national leading improvement for health and well-being programme improvement methods workshop 1

National Leading Improvement for Health

and Well-being Programme

Improvement Methods Workshop 1

http://www.idea.gov.uk/idk/home.do

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

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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










• 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


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


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


•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


The Expressive: Social Specialist


Verbal A TalkerInspiring Overly dramaticAmbitious ImpulsiveEnthusiastic UndisciplinedEnergetic ExcitableConfident EgotisticalFriendly FlakyInfluential Manipulating


The Amiable: Relationship Specialist


Patient HesitantRespectful Wishy WashyWilling PliantAgreeable ConformingDependable DependentConcerned UnsureRelaxed Laid BackOrganizedMatureEmpathetic


The Analytical: Technical Specialist


Accurate CriticalExacting PickyConscientious MoralisticSerious StuffyPersistent StubbornOrganized IndecisiveDeliberateCautious


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

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

540

550

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570

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2007 2008

300

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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



400ideas

generated

75ideas

harvested

20ideas

developed

8ideastested

4ideas

implemented

£££££

Idea IdeaIdea

IdeaIdea Activity •Vote for the ideas you like best•Identify the top 10



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



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



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

national leading improvement for health and well-being programme improvement methods workshop 1

Documents

improvement guide

healthcare improvement

service improvement

national leading improvement

organisational performance

implementtest change

important economic factors

current situation