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