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HEALTH CARE SYSTEMS Every system is perfectly designed to achieve exactly the results it gets.

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Presentation on theme: "HEALTH CARE SYSTEMS Every system is perfectly designed to achieve exactly the results it gets."— Presentation transcript:

1 HEALTH CARE SYSTEMS Every system is perfectly designed to achieve exactly the results it gets

2 THE HEALTHCARE PROCESS The Patient 133 People to take care of the patient

3 Avedis Donabedian (1919 – 2000) Outcome Process Structure

4 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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6 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!

7 The Improvement Skeleton Reliable Design The Model for Improvement Data Collection and Analysis Engaging Clinicians Understanding Variation


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