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National Leading Improvement for Health
and Well-being Programme
Improvement Methods Workshop 1
2
1. Set Direction: Mission, Vision and Strategy
Make the status quo uncomfortable
Make the future attractive
3. Build Will• Plan for improvement• Set aims/allocate resources• Measure system performance• Provide encouragement• Make financial linkages• Learn subject matter
5. Execute Change• Use Model for Improvement for
design and redesign• Review and guide key initiatives• Spread ideas• Communicate results• Sustain improved levels of performance
4. Generate Ideas• Understand organisation as a system• Read and scan widely, learning from
other industries and disciplines• Benchmark to find ideas• Listen to patients• Invest in research and development• Manage knowledge
2. Establish the Foundation• Prepare personally• Choose and align the senior team
• Build relationships• Develop future leaders
• Reframe operating values• Build improvement capability
Source: Robert LloydExecutive Director Performance Improvement
Institute for Healthcare Improvement January 16, 2007
Start out◦ Establish rationale and gain support
Define and scope◦ Start in right area and develop
structure Measure and understand
current situation ◦ Understand change to achieve aims
Design and plan activities Plot and implement
◦ Test change ideas before implementing
Sustain and share◦ learn
Throughout the initiative•Stakeholder engagement and involvement•Sustainability•Measurement•Risk and issues management•Project documentation and gateway criteria
Google – NHSI quality and service improvement handbook
4
Knowledge of Systems
Theory of knowledge
Knowledge about Variation
Knowledge of Psychology
W Edwards Deming (1994) The New Economics
4 equally important parts of improvement
Diagnostic tools e.g. Process &
systems thinking
Project and programme
management
User and public
involvement
Change management
Discipline of Improvement in Health and Social Care (Penny 2003)
People Process
What
How
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done?
What hunches do we have?
What can we learn as we go along?
Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco
Political – what are the key political drivers of relevance?
Economic – what are the important economic factors?
Social – what are the main social and cultural aspects?
Technological - what are current technology imperatives, changes and innovations?
Legal - what current and impending legislation factors?
Environmental - What are the environmental considerations, locally and further afield?
Macro
Meso
Micro
©Profound Knowledge Products, Inc. 2008 All Rights Reserved
Ask yourself
•What are the problems that cause the bigger problem?
•What are you trying to achieve? (aim for each driver)
•How will you know a change is an improvement ? (outcome measures for each driver )
Drivers
Which in turn contribute directly to the ‘bigger’ aim
AimThe ‘big’ dots
Ask yourself
•What is the big (possibly strategic) problem you are addressing?
•What are you trying to achieve? (aim)
•How will you know a change is an improvement ? (outcome measures)
Ask yourself
What changes can you make that will result in the improvement you seek?
•What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing?
•How will you know a change is an improvement? (process measures for each intervention)
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Interventions The ‘small’ frontline dots
Contribute directly to the drivers
Reducing harm in perioperative
care
Reduce surgical site infections
Improve team work and
communications
Appropriate use of prophylactic antibodies
Maintain normothermia
Maintain glycaemic control in known diabetes
Use recommended hair removal methods
Use of the WHOSurgical safety checklist
Primary Drivers Secondary Drivers
Ref. Patients Safety First
The Model for Improvement breaks things down into small steps and works of the ‘little dots’ – at the frontline
These small steps should be part of the answer to the question of how to move the big dots
Align all improvement projects to strategy
An example Process Map:
Process Mapping The patient journey
◦ Who does what to the patient?◦ Define which group of patients◦ Define the scope (beginning
and end)◦ Identify everyone involved◦ Together, write it down or
draw it Other (sub-) processes
◦ Transport◦ Communication
How many steps? How many hand-offs? What is the approx. time of
or between each step? Where are possible delays
and why? Where are the problems for
users, carers and staff? How many steps do not
“add value”? WASTE!
Ask why 5 times!!
“Lean thinking is not a manufacturing tactic or a cost reduction programme, but a management strategy that is applicable to all organisations because it has to do with improving processes. All organisations – including health care organisations – are composed of a series of processes, or sets of actions, intended to create value for those who use or depend on them (customer/patients)” IHI: Going Lean in Health
Care 2005
Defects – “stuff” that is not right and
needs fixing e.g. a leaky tap
Inventory – “stuff” waiting to be
worked on e.g. patients
on a waiting list Overproduction – too much “stuff”
e.g.. requesting unnecessary tests and X-rays
Motion – unnecessary movement e.g. having to walk up and down
the ward to obtain appropriate supplies
Transportation – moving “stuff” e.g.
moving patients from ward to ward
Waiting – people
waiting for “stuff” to arrive
e.g. waiting for a ward
round
Injuries – damage to people e.g. stress
Processing waste – “stuff” we have to do that doesn’t add value.
E.g continuing to care for patients in hospital when they could be discharged
What is Waste?Lean Principles
Mark Rahman NHS Scotland
17
Ishikawa (Fishbone) Diagrams
PPPP
People Place
Procedures Policies
18
‘The 80-20 Rule’ ‘The Law of the Vital Few’ For many phenomena,
80% of the consequences stem from20% of the causes
Observation that 80% of income went to 20% of the population
Vilfredo Pareto, 1906
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done?
What hunches do we have?
What can we learn as we go along?
Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco
• The more specific the aim, the more likely the improvement
• Repeated clarification - without it aims drift
• Meet needs of external customers
Model for Improvement: moving the little dots
4 equally important parts of improvement
Diagnostic tools e.g.. Process and systems
thinking
Project and programme
management
User and public involvement
Change management
Discipline of improvement in health and social care (Penny 2003)
Ways of helping others to change: Building trust and relationships Creating rapport Managing conflict Negotiation Effective communication
Analytical•formal•measured + systematic•seek accuracy / precision•dislike unpredictability and surprises
Driver•business like•fast + decisive•seek control•dislike inefficiency and indecision
Amiable•conforming•less rushed + easy going •seek appreciation•dislike insensitivity and impatience
Expressive•flamboyant•fast + spontaneous•seek recognition•dislike routine and boredom
Personal styles Controlsemotions
Ask Tell
Showsemotions
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
What are your fears about change?How do you behave under stress?
Analytical•formal•measured + systematic•seek accuracy / precision•dislike unpredictability and surprises
Driver•business like•fast + decisive•seek control•dislike inefficiency and indecision
Amiable•conforming•less rushed + easy going •seek appreciation•dislike insensitivity and impatience
Expressive•flamboyant•fast + spontaneous•seek recognition•dislike routine and boredom
Personal styles Controlsemotions
Ask Tell
Showsemotions
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
Analytical•not enough information•making a wrong decision•being forced to decide
Driver•loss of control•failure•lack of purpose
Amiable•damaged relationships•confrontations•not being recognised for efforts
Expressive•being ignored•being asked for detail•being linked with failure
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press,
London
Analytical•will withdraw
Driver•will become autocratic
Amiable•will submit
Expressive•will become offensive/sarcastic
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
Personal styles
Ask Tell
Driver•Objective focused•Know what they want and how to get there•Sometimes tactless and brusque•Hardworking, high energy. Does not shy from conflict
Controlsemotions
Showsemotions
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
•Natural sales people and story tellers•Warm and enthusiastic but can be competitive •Good motivators and communicators•Can exaggerate, leave out facts and details
•Highly detail orientated•Can have difficulty making decisions without all the facts•Tend to be highly critical•Very perceptive
•Kind hearted people who avoid conflict•Can blend into any situation•Can appear wishy-washy and have difficulty with firm decisions•Can be quiet and soft spoken
Expressive Amiable
Analytical
The Driver: Command Specialist
Perceived positively as: Perceived negatively as:
Decisive PushyIndependent One man/woman showPractical ToughDetermined DemandingEfficient DominatingAssertive An AgitatorA risk taker Cuts cornersDirect InsensitiveA problem solver
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
The Expressive: Social Specialist
Perceived positively as: Perceived negatively as:
Verbal A TalkerInspiring Overly dramaticAmbitious ImpulsiveEnthusiastic UndisciplinedEnergetic ExcitableConfident EgotisticalFriendly FlakyInfluential Manipulating
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
The Amiable: Relationship Specialist
Perceived positively as: Perceived negatively as:
Patient HesitantRespectful Wishy WashyWilling PliantAgreeable ConformingDependable DependentConcerned UnsureRelaxed Laid BackOrganizedMatureEmpathetic
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
The Analytical: Technical Specialist
Perceived positively as: Perceived negatively as:
Accurate CriticalExacting PickyConscientious MoralisticSerious StuffyPersistent StubbornOrganized IndecisiveDeliberateCautious
Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London
Task focus
People focus
Passive Aggressive
Get it right
Get it done
Get along
Get appreciation
Driver
ExpressiveAmiable
Analytical
Another way of looking at it
Indicate◦ A person’s interests &
priorities◦ Behaviour and actions◦ Strengths and
weaknesses
Use this insight to◦ Choose effective ways to
communicate ideas◦ Know how to work better
with that person
32
Think about • Your strength
• Your team strength
• How the team can be more effective
• The style who may cause most difficulty
Affection Trust
Distrust Respect
Extent to which I believe
you care about me
Extent to which I believe you are competent and capable
LOW
HIGH
HIGH
Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done?
What hunches do we have?
What can we learn as we go along?
Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco
Aspect Improvement Accountability Research
Aim Improvement of care Comparison, choice, reassurance, spur for
change
New knowledge
Methods:
• Test Observability
Tests are observable No test; merely evaluate current performance
Test blinded or controlled tests
• Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small sequential samples
Obtain 100% of available, relevant data
“Just in case” data
• Flexibility of
Hypothesis
Hypothesis flexible, changes as learning takes
place
No hypothesis Fixed hypothesis
• Testing Strategy Sequential tests No tests One large test
• Determining if a Change is an Improvement
Run charts or control charts
No change focus Hypothesis, statistical tests (t-test, F-test, chi
square), p-vlaues
• Confidentiality of the Data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
Robert Lloyd Executive Director IHI adapted from Solberg L, Mosser G, McDonald S (1997) Three faces of performance
measurement: Improvement, accountability and research Journal of Quality Improvement Vol. 3 No 3
37
540
550
560
570
580
590
600
610
2007 2008
300
350
400
450
500
550
600
650
Jan-07
Feb-07
Mar-07
Apr-07 May-07
Jun-07
Jul-07 Aug-07
Sep-07
Oct-07 Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08 May-08
Jun-08
Jul-08 Aug-08
Sep-08
Oct-08 Nov-08
Dec-08
21.6 23.9 23.3 22.6 28.8 22.7 23.8 22.8 28.7 22.9 24.2 23.3 28.6 22.8 23.9 23.2 23.7 28.5 23.2 23.5 23.1 27.7
What does this data tell you?What does this data tell you?
Mean = 24.4
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Wee
kly
pro
du
ctio
n v
olu
me
July Aug OctSeptWeek
Ask yourself
•What are the problems that cause the bigger problem?
•What are you trying to achieve? (aim for each driver)
•How will you know a change is an improvement ? (outcome measures for each driver )
Drivers
Which in turn contribute directly to the ‘bigger’ aim
AimThe ‘big’ dots
Ask yourself
•What is the big (possibly strategic) problem you are addressing?
•What are you trying to achieve? (aim)
•How will you know a change is an improvement ? (outcome measures)
Ask yourself
What changes can you make that will result in the improvement you seek?
•What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing?
•How will you know a change is an improvement? (process measures for each intervention)
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Interventions The ‘small’ frontline dots
Contribute directly to the drivers
42
Think about Question 1 of The Improvement Model and the primary and secondary drivers of your improvement work What ARE you trying to achieve? How will you KNOW that a change is an improvement?
How can you display measures for improvement on run charts to share with others – the big dots and the little dots?
Link improvement measures to strategic measures
Streams of thinking Valleys
First-order change Second-order change
Underlying mental model
Unaltered Altered
Specific way we do something
Changed Changed
Creativity: The connecting and rearranging of knowledge — in the minds of people who will allow themselves to think flexibly — to generate new, often surprising ideas that others judge to be useful.
Innovation occurs when a creative idea is put into practice.
Vast majority of creative thoughts are never acted upon: Creativity without innovation
ImaginationCreativity
Doing and changingInnovation
400ideas
generated
75ideas
harvested
20ideas
developed
8ideastested
4ideas
implemented
£££££
Lets be creative!
Pick up your pen and turn each box into a different object
Attention Escape Movement
Paul Plsek
GP surgery A way for people to get information and help for them to stay healthy
Health records A way for certain bits of information about health history and needs are instantly available
Access to..... A way of getting those with health needs (patients) together with those who can help (providers)
ideas or wild scenarios which may serve as catalysts or "stepping stones“ to help make an intuitive leap to a really good idea.
By doing this useful concepts and ideas can be developed Judgement is suspended and thinking is
more free connections or associations made between
seemingly unrelated pieces of information
Imagine....................
All staff in the ambulance service have been struck down with a mystery illness that means the whole ambulance service is unavailable for the next year.
What could you do to get adult patients to the care they need?
Rules of brainstorming
Criticism is ruled out◦ There are no bad ideas at
this stage Go for quantity
Encourage wild ideas
Build on the ideas of others
One conversation at a time
‘The way to get good ideas is to get lots of ideas and throw the bad ones out’
Linus PaulingNobel Prize winning chemist
ImaginationCreativity
Doing and changingInnovation
400ideas
generated
75ideas
harvested
20ideas
developed
8ideastested
4ideas
implemented
£££££
Idea IdeaIdea
IdeaIdea Activity •Vote for the ideas you like best•Identify the top 10
ImaginationCreativity
Doing and changingInnovation
400ideas
generated
75ideas
harvested
20ideas
developed
8ideastested
4ideas
implemented
£££££
White hat
Data, facts and information
Yellow hat
Positives, benefits, good things
Black hat
Negatives, warnings, pitfalls
Green hat
Creative possibilities, new ideas
Red hat
Feelings, intuitions
Blue hat
Control or direction in thinking
DeBono E (1985) Six Thinking Hats Black Bay
DeBono’s 6 hats: different approaches
Thinking Leading Doing
orchestratingorganisingorder and structureBLUE
analyticalobjectivefactual WHITE
emotional works onhunches and intuitionRED
positive judgementopportunitypotential YELLOW
negative judgementwon’t work becauseBLACK
creativitybrain stormingthinking widelyGREEN
not emotionally involved micro manageleads by objective knowledge
wins hearts and mindsunderstanding, gutscaught in emotionmanages instinctivelytypically weak on facts
develops people by being enthusiasticpublicly positivelacks antenna for things gone awry
seeks to minimise risks and dangerscan damper enthusiasm often avoids opportunitypragmatic/realism
leads by innovationadapts leading edge approachesmay fail to take others with themforgets to be pragmatic or finish the job
self directionempowers othersenables others to get on with the job
analysework with detaillook at both sidesseek facts
trust own instinct with peoplesensitive to others feelings
see the bright sideidentify possibilitiesencourage others
‘fire hose’act conservativelymay judge too soon
innovatecreatestretchgenerate ideassee things others don’t
order and structuresortprioritisesthink ahead
DeBono E (1985) Six Thinking Hats Black Bay
ImaginationCreativity
Doing and changingInnovation
400ideas
generated
75ideas
harvested
20ideas
developed
8ideas
tested
4ideas
implemented
£££££
Solution / change in
organisation A
Change principle Change principle
Solution / change in
organisation B
We planned to….. ( state the basic plan) In order to ….. (tie it back to the Aim)
What we did was….. (brief description of actions)
Looking at what happened, what we learned from this was….. ( lessons learned)
What we plan to do next is …. (state next plan)
© Paul Plsek
P
D
S
A
ImaginationCreativity
Doing and changingInnovation
400ideas
generated
75ideas
harvested
20ideas
developed
8ideastested
4ideas
implemented
£££££
‘there has to be a great deal of continuous
improvement surrounding innovation’
Cole R (2001) From continuous improvement to continuous
innovation QMJ Vol. 8, No.4
Aim
Time
Continuous improvement
Innovation
Boaden, Harvey, Moxham Proudlove (2008) Quality Improvement: theory and practice in healthcare
NHS Institute for Innovation and Improvement Improvement Leaders’ Guides
NHS Evidence specialist collection on innovation and improvement www.library.nhs.uk/IMPROVEMENT
NHSI: Thinking Differently◦ Google: Thinking Differently book NHS
Paul Plsek: Directed Creativity ◦ http://www.directedcreativity.com
Roger von Oech: Creative Think ◦ http://www.creativethink.com
Please complete your feedback forms for us
At Improvement workshop 2 Be prepared to share
◦ What you have done ◦ What you wish you had done differently◦ What you have learned about improvement
Next time◦ Managing transitions◦ Variation◦ Engaging others◦ Sustainability and spread