Driver Diagrams - Wendy Jamieson

Driver

Diagrams

Wendy Jamieson – Manager Clinical Leadership and Improvement Program

Clinical Excellence Commission [email protected] Mob 0434 - 078 026 Twitter @wendyejamieson

mailto:[email protected]

About this Workshop

• Lots of content in some slides For you to refer back to when you are doing your project

• Some staff will have solid knowledge and others not – be patient!

• Chatham House Rules – what’s said in the room stays in the room

• Ask questions any time

• Mobiles on silent

• Pre-Post Knowledge Survey

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Driver Diagram - Overview

• A Driver Diagram (DD) is a powerful tool that helps you translate a problem into an improvement project using an:

Aim Statement Primary & Secondary Drivers Relationship Arrows Solutions Measures

• It is used to scope a project and to clarify the plan for reaching the desired aim

• It captures an entire improvement project in a single diagram which can be reviewed / updated at every team meeting.

• Originally developed by IHI in USA & used by the NHS Reference: http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/GoldmannDriver.aspx

http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/GoldmannDriver.aspx



Driver Diagram

Within 12 months,

David will lose 40 kg

Decrease Calorie intake

Increase Exercise to burn more

calories

Primary Drivers & R’ship Arrrows

Secondary Drivers & Arrows Eat less fried food

Reduce alcohol intake

Reduce drinking coke

Drink less coffee & use skim milk

Reduce volume of food eaten

Eat more fresh fruit

Stop eating chocolate between meals

Eat more low calorie food

Ride bike more

Go to gym more

Sit less at work desk

Use stairs more

Eat less dessert

Start a regular sport

Stop driving car to work

Wear pedometer more

On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.

Solutions & Arrows Impact: High Implementation: Easy

Only drink Alcohol on Fri & Sat night (2 std drinks )

Stop drinking coke - Carry a water bottle everywhere

Buy only Skim Milk and reduce coffee to 2 a day

Serve meals on small/side plate

Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)

Eat berries for dessert

Move to a adjustable / standing desk. Stand for 2 hrs + a day

On Sunday plan how to get to work M-F: ride bike, walk/jog,

(don’t drive car)

Play soccer all year round

Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps

Only take stairs (don’t use lift)

Personal trainer at gym x 2 week

Gastric Banding Surgery

See GP & a dietician

Impact: High Implementation: Easy

Impact: High Implementation: Hard


Impact: Low Implementation: Easy











Team Members: • David • David’s wife • David’s children • etc • Project Sponsor – Davids Mother

The Problem: David is over weight as he is 130kg (Nov 2015)

Priority PDSA

Process Measure: • How much: Reduce Calorie

intake by 30% • By when: 2 months

Process Measure: How much: Increase by calories burnt by 40% By when: 2 months

Aim Statement with measurable

Stretch goal Process Measure: • How much: Reduce alcohol

intake by 80% • By when: 1 month

Process Measure: • How much: Meet 100% of

weekly exercise goals. • By when: 1 month

Outcome Measure: • How much: Reduce BMI by

20% • By when: 12 months

Outcome Measure: • How much: Reduce weight

by 40 kg • By when: 12 months

Measures

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CAUTI Driver Diagram

Within 6 months, 100%

of patients admitted to

the ward from ED will have a documented indication for their catheter.

Improve catheter documentation in

medical record

Increase communication re catheters to admitting

medical teams

Discuss indications for in-situ catheter with ward

nurse

Include catheter indication in ward handover notes

100% of medical orders for catheterisation are

documented (not verbal)

More thorough history taking on Admission at ED.

Ensure completeness of documentation of

catheter insertion ie: no gaps in information

Design & implement an AMO handover checklist

Provide Education to ED medical officers re: handover

of catheters

Include catheters indication on Nursing handover checklist

Provide ward nurse with print out of catheter obs from First

Net.

Insert a field for catheter indication on ward handover

notes.

ED to complete catheter insertion record sticker at

time of insertion and provide to ward nurse at handover.

Provide Education to ED medical officers re:

documenting orders for catheter insertion

Enable ward with electronic access to First Net

ED to document catheter insertion & indication in paper

medical record.

Make catheter insertion obs compulsory fields on First Net.


The Problem: Do not know WHY patients from ED have catheters in place.

Team Members: • Nurse educator – Ward & ED • ED med director • Ward NUM

• ED Clinical NUM

Increase communication re: Catheters at

clinical handover btw staff

Increase access to documentation on First

Net.





Measure: • How much: • 100% documented • By when: 6 months Impact: High

Implementation: Hard





Measure: How much: 100% of ED staff will discussed catheters during handover By when: 3 months.

Measure: How much: 100% of catheterised patients will have documentation in their healthcare record about their catheter insertion at the time of their transfer. By when: 6 months.

Measure: How much: All ward AMOs will be made aware that their patient is being transferred with catheter within 1 hour of the transfer being booked By when: 2 months.

Measure: How much: 80% of nursing staff on the ward will be trained on how to use eMR to find catheter information By when: 3 months.

Measure: How much: A complete catheter insertion record will be available in the notes of all catheterised patients By when: 4 months.


Within 6 months,

reduce # of pts admitted to

ward with an IDC by 30%

Reduce the # of pts with existing

(chronic) IDCs who are transferred out

of ED.

Increase equipment availability

ED discharge nurse checks for IDCs that can be removed more frequently before

transferred

Always document planned IDC removal in Med Rec.

Increase # of bladder scanners

Increase supply of in/out catheter

Increase awareness & use of in/out catheters

100% of ED Medical Officers will be

credentialed in IDC competency

Increase the % of pts with an existing IDC that

have a review for on-going clinical need

Include IDC on transfer / HO checklist

EMR Alert in First Net to check after 4 hrs

Use catheter insertion labels

Document in Power chart

Stock take of bladder scanners in Hospital & pool

Repair /trade in broken bladder scanners

Seek funding from Exec for more bladder scanners

Ensure regular stock of in/out catheters in ED

Implement the pre-insertion decision support tool

Medical Educator to provide catheter workshop

Implement Urethral catheter insertion competency

assessment

ED CNE to provide catheter workshop

Include credentialing in ED orientation














The Problem: Ward is receiving from ED too many patients with a In Dwelling catheter inserted.

Team Members: • Team Leader – Ward NUM • ED NUM • ED Medical officer • Continence CNC • ED CNE Educator • Consumer – Past patient

100% of ED staff will be credentialed in IDC competency

Increase communication re:

IDC at handover

100% of ED Nursing staff will be credentialed in IDC

competency

Measure: How much: ED will reduce number of patients discharged with a catheter in situ by 15% By when: 2 months

Measure: How much: 100% of patients will have catheter insertion history included in their ward handover notes By when: 4 months

Measure: How much: Increase purchasing volume of in/out catheters by 75% By when: 2 weeks

Measure: How much: 90% of ED staff will be credentialed in insertion competency By when: 1 month

Measure: • How much: 30%

reduction • By when: 6 months

Measure: How much: Increase purchasing volume of in/out catheters by 75% By when: 2 weeks


Within 6 months, 100% of patients will

have appropriate

catheterisation

Increase availability of equipment

Improve staff awareness of appropriate indications eg:

• NOF • Trauma • Stroke

Better management of falls risk patients

Improve work flow priorities and staff time

management

Increase availability of cleaning

Increase awareness of pts toileting

Improve ward knowledge of correct indications

Labs have clear guidelines on urine collection

Nursing in-service

Doctor in-services

Implement CEC decision support tool

HETI e-learning module

Implement CEC Competency assessment tool

ED Assessment nurse to review Falls risk

Review environmental design of ED for falls risk pts

Medically ordered catheterisations

Establishment of a cleaning trolley in ED

Ensure stock of incontinence supplies

Implement CEC urine specimen collection tool

Implement hospital Urine collection guidelines (see MoH

guideline)

Revise lab order on Power Chart


The Problem: ED is inserting too many Catheters

Team Members: • NUM • Dr (Consultant) • CNC continence • ED CNE • Jnr nurse • Consumer

100% of staff have knowledge

of appropriate indications

ED staff need to increase awareness of appropriate

specimen collection Measures: • Number of

catheters inserted

Measure: • How much: 100% of staff • By when: 1 month

Measure: • How much: 100% of time

bladder scanners accessible • By when: 3 months

Measure: • How much: 100% availability of in

/ out catheters • By when: 3 months

Increase awareness of ID recommendations for

specimens prior to antimicrobial therapy

Ensure supply of in / out catheters

Ensure access to bladder scanner

Measure: • How much: Bladder scanner can

be accessed within 5 minutes. • By when: 3 months

Measure: • How much: 100% of staff have

passed a competency assessment on indications

• By when: 3 months

ID to provide information guidance regarding

Therapeutic Guidelines

Place standing order for in / out catheters

Purchase bladder scanner for ED or borrow for another unit

















Within 6 months, increase rate of

appropriate antibiotic use for

UTI to 90%.

Outcome Measure: How much? By when?

Improve the accuracy of attitudes and beliefs about

appropriate antibiotic commencement among staff

Measure: How much? 50% of staff

have a changed attitudes and beliefs

By when? Within 3 months

Measure: How much? 100% of teams

in the unit

By when? By the end of 6 months

Measure: How much? 50%

improvement in diagnostic accuracy for UTI

By when? By the end of 3

months

Improve the integrity and completeness of the diagnostic process

Improve coordination of the multidisciplinary teams

working in the unit

Increase rate of appropriate testing and

investigations for UTI

Measure: How much? Increase rate by 70%

By when? By the end of 6

months

Eliminate myths associated with UTIs in older patient populations

Deconstruct myths that antibiotics are harmless medicines

Improve perception regarding the usefulness, cost and time burden associated with UTI investigations

Increase the number of rounds per week that is attended by both ward

pharmacist and medical team

Increase availability of clinical microbiologist for advice

Increase time spent on differential diagnosis prior to prescribing ABx

Increase awareness of potential alternative diagnoses for UTIs signs or

symptoms

Remove barriers that preclude appropriate testing for UTI diagnosis

Increase education on how to interpret UA results

Improve language used and recommendations provided on

microbiology reports

Clinical microbiologist and AMS pharmacist to provide

myth busting inservices

Ward pharmacist trained in academic detailing regarding

antibiotic use

Run poster campaign on truth vs myths in antibiotics

Ward pharmacist to be paged by medical team at beginning

of ward round

3 ward rounds a week are pre-booked in MDT’s calendars

Clinical microbiologist to offer dedicated times to provide

advice

Clinical microbiologist is provided with on-call pager for unit

Allocate time for differential diagnosing in rounding

checklist

New policy to institute documentation of differential diagnosis in healthcare record

Implement CEC’s decision support tool for urine specimen collection

Preformat lab order form

Provide nursing and medicine staff with clinical skills training

Clinical microbiology team to review and update micro

reporting templates















Team Members: • Team Leader s– AMS pharmacist

+ CNE • NUM of unit • Snr Registrar • JMO • Registrar • Snr Clinician • Clinical microbiologist / ID MO • Ward pharmacist • Consumer

The Problem: According to AMS pharmacist, our Rehab Unit has a high rate of unnecessary commencement of antibiotics for UTIs


Improve understanding and interpreting of

investigations relating to UTI

Measure: How much? 70% of staff demonstrate improved understanding By when? By the end of 6 months

Clinical microbiology team to provide cheat sheet on how to

interpret urine results

Driver Diagram Steps 1. Define the problem

2. Project Team & Sponsor

3. SMART Aim Statement

4. Literature Review

5. Flow Chart the current process

6. Brainstorm the ‘causes’ of the problem

7. Affinity diagram - Categorise the ‘causes’

8. Define Primary & Secondary Drivers

9. Devise Measures

10. Brainstorm Solutions

11. Assess Priority of Solutions

12. PDSA Cycles

13. Data Collection & Measuring Impact

14. Sustain the Gains & Spread the Idea

15. Regularly update your Driver Diagram

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Learning Outcomes

Participant's will be able to:

Develop a SMART Aim Statement

Flow Chart a process

Brainstorm the ‘causes’ of a problem using ‘post it notes’

Develop an Affinity Diagram

Draw up a Driver Diagram with Drivers, Relationship Arrows & Solutions

Graph Outcome, Process & Barrier measures

Develop and Prioritise Solutions

Plan PDSA cycles

Plan to Sustain & Spread project

Evaluation: Let me know if the learning outcomes were not met.

Use the CEC cheat sheet for Driver Diagrams

Source: NSW Health GEM Workstar – CPI module.

https://gem.workstar.com.au/public/index.cfm?action=l

ogin&returnTo=/

https://gem.workstar.com.au/public/index.cfm?action=login&returnTo=/




Beware of jumping from a problem to a solution

A Driver Diagram assists you to thoroughly diagnose the causes of the problem and devise relevant solutions & measures. Example

A patient arrives in ED with back pain. What do you do?

a) Presume Kidney stones – send straight to theatre

b) Presume Orthopaedic – send straight to theatre

c) Methodically examine the patient and thoroughly investigate to fully diagnose the cause of the back pain.

David is overweight.

He weighs 130kg.

Steps to develop a Driver Diagram

Example

• What is the problem?

David is overweight as he is 130kg (Nov 2015)

• Check that your problem is an issue worth solving?

• Is it a significant issue? Yes, 130kg is overweight

• Does anyone else think it is a problem? Yes, his famous wife thinks so…

• Is there supporting evidence that it’s a problem (qualitative/quantitative)? Yes, 130kg

• Common mistake: Don’t select a solution to implement

It must be a ‘problem’ to investigate / ‘area to improve’

• Document the ‘problem’ in the DD (top left corner)

Step 1: Define the problem you want to fix

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Driver Diagram

The Problem David is over

weight as he is 130 kg

(Nov 2015)

• Gather people with the right expertise

People from all areas of the process under review

Ensure its an Interdisciplinary team

Include a consumer

Appoint a Team Leader

Consider inviting ‘challenging’ characters onto your team

• Appoint a Project Sponsor

• Pre-book regular meetings

• Document the Project Team in the DD

(bottom left corner)

Step 2: Form a Project Team

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Driver Diagram The Problem: David is over weight as he

is 130kg (Nov 2015)

Team Members: • David • David’s wife • David’s children • etc … • Project Sponsor - Mother

First Team Meeting

• Ratify the problem

Do all Team members & your Project Sponsor agree on the problem?

Work on 1 problem at a time

• Beware: Gaining the teams agreement on the ‘problem you are trying to solve’ can be a stormy time

Step 2: Form a Project Team

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Step 3: Develop a SMART Aim Statement with a measurable Stretch Goal

• The first team meeting is used to decide exactly what the team is trying to achieve

• They need to AGREE on:

a) the exact problem they are trying to solve, and

b) the goal/aim/objective they want to work towards

• This is recorded as an Aim Statement


Warning

• Developing an Aim statement can take a while

• It may take time to get the teams consensus on:

What is the actual problem you are trying to solve?

What is the specific Aim and how will you measure it?

• The Aim Statement should meet the SMART criteria:

Specific - objective, scope & criteria

Measurable - quantifiable data

Achievable / Appropriate - can be done & should be done

Result Oriented - stretch goal

Time scheduled - date to be completed



Aim Statement

• State clearly what are you trying to accomplish

• Focus on a measurable outcome

• Include a ‘Stretch Goal’ – a measurable target that is achievable

but also a challenge to obtain

• David’s Example:

‘Stretch Goal’ David losing 40 kg - wont be easy, but it can be done.

Within 12 months,


Step 3: Develop a SMART Aim Statement

Check - Does your Aim statement have a:

1. Timeframe = Within 12 months

2. Stretch goal = lose 40kg (he currently weighs 130kg)

3. Criteria - What are you trying to fix? = David’s weight

4. Scope ie Target population = David

Double check:

The aim statement relates to the original problem

You have NOT put solution in your aim statement?

The scope isn’t too big? ie can you achieve your project with in the timeframe?

You included a specific, measurable stretch goal – do NOT use words like lose ‘some’ weight or lose weight ‘soon’ – be specific

Within 12 months,


Driver Diagram

Within 12 months, David will lose 40 kg

The Problem:

David is over weight as he is

130kg (Nov 2015)

Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother

1. By 30 September 2016, the need for ongoing catheter use will be assessed daily for 100% of catheterised patients .

2. Within 6 months, 90% of urinary catheters inserted in emergency department will be for an appropriate clinical indication.

3. Within 3 months, all catheterised patients discharged from the ED will have a completed catheter insertion sticker included in their medical record.

4. In 8 months’ time no more than 5% of urine specimens collected from catheterised patients in this unit will be inappropriately indicated.

5. By 31st July, the average catheter dwell time in xxxx Unit will be less than 60 hours.

6. Reduce inpatients catheter days by 25% before 31 January, 2016.

7. The number of indwelling catheters used in this emergency department will be reduced by 50% within the next 12 months.

8. Reduce CAUTIs incidence rate to 0 in the next 24 months.

9. Within 3 months, a catheter removal order will be documented in the medical record of 80% of catheterised patients.

10. Reduce the number of unnecessary urine cultures ordered for catheterised patients by 30% before 1 September, 2016.

Step 3: Develop a SMART Aim Statement - CAUTI Examples

Step 3: Develop a SMART Aim Statement Other Clinical Examples

• “Within 1 year, 100% of elective surgical patients will be screened for anaemia pre-

operatively.”

• “Within 6 months, 100% of patients with VRE will be triaged and admitted to a ward bed within four hours”

• “100% of all autologus products collected by the blood Service will meet the Patient Blood Management Guidelines by 1st July.”

• “Within 1 year, 90% of patients suitable for discharge, will be discharged from the ward before 11am”

• “Within 6 months, reduce the number of unnecessary pathology tests in the ED by 50%”

• “Within 12 months, decrease the rate of infections in joint replacement surgery to zero.”

• “Within 8 months, decrease the number of admissions with a primary diagnosis of asthma by 50%.

Step 4: Plan a Literature Review • A literature search is essential if you are to:

identify best practices for the problem under review

prevent reinventing the wheel

• Time efficiency - 1 or 2 team members perform this task

• Decide key words for the search

Resources:

• CIAP - On line Journals & Articles at ‘Clinical Information Access Program’ www.ciap.health.nsw.gov.au

• Search engines www.google.com.au or ww.scholar.google.com

• ACI Innovation Exchange www.aci.health.nsw.gov.au/ie

• Hospital Library / Librarians

http://www.ciap.health.nsw.gov.au/

http://www.google.com.au/

http://www.aci.health.nsw.gov.au/ie

Step 4: Plan a Literature Review • Key words for literature search on David’s problem

Causes of obesity

Weight loss

BMI

Diet & nutrition etc

Step 5: Flow Chart the Current Process On Butchers paper, construct a Flow Chart of the CURRENT process From start to finish

Every step & every decision

Ask at each step ‘Does this

usually happen?’

REMEMBER: Current process

Step 5: Flow Chart the Current Process

Why bother

• So there is a shared understanding by the team of the current process

• It is a way of gathering information / intelligence / facts about the problem

• There is open criticism of the current process Helps to identify bottle necks

• The complexity of the process can be identified and managed in the future

• A better process maybe identified which may later become the NEW / improved process

David’s Day

7am David wakes up

Breakfast: Coco Pops, 2 x p/butter toast, coffee

8.30am drives 5kms to wrk.

9am Sits at desk all morning. Drinks coke &

coffee. Snacks on chocolate.

Lunch: 2 x Big Mac & fries

5.30pm drives home

11.30pm bed

Sits at desk all afternoon & snacks: chocolate & coke.

7pm Dinner (takeaway) & beer

Week day or

weekend?

Week day Weekend

Breakfast: Coco Pops, 2 x p/butter toast, fried eggs, sausage & bacon, coffee.

6pm watches TV with a beer

Watches more TV & more beer

Saturday or

Sunday?

Saturday Sunday

9am Drives kids to sport. Reads paper.

Lunch: KFC (8 pieces)

All afternoon - Sits & watches TV /

Movies.

Lunch: 2 pizzas from Pizza Hut

10am might go to the Gym (usually once a month)

Takes lift to level 3.

Patient comes to the ED Patient is seen by triage nurse Patient history and obs are taken Medical assessment undertaken

Is a consult

required? YES NO

Is hospital admission required?

YES NO

Patient is sent home

Is a diagnostic

investigation required?

YES

NO

Is a urine specimen required?

NO

Other diagnostic investigations are performed

Has an IDC been

medically ordered?

YES Insert an IDC and collect specimen if

required

YES

Get patient admitted to the ward

Transfer patient to ward

ED nurse hands over patient to ward nurse

Ward nurse takes baseline obs and checks paperwork

CAUTI flow chart example

Patient arrives in the ED

Patient is seen by triage nurse

Patient is allocated to a bed/area

Patient registration is done

Patient is assessed Assessed as 1-2 priority Assessed as 3-5 priority

Patient placed in high acuity area

Patient placed in low acuity area

Patient assessed by senior clinician Patient assessed by clinician Differential diagnosis is made

Clinical investigations undertaken

Diagnosis made

Treatment commenced

Is immediate

surgery required?

YES NO IDC inserted if needed Patient transferred to the OT

for surgery Insert catheter if needed

Reassess patient

Document patient management plan

Does the patient

need to be admitted?

NO

YES

Discharge patient

Admit patient to ward

CAUTI flow chart example

Step 6: Team Brainstorms the ‘Causes’ of the Problem

Team members write on ‘post it notes’ all the reasons / causes they can think of, that contribute to the problem:

Done in silence, to cut through the authority gradient

One idea per ‘post it note’

Use as many ‘post it notes’ as needed

Ideas need to be specific (phrases)

Do NOT brainstorm ‘solutions’ – focus only on ‘causes’ of the problem

Stick the ‘post it notes’ on a flat surface (eg: wall or table)

Step 6: Team Brainstorms the ‘Causes’ of the Problem

Brainstorm: What is ‘causing’ David to be overweight? The Flow Chart will highlight many of the ‘causes’

• Team members arrange the ‘causes’ (post it notes) into

Logical Categories and

Assign a Heading to each category

Affinity Diagram – generally have btw 2 to 5 categories

• Remove duplicates: Re-read all the ‘post it notes’ and remove any absolute double ups.

Step 7: Categorise the ‘Causes’ & assign headings

Category Headings = Primary Drivers

Causes = Secondary

Drivers

• Word the ‘Category Headings’ (Primary Drivers) as measurable improvement / action statements ie: How to ‘improve’

• Use words such as

Increase / Decrease

Improve …

More / Less

Start / Stop etc

Step 8: Define each Primary & Secondary Driver

Within 12 months,


Aim Statement

• Reword each cause (post it note) into measurable action statements to form true Secondary Drivers ie:

=

=

Eat less fried food

Go to gym more




=

=

Driver Diagram





calories

Primary Drivers & Relationship Arrows


Driver Diagram




calories









Ride bike more

Go to gym more

Sit less at desk at work

Use stairs more

Eat less dessert



Wear pedometer more

Team Members: • David • David’s wife • David’s children • Etc • Sponsor - Mother


Primary Drivers & Relationship Arrows

Check

Are your Drivers complete – have you forgotten any?

• Ask your team:

“Is there anything else that could improve / impact our aim?”

“What else do we need to do to reach our goal? “

“Is there anything else that could go wrong to prevent us reaching our aim?”


3 types of Measures

1. Outcome (impact) Measures

2. Process Measures

3. Balancing / Barrier / Side Effect Measures

Step 9: Devise Measures

How will you know that a change is an improvement?

Outcome (impact) Measures

• Have a direct impact on the aim

Kgs lost

BMI reduced

Process Measures

• Indirect impact on the aim

Calories burnt

Calories consumed

Barrier / Balancing / Side Effect Measures

• Side effects (knock on effects) as a consequence of changes

If staff say “You can’t do that because … this will happen”

NB: Can add ‘Barrier Measures’ after ‘Solution’ stage

Step 9: Devise Measures Within 12 months,


• How will you know that a change is an improvement?

• Devise specific measures for the Primary Drivers How much

By when

Step 9: Devise Measures

Measure: • How much: Reduce calorie


Measure: • How much: Increase calories burnt

by 40% • By when: 2 months

• Measures can be tweaked at team meetings - they are not set in stone!

Driver Diagram




calories

Primary Drivers & R’ship Arrows









Ride bike more

Go to gym more

Sit less at desk at work

Use stairs more

Eat less dessert



Wear pedometer more


Process Measure: How much: Reduce by 30% By when: 2 months

Process Measure: How much: Increase by 40% By when: 2 months


Process Measure: • How much: Reduce alcohol








Step 10.1: Brainstorm Solutions (change concepts) Brainstorm Solutions (change ideas / interventions) for each secondary driver

• For each secondary driver, the team brainstorms (or researches from

literature) specific ideas/solutions to address the driver

WHAT exactly are you going to do next week / next month &

HOW exactly are you going to do it?

• Place solutions in DD and draw arrows to relationships


Secondary Drivers Solution (change concept)

Move to a adjustable / standing desk.

Stand for 2 hrs + a day




Driver Diagram

Within 12 months,




calories

Primary Drivers

Secondary Drivers Eat less fried food








Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions









(don’t drive car)







Team Members: • David • David’s wife • David’s children • etc • Sponsor – Mother












Driver Diagram

Within 12 months,




calories

Primary Drivers









Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions









(don’t drive car)











Actions Effect / Impact









Driver Diagram

Within 12 months,




calories

Primary Drivers









Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions









(don’t drive car)











Actions Effect / Impact









Step 10.2: Brainstorm Solutions then Barrier Measures

Barrier Measures • Side effects (knock on effects) as a consequence of solutions

(change concepts)


(don’t drive car)

Solution

Barrier Measure: How Much: David arrives at work, on time (9am) 100% of time. By when: 1 Month

• What can go wrong? David might be late to work… often !

Driver Diagram

Within 12 months,




calories

Primary Drivers









Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions









(don’t drive car)



















Barrier Measure: How much: Arrive at work on time (9am) 100 % of time . By when: 1 month

Step 11: Assess Priority of Solutions

• You have many Solutions – which ones will you test / implement first?

Assess each solution for:

Ease of Implementation – will it be Easy or Hard to implement? • Will it cost a lot $$$ ? • Can it be done next week? • Will it take: hours, weeks or months to embed? • Will many people have to be re-trained / educated?

Impact on the Aim – will it have High or Low impact on the Aim

Statement? • How much will the solution effect the:

Problem Aim statement Outcome measures


Secondary Drivers Solution (change concept)

Move to a adjustable / standing desk.

Stand for 2 hrs + a day






Priority


• Solutions that you predict will have high impact & are easy to implement should be tested as a priority using a PDSA Cycle.

Step 11: Assess priority of solutions



Step 11: Assess priority of solutions

• Any solution that has an impact on 2 or more Secondary

Drivers should also be a priority Look for 2 or more Relationship Arrows from a Solution

Secondary Drivers Solution (change concept) Priority


Driver Diagram

Within 12 months,




calories

Primary Drivers









Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions Impact: High Implementation: Easy









(don’t drive car)





















Team Members: • David • David’s wife • David’s children • etc • Sponsor – Mother


Priority PDSA



Proces Measure: • How much: Reduce alcohol




















“The most successful improvement projects are those that get into testing -

PDSA – the quickest” Don Berwick - IHI

PDSA - AKA – “Rapid Cycle Testing”

In summary

the steps of a Driver Diagram

are …

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiV1KuM6uTJAhWl3aYKHY6xCTIQjRwIBw&url=http://supplychaininsightsglobalsummit.com/steps-4-5-to-regain-manufacturing-prowess/&bvm=bv.110151844,d.dGY&psig=AFQjCNEotZkISFDroT-c685x2PDth6ywKg&ust=1450508133248429

Driver Diagram

Within 12 months,




calories

Primary Drivers & R’ship Arrrows









Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions & Arrows Impact: High Implementation: Easy









(don’t drive car)





















Team Members: • David • David’s wife • David’s children • etc


Priority

Process Measure: • How much: Reduce Calorie


Process Measure: How much: Increase by calories burnt by 40% By when: 2 months

Aim Statement with measurable

Stretch goal Process Measure: • How much: Reduce alcohol




Measure: • How much: Reduce BMI by


Measure: • How much: Reduce weight


Measures












• A DD is a living document • Each Team meeting you can review your DD and add or re-word:

Aim Statement Primary & Secondary Drivers Relationship Arrows Measures Solutions

• Don’t get too hung up on detail Its NOT a Thesis It’s a practical tool to help you improve

Remember: Don’t put a ‘solution’ into your Aim Statement The Primary & Secondary drivers start to hint at ‘change

concepts’ or solutions.

In Summary

Outcome for David after 12 months

1. Define the problem you want to fix – See scenario on your table. Start DD on butchers paper – document the problem.

2. Form a Project Team (interdisciplinary & include a consumer) – Who would you have in your team and as Project Sponsor?

3. Develop a SMART Aim Statement with a measurable stretch goal

4. Plan a Literature Review – What key words would you search?

5. Flow Chart the CURRENT Process: On butchers paper, draw steps & decisions from start to finish of the CURRENT process. (Choose 1 unit and flow chart its current process)

6. Team brainstorm the ‘causes’ of the problem (in silence with ‘post it notes’) NB: focus on ‘causes’ NOT solutions.

7. Affinity Diagram - Categorise the ‘causes’: Sort the ‘causes’ (post it notes) into logical categories and assign a ‘heading’ to each category

Primary Drivers = category headings

Secondary Drivers = the ‘causes’ under each category heading

8. Define each Primary & Secondary Driver

Re-word each post it note as a measurable action statement (driver) – use words such as increase/decrease; more/less; start/stop; extend/reduce etc

Place Primary & Secondary drivers in the DD and draw Relationship Arrows from right to left to corresponding relationships.

9. Devise Measures: State how you will measure relevant drivers & solutions: ‘How much & by when’.

10. Brainstorm Solutions (change ideas / interventions) for each secondary driver and draw in Relationship Arrows. Then devise “Barrier Measures”.

11. Assess Priority of Solutions: Assess each solution for a) Impact (high/low) & b) Ease of Implementation (easy/hard). Also prioritise solutions which impact 2 or more drivers. Prioritise which solutions to test using a PDSA cycle.

12. PDSA Cycles: Test high priority solutions via a PDSA cycle and report progress at team meetings

13. Data Collection & Measuring Impact: Develop data collection tools, collect data and graph results. Regularly report at team meetings.

14. Plan to Sustain the Gains & Spread the idea

15. Regularly update your Driver Diagram - A Driver Diagram is live document that should be reviewed (added to / amended) at each team meeting.

Your turn - Work shop a CAUTI problem

Plan Do Study Act (PDSA) Cycle

• Test high priority solutions via a PDSA cycle and report progress at team meetings

Testing a ‘change’ / ‘intervention’ is not always easy:

Things may happen that were not planned

The change may not impact the measures

There may be unwanted side effects

Step 12: PDSA Cycles


1. Plan your change: What you are going to change,? Who is going to do it? When & where will it be done? Data: How will you measure it?

2. Carry out your change and observe & measure

3. Study the data & anecdotes

4. Act on the data: What will you do next?

One priority solution at a time

Driver Diagram

Within 12 months,




calories

Primary Drivers









Ride bike more

Go to gym more


Use stairs more

Eat less dessert



Wear pedometer more


Solutions Impact: High Implementation: Easy








On Sunday plan how to get to / from work M-F: ride bike, walk/jog, (don’t drive car)























Priority



Aim Statement Process Measure: • How much: Reduce alcohol




Measure: • How much: Reduce weight


Measure: • How much: Reduce BMI by














Step 12: PDSA Cycles On Sunday plan how to get to/from work M-F: ride bike,

walk/jog, (don’t drive car) Getting to/from work – Week 1 & 2

PLAN: First 2 weeks, plan (goal) to walk 5kms to work in the morning: Mon, Wed & Fri and catch train home in evening. Drive car other days. (Ease himself into new exercise regime) Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight, BMI.

DO: Carry out plan (above). • Collect exercise achievements

in a Tally Sheet.

STUDY: Every Sunday review past weeks exercise data. • Were the goals achieved?

ACT: After reviewing the data, act on the results. • If he did reach his

predicted goal, can he exercise more next week?

• If goals not reached, why not & what can be done?

Step 12: PDSA Cycles On Sunday plan how to get to work M-F: ride bike,


PLAN: Weeks 3 & 4, plan (goal) to walk 5kms to work in the morning 5 days a week. Catch train home in the evening. Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight.

DO: Carry out plan (above). Collect exercise achievements in a Tally Sheet.

STUDY: Every Sunday review past weeks exercise data. Were the goals achieved?

ACT: After reviewing the data, act on the results. If he did reach his predicted goal, can he exercise more next week? If goals not reached, why not & what can be done?



PLAN: Weeks 5 & 6, plan (goal) to walk & JOG part of the 5kms to work, 5 days a week. Catch train home in the evening. Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight.






PLAN: Weeks 7 & 8, plan (goal) to walk & jog part of the 5kms to work on Mon, Wed & Fri. Tue & Thur ride BIKE to & from work. Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight.




Step 12: PDSA Cycle Ramp

Week 1&2: walk 5kms to work on Mon, Wed & Fri AM

Week 3 & 4: walk to work 5 mornings a week.

Weeks 5 & 6: walk & jog part of the 5kms to work 5 mornings a week

Week 7 & 8: walk & jog M,W,F. Ride bike to & from work Tu & Th.

David Getting to/from work

• The completion of each PDSA cycle leads directly into the start of the next cycle

• A team learns from the test:

what worked

what didn’t work

what should be kept, changed, or thrown out and

new knowledge to plan the next test

• People are far more willing to test a change if they know that changes can and will be amended as needed (call it a trial / pilot).


“The most successful improvement projects are those that get into testing -

PDSA – the quickest” Don Berwick - IHI

PDSA - AKA – “Rapid Cycle Testing”


Low calorie meals

Getting to / from Work

Personal trainer

Measurement

Process Measures: • Kms walked / jogged / cycled per week • % daily exercise goals met per week • Calories burnt

But …. So what! Do the process measures impact the Aim?

• Did David lose weight? Outcome Measures

• Weight Kgs • BMI

Step 13: Data Collection & Measuring Impact


Outcome Measure - Annotated Run Chart

70

80

90

100

110

120

130

David's Weight (kgs) (Outcome/Impact Measure)

Davids Kgs Stretch goal 90 kg

Kgs

Stretch Goal = 90 kg

Started walking to

work 5 days M-F

Started walk / jog

M-F

Started walking to

work 3 days M,W,F.

Hurt leg - no exercise

Davids Son's wedding

celebrations

Meals on side plate to reduced

volume

Started bike T&Th, walk / jog

M-F

Menu plan: Started low

calorie diet & reduced alcohol

Standing desk at work

Take stairs at work

Personal Trainer

PRESENTATION NAME – MONTH YYYY PRESENTER NAME

77

Mon Tue Wed Thur Fri Sat Sun

Numerator:

# daily exercise

goals met

Denominator: Total number

of daily exercise goals

for week

% daily exercise

goals met for week

Total Kms for

week

Week 1 (3 goals)

Walk to

work

Walk to

work

Walk to

work 2 3 67% 10

Week 2 (3 goals)

Walk to

work

Walk to

work

Walk to

work 3 3 100% 15


Tally Sheet Legend: Achieved goal

Did NOT

achieve goal

Step 14: Sustaining the Gains & Spreading the Improvement

Some of the practices that help make improvements permanent (sustained) in an organisation are:

1. Standardisation

2. Documentation

3. Measurement

4. Training

Periodic self-audits can be useful in determining whether these practices are being followed

Beware:

• Many people make improvements only to discover later that things have somehow returned to the old level or that some new problem has been created.


79


British National Health Service Sustainability Model • Complete the British NHS Sustainability Survey and score your project? • The closer the score to 100, the better chance of successful sustainability

Score of 55 or higher offers reason for optimism. Score of 45 or lower suggests reason for concern.

Step 14: Sustaining the Gains & Spreading the Improvement British National Health Service Sustainability Model

1) Benefits beyond helping patients - Improves efficiency and makes jobs easier 2) Creditability (to affected staff) of benefits from improved process - Benefits are immediately obvious, supported by evidence and believed by stakeholders 3) Adaptability of improved process - The process can be adapted to organisational changes and there is a system for continually improving the process 4) Staff involvement and training to sustain the process - Staff have been involved from the beginning and adequately trained to sustain the improved process 5) Staff attitudes toward sustaining the improved process - Staff feel empowered and believe the improvement will be sustained 6) Senior leaders responsibility taking and staff action toward the leader - Organisational leaders take responsibility for efforts to sustain the process, and staff generally share information with and actively seek advice from the leader.


81

Step 14: Sustaining the Gains & Spreading the Improvement British National Health Service Sustainability Model

7) Clinical leaders responsibility taking and staff action toward the leader - Clinical leaders take responsibility for efforts to sustain the process, and staff generally share information with and actively seek advice from the leader 8) Effectiveness of the system to monitor progress of the improvement - A system monitors progress using evidence, acts on it and communicates results. 9) Fit with the organisation ion's strategic aims and culture - There is a history of successful sustainability; improvement's goals are consistent with organisation's strategic aims. 10) Infrastructure to sustain (staff, facilities, equipment etc) - Staff, facilities and equipment, job descriptions, policies, procedures and communication systems are appropriate to sustaining the improved process.

Spreading the Improvement Do you have a plan to roll out your project in other

areas?

ACI Innovation Exchange http://www.aci.health.nsw.gov.au/ie

Quality Awards

Present at conference

Poster

Journal article






Review of your project 12+ months on after ‘completion’ Project Sustainability

Have you been able to sustain the gains made in your project? Do you conduct regular measurement regarding your project?

Project Spread

Have you rolled out your project in other areas? Was your project summary uploaded into the ACI Innovation

Exchange http://www.aci.health.nsw.gov.au/ie Did you submit your project into a Quality Award? Have you presented your project at a conference?

Building capacity in your LHD

Have you been involved or led any additional improvement projects?


Step 15: Regularly update your Driver Diagram

• A Driver Diagram is live document that should be reviewed at each team meeting

more drivers maybe discovered and the literature may reveal more drivers and solutions to test

• Remember: Not all Team Driver diagrams will be the same – different teams will find different drivers.

Questions

• You Tube videos from NHS:

Driver Diagrams Lesson 1 of 3 Introduction https://www.youtube.com/watch?v=2mBpJIzzYI8

Driver Diagrams- Lesson 2 of 3- Reasons to use driver diagrams https://www.youtube.com/watch?v=xXRym4aFLa4

Driver diagrams Lesson 3 of 3 How to develop a driver diagram https://www.youtube.com/watch?v=BhY-rw9ejDk

• Driver Diagram References:

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html#sthash.GNk7SHIo.dpuf

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html#sthash.Kfs7TJjL.dpuf

http://www.kingsfund.org.uk/projects/pfcc/driver-diagrams


• PDSA References:

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

More information on Driver Diagrams & PDSA

https://www.youtube.com/watch?v=2mBpJIzzYI8

https://www.youtube.com/watch?v=xXRym4aFLa4

https://www.youtube.com/watch?v=BhY-rw9ejDk








http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.htmlsthash.GNk7SHIo.dpuf



http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.htmlsthash.Kfs7TJjL.dpuf













87

Links to other Clinical Quality & Safety Websites: State: • Clinical Excellence Commission: www.cec.health.nsw.gov.au • Agency for Clinical Innovation: www.aci.health.nsw.gov.au • Bureau of health Information: www.bhi.nsw.gov.au National: • Australian Commission on Quality and Safety: http://www.safetyandquality.gov.au/ • Australian Association for Quality in Health Care (AAQHC): https://www.aaqhc.org.au/ • Authoritative information and statistics to promote better health and wellbeing http://www.aihw.gov.au/data/ International: • Institute for healthcare Improvement resources http://www.ihi.org/resources/Pages/default.aspx or do you

just want www.ihi.org • Intermountain healthcare (transforming

healthcare) https://intermountainhealthcare.org/about/transforming-healthcare/ • Agency for Healthcare research and quality: www.ahrq.gov • National Patient Safety Agency: www.npsa.nhs.uk • Institute for Innovation and improvement: www.institute.nhs.uk • Scottish Patient Safety Programme: www.patientsafetyalliance.scot.nhs.uk • Healthcare Improvement Scotland www.healthcareimprovementscotland.org • Koawatea Healthcare system innovation and improvement: http://koawatea.co.nz • The International Society for Quality in Healthcare: http://www.isqua.org/home

http://www.cec.health.nsw.gov.au/

http://www.aci.health.nsw.gov.au/

http://www.bhi.nsw.gov.au/

http://www.safetyandquality.gov.au/

https://www.aaqhc.org.au/

http://www.aihw.gov.au/data/

http://www.ihi.org/resources/Pages/default.aspx

http://www.ihi.org/

https://intermountainhealthcare.org/about/transforming-healthcare/



http://www.ahrq.gov/

http://www.npsa.nhs.uk/

http://www.institute.nhs.uk/

http://www.patientsafetyalliance.scot.nhs.uk/

http://www.healthcareimprovementscotland.org/

http://koawatea.co.nz/

http://www.isqua.org/home

Driver Diagram Template


Process Measure: How much? By when?




Impact: High Low Implementation: Easy Hard

















Team Members: • Team Leader – • Consumer • Xx • Xx • xx • xx • Project Sponsor -

The Problem:





Driver Diagram Template

SMART Aim

Statement with stretch

goal


Primary Driver




Primary Driver

Primary Driver

Primary Driver


Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Secondary Driver

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution

Solution


















Team Members: • Team Leader - • . • . • . • . • . • Consumer – • PROJECT SPONSOR -

The Problem: xxxxxx





Barrier Measure: How much? By when?

1. Define the problem you want to fix – See scenario on your table. Start DD on butchers paper – document the problem.

2. Form a Project Team (interdisciplinary & include a consumer) – Who would you have on team & as a Project Sponsor?

3. Develop a SMART Aim Statement with a measurable stretch goal

4. Plan a Literature Review – What key words would you search?

5. Flow Chart the CURRENT Process: On butchers paper, draw steps & decisions from start to finish of the CURRENT process. (Choose 1 unit and flow chart its current process)

6. Team brainstorm the ‘causes’ of the problem (in silence with ‘post it notes’) NB: focus on ‘causes’ NOT solutions.

7. Affinity Diagram - Categorise the ‘causes’: Sort the ‘causes’ (post it notes) into logical categories and assign a ‘heading’ to each category

Primary Drivers = category headings

Secondary Drivers = the ‘causes’ under each category heading

8. Define each Primary & Secondary Driver

Re-word each post it note as a measurable action statement (driver) – use words such as increase/decrease; more/less; start/stop; extend/reduce etc

Place Primary & Secondary drivers in the DD and draw Relationship Arrows from right to left to corresponding relationships.

9. Devise Measures: State how you will measure relevant drivers & solutions: ‘How much & by when’.

10. Brainstorm Solutions (change ideas / interventions) for each secondary driver and draw in Relationship Arrows.

11. Assess Priority of Solutions: Assess each solution for a) Impact (high/low) & b) Ease of Implementation (easy/hard). Also prioritise solutions which impact 2 or more drivers. Prioritise which solutions to test using a PDSA cycle.

12. PDSA Cycles: Test high priority solutions via a PDSA cycle and report progress at team meetings

13. Data Collection & Measuring Impact: Develop data collection tools, collect data and graph results. Regularly report at team meetings.

14. Plan to Sustain the Gains & Spread the idea

15. Regularly update your Driver Diagram - A Driver Diagram is live document that should be reviewed (added to / amended) at each team meeting.

Driver Diagram Steps

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Driver Diagrams - Wendy Jamieson

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