Jean Penny BPR Leicester Royal Infirmary

North East Leading Improvement for Health and Well-being Programme Improvement Methods Workshop 1

Jean Penny BPR Leicester Royal Infirmary 1994 - 1999
All working life in NHS Diagnostic Radiographer and teacher Improvement roles since 1994 BPR Leicester Royal Infirmary National Patients ‘Access Team NHS Modernisation Agency 2002 – 2005 NHS Institute for Innovation and Improvement Awarded OBE for services to NHS 2003 Visiting professor University of Derby 2008

Introductions Who are you? Where are you from?
Which of the 10 work streams are you working on 3

Improvement workshop 1: agenda
Leadership and improvement Linking strategic aims to frontline change Valuing the differences Coffee 11.00ish Lunch 12.30ish Tea 2.30ish Finish by 4.00pm at the latest Prediction Different experiences Different knowledge and skills Some will be new Some will be familiar - from your first event Some you will know Today you will have time to think about how to apply to your work

Leadership and improvement

Leadership framework for improvement
1. Set Direction: Mission, Vision and Strategy Make the future attractive Make the status quo uncomfortable 3. Build Will Plan for improvement Set aims/allocate resources Measure system performance Provide encouragement Make financial linkages Learn subject matter 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 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 2. Establish the Foundation Reframe operating values Build improvement capability Prepare personally Choose and align the senior team Build relationships Develop future leaders Source: Robert Lloyd Executive Director Performance Improvement Institute for Healthcare Improvement January 16, 2007

Basics of improvement

Knowledge about Variation Knowledge of Psychology
Deming Knowledge of Systems Theory of knowledge Knowledge about Variation Knowledge of Psychology W Edwards Deming (1994) The New Economics

Discipline of improvement
4 equally important parts of improvement People User and public involvement Diagnostic tools e.g. Process and systems thinking Process What Change management Project and programme management How Discipline of improvement in health and social care (Penny 2003)

‘Every single person is enabled, encouraged and capable to work with others to improve their part of the service.’ People User and public involvement Diagnostic tools e.g. Process and systems thinking Process What Change management Project and programme management How Discipline of improvement in health and social care (Penny 2003)

Act Plan Study Do What are we trying to accomplish?
Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Model for Improvement What are we trying to accomplish? How will we know that a Measuring processes and outcomes change is an improvement? What change can we make that will result in improvement? What have others done? What hunches do we have? What can we learn as we go along? Act Plan Study Do 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 11

Linking strategic goals and frontline improvement

Defining status and position
Tools to find out the current status and position of an organisation or individual in relation to their environment and current role. Use as a basis for future planning and strategic management. Prioritisation – ‘something considered to be more important than other things’ (PMMI, 2006)

PESTLE 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?

Discussion 1: Using PESTLE take stock of the position of your improvement topic then Use PESTLE to map the things that will influence the way your service is delivered

Tools and techniques: PESTLE & SWOT

Understand the Complexity of Your Project
Macro Meso Micro ©Profound Knowledge Products, Inc All Rights Reserved

Aim The ‘big’ dots Drivers Interventions The ‘small’ frontline 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 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 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 Interventions The ‘small’ frontline dots Contribute directly to the drivers

? The strategic aim (and big problem) Primary Drivers:
Contribute directly to the strategic aim Secondary Drivers: Contribute directly to primary drivers The interventions / change ideas that contribute directly to secondary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 ? Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3

Reduce surgical site infections
Primary Drivers Secondary Drivers Appropriate use of prophylactic antibodies Maintain normothermia Reduce surgical site infections Maintain glycaemic control in known diabetes Reducing harm in perioperative care Use recommended hair removal methods Use of the WHO Surgical safety checklist Improve team work and communications Ref. Patients Safety First

Developing measures to support an objective
Make effective use of existing public housing Work with registered social landlords to develop public housing Manage housing benefit effectively To provide accessible rented housing Percentage dwellings empty Relet intervals for all public housing Percentage housing stock in good repair Total number of dwellings available Speed of processing claims Accuracy of processing claims

Discussion 2: Consider the position of your improvement topic in a driver diagram Is it a primary or secondary driver? What would your driver diagram look like?

The Model For Improvement

Measurement: Big dots and little dots
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

First define the problem
Root Cause Analysis (5 Whys) Process Mapping Ishikawa (Fishbone) Brainstorming Data Pareto Analysis And more..... 25 25

Define The Problem Secondary Care Primary Care Social Care
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 An example Process Map: Secondary Care Primary Care Social Care Tertiary care 26 26

Analysing a process map
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!! 73

Why is Lean Relevant? “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 Eliminating Non Value Add has a major impact on Quality, Cost and Service Delivery

What is Waste? Lean Principles Motion – unnecessary
movement e.g having to walk up and down the ward to obtain appropriate supplies 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 Inventory – “stuff” waiting to be worked on e.g patients on a waiting list What is Waste? Lean Principles Overproduction – too much “stuff” e.g. requesting unnecessary tests and X-rays Waiting – people waiting for “stuff” to arrive e.g waiting for a ward round Defects – “stuff” that is not right and needs fixing e.g a leaky tap Injuries – damage to people e.g stress Transportation – moving “stuff” e.g moving patients from ward to ward Mark Rahman NHS Scotland

Analysis of a process map
For each step ask ‘does it add value?’. If not ask: Can it be eliminated? Can it be done in some other way? Can it be done in a different order? Can it be done somewhere else? Can it be done in parallel? Can any “Bottlenecks” be removed? Is it being done by the most appropriate person?

What are the problems for users, carers and staff and what are the causes of the problem?
Ishikawa (Fishbone) Diagrams People Place PPPP Procedures Policies 31 31

Example Cause & Effect Diagram
© 2004 Institute for Healthcare Improvement 32 32

Use Pareto Principle to identify cause(s) of problem to work on first
‘The Rule’ ‘The Law of the Vital Few’ For many phenomena, 80% of the consequences stem from 20% of the causes Observation that 80% of income went to 20% of the population Vilfredo Pareto, 1906 33 33

Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives The more specific the aim, the more likely the improvement Repeated clarification - without it aims drift Meet needs of external customers Model for Improvement What are we trying to accomplish? How will we know that a Measuring processes and outcomes change is an improvement? What change can we make that will result in improvement? What have others done? What hunches do we have? What can we learn as we go along? Act Plan Study Do 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 34

Discussion 3: Have you defined the problem and agreed the aim for your improvement topic? Can you verbalise it in order to communicate? Use a fishbone diagram to start to identify the causes of the problem 35 35

Valuing the differences

4 equally important parts of improvement User and public involvement Diagnostic tools e.g. Process and systems thinking Change management Project and programme management Discipline of improvement in health and social care (Penny 2003)

Managing The Human Dimensions Of Change
Ways of helping others to change: Building trust and relationships Creating rapport Managing conflict Negotiation Effective communication

No rights or wrongs just differences!
Value (and learn about) the differences

Personal styles What are your fears about change?
How do you behave under stress? Personal styles Controls emotions Analytical formal measured + systematic seek accuracy / precision dislike unpredictability and surprises Driver business like fast + decisive seek control dislike inefficiency and indecision Ask Tell Amiable conforming less rushed + easy going seek appreciation dislike insensitivity and impatience Expressive flamboyant fast + spontaneous seek recognition dislike routine and boredom Shows emotions Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Personal styles Controls emotions Analytical Driver Ask Tell Amiable
formal measured + systematic seek accuracy / precision dislike unpredictability and surprises Driver business like fast + decisive seek control dislike inefficiency and indecision Ask Tell Amiable conforming less rushed + easy going seek appreciation dislike insensitivity and impatience Expressive flamboyant fast + spontaneous seek recognition dislike routine and boredom Shows emotions Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Fears about change Analytical Driver Amiable Expressive
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

Under stress Analytical Driver Expressive Amiable will withdraw
will become autocratic Expressive will become offensive/sarcastic Amiable will submit Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Personal styles Controls emotions Analytical Driver
Highly detail orientated Can have difficulty making decisions without all the facts Tend to be highly critical Very perceptive Objective focused Know what they want and how to get there Sometimes tactless and brusque Hardworking, high energy. Does not shy from conflict Ask Tell Expressive Amiable Natural sales people and story tellers Warm and enthusiastic but can be competitive Good motivators and communicators Can exaggerate, leave out facts and details 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 Shows emotions Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

How to recognise personal styles
The Driver: Command Specialist Perceived positively as: Perceived negatively as: Decisive Pushy Independent One man/woman show Practical Tough Determined Demanding Efficient Dominating Assertive An Agitator A risk taker Cuts corners Direct Insensitive A problem solver Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 12

The Expressive: Social Specialist Perceived positively as: Perceived negatively as: Verbal A Talker Inspiring Overly dramatic Ambitious Impulsive Enthusiastic Undisciplined Energetic Excitable Confident Egotistical Friendly Flaky Influential Manipulating Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 13

The Amiable: Relationship Specialist Perceived positively as: Perceived negatively as: Patient Hesitant Respectful Wishy Washy Willing Pliant Agreeable Conforming Dependable Dependent Concerned Unsure Relaxed Laid Back Organized Mature Empathetic Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 14

How to recognise personal style
The Analytical: Technical Specialist Perceived positively as: Perceived negatively as: Accurate Critical Exacting Picky Conscientious Moralistic Serious Stuffy Persistent Stubborn Organized Indecisive Deliberate Cautious Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 15

Another way of looking at it
Finding the balance Another way of looking at it Task focus Analytical Driver Get it right Get it done Aggressive Passive Get along Get appreciation Expressive Amiable People focus

Discussion 4: The Importance of Personal Styles
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 Think about Your team strength How the team can be more effective The style of the individual who may cause most difficulty

Trust: Caring & Competency
HIGH Affection Trust Distrust Respect Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill Extent to which I believe you care about me LOW HIGH Extent to which I believe you are competent and capable

Measuring for improvement (not judgement)

The Three Faces of Performance Measurement
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 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

Charts vs. Tables 56 56

What does this tell us?

Given two different numbers, one will always be bigger than the other!
Something very important! Last month This What action is appropriate?

What does this data tell us?
60

What does this data tell us?
Mean = 24.4 5 10 15 20 25 30 1 2 3 4 6 7 8 9 11 12 13 14 16 17 18 19 21 22 Weekly production volume July Aug Oct Sept Week 61

Run charts Seven one side DO Seven down (or up)
90 80 70 Average based on first 10 days 60 Seven down (or up) Seconds to answer phone 50 40 DO 30 20 10 1 4 7 10 13 16 19 Day Look for a run of seven points all above or all below the centre line, or all increasing or all decreasing 62

How often you measure can also have an effect on how you look at the results
Mike Davidge NHS Institute for Innovation and Improvement

Monthly data shows improvement
The chart shows the average monthly length of time before patients got to the Stroke ward

Weekly data tells a slightly different story

Patient level data adds another level of understanding

Aim The ‘big’ dots Drivers Interventions The ‘small’ frontline 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 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 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 Interventions The ‘small’ frontline dots Contribute directly to the drivers

Discussion 5: Measuring for Improvement
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 68 68

Change principle Change principle
Transferring solutions is rarely effective, Transfer change principles… Change principle Change principle Solution / change in organisation A Solution / change in organisation B

Speaking in PDSA Language
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) P D S A © Paul Plsek

Reviewing the experience Planning the next steps
The Learning Cycle Having an experience Reviewing the experience Concluding from the experience Planning the next steps Honey & Mumford, 1992 72 30 72

Discussion 6: Developing change ideas
Where will the change ideas come from? How will you gather them? How will you test them? Go back to your driver diagram Ideas for change: Yours and others Experience Brainstorming Evidence Steal ideas shamelessly

Leadership framework for improvement
1. Set Direction: Mission, Vision and Strategy Make the future attractive Make the status quo uncomfortable 3. Build Will Plan for improvement Set aims/allocate resources Measure system performance Provide encouragement Make financial linkages Learn subject matter 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 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 2. Establish the Foundation Reframe operating values Build improvement capability Prepare personally Choose and align the senior team Build relationships Develop future leaders Source: Robert Lloyd Executive Director Performance Improvement Institute for Healthcare Improvement January 16, 2007

4 equally important parts of improvement Two sides of improvement Helps ‘what’ and ‘how’ User and public involvement Diagnostic tools e.g. Process and systems thinking Change management Project and programme management Discipline of improvement in health and social care (Penny 2003)

Deming’s System Of Management
Knowledge of Systems Theory of knowledge Knowledge about Variation Knowledge of Psychology W Edwards Deming (1994) The New Economics “If I had to reduce my message for management to just a few words, I’d say it all had to do with reducing variation.”

Discussion 7: So what?????? Do you / your organisation currently use improvement tools and techniques? What are you going to do next? One thing you will do as a result of today One thing you have learnt / Ah-ah moment 79 79

Use resources 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 General Improvement Skills Process and systems thinking Personal and organisational development

Improvement workshop 2 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

Have a Safe Journey Home 
Goodbye and Thanks! Have a Safe Journey Home 

Jean Penny BPR Leicester Royal Infirmary

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