Introduction to Improvement

The First Law of Improvement

“Every system is perfectly designed to achieve exactly

the results it gets.”

Dr Paul Bataldan

All improvement requires change but not all change will result in an improvement

Langley et al, 2009

The Improvement Guide

The Typical Approach

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; 2008. Available: www.ihi.org p26

Applied Science Approach

‘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. BerwickFormer Administrator of the Centres for Medicare &

Medicaid Services Professor of Paediatrics and Health Care Policy

at the Harvard Medical School

The Model for Improvement

Will

Ideas Execution

Developing Ideas that will contribute to making processes and outcome better

QI

Key Factors for Quality Improvement

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

History – Where has it come from?

• W.E.Deming (1900-1993)• 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

Model for ImprovementAct on the plan - Testing

The Improvement Guide, API

Aim

Measures

Changes

Implementation

Question 1: What are we trying to accomplish?

13

Check points - developing an Aim Statement

AIM Content • Explicit over arching description• Specific actions or focus• Unachievable by hard work

aloneAIM Characteristics

• Measurable (How good?)• Time specific (By when?)• Define participants and

customers

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

Exercise

Think about if you were challengedto do a marathon…..

•Identify an aim (what do you want to achieve, how good, by when?)

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!

Define measures that will measure the impact of theImprovement 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

How will we know a change is an improvement?

Measurement of Improvement Work

Measures

Exercise:Think about if you were challengedto do a marathon…

•Identify measures (how will you know?)

‘Change’ can mean different things

Model for Improvement Q3 What changes can we make that will result in improvement?

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

Innovative thinking....!

23

A Practical Need Often Drives Creativity!

Change Ideas Exercise:Think about if you were challengedto do a marathon…

•Identify changes (what changes can you make?)

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.

Do Study Act Plan Do Study Act

“What will happen if we try something different?”

“Let’s try it!”“Did it work?”

“What’s next? ”

Cycles of Tests Build Confidence

AP D

S

AP

D S

APD

SA P

DSProposals, theories, hunches, intuition

Changes that will result in improvement

Learning from data

PDSA Testing - simulation exercise

The Skittle Challenge

The Skittle Challenge• 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…

PDSA # Theory Prediction

1 Start with No. 5 empty

Will have 3 skittles left

2

3

4

5

6

Run Chart to Measure Performance

Test 1ABCXYZ

Test 2 - XYZABC

Test 2 123456

Tests 3-6 987654

2

1

3

654

10987

1514131211

The Skittle Challenge

• Consistency of purpose • Prediction• Planning• Documentation• Sharing and stealing!• Learning from failure

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, 15-13.

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

• 1 client• 1 day• 1 case• 1 worker

Move to 3,5,7…. as confidence grows

Start Small

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!

Based on slide © IHI 2009

Sequence for improvement

Develop a change

Test a change

Implement a change

Sustain & spread a change to other locations

Support with data and consideration of people

Theory &prediction

Test under avariety of conditions

Make partof routineoperations

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