Understanding whether a change is an improvement
Example measurement scrap book
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09Jul-0
9
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10Jul-1
0
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
0
10
20
30
40
50
60Safety Thermometer: Patient's Worst New Pressure Ulcer
It is important to check you denominator – in this month the number of patients surveyed was only 10 – this explains the astronomical data point
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09Jul-0
9
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10Jul-1
0
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
0
10
20
30
40
50
60
Safety Thermometer: Patient's Worst New Pressure UlcerThis is where the team
Implemented Intentional Rounding – it doesn’t seem to have made a difference to the
data
Why could this be?
The team had gone straight ahead with implementing
Intentional Rounding using a form taken from another trust
– this form was focussed on Falls. Work needed to be done to Improve the rounding form
through testing
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09Jul-0
9
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10Jul-1
0
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
0
10
20
30
40
50
60
Safety Thermometer: Patient's Worst New Pressure Ulcer
The team carried out PDSA cycles with the form and Implemented Intentional Rounding this month
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09Jul-0
9
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10Jul-1
0
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
0
10
20
30
40
50
60
Safety Thermometer: Patient's Worst New Pressure Ulcer
Here’s a shift!
What are the success factors? How can we ensure we replicate them?
This shift clearly shows that improvement work has had a positive effect as the percentage of patients with a new Pressure Ulcer is going down.
What next?
Did your trouble shooting as a team bring you to the
conclusion that your outcomes are improving?
What were the success factors?
Are there any negative consequences?
Check your balancing measures
How can you ensure you continue to replicate success
factors?
Celebrate - stick your charts up and talk about
measurementContinue to analyse your
data