Using Quality

Improvement ToolsMargaret Stone and James Innes

Introduction

1. Introduction to tutors

2.Project speed dating

3.Diagnosing the context for improvement work

4.Quality tools

5.Moving the project forwards

6.Questions

Learning outcomes

After the session on using Quality Improvement Tools, participants will be able to:

1. Diagnose the context for the patient safety related project.

2. Use quality tools to understand the patient safety issue.

3. Understand the next steps to move the project forwards.

Project speed dating

In your table groups:

90 secs to explain your project to the rest

of the group

Title

What is the issue you are trying to solve?

Why – do you have data to show that there is

an issue?

When bell rings, the next person has 90 secs

to explain their project

…….

Diagnosing the context for

improvement workJames Innes

Context is everything –Professor Paul Bate

The role of context in successful improvement –Professor Glenn Robert and Professor Naomi Fulop

How does context affect quality improvement? –Professor John Øvretveit

The problem of context in quality improvement –Professor Mary Dixon-Woods

What is context?

“context refers to the why and when of change, and concerns itself both with

influence from the context external to the provider (such as the prevailing economic,

social, political environment) and influences internal to the organisation under study (for example its resources, capabilities, structure,

culture and politics).”

A tool for understanding context for QI

MUSIQ(The Model for Understanding Success in Quality)

Heather Kaplan, Lloyd Provost, Craig Froehle, Peter MargolisBMJ Qual Saf 2012; 21:13-20

Model for Understanding Success in Quality (MUSIQ)

• Tool designed to help you assess aspects of your local context that may affect the success of your quality improvement project

➢ QI project team: diversity, leadership, subject matter knowledge, experience of working together.

➢ Microsystem: motivation to change, stable leadership, capability for change, culture.

➢ QI Support and capacity: data infrastructure, QI resources, access to QI knowledge.

➢ Organization: Culture focused on improvement, QI leadership, strategic importance.

➢ Environment: promoting culture of improvement, do external pressures focus attention on your project.

Model for Understanding Success in Quality (MUSIQ)

• Excel calculator

• Download from the microsite tools page

• Project lead to fill out with your QI coach at the start of your project

• Score each element of context, and it will calculate your total score

168 Highest Possible MUSIQ Score

120-168 Project has a reasonable chance of success

80-119 Project could be successful, but possible contextual barriers

50-79 Project has serious contextual issues and is not set up for success

25-49 Project should not continue as is; consider deploying resources to other improvement activities

24 Lowest Possible MUSIQ Score

• Look at areas of weakness and see if you can address at the start of the project

MUSIQ

Thinking about your own context, rate your readiness in each of the following

areas:

Not ready at all

Totally ready

Don’t knowN/A

1 2 3 4 5 6 7 0

➢QI project team

➢Microsystem

➢QI Support and capacity

➢Organization

➢Environment

Neutral

Quality ToolsMargaret Stone

What are quality tools?

Tools used to systematically and objectively investigate a

problem/issue and try to determine different areas that can be

changed to improve quality in a system.

Good lists of those used in the NHS at:

https://improvement.nhs.uk/resources/quality-service-improvement-

and-redesign-qsir-tools/

http://www.pharmacyqs.com/common-quality-improvement-tools/

We will consider

Process mapping Stakeholder analysis

Cause and effect Driver diagram

Process mapping

Map or flow chart of a journey through a process

Often from patient’s perspective

Tips:

Be honest Map what, who, how long, (where)

Involve lots of people Be prepared for problems/solutions

Don’t make assumptions Create with different coloured post-

it notes

Break down into lots of

steps

Go with most commonly used process

Include branches and side

loops

Agree start and finish points

Process maps

Stakeholder analysis

Used to identify everyone who needs to be involved in the QI project and how much time is needed for their commitment.

Use if project is bigger than just pharmacy, especially if it goes outside organisation.

Structured way to identify stakeholders, prioritise their importance to the project, then analyse their readiness for change.

Then you know who to approach, when and how to motivate them.

Prioritising importance

Cause and Effect

Form of root cause analysis, also called “fishbone”.

Systematic way to look for influencing factors.

Do with a group of people.

Be prepared for problems/solutions.

Considers different factors:

Patient Individual (staff)

Task Communication

Education and Training Equipment and Resources

Working Condition Organisational and Strategic

Patient

factors:Clinical condition

Physical factors

Social factors

Psychological/

mental factors

Interpersonal

relationships

Individual

(staff) factors:Physical issues

Psychological

Social/domestic

Personality

Cognitive factors

Task factors:Guidelines/

procedures/

protocols

Decision aids

Task design

Communicatio

n factors:Verbal

Written

Non-verbal

Management

Team factors:Role congruence

Leadership

Support + cultural

factors

Education +

Training Factors:Competence

Supervision

Availability /

Accessibility

Appropriateness

Equipment +

resources:Displays

Integrity

Positioning

Usability

Working condition

factors:Administrative

Design of physical

environment

Environment

Staffing

Workload and hours

Time

Organisational +

strategic factors:Organisational

structure

Priorities

Externally imported

risks

Safety culture

Problem

or issue

(CDP/SDP)

Driver Diagram

Used with big projects to show an overall quality improvement goal can be broken down into its underpinning drivers and sub-projects.

Useful if you will be measuring improvement – helps you work out what to measure, and the impact of a specific change.

Brainstorm with a group of people.

Agree on 1 overall, measurable project goal.

Build a driver diagram.

Agree which drivers/actions you will prioritise to achieve the overall goal.

Driver diagram

Primary driver 1

Secondary driver 1

Change idea 3

Change idea 4

Change idea 5

Secondary driver 2

Primary driver 2

Secondary driver 3

Change idea 1

Change idea 2

Aim

Over to you……………

4 activities on tables

1. Process mapping

2. Stakeholder analysis

3. Cause and effect diagram

4. Driver diagram

2 tools each

Based on 1 project from the group.

Table hosts to guide activity

Break time!!

Chat to our industry

supporters.

Chat more about your

individual project

ideas.

Find out more about

the UKCPA.

Over to you……………

4 activities on tables

1. Process mapping

2. Stakeholder analysis

3. Cause and effect diagram

4. Driver diagram

2 tools each

Based on 1 project from the group.

Table hosts to guide activity

Moving the project forwardJames Innes

The sequence of improvement

Identification of quality

issue

Understanding the problem

Developing a strategy and change ideas

Testing Implementation & sustaining the

gains

The sequence of improvement

Identification of quality

issue

Understanding the problem

Developing a strategy and change ideas

Testing Implementation & sustaining the

gains

“Tools used to systematically and objectively

investigate a problem/issue and try to

determine different areas that can be

changed to improve quality in a system.”

The sequence of improvement

Identification of quality

issue

Understanding the problem

Developing a strategy and change ideas

Testing Implementation & sustaining the

gains

The big question…

Do I:

Simply implement identified solutions/change

ideas for my project?

Test solutions/change ideas first and then scale

up?

Dr Ronald A Heifetz. LEADERSHIP WITHOUT EASY ANSWERSHarvard University Press, 1994

The Messiness of Life!

34

“Some problems are so complex that you have to be highly intelligent and well informed just to be undecided

about them.”--Laurence J. Peter

A good reference on this topic is “Wicked Problems and Social Complexity “

by Jeff Conklin, Ph.D., Chapter 1 in Dialogue Mapping: Defragmenting Projects through Shared Understanding. For more information see the CogNexus Institute website at http://cognexus.org, 2004.

A P

DS

A

P

D

S

APD

S

AP

DS

Rapid cycle

testing

Develop a strategy

Prioritise and pick

change ideas

Observe the results

Implement,

adapt or

abandon

A structured approach to tackle complex problems…

Top tips to move from strategy to action

1. Leverage your existing assets:

Can you identify a project lead, project sponsor

Use MUSIQ to improve context for your project

Can you be explicit about the aim of your project, timeline and what you will need to drive project forwards e.g. access to data, staff time etc.

Top tips to move from strategy to action

2. Build a Coalition for Change:

How can you engage and inspire people about the project?

Use stakeholder map to identify champions for this work. How can you give them a central role?

Use the power of multiple communication channels (traditional vs disruptive) to build will

Top tips to move from strategy to action

3. Build Capability:

Use QI approach that is being championed by

your organisation

3 is the magic number for building capability in a

project team around QI method you will be using

Top tips to move from strategy to action

3. Build Capability:

NHS Improvement: https://improvement.nhs.uk/resources/quality-service-

improvement-and-redesign-qsir-tools/

Pharmacy QS: http://www.pharmacyqs.com/common-quality-improvement-

tools/

Health Foundation Q Community