1. North Tees and Hartlepool NHS Foundation Trust Clinical Leadership Development Programme Leadership and Improvement

2. 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
Improvement: 17 years and still learning

3. Agenda Understanding the skill of improvement
Linking strategic goals and frontline improvements

4. You have all made improvements
What tools and techniques, knowledge and skills are needed to make good sustainable improvements?
If you are familiar with ‘Lean’ ‘LIPS’ ‘Productive Ward’’, what are the underpinning tools and techniques

5. Theory of constraints Any improvement is a change Eliyahu Goldratt
not every change is an improvement
but we cannot improve something unless we change it
Eliyahu Goldratt
Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

6. Theory of constraints Any improvement is a change
any change is a perceived threat to security
there will always be someone who will look at the suggested change as a threat
Eliyahu Goldratt

7. Theory of constraints Any improvement is a change
any change is a perceived threat to security
any threat to security gives rise to emotional resistance
you can rarely overcome emotional resistance with logic alone
Eliyahu Goldratt

8. “Anyone who thinks you can overcome emotional resistance with logic was probably never married”

9. Theory of constraints Any improvement is a change
any change is a perceived threat to security
any threat to security gives rise to emotional resistance
emotional resistance can only be overcome by a stronger emotion
Eliyahu Goldratt

10. Share the problem not the solution
What to change?
Pin point the core problems
What to change to?
Construct (simple) practical solutions
How to cause the change?
Induce the appropriate people to invent such solutions
they must own the problem
Eliyahu Goldratt
Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

11. 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

12. 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

13. 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)

14. ‘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)

15. Linking strategic goals and frontline improvement

16. Understand the complexity of your project
Macro
Meso
Micro
©Profound Knowledge Products, Inc All Rights Reserved

17. 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

18. ? 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

19. 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

20. ‘High level Aims and objectives’
North Tees and Hartlepool NHS Foundation Trust Corporate strategy 2010 – 2015
Patient safety
Patient satisfaction
Staff satisfaction
Provider of choice
Quality of services
Governance and mandatory services
Financial stability
New facilitates
Care delivered closer to home
‘High level Aims and objectives’
Pages

21. ? 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

22. 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

23. 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
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 organizational performance 2nd ed,
Jossey Bass Publishers, San Francisco 23

24. First define the problem
Root Cause Analysis (5 Whys)
Process Mapping
Ishikawa (Fishbone)
Brainstorming
Pareto Analysis
etc
And
User and staff stories and anecdotes 24

25. 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 25

26. Example Cause & Effect Diagram
© 2004 Institute for Healthcare Improvement 26

27. 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 27

28. 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 process, outcomes and
balancing
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 28

29. 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

30. Charts vs. Tables 30

31. What does this tell us?

32. What does this tell us?

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

34. What does this data tell us? 34

35. 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 35

36. Run charts Seven one side DO Seven down (or up)90 80 70 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 36

37. How often you measure can also have an effect on how you look at the results
Average length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
0.5 1
1.5 2
2.5 3
3.5 4 5 6 7
Months
Average length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Weeks
Patient length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Patients
Mike Davidge NHS Institute for Innovation and Improvement

38. North Tees and Hartlepool NHS Foundation Trust
Corporate strategy 2010 – 2015
Strategic measures
Patient safety
Patient satisfaction
Staff satisfaction
Provider of choice
Quality of services
Etc etc

39. 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

40. 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?
Change ideas: 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 40

41. 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

42. PDSA cycle for learning and improvement
Act
Plan
objective
questions and
predictions (why)
plan to carry out
the cycle (who,
what, where, when)
what changes
are to be made?
next cycle?
Study Do
complete the
analysis of the data
compare data to
predictions
summarise what
was learned
carry out the plan
document problems
and unexpected
observations
begin analysis
of the data

43. 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

44. Repeated PDSA cycles work towards the AIM
What am I trying to achieve?
How will I know a change is an improvement?
What changes can I make that will result in the improvement
PDSA
PDSA
PDSA
PDSA
Data Driven Change
PDSA
Hunches
Theories
Ideas
Change in Team Culture
Need to start small!!

45. Leading improvement 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

46. What are the three key messages you have got from this session?
Think quietly by your self for a few minutes

47. Act Plan Study Do What are we trying to accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
Act
Plan
Study Do