Introduction to Quality Improvement in Practice Shalani Raghavan Susan Hannah Scottish Government...
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Introduction to Quality Improvement in Practice Shalani Raghavan Susan Hannah Scottish Government Leading Improvement Team
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Transcript of Introduction to Quality Improvement in Practice Shalani Raghavan Susan Hannah Scottish Government...
Introduction to Quality Improvement in Practice
Shalani RaghavanSusan Hannah
Scottish GovernmentLeading Improvement Team
Aims of this session• Brief introduction to the 3 Step Improvement Framework
and the Model for Improvement• Invite you to consider how the Model for Improvement and
its methodology can help you deliver on Quality Improvement – both strategically and operationally
• Recognise your role in enabling and creating the conditions for Improvement
• Raise awareness of the support available to you to implement the Model for Improvement in your area
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Public FinancesFall in Government expenditure
The six questions to be asked of EVERY change programme…
1AimIs there an agreed aim that is understood by everyone in the system?
2Correct changesAre we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact on our aim?
3Clear change methodDoes everyone know and understand the method(s) we will use to involve?
4MeasurementCan we measure and report progress on our improvement aim?
5Capacity and capabilityAre people and other resources deployed and being developed in the best way to enable improvement?
6Spread planHave we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?
Leading Improvement Team – Our Key Objectives
• To lead project-based, organisation wide programme of improvement activity addressing key organisational and policy challenges within Scottish Goverment.
• A capability and capacity building programme to facilitate improvement across Public Services.
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LIT: Current work• Support for Early Years Collaborative and
CPP’s• Education: Attainment, STEM• Health: Physical Activity• Justice: Building Safer Communities• Corporate: FOI• Awareness sessions and seminars• 3 day training course
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The Primary Drivers of Improvement
Will
Ideas Execution
Having the Will (desire) to change the current state to one that is better
Developing Ideas that will contribute to making processes and outcome better
Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas
QI
By what method?
W. Edwards Deming
"Quality is never an accident; it is always the result of high intention,
sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”
1941, William A. Foster
Improvement Science
W Edwards DEMING (1900-93)
“It is not necessary to change. Survival is not mandatory.”
“Stamping out fires is a lot of fun, but it is only putting things back the way they were.”
“There is no substitute for knowledge”
No model is perfect,some are useful.
Drug & Alcohol Game
W. Edwards Deming
Appreciation of the System
Subject Matter Knowledge
Understanding Variation
Psychology
Theory of Knowledge
What is a System?
A system is an interdependent group of people, processes or items with a
common purpose.
“Every system is perfectly designed to get the results it
gets.”
Senge
Deming’s Concept ofthe Lens of Profound Knowledge
Subject Matter Knowledge
Subject Matter Knowledge: Specialist knowledge and skills required to be a good practitioner
Profound Knowledge: The interaction of the theories of systems, variation, knowledge and psychology.
Profound Knowledge
Improvement
Different Types of Systems
Public Services!
“quality improvement”
The combined and unceasing efforts of everyone –professionals, patients and their
families, researchers, payers, planners, administrators, educators – to make changes
that will lead to better outcome, better system performance,
and better professional development.
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3
Fixing the plane while it’s flying!
So, in a chaotic world how can we get sustainable change that results in an
improvement?
We need a method for testing change that ensures it is right and reliable in a
given situation
Use the Model for Improvement to test and implement changes
Our change theory
• A clear and stretching goal– SOON is not a time, SOME is not a number
• A method• Predictive, iterative testing
– Small tests of change, less risky, but quick results
HOPE is not a plan
The Model for Improvement
The Improvement Guide, API
Aim
Measures
Changes
Execution
“Aims create systems”
Deming
The six questions to be asked of EVERY change programme…
1AimIs there an agreed aim that is understood by everyone in the system?
2Correct changesAre we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact on our aim?
3Clear change methodDoes everyone know and understand the method(s) we will use to involve?
4MeasurementCan we measure and report progress on our improvement aim?
5Capacity and capabilityAre people and other resources deployed and being developed in the best way to enable improvement?
6Spread planHave we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?
Aim
• Aligned – provides a clear sense of what you are trying to accomplish
• Numeric and Timed – How much, by when• Specific – who, where?• Unachievable by hard work alone• Non-negotiable (once set)
Aim Statements
• To reduce infant mortality, i.e. deaths by 12 months of age (including stillbirths) by 15% by end-2015.
• 100% of nurseries will be participating in Childsmile by June 2013
• The EYC will be a prominent agenda item at each CPP meeting by June 2013
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Aim Statement Exercise: You
Make the Call!
Scotland, the best small country in the world
THE BAD
Our outpatient testing and therapy patient satisfaction scores are in the bottom 10% of the
national comparative database we use. As directed by senior management, we need to get the score above the 50th percentile by the end of the 2ndQ of
2011.
THE UGLY
By the end of 2012, hospital mortality will be reduced by 15% in
Scotland
THE GOOD
Model for Improvement Q1: What are we trying to accomplish?
Take Aim
• Take 5 minutes to think about a possible improvement aim for a project or policy that you are involved in.
• Discuss it with the person next to you and give them feedback on theirs.
Exercise: Setting an Aim
Aim statement: What will you do, how much and by when?
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
A clear stretch aim that is:
•Is aligned directly to what you want to achieve (what)
•Is quantifiable (how much)
•Identifies a time frame for achieving the aim (by when)
•Unachievable by hard work alone (change will be necessary)
Now we have an aim, we need a Driver Diagram!
A useful tool to help us understand the system and organise our ideas
and measures
What are the things that are going to
influence the aim?
Aim statement:general description
of desired Improvement
(what, how muchby when)
Key factors that willInfluence the aim
Secondary factors which will influence delivery of theprimary drivers
Here’s what it looks like…
Theories about what will drive improvement
Aim Primary Drivers Secondary Drivers
Why a Driver Diagram?
Helps to organise theories about how to improve a system to meet the aim
It displays visually our ideas on the areas we can improve to leverage the improvement we want to achieve – organises information with different levels of detail
It helps a team to think critically about the issues that have the greatest impact on the desired outcome and which things will most influence those primary drivers.
Shows several strategies for achieving the aim
Driver diagramPrimary DriversKey factors which you need to influence in order to move
towards the aim. These drivers may act independently or in concert to achieve the overall goal.
Secondary Drivers
Underpinning factors affecting the associated primary driver(s). They can be used to create projects or a change package that will affect the primary drivers.
AIMPRIMARYDRIVERS
By 2024, x% ofadults and x% ofchildren will meetphysical activity
guidelines
People walk orcycle to work orschool, and are
active during workor school
People regularlytake part in sport
and recreationactivities in their
leisure time
People are awareof the physical
activity guidelines,and the health
benefits ofphysical activity
SECONDARYDRIVERS
Safe, attractive routes for walking and cycling are available
Planning processes prioritise the creation of a builtenvironment that encourages people to be more active
The transport infrastructure enables people to choose to makecar free journeys
Workplace policies (NHS, Local Authorities, privatecompanies, education providers) prioiritise, facilitate and
reward active travel to and from work and during work hours
Health and Care providers establish effective person centredphysical activity pathways in all relevant settings, to enable
and support people to take part in physical activity
People can access affordable suitable sport and recreationfacilities locally
Schools, universities and colleges prioiritise physical activity intheir estates, green space and infrastructure planning
Schools teach the benefits of physical activity and encouragelevels of activity to meet guidelines
Public messages on the health and social benefits of physicalactivity and the dangers of inactivity are consistent and
effective
The most up to date evidence, best practice and lessonslearned in increasing physical activity are shared and used to
inform service improvement
Local communities and individuals are supported to work toovercome barriers to people being physically active
Policies, services and infrastructure are planned and deliveredin an integrated way, in partnership with local communities, to
enable people to take part in physical activity
Active play for children is encouraged and supported
Draft physical activity driver diagram
Now you drive…• Pick one of your aims from
before.• Discuss and sketch out what
would be the primary and secondary drivers for this aim
It’s ok if there are only 1 or 2 primary
drivers
PrimaryDriversOutcome
SecondaryDrivers
Ideas for ProcessChanges
AIM:A New
ME!
Calories In
Limit dailyintake
TrackCalories
CaloriesOut
Substitutelow calorie
foods
Avoidalcohol
Work out 5days
Bike towork
PlanMeals
Drink H2ONot Soda
drives
drives
drives
drives
drives
drives
drives
drives
Exercise
Fidgiting
HackySack inoffice
What Changes Can We Make?Understanding the System for Weight Loss
“Every system is perfectly designed to
achieve the results that it gets”
© Richard Scoville & I.H.I.
PrimaryDriversOutcome
SecondaryDrivers
Ideas for ProcessChanges
AIM:A New
ME!
Calories In
Limit dailyintake
TrackCalories
CaloriesOut
Substitutelow calorie
foods
Avoidalcohol
Work out 5days
Bike towork
PlanMeals
Drink H2ONot Soda
drives
drives
drives
drives
drives
drives
drives
drives
• Weight• BMI• Body Fat• Waist size
• Daily caloriecount
• Exercisecalorie count
• Days betweenworkouts
• Avg drinks/week
• Runningcalorie total
• % ofopportunitiesused
• Sodas/week
• Meals off-plan/week
• Avg cal/day
Exercise
Fidgiting
HackySack inoffice
Percent of dayson bike
Etc...
How Will We Know We Are Improving?Understanding the System for Weight Loss with Measures
Measures let us• Monitor progress in improving
the system• Identify effective changes
Driver Diagram
AIM PRIMARY DRIVERS SECONDARY DRIVERS
Measurement for Improvement
The Improvement Guide, API
Aim
Measures
Changes
Execution
Now back to this….
Model for Improvement Q2: How will 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!
Why Do You Need Data and Information?
• To plan for improvement• For testing change• For tracking compliance• For monitoring long term progress and sustainability• To tell the story of your improvement journey
How Do We Know if a Change is an Improvement?
“If you can’t measure it, you can’t IMPROVE it”
Why Real Time Is Important for Measurement?
• Aggregate measures alone do not lead to predictions about future performance or insights to explain past variations
• Displaying data over time (using run charts or control charts) allows us to make informed predictions, and thus make changes to create different results
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0
10
20
30
40
50
60
70
80
Avg BeforeChange
Avg AfterChange
Cycl
e Ti
me
(min
.) Aggregated Data Cycle time results for units 1, 2 and 3
Data for improvement?
Does this show an improvement?
Data over time - dynamic data
0102030405060708090
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date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Change MadeCycle Tim
e (m
in.)
0102030405060708090
100
date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Change Made
Cycle Tim
e (m
in.)
Unit 1
Unit 3
Unit 2
0102030405060708090
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date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Change MadeC
ycle Tim
e (m
in.)
Unit 2
Depends…. Which unit has improved?
What measures?
Outcome measures – directly relates to the overall aim what is the result? how is the system performing?
Process measures – are the processes that contribute to the aim performing as planned?
Balancing measures – assessing from different dimensions
unanticipated consequences, other factors influencing the outcome
How do you measure up?
• Looking at your driver diagram, can you identify any suitable measures that would help you to understand how you were progressing?
• Just take 5 minutes to discuss…• Tabout possible outcome, process and hink
balancing measures
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A NEW HEALTHIER ME!!
CALORIESIN
CALORIES OUT
Limit daily intake
Substitute low calorie
Limit alcohol
Exercise
Fidgeting
CAUSEEFFECT
Driver diagram with measures
MEASURES1. Rate ofweight loss / week2. Reduction in units of alcohol / week3. Time spent exercising / week4. Feel good factor
Tests of changeSecondary driversPrimary driversAim
Track calories
Plan meals
Drink water not coke
Gym 5 x per week
Cycle to work
Chi balls
Weight, BMI, waist size
Meals off plan
Average drinks / week
Exercise Calorie count
Daily calorie count
Days betweenworkouts
% of daysOn bike
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