1. Why do clinicians do audits? Why do you want to improve care?

2. What are values?

3. Values are principles and beliefs that guide our actions

4. What are the values of your patients?

5. In clinical practice whose values do we need to be aware of?

6. Respect for the diversity of values

7. Patient-centred and safe Public health driven Prevention-focussed Professionally-inspired P Objectives clear Outcome driven O Evidence based E Team delivered T Integrated I Cost efficient and effective Clinically governed C

8. Introduction to clinical systems improvement

9. What is the perfect healthcare system? No needless deaths No needless suffering No delays No waste No inequalities No feelings of helplessness

10. Important questions You are providing a service – so who is the customer? Is there variability, waste, poor morale, poor value for money and defects in your system? Does your system have the capacity to cause harm? How much of your system adds value from the patient’s perspective? Has your system been designed?

11. Why use clinical systems improvement methodologies? They are good at discovering waste in a system Can tackle the problems in your service Can reduce waiting times Can revolutionise your service (given commitment) Require a team of key stakeholders who can analyse a problem from different perspectives (including that of the patient) Who are the stakeholders in a better Malawian healthcare system?

12. Which methodologies are useful to use when considering your audits? Root cause analysis and the use of ‘5 whys’ to truly discover the problem Ask the question ‘why?’ 5 times to get to the bottom of the problem

13. 5 whys example The patient was late in theatre, it caused a delay. Why? There was a long wait for a trolley. Why? A replacement trolley had to be found. Why? One of the trolley's wheels was worn and had broken. Why? It had not been regularly checked for wear. Why? The root cause - there is no equipment maintenance schedule. Setting up a proper maintenance schedule helps ensure that patients should never again be late due to faulty equipment. This reduces delays and improves flow. If you simply repair the trolley or do a one-off safety rail check, the problem may happen again sometime in the future.

14. 5 Whys group exercise In small groups, think of a problem that you have all experienced As the question ‘why?’ 5 times to identify the root cause How will you plan to improve the root cause?

15. Was that easy? Some things are considered “undiscussible” but may be the underlying cause of organisational problems Think about an example in your own work Divide a page into two columns In the right column: write down an actual or imagined conversation about an unsolved organisational problem on the right In the left column: write your unspoken thoughts & feelings relating to the conversation Now you are more aware of any “undiscussable” problems, think about how you might discuss them

17. Define a patient journey In two groups, discuss the patient journey for a 22 year old woman presenting with obstructed labour What are all the steps that she experiences from arriving at the hospital? – All the members of staff she meets – All the procedures she undergoes – Map these steps out as a flow chart on paper

18. Arrival Midwife Assessment History & examination Differential diagnosis Handover to clinical officer History and examination Differential diagnosis Develop plan of care Is our patient journey wasteful? Does every step add value to our patient?

19. Waste that does not add value Unnecessary movement of patients Unnecessary motion (equipment and consumables not to hand) Waiting Unnecessary tests and investigations Over processing (repeated history taking, examinations etc) Errors Overdurden of staff

20. Can you improve your patient’s journey?