national leading health and wellbeing programme 14 march 2014 leadership for improvement jean penny

National Leading Health and Wellbeing Programme

14 march 2014

Leadership for improvement Jean Penny

All working life in NHSDiagnostic Radiographer and teacherImprovement roles since 1994

BPR Leicester Royal Infirmary 1994 - 1999National Patients ‘Access Team 1999 - 2002NHS Modernisation Agency 2002 – 2005NHS Institute for Innovation and Improvement 2005 -2008

Awarded OBE for services to NHS 2003Visiting professor University of Derby 2008

[email protected] Improvement: 19 years and still

learning

Linking strategic goals and frontline improvements

Measuring for improvement not judgement

Developing and testing change ideas

“All models are wrong but some are useful”

W Deming

“A promise to learnA commitment to act”

D Berwick

Find two other people who you have not worked with before

Watch the slideshow Remember as many images as possible

◦ The countdown slide is not one of the images!

No writing down or conferring!

Any improvement is a change◦not every change is an improvement◦but we cannot improve something unless

we change it

Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River

Press, Massachusetts

Any improvement is a change any change is a perceived threat to security◦there will always be someone who will

look at the suggested change as a threat

Eliyahu Goldratt

Any improvement is a change any change is a perceived threat to security

any threat to security gives rise to emotional resistance◦ you can rarely overcome emotional resistance

with logic alone

Eliyahu Goldratt

“Anyone who thinks you can

overcome emotional

resistance with logic was probably

never married”

Any improvement is a change any change is a perceived threat to

security any threat to security gives rise to

emotional resistance emotional resistance can only be

overcome by a stronger emotion

Eliyahu Goldratt

What to change?◦ Pin point the core problems

What to change to?◦ Construct (simple) practical solutions

How to cause the change?◦ Induce the appropriate people to invent such solutions ◦ they must own the problem

Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River

Press, Massachusetts

Have a goal Be honest and understand where you are

today Have a plan Never underestimate the power of small

positive changes. Tiny incremental changes add up and make a large impact

Commitment to continuously improve

August 2012

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

The interventions / change ideas that contribute directly to secondary drivers

Secondary Drivers:Contribute directly to

primary drivers

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

?

Primary Drivers:Contribute

directly to the strategic aim

The strategic aim (and

big problem)

Linking strategic goals and frontline improvements

If I had one hour to save the world, I would spend 59 minutes defining the problem and one minute finding a solution

A Einstein

Ishikawa (Fishbone) Diagrams

PPPP

People Place

Procedures Policies

What are you trying to accomplish?

How will you know that a change is an

improvement What changes can you make that will result in an

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 organizational 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

http://www.institute.nhs.uk/productive_general_practice/general/knowing_how_we_are_doing.html

0102030405060708090

Day

1 4 7 10 13 16 19

Seco

nds

to

answ

er p

hon

e

Seven one side

Seven down (or up)

Change

Just like a TPR chart

Average length of pre-ward stayStroke Ward

from 01/2007 to 07/2007

0

0.5

1

1.5

2

2.5

3

3.5

1 2 3 4 5 6 7Months

Mike Davidge NHS Institute for Innovation and

Improvement

Average length of pre-ward stayStroke Ward

from 01/2007 to 07/2007

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Weeks

Patient length of pre-ward stay Stroke Ward

from 01/2007 to 07/2007

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Patients




improvement?





How is a paradigmformed?

Streams of thinking Valleys

Creativity: The connecting and rearranging of knowledge 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

Breaking the rules

Identify the underlying assumptions, mental models, unwritten rules and thinking that maintain the status quo.

Then deliberately think around them to create new ideas for service delivery

Ask ◦ Why is that step there? What are the unwritten rules

behind what is going on here? ◦ What aspects of the rule can we break? And what

aspects of the rule would we want to keep and why?

You are creative?

Lets be creative!

Pick up your pen and turn each box into a different object

Coffee

Some Idea’s

Pyramid from above

Mouse hole

Stepping stones Off beat ideas and wild scenarios can serve

as catalysts or mental stepping stones to help us make an intuitive leap to a really good idea

Scenario: A mysterious virus has affected all who work in the Ambulance Service. So they are unable to work. Everyone else is completely unaffected.

How are you going to do to link users to the care they need? Be Creative !!!

http://www.institute.nhs.uk/building_capability/new_model_for_transforming_the_nhs/thinking_differently_guide

Attention Escape Movement

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

Attention Escape Movement De Bono (2000) Six thinking hats Penguin London

Use on one idea

ImaginationCreativity

Doing and changingInnovation

400ideas

generated

75ideas

harvested

20ideas

developed

8ideastested

4ideas

implemented

Practicality, Impact, Cost, Outcome

Attention Escape Movement




improvement?





Solution / change in

organisation A

Change principle Change principle

Solution / change in

organisation B

PDSA cycle for learning and improvement

Act

• what changes are to be made?

• next cycle?

Plan•objective• questions and predictions (why)• plan to carry out the cycle (who, what, where, when)

Study

•complete the analysis of the data

•compare data to predictions

•summarise what was learned

Do

• carry out the plan• document problems and unexpected observations• begin analysis of the data

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

PDSA

PDSA

PDSA

PDSA

PDSA

Data Driven Change

Change in Team Culture

Hunches

Theories

Ideas

Aim•What am I trying to achieve?•How will I know a change is an improvement?•What changes can I make that will result in the improvement

Need to start small!!

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

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 driversActivity: Process and outcome measures?

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

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

Think quietly by your self for a few minutes Then find two others and share

Work with your team /colleagues: value differences Really understand the problem Develop aims and measures: What are you trying to

achieve? Measure for improvement: How will you know a change

is an improvement? Gather change ideas: What changes can you make that

will result in the improvement you want? Test change ideas (PDSA cycles) before implementing

and learn from things that do not work Link frontline changes to strategic objectives Share achievements and learning with others

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

national leading health and wellbeing programme 14 march 2014 leadership for improvement jean penny

Documents

primary drivers intervention

massachusetts slide

threat eliyahu goldratt

countdown slide

suggested change

improvement jean penny

testing change ideas

d berwick slide