27 October 2011
A consistent approach to the methodology

Model for
Improvement &

Part One:
Where does it come from?
Part Two:
What is it and
How does it work?
Improvement methodology

Part One:
Where does it come from?
Part Two:
What is it and
How does it work?
Improvement methodology

QI
In an article in the Journal of Quality Improvement,
92 QI projects were compared. What was the timeframe from problem
Identification to completion of first pilot?
1.
23 days
2.
60 days
3.
397 days
4.
504 days
Improvement methodology

QI
In an article in the Journal of Quality Improvement,
92 QI projects were compared. What was the timeframe from problem
Identification to completion of first pilot?
1.
23 days
2.
60 days
3.
397 days
4.
504 days
Improvement methodology

 504 days from problem identification to completion of first pilot
 397 days from first team meeting to the end of first cycle
 75 days to describe current situation in flowchart
 62 days for data collection if change was improvement
Alemi, Safaie, Neuhauser
“A Survey of 92 Quality Improvement Projects.”
Journal of Quality Improvement
2001 , 27(11): 619-632
Improvement methodology

There’s a lot of material out there
Improvement methodology

So what now?
Improvement methodology

What mindset?
 We’ll conduct a 3 month pilot then we’ll roll out
 We’ll just tell staff that this is the new way of working
 We’ll do an audit to get a baseline and then repeat it after 6 months
 We want all our departments to be 100% efficient, it’s taxpayers money we’re spending after all
Results in LAME thinking not
LEAN thinking
L ean A s M isguidedly E xecuted
Improvement methodology

Science of Improvement

The Lens of
Profound
Knowledge
Appreciation of a system
Theory of
Knowledge
Understanding
Variation
Psychology

Subject Matter
Knowledge
Subject Matter Knowledge:
Knowledge basic to the things we do in life. Professional knowledge.
Profound Knowledge: The interplay of the theories of systems, variation, knowledge, and psychology.
Profound Knowledge

Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement.
Subject Matter
Knowledge
Improvement
Profound Knowledge

What insights might be obtained by looking through the Lens of
Profound Knowledge at your project?
Appreciation for a System
• Interdependence, dynamism
• World is not deterministic
• Optimisation, interactions
• System must have an aim
Understanding Variation
• Variation is to be expected • Interaction between people
• Common or special causes
• Ranking, tampering
• Potential mistakes
Theory of Knowledge
• Prediction
• Intrinsic motivation, movement
• Beliefs, assumptions
• Will to change
• Learning from theory, experience
• Operational definitions
• PDSA for learning and improvement

Profound Knowledge: Systems Thinking
Appreciation of a
System
Theory of
Knowledge
Psychology
Understanding
Variation

Deming’s original diagram
“A system is a network of interdependent components that work together to try to accomplish the aim of the system”
Improvement methodology

I’m sure glad the hole is not in our end!
People unclear on the concept of a system!

The System is perfectly designed to achieve the results it gets.
If each part of a system, considered separately, is made to operate as efficiently as possible, then the system as a whole will not operate as effectively as possible.
- Ackoff (1981)

Profound Knowledge: Psychology
Psychology
• Interaction between people
• Intrinsic motivation
• Beliefs & assumptions
• Will to change
We understand that we have bad systems, not bad people
Appreciation of a
System
Theory of
Knowledge
Psychology
How many of us come to work to do a bad job?
Understanding
Variation

The impact?
 Communications
“NHS staff save lives every day – 1000 Lives Plus will help save more”
 Leadership
– Approach to motivation
Improvement methodology

Profound Knowledge: Variation
Understanding Variation
• Variation is to be expected
• Common or special causes
• Ranking, tampering
• Potential mistakes
Appreciation of a
System
Theory of
Knowledge
Psychology
Understanding
Variation
“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.” W E Deming

The MBFC Index
You will need a coin
And two free hands!
Just how competitive can you get?
Improvement methodology

Lessons?
 It’s easy to react in the wrong way
 Natural variation is really quite large
 It’s the system not the individual
But when will we know that there really is something there?
Improvement methodology

Walter A. Shewhart
(early 1920’s, Bell Laboratories)
 While every process displays variation:
 some processes display controlled variation (common cause)
– stable,consistent pattern of variation
– constant causes/ “chance”
 while others display uncontrolled variation
– pattern changes over time
– special cause variation/“assignable” cause
Improvement methodology

Shewhart’s purpose
 Data contains both signal and noise . To be able to extract information, one must separate the signal from the noise within the data.
Improvement methodology

A typical process control chart
80
70
60
50
40
30
20
10
0
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
Improvement methodology

Part One:
Where does it come from?
Part Two:
What is it and
How does it work?
Improvement methodology

Profound Knowledge: Theory of
Knowledge
Appreciation of a
System
Theory of Knowledge
• Prediction
• Learning from theory, experience
• Operational definitions
• PDSA for learning and improvement
Theory of
Knowledge
Psychology
Understanding
Variation
Improvement methodology

 A change is a prediction
 Comparing the predictions to the results of a test of change is a key source for learning
 A “good” theory makes clear predictions that can be used…
– to confirm or modify the theory,
– to generate new exploration, and
– to suggest practical application
Improvement methodology

Improvement methodology

What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
AIM
Improvement methodology

Aim Exercise
Improvement methodology

Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Goals
&
Measurement
AIM
Improvement methodology

Improvement methodology

Measurement
Tracking a few key measures over time is the single most powerful tool a team can use.
Improvement methodology

What are we trying to accomplish?
How will we know that a change is an improvement?
What change(s) can we make that will result in improvement?
Change(s)
Improvement methodology
Goals
&
Measurement
AIM

Improvement methodology

Test ….
 Most improvement usually requires change…..
 however not all change is an
Improvement!
Improvement methodology

Act
Adapt?
Adopt ?
Abandon?
Next cycle?
Plan
Objective
Questions and predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Study
Complete the analysis of the data
Compare data to predictions
Summarize what was learned
Do
Carry out the plan
(on a small scale)
Document problems and unexpected observations
Begin analysis
Improvement methodology

“Negative results on the fish…
Let’s try rubbing two sticks together.”
Improvement methodology

Sequential building of knowledge
Include a wide range of conditions in the sequence of tests
Theories, hunches,
& best practices
A P
S D
A
S
P
D
A P
S D
Breakthrough
Results
A P
S D
Implement a change
Test new conditions
Test a change
Develop a change
Improvement methodology

PDSA Cycle Example
A P
S D
AIM: Improve Communication and obtain appropriate intervention
Cycle 1? : Implement….
Wide Scale Cycles : when might it fail ?
Cycle 1D: SBAR use on Unit A for a week
A P
Cycle 1C: Three nurses requested to use SBAR form for their shift.
S D
Cycle 1B:Same nurse to use revised form for two physicians for two nights.
Cycle 1A: One nurse to use SBAR form to report on one patient to one physician.
Change: Communication process to Physicians
Improvement methodology

Why test?
 Learning
 Confidence
 Resistance
Improvement methodology

How small is small ?
Improvement methodology

SKIN Bundle Compliance
Data collection, feedback and testing
Many PDSAs on different elements of the bundle continued to achieve process reliability
Implementation and spread throughout unit

Days between pressure damage events

This is a practical approach
 Learning by doing
“Improvement happens project by project and in no other way”
Joseph Juran
 Bottom up so perfect for students
Improvement methodology

The Ohno circle test
 Stand in circle
 Watch and note down what you see
 Go and make improvements