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The Must Haves

Title

• Improving our Improvement: Building Our Field

– Sue Butts-Dion

–Ginna Crowe

– Jane Taylor

Disclosures• No Disclosures

• One Question

– Potential Article about Our Experience Together

• Framework of Choosing a Method– Pictures of the Frame?

• No Individual Names – Unless Quote and

Permission

Today’s Objectives

• Discuss multiple improvement methods and what differentiates them and develop criteria for method selection appropriate to their improvement work

• Participate in a simulation of a creative and integrated improvement method (EBCD)

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This session is for the improvement enthusiast! Through aninteractive all-teach-all-learn method, participants will exploretheir own commitment to improvement, identify and discussmultiple improvement methods, and align these methods withfoundational improvement theory. This learning activity willlead us toward a robust, practical framework that supportswise action and creativity. We will also explore Experience-Based Co-Design (EBCD), a method that integrates patients,families, and staff into the design of care.

Improving our Improvement: Building Our Field

Welcome Enthusiasts!

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Our Why!

Sue

Jane

Ginna

The Plan

A good plan never survives ground contact..

Paraphrased Helmuth von Moltke.

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Todays Good Plan

Agenda Plan-

• Open

• Conversations– Exploring Our History

– Using Our Theory

– Choosing Our Method(s)

• Simulation– Explore a New Method

– Test Our Framework

• Close

Time Plan - modifiable

• Breaks– 10:15 – 10:45 (?)

– 2:00 – 2:30 (?)

• Lunch – 12:00 – 1:00

DialogueDialogue, as I define it here, is about a shared inquiry, a way of thinking and

reflecting together. It is not something you do to another person. It is something

you do with another person. Indeed, a large part of learning this has to do with

learning to shift your attitude about relationships with others so that we gradually

give up the effort to make them understand us and come to a greater

understanding of ourselves and each other.

William Issacs Dialogue the Art of Thinking Together

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Who will be in the Conversation?

• Name/Organization

• Role

• Where you are from?

• One thing fun about your self?

• And why are you here? What caused you to select this session?

Conversation:Exploring Our History

God cannot alter the past, though historians can.

Samuel Butler

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Improvement has been going on for years!

“Negative results on the fish…Let’s try rubbing two sticks

together.”

• 1600 BCE– Edwin Smith Papyrus; an

Ancient Egyptian medical text on surgical trauma

– The first translation of the papyrus changed the understanding of the history of medicine.

– Egyptian medical care was not limited to the magical modes of healing. Instead, rational, scientific practices were used, constructed through observation and examination.

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LateMajority

Early Majority

Early Adopters Laggards

Adopter Categories

2.5% 13.5% 34% 34% 16%

Source: E.M. Rogers, Diffusion of Innovations (1995)

ADOPTER EXERCISES

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Who are the innovators we know in healthcare?

“It's a terrible thing to look over your shoulder when you are trying to lead - and find no one there”

Franklin D. Roosevelt

Shiny Object PhenomenonWhat Is Shiny Object Syndrome?Shiny Object Syndrome (Objectivius Shinium Syndromus) is defined as the attraction to objects that exhibit a glassy, polished, gleaming or otherwise shiny appearance. Something as simple as a reflection in your peripheral vision may easily distract your attention. Over time, you’ll find that your attention to said object is directly correlated to it’s shininess and your attention fades as the shininess wears off.http://impossiblehq.com/shiny-object-syndrome

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Our Paradigm

It is about….

• Building our field

• Using what is useful

• Guided by Theory

It’s not about…

• Hierarchy

• Fidelity

• Methods and tools

It’s about leveraging our enthusiasm for what works.

Conversation:Using Our Theory

Experience without theory is blind, but theory without experience is mere intellectual play.

Immanuel Kant

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SOME FUN VIDEOSKINESTHETICALLY EXPLORING IMPROVEMENT THEORYALIGNING WITH THE LITERATURE

By what theory of Improvement have you been influenced?

Appreciation

of a system

Understanding Variation

Theoryof

Knowledge Psychology

Deming’s System of Profound Knowledge

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SYSTEMS

What do we know or believe about systems?

What is in our system lens?

• A system is a network of interdependent components that work together to try to accomplish the aim of the system.

• The beginning of the system starts with the customer

• If each part of a system, considered separately, decides to operate as efficiently as possible, then the system as a whole will not operate to maximum effectiveness.

• The obligation of any component is to contribute its best to the system, not to maximize its own …measures.

• We should work on our processes, not the outcome of our processes….

Hamilton Consulting, LLC & Performance Management Group

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Collection of thoughts and excerpts from variousW. Edwards Deming publications and teachings

VARIATION

• Variation Exists!

• Common cause variation is always present • Common causes tend to be numerous• Common cause variation is produced by the

aggregate of the variation in all the variables. It is also known as: random variation, chance variation, or unassignablecause of variation

• Special causes are not present at all times• Special cause is in addition to common

cause • Special cause is produced by a non-typical

variable. Special causes are also known as assignable and non-random

• Mistake 1. To react to an outcome as if it came from a special cause , when actually it came from a common cause.

• Mistake 2. To treat an outcome as if it came from common causes of variation, when actually it came from a special cause.

What do we know or believe about variation?

What is in our theory of variation lens?

Hamilton Consulting, LLC & Performance Management Group

Collection of thoughts and excerpts from various W. Edwards Deming publications and teachings

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PSYCHOLOGY

What do we know or believe about psychology?

What is in our psychology or human interaction lens?

• People are different from one another. A manager of people must be aware of these difference, and use them for optimization of everybody's abilities and inclinations. This is not ranking ..

• Merit awards and ranking are demoralizing. Rewards motivate people to work for rewards.

• Some extrinsic motivation helps to build self-esteem. But total submission to extrinsic motivation leads to destruction of the individual.

Hamilton Consulting, LLC & Performance Management Group

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Collection of thoughts and excerpts from various W. Edwards Deming publications and teachings

KNOWLEDGE

• Information is not knowledge

• A statement devoid of rational prediction does not convey knowledge

• Knowledge is built on theory

• Without theory there are no questions: Without questions there is no learning

• No number of examples establishes a theory, yet a single unexplained failure of a theory requires modification or even abandonment of the theory

• There is no such thing as a fact

What do we know or believe about knowledge?

What is in our knowledge or learning lens?

Hamilton Consulting, LLC & Performance Management Group

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Important Milestones for Profound Knowledge Components

Variation

Systems

Psychology

Knowledge

1900 1920 1940 1950 1960 1970 1980 1990 2000Shewhart

Control

Chart 1924

Design of

Experiments

Sir Ronald

Fisher, 1925

Sampling

methods

Developed,

H. F. Dodge

Use of statistical

methods to

support the war

effort 1941 - 1945

Enumerative vs

Analytic

Studies, Deming, 1960

Shewhart’s 1931 and 1939

Books on Quality Control*

Principles of Systems

Jay Forrester, 1968

General Systems

Theory

Lugwig von

Bertalanffy,

1949

5th Discipline

Peter Senge

1990

Theory of Constraints

E. Goldratt, 1990The Goal

E. Goldratt,1984

Scientific Management.

F.Taylor, Frank &

Lillian Gilbreth,

Hawthorne experiments,

Elton Mayo, 1927

Anthropology

experts

apply theory

to business,

Edward Tolman,

1932

Organization

Development

D. McGregor

Tavistock

institute 1951

Eric Trist

Socio-technical

System

Open Systems

Fred EmeryMaslow –

Hierarchy

of Needs1962

Participatory

Management

Mary Parker

Follett, 1925

Human Side of

Enterprise

D. McGregor,

1960

Motivation Theory

Herzberg, 1968

Lewin’s

Equation

Kurt Lewin,

1920

Mind & The World

Order, C.I. Lewis

1929*Double Loop Learning in

Organizations, Chris

Argyris, 1974

John Dewey

Realism of

Pragmatism, 1905

How We Think

Dewey, 1933

Experiential Learning Theory

Carl Rogers, 1969

Adult Learning Theory

Malcolm Knowles, 1975Descriptive & Normative

Learning Models, Carlile

& Christensen, 2005

Holistic Management,

Stafford Beer, 1959

Creating the Corporate

Future, Russell Ackoff,

1981

Relationship

Awareness

Theory, Elias

Porter, 1971

Attribution error

termed by Lee

Ross, 1977

Langley et all, V2, p. 86-87

Important Milestones for Profound Knowledge Components = The Science of Improvement

Variation

Systems

Psychology

Knowledge

1900 1920 1940 1950 1960 1970 1980 1990 2000 2010 Shewhart

Control

Chart 1924

Design of

Experiments

Sir Ronald

Fisher, 1925

Sampling

methods

Developed,

H. F. Dodge

Use of statistical

methods to

support the war

effort 1941 - 1945

Enumerative vs

Analytic Studies,

Deming, 1960

Shewhart’s 1931 and 1939

Books on Quality Control*

Principles of Systems

Jay Forrester, 1968

General Systems

Theory

Lugwig von

Bertalanffy,

1949

5th Discipline

Peter Senge

1990

Theory of Constraints

E. Goldratt, 1990

The Goal

E. Goldratt,1984

Scientific Management.

F.Taylor, Frank &

Lillian Gilbreth,

Hawthorne experiments,

Elton Mayo, 1927

Anthropology

experts

apply theory

to business,

Edward Tolman,

1932

Organization

Development

D. McGregor

Tavistock

institute 1951

Eric Trist

Socio-technical

System

Open Systems

Fred Emery

Maslow –

Hierarchy

of Needs1962

Participatory

Management

Mary Parker

Follett, 1925

Human Side of

Enterprise

D. McGregor,

1960

Motivation Theory

Herzberg, 1968

Lewin’s

Equation

Kurt Lewin,

1920

Mind & The World

Order, C.I. Lewis

1929*

Double Loop Learning in

Organizations, Chris

Argyris, 1974

John Dewey

Realism of

Pragmatism, 1905

How We Think

Dewey, 1933

Experiential Learning Theory

John Dewey, Jarvis, Boud

and Walker Carl Rogers, 1969

Adult Learning Theory

Malcolm Knowles etc 1975

Descriptive & Normative

Learning Models, Carlile

& Christensen, 2005

Holistic Management,

Stafford Beer, 1959

Creating the Corporate

Future, Russell Ackoff,

1981

Relationship

Awareness

Theory, Elias

Porter, 1971

Attribution error

termed by Lee

Ross, 1977

Adapted from Langley et all, Improvement Guide V2, p. 86-87 [a few additions]

Wheeler

Chambers

Design of

Experiments

Ron Moen,

Judgment

Sampling

methods

Shewhart

Control

Chart 1924

SPC

application

to service

processes

Capra: Ecological

system application to

organizations

Transformative

Learning Theory

Mezirow et al

Organizational

Development

theory

Organizational Learning Theory

and development

Adult

Development

theory

Temperament

Development

theory

Knowledge

Management Theory

Technical and Adaptive

Leadership Heifitz

System Accounting

Goldratt

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Appreciation

of a system

Understanding Variation

Theoryof

Knowledge Psychology

Deming’s System of Profound Knowledge

Process

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Conversation:Choosing Our Method(s)

Don't let the perfect be the enemy of the good.Gretchen Rubin

Carousel of Progress(?)

Many involved in improvement are searching for a “perfect road map” to accomplish an improvement project

DMAIC

Measure

Analyze

Improve

Control

Define

FOCUS

PDCA

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Improvement Methods “Carousel” of Progression

• Lean– 1500 -1913 Flow Production

Venetian Arsenal & Ford– 1930—1950s Toyota Production

System

• Shewhart Cycle – (?) BC – Cavemen – 1939 Shewhart– 1950 Modified by Deming (wheel)– 1951 Japanese PDCA Cycle– 1986 Reintroduced by Deming PDSA– 1987 Moen Nolan Theory Prediction– 1993 Remodified by Deming

Shewhart Cycle

• Six Sigma (DMAIC DMADVb) – 1980 Motorola

• 10 Step Method – 1986 JCAHO The Agenda for Change

• FOCUS – PDCA (PDSA)– Late 1980’s Executive Learning Inc.

working with Hospital Corporation of America added FOCUS to PDCA

• Lean Six Sigma – late 1990’s both AlliedSignal and Maytag

integrated Lean and Six Sigma Ideas

• Model for Improvement (MFI) – 1994 Associates in Process Improvement

added three questions to PDSA – 1996 The Improvement Guide 1st Ed. -

2009 The Improvement Guide 2nd Ed.

• FAST- PDCA– Late 1990’s Executive Learning Inc.

• FADE Model– 2014 Organizational Dynamics Institute

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The Institute for Healthcare Improvement takes a unique approach toworking with health systems, countries, and other organizations onimproving quality, safety, and value in health care. This approach is calledthe science of improvement.

The science of improvement [in healthcare] is an applied science thatemphasizes innovation, rapid-cycle testing in the field, and spread in orderto generate learning about what changes, in which contexts, produceimprovements. It is characterized by the combination of expert subjectknowledge with improvement methods and tools. It is multidisciplinary—drawing on clinical science, systems theory, psychology, statistics, andother fields [adult and organizational learning]..........

IHI’s methodology traces back to W. Edwards Deming (1900-1993), whotaught that by adhering to certain principles of management, organizationscan increase quality and simultaneously reduce costs

http://www.ihi.org/about/Pages/ScienceofImprovement.aspx

THE SCIENCE OF IMPROVEMENT

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BUILDING OUR METHODS COLLAGE

CRITERIA EXERCISE ...

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Simulation EBCD: Experience Based Co-Design

Testing Our Framework on a

Shiny New Object

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@learningandimproving.com 37

Research and Evidence designing human experience

The continuum of patient influence. ( Bate and Robert pg. 10)

complaining

giving information

listening & responding

consulting & advising

experience-based co-design

Participatory experience

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To For With With & With

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Core Group

Advisory groupPatient Staff

Co-design Group

Individual co-design groups ++

Co- design Group

The experience –based co-design process. ( Bate and Robert pg. 120)

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planning

data collection

workshop

action groups

review and evaluate

data analysis

data feedback process

Key points...

Experience Co-design

1. Capture patient/family and staff stories about their care experiences

2. Identifying and honing-in on experience through touchpoints or key defining moments within the overall narrative – highs and lows of the journey

3. Bringing patients (families) and staff together to use touchpoints as a focus for improvement

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Our Learn By Doing

• Overview

• Modified Simulation

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WHEN TO USE THIS METHOD?

Testing our Framework…..

@learningandimproving.com 42

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A Word: warning?

Anyone who is a control freak or prefers top-down change

should therefore probably stay away from EBD ….

PB & GR (pg. 20)

Closing

@learningandimproving.com 44