Introduction to Improvement for Safety

Day 2

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Your facilitators today are:-

Amanda HuddlestonImprovement Lead: MSc,QN, HV, RN.

&Wendy Stobbs

Improvement Lead: MA, MSc, RGN.

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Agenda Day 2 9.00 Registration & Coffee 9.30 Evaluation Feedback & Review of Day 1 – Driver Diagrams10.00

Engaging People in Improvement – Change Models and Stakeholders

11.15 Coffee11.30 Engaging Teams in Improvement - Tools12.30 Lunch13.00 Measurement for Improvement 15.00 Coffee15.15 PDSA Cycles16.00 Summary of the day, homework & evaluation16.30 Close

Evaluation Feedback• Cold room• PDSA• More group work to include all team members• More focus on root cause than solutions• Handouts pre session

Evaluation Feedback• Good content• Enjoyed project focused learning• Balanced and useful day• Informative• Practical

Learning Objectives for Day 2• Review of your driver diagrams• Understand how human factors may impact

your initiative• Have a basic understanding of measurement

for improvement and how it applies to your initiative

• Understand how PDSA cycles can aid your initiative testing.

Day 1 Recap

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if achange is an improvement?

CHANGE: What changes can we makethat will result in improvement?

Model for Improvement

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Setting an Aim• What are you trying to accomplish?• What? By how much? By when?

SafeTimelyEffectiveEfficientEquitablePatient

Centred Crossing the Quality Chasm: A New Health System for the 21st Century, 2001 Institute of Medicine

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Driver Diagrams- what are the component parts?

• Aim or goal of the improvement effort

• Primary drivers - system components that contribute directly to the chosen aim or goal. Processes, rules of conduct, structure

• Secondary drivers - elements of the primary drivers and which can be used to create change projects. Components and activities

• Relationship arrows - show the connection between the primary and secondary drivers. A single secondary driver may impact upon a number of primary drivers

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90% of patients in Bay 1 receive their

lunch of choice

everyday by 12.30 by July

2013

Know what patients want / need for lunch

Lunch & equipment arrives on time

Ward Staff are available to give

out lunch

Patients are available to receive

lunch

Menu cards distributedChoices recorded &

communicated

Diet requirements understood

Numbers established & communicated

Time for delivery agreed

Access to ward available

Allocate lunch dutyComplete other tasks prior to

lunch arrival

Staff appropriately trained

Schedule inpatient appts appropriately

Appropriately positioned

Maintained at appropriate temperature

Aim / Outcome Primary Drivers Secondary Drivers

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Engaging people in your Improvement Project

Understand human responses to change

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Change is situational: new site, new boss, new team roles, new policy.

Transition is the psychological process people go through to come to terms with new situations

William Bridges

Change is different from transition

Change can be instant, transition takes time.20

William Bridges

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Marathon Model

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Winners?

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Heroes or villains?

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What is a stakeholder?

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What is a stakeholder?• A stakeholder can be defined as any person, or

group, who has an interest in the project or could be potentially affected by its delivery or outputs.

• Correct stakeholder identification is a critical component of the initial scoping phase.

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Identifying Stakeholders• Who is influential in this area?• Who will be affected by any decisions on the issue

(individuals and organisations)?• Who runs departments with relevant interests?• Who else is influential on this issue?• Who can obstruct a decision if not involved?• Who has been involved in this issue in the past?• Who has not been involved, but should have been?

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Stakeholder GridIn

flu

en

ce o

r P

ow

er

Interest

Key Player

Meet Needs

Inform Consider

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Readiness for Change – Influencing

Source: NHS III

• Identify who might be for, or against your project and proposed changes.

• You can then plan necessary influencing activities.

Recognise values, beliefs & needs

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Understand their perspective

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Acknowledge Behaviours• Sceptics & cynics• Reflectors & rationalisers• Quiet & cautious• Anger Vs apathy• Beware zealots & welcome laggards • A point of view that challenges can prevent an

issue further on

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Coffee Break

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Engaged teams…. • Have shared goals• Feel valued• Trust each other• Are trusted• Review progress, goals & issues regularly & together• Are multi-skilled/multidisciplinary• Communicate & collaborate• Have autonomy & are empowered• Support improvement & will make changes!

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Communicate• Clarify any confusion, assumptions and

misunderstandings about your project• Make sure that someone is responsible for each

task, timescales etc• Identify who needs to be communicated with for

each task• Prevent duplication of effort-yours & theirs• Proactively plan to unearth issues, gaps in

responsibility, misunderstanding, miscommunication

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Engaging – Tell the story, share your vision

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Frame it for them:• Aims• Bring it to life• Current state - problems, issues, facts,

figures• Future state - expectations, evidence• Learn to Listen

Why People Engage

• Regulatory mandate• Risk management issue• “If you knew, or should

have known, and don’t act…”

• Evidence• Data• Logic• Business case—

Return on Investment

• Stories—recent, local, real

• Videos? Bring a patient along?

• “How many people will be affected?”Source: Reinertsen

Lift Speech• 30 second speech to explain project to others.• Snappy….so it’s remembered!• Should reflect the Aim• Used consistently

Have a go!

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Engagement and Stakeholder Management Tools

For engagement– WIIFM– De Bonos 6 thinking hats

• For organisation– RACI

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WIIFM?

Key people or group

What’s In It For Me (WIFM)? What could they do

to support or prevent the

improvement initiative?

What could/should we do to reduce non-compliance

activities or support compliant

ones?

+Impact

-Risk

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RACI Matrix

ActionsRoles/names

                       

 

                           

                           

                           

                           

                           

                           

RACI: R = responsible A = accountable C = consulted I = informedIndicate on the matrix which of your stakeholders are accountable for the action,

responsible for the action, need to be consulted about the action or need to be kept informed of the action

RACI Matrix

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De Bono’s 6 Thinking Hats

Managing the thinking process: Could you summarise finding so far?

Information / data needs: What are the facts

Ideas: Is there a different way of looking at this?

Benefits / positives: Can we list them?

Negatives / risk: What can go wrong?

Emotion / gut feeling: What is your gut feeling?

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References and resources• http://www.immi.gov.au/about/stakeholder-engagement/_pd

f/stakeholder-engagement-practitioner-handbook.pdf• http://www.kotterinternational.com/• http://www.mindtools.com• http://www.changemodel.nhs.uk/pg/dashboard• http://www.businessballs.com/• http://www.advancingqualityalliance.nhs.uk

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Introduction to Measurement

The Model for Improvement

© AQuA Academy 49

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if achange is an improvement?

CHANGE: What changes can we makethat will result in improvement?

How Do We Know if a Change is an Improvement?

“You can’t fatten a cow by weighing it”- Palestinian Proverb

• Improvement is NOT about measurement

• However…

“If you can’t measure it,

you can’t IMPROVE it”

Measurement in ContextAspect Improvement Accountability Research

Aim Improvement of care Comparison, choice, reassurance, spur for

change

New knowledge

Methods:• Test Observability

Test observable No test, evaluate current performance

Test blinded or controlled

• Bias Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

• Sample Size “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

• Flexibility of Hypothesis

Hypothesis flexible, changes as learning takes

place

No hypothesis Fixed hypothesis

• Testing Strategy Sequential tests No tests One large test

• Determining if a change is an improvement

Run charts or Shewhart control charts

No change focus Hypothesis, statistical tests (t-test, F-test, chi square),

p-values

• Confidentiality of the data

Data used only by those involved with improvement

Data available for public consumption and review

Research subjects’ identities protected

The Measurement Trinity1. Defining your measures

What am I going to measure and why?

2. Measurement and data collection planHow will I collect data?

3. Reporting planHow am I going to present my data?

The Measurement Journey

Attributes of Project Measures

© AQuA Academy 55

• Small number (<8) of key measures that refer to the project goals

• Balance – together describe a great system of care• Suggested goals based on current system,

improvement agenda, ‘state of the art’• Clearly defined for common data collection and

reporting

Thinking at Two Levels• Measures & goals are linked to drivers – track team progress

on outcomes and key processes.

• You will report project-level measures to your sponsor and your teams:

Clinical outcome & process measures (e.g. Average of team values, Percent of teams achieving goals, etc.)

Ratings of team project participation and progress (Percent of teams with sponsor, Percent participating in calls, etc.)

• Teams select measures to report based on their aim

• Measures should align with team aim

• Teams also collect local ‘change’ measures to track progress on testing and changes

Project Level

Team Level

Types of Measures• Outcome Measures

– Where are we ultimately trying to go?– Point to qualities that are valuable to stakeholders i.e. how

is the system performing? What is the result?• Process Measures

– Are we doing the right things to get there?– Track that steps in the system are performing as planned. – Help identify if changes are leading to improvement.

• Balancing Measures– ……………….

When thinking about balancing measures

• To patients• But also other parts of the

healthcare system• Balancing Measures help us

‘keep an eye on’ other aspects of the system as we focus on improving one part

Unintended Consequences

Group Work

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Plans & Definitions

How Big is Your Banana?

1. Create a step-by-step guide to capture the concept of “banana size” using the equipment in the envelope

2. Measure your banana according to your guide, write down the result (on a different piece of paper) and keep it secret!

3. Put your guide, the equipment and banana in the envelope. Keep your result, facilitator will now move bananas!

4. Measure the new banana using equipment and guide in envelope and record.

What did the Banana Say?• You need an intimate understanding of team your

working with. • Understand what they are trying to achieve and how

it relates to patients.

This will help team to determine; – what to measure– how to design a simple & effective measurement

tools– provide guidance on collection, interpretation and

representation of data

Defining / Naming Measures• Names of measures should be objective statements

about what is actually being measured – percent of missing charts– wait time to see the doctor– the number of ED visits – length of stay for a particular DRG

• Avoid placing goals and targets in the name of the measure, unless you’re counting ‘defects’ against some quality standard– percent of patients with antibiotics administered within 1

hour of surgery

An Operational Definition...… is a procedural description of what to measure and the steps to follow to measure it consistently.

• Gives communicable meaning to a concept• Tells what you need to count or measure• Specifies measurement methods and equipment• Identifies criteria and exclusions

… is the basis for reliable measurement ND

IHI Measurement Planning Form MeasureType Outcome Process BalancingWhy is this measure needed in our project?

Operational Definition

ExclusionsUseful StratifiersData Collection & Sampling Method

DisplayGoal Source

Aim:90% of patients in Bay 1 receive their lunch of choice everyday by 12.30 by July 2013

Measures Definition Sample Accountable Collection Schedule

Start Date

Numerator Denominator

Chart

Outcome Measures

Percentage of patients receiving lunch of choice

Number of patients receiving their meal of choice in bay 1 each day recorded as a proportion of occupied beds.

Process Measures

Percentage of patient menu cards completed each day

Number of days when lunch arrived on time

Number of cards completed for patients in bay 1 each day recorded as a proportion of occupied beds.

Total days each month when lunch arrived by agreed time.

Balancing Measures

Additional Staffing Costs?

Reduction in food waste

Staffing costs for bay 1 in £s

Number of meals returned by patients in bay 1

Group Work

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Sampling & Data

Sample sizes for QI-

Data Collection Plan• DATA COLLECTION PLAN• Who is responsible for actually collecting the data?• How often will the data be collected? (e.g., hourly, daily,

weekly or monthly?)• What are the data sources (be specific)?• What is to be included or excluded (e.g. only inpatients are to

be included, or only stat lab requests should be tracked).• How will this data be collected?• Manually ______ From a log ______ From an automated

system• Are these data:• Attributes data? ______ or Variables data? ______

Data Collection Plan Cont.....• BASELINE MEASUREMENT• What is the actual baseline number?

______________________________________________• What time period was used to collect the baseline?

___________________________________• TARGET(S) OR GOAL(S) FOR THIS MEASURE• Do you have target(s) or goal(s) for this measure?• Yes ___ No ___• Specify the External target(s) or Goal(s) (specify the number, rate or

volume, etc., as well as the source of the target/goal.)• Specify the Internal target(s) or Goal(s) (specify the number, rate or

volume, etc., as well as the source of the target/goal.)

Coffee Break

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PDSA Cycles

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if achange is an improvement?

CHANGE: What changes can we makethat will result in improvement?

Model for Improvement

© 2013 AQuA

PDSA Cycles

Consensus &

Buy In!

© 2013 AQuA

Reasons to test changes

• To increase your belief that the change will result in improvement. • To decide which of several change ideas will lead to the desired

improvement. • To evaluate how much improvement can be expected from the

change. • To decide whether the proposed change will work in the actual

environment we are working in. • To see which ideas didn’t work and why. • To evaluate costs, social impact, and side effects from a proposed

change. • To minimise resistance upon implementation-uses staff to test

change so they see for themselves.• To see if what we assume is correct

We’ve all done at least one!

Ever tried a PDSA cycle?

PDSA In Action!

Pace & pressure!• Smaller Scale Tests: One patient, one staff, try it once to

get started, talk it through before trying• Test Multiple Drivers: Assign individual responsibility for

testing changes• Test Multiple Change Ideas: Work in parallel to

accelerate learning• Use Volunteers: Don’t waste time persuading!• Instant feedback: PDSA means you know if it worked &

you don’t need to wait 2 weeks for someone to tell you!

How long will a PDSA test take?• Years• Quarters• Months• Weeks• Days• Hours• Minutes

Always plan to drop down “two levels” to plan a Test Cycle!

Failure (or is it…?)A. Be sure to distinguish the reason:

– Change was not executed– Change was executed, but not effective

B. If the prediction was wrong – not a failure!– Change was executed but did not result in

improvement– Local improvement did not impact the secondary

driver or outcomeC. In either case, we’ve improved our understanding

of the system!

You aren’t the only ones

"I did not fail one thousand times; I found one thousand ways how to not

to make a light bulb.” Thomas Edison

Testing or implemented?• Testing

– Trying and adapting ideas and knowledge on small scale.– Learning what works in your system.

• Implemented– Making this change a part of the day- operation of the

system – a permanent change in how work is done – Would the change persist even if its champion were to

leave the organisation?– The change is permanent - need to develop all support

infrastructure to maintain change– High expectation to see improvement (no failures)

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PDSA Pilot PDSA Implementation

Support needed = LOW

Support needed = HIGH

Tolerance for failure = HIGH

Tolerance for failure = LOW

People involved = FEW People involved = MANY

Time = SHORT Time = LONGER

F B+

Questions?

I. Start to plan your tests of changeII. Think small: 1 change idea, I area, 1 member of

staff, 1 patient.III. Repeat if successful: 1 change idea 1 area, 2 staff, 2

patients,IV. Still successful? Roll out wider:1 area, 3 staff, 3

patients

References• http://www.ihi.org/Pages/default.aspx• https://www.aquanw.nhs.uk/• http://www.healthcareimprovementscotland.

org/welcome_to_healthcare_improvem.aspx• Google

Home Work• Ensure your project has a

• A set of measures• A set of operational definitions (for each measure)• Ideas for some things that you may start to change to

make improvements

We will be looking to share some of these at the next session• If you have any visual data for your project bring it along• We would encourage you to complete your ‘Reflective log’• And your i-Resilience

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