patients or providers - Collect only during cycles Adapting Changes During PDSA Cycles

13. Run Chart- Data for Learning & Improvement Measure Time

14. Outcome Measures Guide Learning about how the reliability of the process is achieving our aim. Process Measures Guide Learning about how our testing is improving reliability of the process. PDSA Measures Guide Learning about our testing.

15. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

16. Early Years Collaborative R P P P Pre-work A A D D D A S S S LS1 2 day Kickoff 2 day LS 2 day LS 2 day LS Etc… Expert meetings Cluster meetings Supports Expert QI & Early Years faculty Networking events Listserv Site Visits Phone conf Assessments Monthly Reports via web Key Changes Improvement Measures Oct 2013 Oct 2012 Jan 2013 May 2013 TBC TBC

17. R WORKSTREAM 1 (conception to 1 year) Theory of what actions will reduce infant mortality Theory of what drives infant mortality Improved teamwork, communication, skills and collaboration 2⁰ Aim 1⁰ Poverty Improved money management Quality Of Home Environment Improved rate of breastfed babies Domestic Abuse & Violence Societal Issues Quicker diagnoses of Neonatal Abstinence Syndrome Workforce Issues Transport, Community Capacity & Cultures Reduce infant mortality Improved leadership, culture and planning Access To Services Improved family centred response Employment • Detailed aim: • To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of: • stillbirths (from 4.9 per 1000 births in 2010 to 4.3 per 1000 births in 2015) • infant mortality (from 3.7 per 1000 live births in 2010 to 3.1 per 1000 live births in 2015) Attachment Improved stability / permanence for LAC Health Post-birth actions Improved identification Parenting skills Improved joint working Improved management and quality of care Smoking / Alcohol & Drug Misuse Improved sharing of information Nutrition Improved access Pre-birth actions Mental health & wellbeing Identification & reasons for current resilience Version: 06/03/2013

18. WORKSTREAM 2 (1 year to 30 months) R Theory of what actions will ensure developmental milestones are reached Theory of what drives developmental milestones Improved teamwork, communication, skills and collaboration 2⁰ Aim 1⁰ Poverty Improved money management Quality Of Home Environment Domestic Abuse & Violence Improved child’s dental health Societal Issues Workforce Issues Improving child nutrition Transport, Community Capacity & Cultures Improving brain development and physical play Children have all the developmental skills and abilities expected of a 27-30 month old Access To Services Improved family centred response Employment Health Improved stability / permanence for LAC Child’s physical & mental health and emotional development Attachment Improved early identification Early Learning & Play Additional Support Improved joint working Detailed Aim: 85% of all children within each CPP have reached all of the expected developmental milestones at the time of the child’s 27-30 month child health review by end-2016 Level of education Improved sharing of information Misuse of alcohol & drugs Improved management, planning and quality of services Carer’s physical & mental health and skills Nutrition Disabilities & Mental health Improved leadership, culture and planning Parenting skills & knowledge Identification & reasons for current resilience Version: 06/03/2013

19. R WORKSTREAM 3 (30 months to start of primary school) Theory of what actions will ensure developmental milestones are reached at the start of primary school Theory of what drives developmental milestones 2⁰ Aim 1⁰ Improved teamwork, communication and collaboration Poverty Quality Of Home Environment Improved uptake of benefits Domestic Abuse & Violence Improved child’s dental health Societal Issues Workforce Issues Improving child nutrition Transport, Community Capacity & Cultures Children have all the developmental skills and abilities expected at the start of primary school Improving brain development and physical play Access To Services Employment Improved family centred response Early Learning & Play Improved stability / permanence for LAC Health Child’s physical & mental health and emotional development Attachment Improved identification Additional Support Improved joint working Detailed Aim: 90% of all children within each CPP have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017 Level of education Improved management, planning and quality of services Misuse of alcohol & drugs Improved sharing of information Carer’s physical & mental health and skills Nutrition Improved leadership, culture & planning` Disabilities & Mental health Parenting skills & knowledge Identification & reasons for current resilience Version: 06/03/2013

20. WORKSTREAM 4 (Leadership) R Theory of what actions will ensure leadership support Theory of what drives leadership support 2⁰ 1⁰ Aim Build commitment with partners to focus on delivery Establish an EYC Implementation Committee Early Years Collaborative is a strategic priority & underpins all policy planning and operational activity CPPs communicate the EYC with enthusiasm and consistency Ensure a feedback mechanism for issues raised in Walk-rounds Leaders illustrate how users are included in design, improvement, and delivery of Early Years Ensure the development of a measurement system used to understand and drive quality indicators Leaders facilitate change by cultivating innovation from intelligence, insights and wisdom of people working together Provide the Leadership System to support quality improvement across the Early Years Collaborative Assign a senior leader to each improvement area (Workstreams 1-3 and measurement) Early Years Collaborative values, culture and behaviours are modelled by all leaders at all levels Leaders demonstrate their ability to set direction and engage and mobilise staff to constantly improve quality of service Establish Programme Management and remove barriers Meet regularly with the Implementation Committee to track progress and remove barriers Leaders can describe how they personally maintain early years focus within their working environment Display data that depicts progress towards aim Detailed Aim: Timely delivery of all three workstream “stretch aims” Early years executive and operational leads are identified Ensure that the senior team participates in Walk-rounds Measurement plan and priorities are established and triangulation with other key data Infrastructure to support delivery of Early Years Collaborative Place quality issues at the top of senior leader meeting agendas Spread plan is in place for core and innovative work Add Early Years Collaborative and outcomes to the CPP agenda Strategy for capturing, celebrating and spreading innovation Version: 06/03/2013

21. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

22. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system… A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Note: The size of the rectangles is meant to be indicative of population size, not cost.

23. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system… A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. People who have “fallen through the cracks” of our “rescue-care” system. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Note: The size of the rectangles is meant to be indicative of population size, not cost.

24. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system… Sub-groups, people from the high cost high utilization sub-population that can be stratified based upon relatively similar needs. A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. People who have “fallen through the cracks” of our “rescue-care” system. Sub-groups based more on needs and less on conditions. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Note: The size of the rectangles is meant to be indicative of population size, not cost.

25. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system… Interventions intended to address the needs of high cost high utilization sub-groups, Plan Do Study Act cycles. Sub-groups, people from the high cost high utilization sub-population that can be stratified based upon relatively similar needs. A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. People who have “fallen through the cracks” of our “rescue-care” system. Sub-groups based more on needs and less on conditions. Some interventions will work and some will not. All should result in learning and start on the smallest practical scale. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Note: The size of the rectangles is meant to be indicative of population size, not cost.

26. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

27. Repeated Use of the PDSA Cycle for Testing Changes That Result in Improvement Mini-measure tracks improvement cycles Spreading DATA Sustaining the gains Implementation of Change Wide-Scale Tests of Change Hunches Theories Ideas Follow-up Tests Sequential building of knowledge under a wide range of conditions 48 Very Small Scale Test

28. Scottish Borders - Run chart of run charts! R

29. Scottish Borders - PDSAs completed R

30. Test! Test! Test! • Burt Sandeman’s Story Post LS1: • The Challenge To Be Quick • Burt Sandeman’s Story Post LS2: • The F-Word • Looked after two-year olds: • My Prediction Was Wrong

31. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

32. Act with the Individual Dad’s Care Asset Based Community Development in N. Ayrshire

33. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

34. Things to Consider to “Scale-up” Determine full scale at project setup and milestones to reach full scale Different changes may require different scale-up strategies Consider different dimensions of structure Information technology Physical (e.g. space, equipment, capacity) Human resources (workforce organization and capabilities) Financial Learning system Use “5x” (5--25--125--625--3125---) thinking to predict/define the structural issues and set a path forward for testing (What is working when testing with x that probably won’t work with 5x, ...?) Standardize processes (e.g. training, referral) Understand oversight requirements as the system grows

35. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI

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37. Keeping an eye on the journey The Work Remaining to Do You are here! Aim

39. Components of a Learning System • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing changes sequentially • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • Periodic review • People to manage and oversee the learning system From Tom Nolan PhD, IHI