Insert name of presentation on Master Slide A consistent approach to the methodology 27 October 2011 Presenters: Mike Davidge & Joy Whitlock

Model for Improvement & PDSA Cycles Model for Improvement

Part One: Where does it come from? Part Two: What is it and How does it work? Improvement methodology

Part One: Where does it come from? Part Two: What is it and How does it work? Improvement methodology

QI In an article in the Journal of Quality Improvement, 92 QI projects were compared. What was the timeframe from problem Identification to completion of first pilot? 1.23 days 2.60 days days days

Improvement methodology QI In an article in the Journal of Quality Improvement, 92 QI projects were compared. What was the timeframe from problem Identification to completion of first pilot? 1.23 days 2.60 days days days

Improvement methodology Journal of Quality Improvement  504 days from problem identification to completion of first pilot  397 days from first team meeting to the end of first cycle  75 days to describe current situation in flowchart  62 days for data collection if change was improvement Alemi, Safaie, Neuhauser “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11):

There’s a lot of material out there Improvement methodology

So what now? Improvement methodology

 We’ll conduct a 3 month pilot then we’ll roll out  We’ll just tell staff that this is the new way of working  We’ll do an audit to get a baseline and then repeat it after 6 months  We want all our departments to be 100% efficient, it’s taxpayers money we’re spending after all What mindset? Improvement methodology Results in LAME thinking not LEAN thinking Lean As Misguidedly Executed

Science of Improvement

Appreciation of a system Understanding Variation Theory of Knowledge Psychology The Lens of Profound Knowledge QI

Two Types of Knowledge Profound Knowledge Subject Matter Knowledge Profound Knowledge: The interplay of the theories of systems, variation, knowledge, and psychology. Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.

Knowledge for Improvement Profound Knowledge Subject Matter Knowledge Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Improvement

Appreciation for a System Interdependence, dynamism World is not deterministic Optimisation, interactions System must have an aim Whole is greater than sum of the parts Understanding Variation Variation is to be expected Common or special causes Ranking, tampering Potential mistakes Theory of Knowledge Prediction Learning from theory, experience Operational definitions PDSA for learning and improvement Psychology Interaction between people Intrinsic motivation, movement Beliefs, assumptions Will to change What insights might be obtained by looking through the Lens of Profound Knowledge at your project?

Profound Knowledge: Systems Thinking Appreciation of a System Understanding Variation Theory of Knowledge Psychology

Deming’s original diagram Improvement methodology “A system is a network of interdependent components that work together to try to accomplish the aim of the system”

I’m sure glad the hole is not in our end! People unclear on the concept of a system!

Two Fundamental System Principles The System is perfectly designed to achieve the results it gets. If each part of a system, considered separately, is made to operate as efficiently as possible, then the system as a whole will not operate as effectively as possible. - Ackoff (1981)

Profound Knowledge: Psychology Appreciation of a System Understanding Variation Theory of Knowledge Psychology Interaction between people Intrinsic motivation Beliefs & assumptions Will to change We understand that we have bad systems, not bad people How many of us come to work to do a bad job?

 Communications “NHS staff save lives every day – 1000 Lives Plus will help save more”  Leadership –Approach to motivation The impact? Improvement methodology

Profound Knowledge: Variation Appreciation of a System Understanding Variation Theory of Knowledge Psychology Understanding Variation Variation is to be expected Common or special causes Ranking, tampering Potential mistakes “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.” W E Deming

Improvement methodology The MBFC Index You will need a coin And two free hands! Just how competitive can you get?

 It’s easy to react in the wrong way  Natural variation is really quite large  It’s the system not the individual Lessons? Improvement methodology But when will we know that there really is something there?

Improvement methodology Walter A. Shewhart (early 1920’s, Bell Laboratories)  While every process displays variation:  some processes display controlled variation (common cause) –stable,consistent pattern of variation –constant causes/ “chance”  while others display uncontrolled variation –pattern changes over time –special cause variation/“assignable” cause

Improvement methodology Shewhart’s purpose  Data contains both signal and noise. To be able to extract information, one must separate the signal from the noise within the data.

Improvement methodology Upper process limit Mean Lower process limit A typical process control chart

Part One: Where does it come from? Part Two: What is it and How does it work? Improvement methodology

Profound Knowledge: Theory of Knowledge Appreciation of a System Understanding Variation Theory of Knowledge Psychology Theory of Knowledge Prediction Learning from theory, experience Operational definitions PDSA for learning and improvement Improvement methodology

 A change is a prediction  Comparing the predictions to the results of a test of change is a key source for learning  A “good” theory makes clear predictions that can be used… –to confirm or modify the theory, –to generate new exploration, and –to suggest practical application Prediction Based on Theory Improvement methodology

Model for Improvement Improvement methodology

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 AIM Improvement methodology

Aim Exercise Improvement methodology

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 AIM Goals & Measurement Improvement methodology

You can’t fatten a cow by weighing it…. Improvement methodology

Measurement Tracking a few key measures over time is the single most powerful tool a team can use. Improvement methodology

What are we trying to accomplish? How will we know that a change is an improvement? What change(s) can we make that will result in improvement? AIM Goals & Measurement Change(s) Improvement methodology

What changes can we make that lead to an improvement? Improvement methodology

Test ….  Most improvement usually requires change…..  however not all change is an Improvement!

Act Adapt? Adopt ? Abandon? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan (on a small scale) Document problems and unexpected observations Begin analysis The PDSA Cycle: Improvement methodology

Test of change have been going on for years “Negative results on the fish… Let’s try rubbing two sticks together.”

Breakthrough Results Theories, hunches, & best practices Learning and improvement AP SD Evidence & Data AP SD AP SD AP SD Develop a change Test a change Test new conditions Implement a change Building Knowledge with Multiple PDSA Cycles Sequential building of knowledge Include a wide range of conditions in the sequence of tests Improvement methodology

PDSA Cycle Example Change: Communication process to Physicians AIM: Improve Communication and obtain appropriate intervention DATA AP SD A P S D AP SD D S P A D S P A Cycle 1A: One nurse to use SBAR form to report on one patient to one physician. Cycle 1D: SBAR use on Unit A for a week Cycle 1?: Implement…. Wide Scale Cycles : when might it fail ? Cycle 1B:Same nurse to use revised form for two physicians for two nights. Cycle 1C: Three nurses requested to use SBAR form for their shift.

Improvement methodology Why test?  Learning  Confidence  Resistance

Improvement methodology How small is small ?

Data collection, feedback and testing Many PDSAs on different elements of the bundle continued to achieve process reliability Implementation and spread throughout unit SKIN Bundle Compliance

Days between pressure damage events

 Learning by doing This is a practical approach Improvement methodology “Improvement happens project by project and in no other way” Joseph Juran  Bottom up so perfect for students

The Ohno circle test  Stand in circle  Watch and note down what you see  Go and make improvements