Quality Improvement:Tools, Techniques and Considerations

Dr Mark AttahGP Partner, Octagon Medical Practice, Cambridgeshire

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

project

A Model of L S Change

Identifying

need for

change

Framing/

reframing

the

issues

Engaging/

connecting

others

Making

pragmatic

change in

multiple

processesAttracting

further interest

After some time Settling inPossible outcomes

1. sustainable norm

2. plateau

3. run out of energy

Living with

results and

consequences

Maybe later

Repeats

many times

in hard to

predict ways

Time delay

Three dimensions of large scale (transformational) change

Depthof change vis-à-vis

current ways of

thinking and doing;

a.k.a cognitive-

behavioural or

paradigm shift

Pervasivenessof change; does it affect whole or

only portion

of the system?

Sizeof system experiencing change; e.g.

geography, numbers of people

Refs: Mohrman A. et. al. Large-Scale

Organizational Change. Jossey-Bass,

1989 and Levy A. Second-order planned

change: definitions and

conceptualizations. Org. Dynamics.

Summer 1986, 15:5-20

What If Bigger Fixes Nothing?

Improvement or transformation?

Improvement Transformation

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

Your vision of the future and why? (shared purpose)

Aligning our efforts

“Are we going in the same direction in the activity we’re involved in ... like a school of fish?”*

*Focus group participant

Shared Values

A ‘prerequisite’ for successful large scale change

What is purpose?

A purpose statement sets out our burning ambition

- why this change is important to you

- why this solution rather than any other

A vision is the ideal picture in your mind, and in the minds of your people.

“A clear vision helps to empower your purpose. It shows the desired end result and so provides the motivation

to work toward that goal”

Jeff Randleman

A 3-word concept

Why is shared purpose important?

The evidence – globally

“Shared purpose is a common

thread in successful change

programmes. Organisations with

strong shared purpose consistently

outperform those without it”.

What makes change successful in the NHS? - Gifford

et al 2012 (Roffey Park Institute) and Management

Agenda 2013 - Boury et al (Roffey Park Institute)

The evidence

Growing literature demonstrating & discussing the importance of shared values, before & underpinning any other changes (structures, processes, incentives, infrastructure)• eg implementing integrated care

Failure to invest in establishing shared purpose, based on common values, results in wasted effort and disappointing results later

What happens when shared purpose is absent?

- Other factors move into the space and become ‘de facto’ purpose e.g. cost cutting and targets.

- Change efforts go off course or run out of energy.

Getting some balance…

Mental models of change – striking a balanceHow we think about engagement

Start with the end in sight

Large scale change usually fails

Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey of company executives

70%

25%

5%

Most transformation efforts fail

30 70

Employee resistance

to change

Management behavior

does not support change

Inadequate resources or budget

Other obstacles

39

33

14

14

Organizational

health factors

% of

efforts

failing to

achieve

target

impact

70% of change programs fail …

… mainly because organizational health gets

in the way

Source: Scott Keller and Colin Price, Beyond Performance: How Great Organizations Build Ultimate Competitive Advantage. 2011

Objectives

DESIRED OUTPUTS AIM

A shared vision for what the

Collaborative wants to achieve

Clarity of WHAT by WHEN

A shared purpose that underpins this

transformation

Clarity of WHY you want to

achieve this chosen change

A shared set of values that underpin

this shared purpose

The ‘WAY’ the collaborative will

work together to deliver this

change

A set of agreed design rules that this

Collaborative will use to drive

development and selection of solutions

Criteria to influence ‘HOW’ we

achieve this change

Define the Problem

QIP vs Audit

“what is the right thing to do?”

vs

“are we doing the right thing in the right way?”

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

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

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1426185/

• An evidence-based improvement

methodology ensures that our

change will be delivered in a

planned way that follows tried-and

tested methods for assuring

success.

Change Model framework

Model for Improvement

The “Model for Improvement”

What are we trying to

accomplish?

How will we know

that a change is an

improvement?

What changes can

we make that will

result in an

improvement?

Plan

DoStudy

Act

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., 1994. The Foundation of Improvement, Quality Progress, June 1994

Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

• 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

DoStudy

Meeting rooms

Real world

Approve

Design Design Design Design

Implement !

Spending more time on the WHAT than the HOW!

Courtesy of Patient Safety First

© NHS Institute for Innovation and Improvement 2010. All rights reserved.

Meeting rooms

Real world

Courtesy of Patient Safety First

Implement

Approve

Test & refine

Test & refine

Test & refine

Design

Measurement

Which is typical of your organisation?

© NHS Institute for Innovation and Improvement 2010. All rights reserved.

Traditional Approach to Activities

Suggested Approach

P D

P D S A

S A

Time

PDSA Cycle

Which is typical of your organisation?

Time saved

© NHS Institute for Innovation and Improvement 2010. All rights reserved. 37

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.

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?

The Model for Improvement

Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

Plan-Do-Study-Act

disciplined framework ensures every part is done every time

facilitates rapid prototyping and rolling out of new ideas

5127

Using a driver diagram

A method or tool or process for use by individuals or teams to generate and organise strategy

Driver Diagrams

AIM –an improved system

Primary driver 1

Primary driver 2

Secondary driver 1

Secondary driver 2

Secondary driver 3

Secondary driver 4

Secondary driver 5

CHANGE 1

CHANGE 2

CHANGE 3

CHANGE 4

CHANGE 5

CHANGE 6

CHANGE 7

AIM PRIMARYDRIVERS

SECONDARYDRIVERS

CHANGES TO TEST

CauseEffect

Drives

Photo: Jim Pennucci

Overwhelming?

Avoid silver bullet thinking

Avoid silver bullet thinking

We have a major problem with access in

our surgeryThe solution is

obvious. I’ve looked at the evidence and we need to bring in telephone triage.

Avoid silver bullet thinking – The multiple drivers of GP access

AIM PRIMARYDRIVERS

SECONDARYDRIVERS

CHANGE TO TEST

Improveaccess

Doctors (capacity)

Demand

Dealing (efficiency)

Appt system

Supply of GP time

Organisation of GP time

Pt help-seeking

Deflecting demand

Creating our own workload

Planning care

Appt system project

GP rota change project

Community education

Waiting room TV

PILS & CDs & DVDs

Feel better faster

Student sick notes

Reception signposting

Test results

Consulting skills

Longer appts

Guaranteed interpreters

Dealing w failed referrals

Chronic disease pathways

Review periods

More TelC’s

Email appts

Continuity

Telephone triage

Driver DiagramsWeight loss example

2 stone weight

loss in 12 months

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat meals

Buy only 1

sandwich

Water bottle for

work bag

Fruit for dessert

Put away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Take stairs2 stone weight

loss in 6/12

Look for patterns

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat mealsBuy only 1

sandwich

Water bottle for

work bag

Fruit for dessertPut away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Take stairs

Be more active during

the dayDo sport

Drink less alcohol

Substitute lower calorie

foods

Eat less

Marshall the mass of ideas

2 stone weight

loss in 6/12

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat meals

Buy only 1

sandwich

Water bottle for

work bag

Fruit for dessert

Put away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Be more active

during the day

Do sport

Drink less alcohol

Substitute lower

calorie foods

Eat lessReduce

calories in

Increase

calories out

Take stairs

2 stone weight loss

in 6/12

Marshall the mass of ideas

Driver Diagrams

Benefits ...

• build complex strategy

• immediate

• visual

Different scenarios ...

1. Share learning

2. Help generate change ideas

3. Marshall a mass of change ideas

4. Survive failure / the unexpected

• avoid “silver bullet”thinking

• highlight overlooked ideas

20 % REDUCTION IN ADMISSIONS

FOR THE OVER 70s

Reduce attendanceat A&E

Reduce conversion to admission

Utilise alternative options

Clinician education

Increase efficiency / streamlining

Best practice clinical management

Data focused plans

Patient education

SPA inreach to A&E / MAU

Utilise SPA

Make more use of paramedics

Work with third sector

Social services input

Better population health

Link to HWB priorities

Proactive mental health care

Optimise LTC management

Rapid discharge options from A&E

Home discharge

Non-home discharge

All GP referrals to be triaged by SPA

Medical team support on phone for paramedics

Extended scope paramedic roles

Increase community hospital beds

Social worker on call in A&E

Funding for volunteer home visitor training

Engagement meeting with local charitiesCauseEffect

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

Process mapping

Helps understand process

Identify critical steps

Consider safety of these steps

Identify redundant steps

Failure mode and effects analysis

Process Map - Example

Go to sleep

Alarm goes off

Groan heavily

Get up!

No

Yes

Process Mapping-2 Stages

• Stage 1

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.

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?

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

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?

Process mapping

Define the boundaries

Start with …..

Stop with ……

Realise I

have a flat

tyre

Drive away

with tyre fixed

Telephone request for

prescription

Is prescription

on repeat?

Print

prescription

Have they

had it

regularly?

Add to special

request list for

next day

Print

prescription

Don’t print

prescription

Add to special

request list for

next day

GP prints

prescription

GP decides if

issues

prescription

Prescription

returned to

front desk for

collection

Prescription

destroyed and

removed from

System

Returned to

prescribing

team – not

signed and

score through it

No

Yes

Yes

Yes

No

No

GP agrees

to prescribe

YesNo

Message to

prescribing

team – not

being

prescribed

Prescribing

team contact

patient to

inform them

Look at the whole process, not just the individual steps.

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

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”

The traditions of measurement

• e.g. A-B comparison, average, huge dataset

Research

• e.g. one-to-many benchmarking comparison, average, large dataset

Judgement

• e.g. continual analysis of single changing process over time

Improvement

What mind sets are at play here?

Mind sets

Research

Improvement

Judgement

Research Judgement Improvement

GoalNew knowledge (not its applicability)

ComparisonReward / punishmentSpur for change

Process understanding

Evaluating a change

Hypothesis Fixed None Multiple and flexible

Measures Many Very few Few

Time period Long, past Long/medium, past Short, current

Sample Large Large Small

Risks in improvement

settings

Ignores time based variation

Over-engineers data collection

Ignores time based variation

Over-reaction to natural variation

Incorrectly perceived as ‘inferior statistics’

Measurement mindsets

Based on L Solberg, G Mosser and S McDonald (1997) The Three Faces of Performance Measurement: Improvement,

Accountability and Research, Journal on Quality Improvement, 23 (3): 135 - 147.

What does this data tell us?

Patients treated in April

600

550

610

540

560

570

580

590

2010 2011

What does this data tell us?

Patients treated

650

600

550

500

450

400

350

300April 2010 April 2011

Plotting the dots - example Run ChartNumber of calls to outreach team (weekly)

November 2010 to June 2011

0

No o

f C

alls

180

160

140

120

100

80

60

40

20

1st Nov 15th Nov 29th Nov 13th Dec 27th Dec 10th Jan 24th Jan 7th Feb 21st Feb 6th Mar 20th Mar 3rd Apr 17th Apr 1st May

Week

Calls per week Median

Statistical Process Control

(SPC) Charts:

No o

f A

dm

issio

ns

0

200

150

100

50

250

Performance Report – Number of Admissions

Week

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

No Admissions Mean Lower Limit (66.5) Upper Limit (222.4)

77