Post on 01-Apr-2015
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HEALTH CARE SYSTEMS
Every system is perfectly designed to achieve exactly the results it
gets
THE HEALTHCARE PROCESS
The Patient133 People to take careof the patient
Avedis Donabedian (1919 – 2000)
Introducing New Policy?
Strategy A
• Form the committee of experts
• Spend at least 6 months and many hours developing the perfect solution
• Educate all the staff over 2-3 days
• Implement house-wide tomorrow
• Look for it in 12 months!
Strategy B• “Stack the deck”• 1 doc, 1 nurse, 1patient, one
PDSA• Reassess and learn from initial
test• Repeat, progressively
increasing confidence in solution then….
• Test under varying conditions before….
• Spread
How do we know change is an improvement?
“You can’t fatten a cow by weighing it” - Palestinian Proverb
Improvement is NOT just about measurement……but you can’t improve something without measuring it!
The Improvement Skeleton
Reliable Design
The Model for ImprovementData Collection
and Analysis
Engaging Clinicians
Understanding Variation