Presentation on theme: "HEALTH CARE SYSTEMS Every system is perfectly designed to achieve exactly the results it gets."— Presentation transcript:
HEALTH CARE SYSTEMS Every system is perfectly designed to achieve exactly the results it gets
THE HEALTHCARE PROCESS The Patient 133 People to take care of the patient
Avedis Donabedian (1919 – 2000) Outcome Process Structure
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
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!
The Improvement Skeleton Reliable Design The Model for Improvement Data Collection and Analysis Engaging Clinicians Understanding Variation