1. An introduction to
Quality Improvement
Models

2. Learning Outcomes Learning about Model for Improvement
Understanding and using Driver Diagrams
Understanding and using Process Mapping
Understanding and working on the PDSA cycle
Being able to apply these to a change for improvement scenario in your role

3. Quality and Improvement
Quality is the degree of excellence in healthcare (Health Foundation Definition)
Quality improvement is better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies

4. “At the core of any model is influence over clinical behaviour to improve quality and minimise waste. Most of the solutions lie within the hearts and minds of our frontline clinical/care staff. The perfect model of care does not exist, and we need to create the capacity to piece together all the learning from other systems.
The commitment, encouragement and resilience of the people who wish to progress this is our greatest asset and some of our answers may not appear so obviously to begin with.”
Extract from Improving quality and reducing inequities: a challenge in achieving best care

5. Six Dimensions of Quality
Safety - do no harm
Timely - without undue delay; who receive and those who give
Effective - produces desired results
Efficient - avoiding waste, including waste of equipment, supplies, ideas, and energy
Equitable - providing care that does not vary because of gender, ethnicity, disabilities etc. in the patient; or at population level
Patient-centred - providing care that is respectful and responsive; needs, and values; seamless; provided with respect and compassion

6. Not a New Idea…
Florence Nightingale
@NHS_HealthEdEng

7. More Modern Statistics
The NHS pays out around £400 million in settlement of clinical negligence claims every year
Leape et al (1993) found 2/3rd mistakes preventable - 28% due to mistake by health professional and 42% due to other factors

8. Quality Improvement in Healthcare
In the words of Dr Mike Evans
@NHS_HealthEdEng

9. Model for Improvement

10. aims measurements change ideas testing ideas before
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result in improvement?
aims
measurements
change ideas
testing ideas before
implementing changes
Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

11. Act Plan Do Study Carry out the plan Collect the data Analysis
Complete the analysis
Compare with predictions
Summarise
Set objectives
Questions
Who, where and when
Collect data to answer questions
What changes are to be made to the next cycle?
Can the change be implemented?
Act
Plan Do
Study
Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

12. Continuous Improvement
PDSA Cycle
How can we achieve this? A P D S A P D S A P D S
SOMETHING
BIG! A P D S A P D S A P D S A P D S A P D S A P D S
Continuous Improvement
Small Steps with data
Data is continuously collected across the small cycyle
Use example Daunting – the Revising the assessment process of doctors – annual review of competency progression –
Could be like this ……
Cycle one Test out new assessment form
Cycle two Try out new location using the new form
Cycle three Orientate one assessor with new form
Cycle Four – Orientate other staff in using form
Feedback and data …crate run chart of the time ti use the form …if it improves the efficiency of the process
Balance measure – how complete the assessment process is
Changing the discharge process …to patients home by 11ma
Id TTOs
PDSA 1 - Consistent ward pharmacist (project lead) Daily check on all drug charts to ensure newly prescribed medicines present in locker
PDSA 2 - Ensure 2 weeks supply of pre-admission medicines in patients locker on transfer to the ward
PDSA 3 - Locker checks PDSA 4 - Ensure 3 weeks supply of pre-admission medicines in patients locker on transfer to the ward
PDSA 5 - Different ward pharmacist (not part of project team A P D S A P D S
Ideas/ theories

13. Spending more time on the WHAT than the HOW!
© NHS Institute for Innovation and Improvement All rights reserved.
Meeting rooms
Design
Design
Design
Design
Approve
Implement !
!! ANIMATED SLIDE !!
1 x  brings in the red text at the bottom
Sometimes all the Doing is done by the wrong people and/or in the wrong place. How many policies have you seen that are overly bulky, completely unworkable? Or
A change has been implemented after it has been designed by a committee after lots of meetings and discussion – only to find it is unpopular and disregarded?
Real world
Spending more time on the WHAT than the HOW!
Courtesy of Patient Safety First

14. Which is typical of your organisation?
© NHS Institute for Innovation and Improvement All rights reserved.
Meeting rooms
Design
Approve
Measurement
!! ANIMATED SLIDE !!
1 x  to bring in question at the bottom
Relate back to Kotter here. How small scale changes can help change the perspective for creating short terms wins which are more certain.
Test & refine
Test & refine
Test & refine
Implement
Real world
Which is typical of your organisation?
Courtesy of Patient Safety First

15.   S A P D P D S A PDSA Cycle Traditional Approach to Activities15
© NHS Institute for Innovation and Improvement All rights reserved.
PDSA Cycle
Traditional Approach to Activities S  A  P D
Time
!! ANIMATED SLIDE !!
1 x  to bring in question at the bottom
Traditionally – minimal planning, lots of doing, and doing it again (due to a lack of plan). Typically no S & A – but another cycle of PD, PD etc
Suggested – loads of P-ing! Typically 3-4 times more time spent in (effective) planning
This can be really frustrating for those not used to it (give an example?) but the joy is that the doing is quicker because the planning was more detailed and thought through.
Consider though that the Planning still does not guarantee success if it’s all done locked away in meeting rooms without involvement of the key people who will be doing the Doing.
Key difference is inclusion of the S and A stages.
Gives us a feedback loop and the opportunity for learning and continual improvement
Ask the final question and allow a minute for discussion.
If nothing forthcoming can give the example provided by a hospital in the North East – when faced with setting up a project to improve yyyy they met on a monthly basis as a working group for approximately a year – planning, planning, planning – but never actually DOING anything…
Optional: Draw completeness / compatibility curve on flipchart – see facilitators pack for guidance
Suggested Approach P D S A
Time saved
Which is typical of your organisation?

16. “Insanity: doing the same thing over and over again and expecting different results”

18. PDSA Measures Accuracy 10: All pieces on Sam and positioned correctly
5: All pieces on Sam but one of more is out of place
1: No Pieces on Sam
Time
Start: When time keeper says so
Stop: When colleague indicated last piece is in place AND removes hand

20. Measurement for Improvement
“You can’t fatten a cow by weighing it” (Palestinian Proverb)
Improvement is not about measurement, but…
How do we know if a change is an improvement?
“if you can’t measure it, you can’t improve it”

21. Driver Diagrams Used to plan improvement project activity
Provide a way of systematically laying out aspects of an improvement project
Three columns:
Aim/Outcome: What needs to be achieved
Primary Drivers: Set of factors that must be addressed to achieve the aim
Secondary Drivers: Specific areas where we plan changes.

22. Aim: An improved system
Schematic view of a system on the left we depict outcome (aim) As we move right we drill down into the network of causes that drive the outcome, from ‘primary’ to ‘secondary’ drivers.
Aim: An improved system
Primary
Driver
Secondary
Explain that the driver diagram is a way of showing visually what we have to do to meet our aim
Click for build
Aim is … read it out. This will be your aim
Click for next build
Identify primary drivers - key influences on outcome of aim
Sometimes we can break those primary drivers down into more factors

23. Aim: An improved system
On the right we depict ideas for system changes that might ultimately impact the outcome. Diagrams represents our theory about how to modify the system to change the outcome.
Aim: An improved system
Primary
Driver
Projects Change
Secondary
Click for next build
Interventions – practical steps we can take to influence driver
Summary
Aim – this links with the first question of Model for Improvement
Driver – key influences on outcome of aim
Intervention – practical steps we can take to influence driver
This is easier to see from an actual example

24. Driver Diagram – Weight Loss
Walk daily commute
Stairs not lift
Exercise
Reduce alcohol intake
Eat Less
Pedometer
Gym work out 3 days
Squash weekends
No pub weekdays
Take packed lunch
Low fat meals
Energy Out
Energy In
Aim:
2 stones lighter!
Note: Top intervention is a measurement device – pedometer. Ask why measuring something can sometimes cause a reaction.
Answers include: Hawthorne effect (knowing we are being measured changes our behaviour), competition (What! I only walked 1000 steps today so far? I must do more)

25. Exercise: Driver Diagram
Using the template provided make a driver diagram for reducing fuel costs

26. Reduce fuel price per gallon Shop at a cheaper petrol station
Outcome
Primary Drivers
Secondary Drivers
Reduce fuel price per gallon
Shop at a cheaper petrol station
Take advantage of loyalty cards
Decrease my Fuel Cost
Reduce miles driven
Walk to work instead of driving
Utilise public transport
Use car pooling
Increase efficiency (miles per gallon)
Increase car efficiency (buy a more fuel efficient car)
Improve driving pattern (improving driving habits)
Avoid unnecessarily accelerating and decelerating

27. Process Mapping
Views the system from patient perspective, following their journey
Help staff understand the complexity of processes
Diagnostic and used as a basis for redesign, actively involving staff in the process

28. Process Map - Example Go to sleep Alarm goes off Is this a work day?
Groan heavily
Get up! No
Yes

29. Process Mapping-2 Stages
Understand what actually happens to the Patient. Where it happens and who is involved.
Stage 2
Use the map to identify steps that could be changed.

30. Using the map Look for bottle necks/constraints (Queues)
Any delays? (eg. Wait for clinician/consent/results/parking)
Repetition (eg.Patient identity check)
Unnecessary travel/movement in the department. (eg. Patient or notes)
Unnecessary steps?
Inefficient order of events?

31. Look at the whole process, not just the individual steps.
We often give more attention to individual steps than the process overall
Mind the gap !

32. Process Mapping What are you trying to achieve?
Describe your aim. For example-To reduce the time Patients spend waiting in out patients.
Who do you need at the meeting?
Do you need to walk the journey yourself?
Do you need to plot the timings/experiences of a series of cases?

33. Process Mapping-What do you need
Your aim
The right people (not just clinicians)
Time
Paper (flip chart/backing paper)
Coloured pens
Post its
Facilitator

34. Process Mapping-What do you need
Your aim
The right people (not just clinicians)
Time
Paper (flip chart/backing paper)
Coloured pens
Post its
Facilitator

35. Summary Driver Diagram – understanding context of outcome
Process Mapping – understanding processes involved in achieving outcome
PDSA – Testing changes in that process and their impact on the context to ensure they are an improvement

36. Resources Available QI Resource website
Links to resources, example projects, events

37. H

39. H

40. Health Education East Midlands Quality Improvement Forum 2016
SAVE THE DATE! Health Education England working across the East Midlands are pleased to announce that the next Quality Improvement Forum will take place on 29th June the Kube, Leicester Racecourse in Oadby, Leicester. Key HEEMQIF16 activities for your diary:
Call for Quality Improvement Projects Abstracts – 1st February 2016
Call for bookings & workshop bookings open –1st February 2016
Abstract submissions close –March 2016
Bookings close –May 2016
HEEMQIF16 – 29th June 2016
Join in the conversation on Twitter #HEEMQIF16 #loveourlearners

41. A Final Thought from Don Berwick
“The most important single change in the NHS in response to this report would be for it to become….a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”
Don Berwick. A promise to learn - a commitment to act. August 2013.