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Using data to measure, understand and improve service delivery
An introduction to Variation and Statistical Process Control (SPC)
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What is SPC?
S = Statistical, because we use some statistical concepts to help understand processes
P = Process, because we deliver our work through processes i.e. how we do things
C = Control, by this we mean predictable
• Continuous and dynamic – to give a better story over time, as opposed comparative and static – used for judgements
• A way of demonstrating and thinking about variation• A simple tool for analysing data – Measurement for
improvement • A tool to help make better decisions• Easy and sustainable to use
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What can it do for me?• Help you really understand the data• Identify the special causes in a process, not just guess what they are• Identify the levels of variation in a system, not just the average• Identify if a process is sustainable - i.e are your improvements
sustaining over time• Identify if a process can meet a target• Identify when an implemented improvement has changed a process -
i.e. it has not just occurred by chance• Help you make better predictions about your service and thus
improve decision making• Help you prove/disprove assumptions and trends about patient
services• Help drive improvement by monitoring the system – and used to test
the stability of a process prior to redesign work, such as Demand and Capacity
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SPC is great, but…It will not:
• Solve your process issues – you will need background intelligence in order to understand the process for potential redesign
• Provide all the answers – SPC analysis is a tool to compliment all other methodologies i.e. process mapping and discovery interviews
• Validate data – SPC is only as valid as the data used• Define operational definitions when collecting data –
this in itself can introduce more variation i.e. ‘measure my left arm’
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Unacceptable decision-making
We need to challenge:
• guesswork - single figure decision making• decisions based on special cause variation• anecdotal data • “known” solutions or assumptions• arbitrary targets – national and local – is the process
really capable of achieving the target?
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Remember…Variation is the key to redesign
Variation exists in all processes around us:- Every patient’s needs are different- Similar patient pathways are normally very different
in each hospital- The way we measure the same things can also be
very different
“If I had to reduce my message for management to just a few words, I’d say it all had to do with reducing variation”
Deming
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Variation in a system is normal
• The variation is caused by factors that are inherent in the system over time
• They affect all outcomes
• This is ‘common cause’ variation
• The causes are ‘unassignable’
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Some variation may not be normal
• The factors are not present in the process all the time
• They do not affect everybody
• They arise because of specific circumstances
• This is ‘special’ or ‘assignable’ cause variation.
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Two types of variation
Natural (common cause) variation• Is inherent in the design of the process• Results in a stable – IN CONTROL – process because the
variation is predictable• Is due to random or chance causes of variation
Special cause variation• Is due to irregular or unnatural causes that are not inherent in a
process – i.e. extrinsic• Results in an unstable – OUT OF CONTROL – process
because variation is not predictable• Is due to non-random or assignable causes of variation (i.e. a
signal that the process has ‘changed’)
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Special Cause Variation
• These are flags that tell you something is not right with the system…they need further investigation
• They are usually attributed to bottlenecks or unusual events – but may also be a signal that the service has been changed through redesign!
• They need to be eliminated from the process (where they can be) before the system is changed
• Changing a system that has special cause variation can actually make it worse
• You are striving for a system that displays only common cause variation
• And then reducing that variation to increase the flow, efficiency and predictability
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Natural (common cause) variation - a stable process in control
0
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F M A M J J A S O N D J F M A M J J A S O N D
Upper process limit
Mean
Lower process
limit
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Special cause variation- an unstable process out of control
0102030405060708090
F M A M J J A S O N D J F M A M J J A S O N D
Upper process limit
Mean
Lower process
limit
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0
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Consecutive trips
Min.
Mean
Upper Process Limit
Lower Process Limit
Accident on motorway - Special Cause
Tyre had puncture – Special Cause
Borrowed helicopter – Special Cause
Stopped by police for speeding – Special Cause
School holidays – Special Cause
COMMON CAUSE VARIATION - Points within the yellow lines is variation you would expect - normal variation of the process (my trip to work) E.G. traffic lights, pedestrians, rush hour
My trip to work…
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Management of variationIs the initial process stable?
Type of variation Natural (common) Special + natural
Right Choice Change the process
Investigate the origin of the special
cause(s)
Wrong Choice Treat normal variation as a special
cause (tampering)
Change the process
Consequences of making the wrong
choice
Increased variation
Wasted resources
Yes No
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In Summary…
Process unclear
Create an SPC chart
Is process stable and ‘IN CONTROL’?
If YES – Reduce Variation by redesign
If, NO – Identify special causes and restart
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Why not just use averages?
‘If I stick my right foot in a bucket of boiling water and my left foot in a bucket of ice water, on average, I’d feel pretty comfortable.’
Davis Balestracci
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• Pause for questions
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Rules for special causes RULE 1 Any point outside one of the control limits
RULE 2 A run of seven points all above or all below the centre line, or all increasing or all decreasing.
RULE 3 Any unusual pattern or trends within the control limits.
RULE 4 The number of points within the middle third ofthe region between the control limits differs markedly from two-thirds of the total number of points.
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Rules for special causes RULE 1 Any point outside one of the control limits
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LCL
UCL
MEAN
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LCL
UCL
MEAN
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Point above UCL
Point below LCL
SPECIAL CAUSES - RULE 1
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Rules for special causes
RULE 2 A run of seven points all above or all below the centre line, or all increasing or all decreasing.
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MEAN MEAN
Seven points above centre line
SPECIAL CAUSES - RULE 2
LCL
UCL
LCL
UCL
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X
X X
X
XXX
X XX
XX
X X
X
XXX
Seven points below centre line
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MEAN MEAN
Seven points in a upward direction
SPECIAL CAUSES - RULE 2
LCL
UCL
LCL
UCL
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XX X
XX
XX X
X
XX X
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X
XX
Seven points in an downward direction
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Rules for special causes
RULE 3 Any unusual pattern or trends within the control limits.
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SPECIAL CAUSES - RULE 3
X
X
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X X X
X
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Cyclic pattern
XX X
XXX
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XXLCL
UCL
LCL
UCL
Trend pattern
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Rules for special causes
RULE 4 The number of points within the middle third ofthe region between the control limits differs markedly from two-thirds of the total number of points.
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SPECIAL CAUSES - RULE 4Considerably less than 2/3 of all the points fall in this zone
X
XX X X
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X X
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LCL
UCL
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X XX
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X X
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X X
LCL
UCL
Considerably more than 2/3 of all the points fall in this zone
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http://www.7daysat.nhs.uk
How to access the SPC charts on the 7DSAT
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05/01/2023
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www.england.nhs.uk
www.england.nhs.uk
05/01/2023
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