health care systems every system is perfectly designed to achieve exactly the results it gets
TRANSCRIPT
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HEALTH CARE SYSTEMS
Every system is perfectly designed to achieve exactly the results it
gets
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THE HEALTHCARE PROCESS
The Patient133 People to take careof the patient
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Avedis Donabedian (1919 – 2000)
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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
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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!
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The Improvement Skeleton
Reliable Design
The Model for ImprovementData Collection
and Analysis
Engaging Clinicians
Understanding Variation