Why do clinicians do audits?
Why do you want to improve care?
What are values?
Values are principles and beliefs that
guide our actions
What are the values of your patients?
In clinical practice whose values do we need to
be aware of?
Respect for the diversity of values
P
• Patient-centred and safe
• Public health driven
• Prevention-focussed
• Professionally-inspired
O
• Objectives clear
• Outcome driven
E
• Evidence based
T
• Team delivered
I
• Integrated
C
• Cost efficient and effective
• Clinically governed
Introduction to clinical systems
improvement
What is the perfect healthcare system?
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No needless deaths
No needless suffering
No delays
No waste
No inequalities
No feelings of helplessness
Important questions
• You are providing a service – so who is the
customer?
• Is there variability, waste, poor morale, poor
value for money and defects in your system?
• Does your system have the capacity to cause
harm?
• How much of your system adds value from the
patient’s perspective?
• Has your system been designed?
Why use clinical systems improvement
methodologies?
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They are good at discovering waste in a system
Can tackle the problems in your service
Can reduce waiting times
Can revolutionise your service (given commitment)
Require a team of key stakeholders who can analyse
a problem from different perspectives (including that
of the patient)
• Who are the stakeholders in a better Malawian
healthcare system?
Which methodologies are useful to use
when considering your audits?
• Root cause analysis and the use of ‘5 whys’ to
truly discover the problem
• Ask the question ‘why?’ 5 times to get to the
bottom of the problem
5 whys example
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The patient was late in theatre, it caused a delay. Why?
There was a long wait for a trolley. Why?
A replacement trolley had to be found. Why?
One of the trolley's wheels was worn and had broken. Why?
It had not been regularly checked for wear. Why?
The root cause - there is no equipment maintenance schedule.
Setting up a proper maintenance schedule helps ensure that
patients should never again be late due to faulty equipment.
This reduces delays and improves flow. If you simply repair the
trolley or do a one-off safety rail check, the problem may
happen again sometime in the future.
5 Whys group exercise
• In small groups, think of a problem that you
have all experienced
• As the question ‘why?’ 5 times to identify the
root cause
• How will you plan to improve the root cause?
Was that easy?
• Some things are considered “undiscussible” but may
be the underlying cause of organisational problems
• Think about an example in your own work
• Divide a page into two columns
• In the right column: write down an actual or imagined
conversation about an unsolved organisational
problem on the right
• In the left column: write your unspoken thoughts &
feelings relating to the conversation
• Now you are more aware of any “undiscussable”
problems, think about how you might discuss them
Define a patient journey
• In two groups, discuss the patient journey for
a 22 year old woman presenting with
obstructed labour
• What are all the steps that she experiences
from arriving at the hospital?
– All the members of staff she meets
– All the procedures she undergoes
– Map these steps out as a flow chart on paper
Is our patient journey wasteful?
Arrival
Midwife
Assessment
History &
examination
Differential
diagnosis
Handover to
clinical
officer
History and
examination
Differential
diagnosis
Does every step add
value to our patient?
Develop
plan of care
Waste that does not add value
• Unnecessary movement of patients
• Unnecessary motion (equipment and
consumables not to hand)
• Waiting
• Unnecessary tests and investigations
• Over processing (repeated history taking,
examinations etc)
• Errors
• Overdurden of staff
Can you improve your
patient’s journey?