2. Introduction to Improvement

3. The First Law of Improvement
“Every system is perfectly designed to achieve exactly the results it gets.”
Dr Paul Bataldan

4. Working harder will not allow us to make the change.

5. All improvement requires change but not all change will result in an improvement
Langley et al, 2009
The Improvement Guide

6. Applied Science Approach
The Typical Approach
Applied Science Approach
Traditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business.
e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable.
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; Available: p26

7. The Model for Improvement
‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’
Dr Donald M. Berwick
Former Administrator of the Centres for Medicare & Medicaid Services
Professor of Paediatrics and Health Care Policy
at the Harvard Medical School
MFI is made up of 2 parts – the thinking part and the doing part
The 3 questions – the thinking part prepares you for the test by asking the ‘so what’ question
They need to be thought through, answered and written down by the improver to ensure that they, and therefore their colleagues, are clear on the benefits to them and their work.
That message often gets lost in the many things we are expected and asked to do and is one of the reasons why so many interventions are not implemented reliably.
If we are not clear on the benefits of something we are much less likely to do it.
The Plan Do Study Act cycle is a simple tool that’s used to test out ideas that will improve your systems and processes while learning what works and doesn’t work.
It’s a structured approach for making small incremental changes to systems that allow you to test on a small scale, learn from successes and failure and redesign as you go
It builds learning and buy in incrementally as tests ramp up and allows clinicians knowledge about their own system is built in to the process

8. QI Key Factors for Quality Improvement Will Execution Ideas
Having the Will (desire) to change the current state to one that is better
Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas
Developing Ideas that will contribute to making processes and outcome better
Will QI
Execution
Ideas

9. History – Where has it come from?
W.E.Deming ( )
American statistician, author, lecturer, professor
Biggest impact on Japanese manufacturing and business
2 types of knowledge – subject matter and profound knowledge
Developed the Plan-Do-Study-Act cycle

10. Model for Improvement Act on the plan - Testing

11. Aim Measures Changes Implementation The Improvement Guide, API
3 questions and a learning cycle
4 basic aspects: aims, measures, changes and execution
The Improvement Guide, API 11 11

12. Question 1: What are we trying to accomplish?
Developing the team’s
Aim Statement
Do some more work on the thinking part.... First question – the aim!

13. Check points - developing an Aim Statement
AIM Content
Explicit over arching description
Specific actions or focus
Unachievable by hard work alone
AIM Characteristics
Measurable (How good?)
Time specific (By when?)
Define participants and customers 13 13

14. EYC Example Aim Statements
To reduce infant mortality, i.e. deaths by 12 months of age (including stillbirths) by 15% by end-2015.
90% of children will receive a bedtime story 3 times a week by the end of the summer term
The EYC will be the first agenda item at each CPP meeting by January 2014

15. Exercise Think about if you were challenged to do a marathon…..
Identify an aim
(what do you want to achieve,
how good, by when?)

16. Question 2: How do we know that a change is an improvement?
Improvement is not just about measurement However… without measurement you will never be able to answer the question!

17. How will we know a change is an improvement?
Measurement of Improvement Work
Define measures that will measure the impact of the
Improvement work
They will monitor and guide your progress
This may take a number of different approaches:
Percent compliance
A count of correct attempts
Verbal feedback

18. This is what you need for a PDSA measure – nothing more

19. Measures Exercise: Think about if you were challenged
to do a marathon…
Identify measures (how will you know?)

20. ‘Change’ can mean different things
Model for Improvement Q3 What changes can we make that will result in improvement?
‘Change’ can mean different things
Change a light bulb, change a nappy, change your car……. reactions to wear and tear or needing replaced - sets things back to where they were
Not necessarily a source of improvement
Improvement is innovative change for the better

21. Selecting Changes
Copy: use the literature, experience of others, hunches and theories
Be strategic: set priorities based on the aim, known problems and feasibility
Avoid low impact changes
Steal shamelessly and learn from others
Use the Driver Diagrams

22. Innovative thinking....!
QI is about making changes that result in lasting improvement not just making changes because something needs replaced or has run its course.
Thinking creatively and bringing about change can be a challenge – we are often follow the accepted norms and not try out new ways of doing things. In some organisations change is a challenging concept where tradition and accepted norms are quietly tolerated, even though we may have a good idea that will make a positive change for the future with more effectiveness and or efficiency.

23. A Practical Need Often Drives Creativity!23

24. Change Ideas Exercise: Think about if you were challenged
to do a marathon…
Identify changes
(what changes can you make?)

25. Why Test Changes?
To increase the belief that the change will result in improvements in your setting
To learn how to adapt the change to conditions in your setting
To evaluate the costs and “side-effects” of changes
Overall to minimise the resistance when spreading the change throughout the organisation.

26.  Do  Study  Act  Plan  Do  Study  Act
Northwest Improvement Initiative
“What will happen if we try something different?”
“What’s next? ”
Four parts of the cycle:
Plan:
Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen?
Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test.
Do:
Carry out the change.
Study:
Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test?
Act:
Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?
“Did it work?”
“Let’s try it!”
© R. Scoville & I.H.I.

27. Cycles of Tests Build Confidence
Northwest Improvement Initiative
Cycles of Tests Build Confidence
Changes that will result in improvement
Learning from data
Working our way up to implementation is a matter of building belief in the effectiveness of a change.
First tests are small scale, under optimal conditions: changes that fail here are discarded quickly.
If they succeed, we explore them in more detail: by replication under other circumstances, with different actors, in different locales, etc. If the change looks robust, it will gather the approval it will need for implementation. Along the way, we’re building confidence in the change.
Proposals, theories, hunches, intuition
© R. Scoville & I.H.I. 31

28. PDSA Testing - simulation exercise
The Skittle Challenge

29. The Skittle Challenge DO NOT EAT the Skittles – yet…
Aim – to be left with one Skittle
Measure – number of Skittles left
Changes – which one to remove first?
– what order to remove them in?
– how you work as a team?
Execution
Put a Skittle on each circle
Remove one to start
Jump over one at a time and remove it
Keep going until you can’t jump over any more
How many are left? (Plot your data and annotations)
Think about how it went and what you could improve next round. (Theory and prediction based on learning)
DO NOT EAT the Skittles – yet…

30. Number of Skittles Left
PDSA #
Theory
Prediction 1
Start with No. 5 empty
Will have 3 skittles left 2 3 4 5 6
Number of Skittles Left 7
Number left 6 5 4 3 2 1
PDSA

31. Run Chart to Measure PerformanceD O W N is G
Test 2 - XYZABC
Test
Test 1
ABCXYZ
Tests

33. The Skittle Challenge Consistency of purpose Prediction Planning
Documentation
Sharing and stealing!
Learning from failure

34. A solution….
6-1, 4-6, 1-4, 7-2, 13-4, 2-7, 11-4, 14-5, 10-3, 3-8, 4-13, 12-14,

35. Measurement and Data Collection During PDSA Cycles
Collect useful data, not perfect data –
data for learning, not evaluation
Use a pencil and paper until the information system is ready
Use sampling as part of the plan to collect the data to reduce workload
Use qualitative data (feedback) rather than wait for quantitative data
Record what went well and what didn’t work so well during the test of change

36. Start Small 1 client 1 day 1 case 1 worker
Move to 3,5,7…. as confidence grows

37. Drop down next “two levels” to plan test cycle!
Smaller Scale Tests: Shrink It! rapid cycles of learning
Years
Quarters
Months
Weeks
Days
Hours
Minutes
Drop down next “two levels” to plan test cycle!

38. Sequence for improvement
Make part
of routine
operations
Sustain & spread
a change to other
locations
Test under a
variety of
conditions
Implement
a change
Theory &
prediction
Test
a change
Study
Act
Plan Do
Support with data and consideration of people
Develop
a change
Based on slide © IHI 2009

39. PDSA Cycles in EYC
Testing approaches to increase attendance at nursery - children with >60% attendance rate
Testing out use of a Safety Brief huddle for staff at a multidisciplinary ‘one stop’ substance misuse clinic
Testing approaches to establish robust recording and sharing of information in relation to gender based violence cases – Health Visitors and Social Workers
Testing an approach to increase uptake of healthy start vitamins