North East
Leading Improvement for Health
and Well-being Programme
Improvement Methods Workshop 1
All working life in NHS
Diagnostic Radiographer and teacher
Improvement roles since 1994
BPR Leicester Royal Infirmary 1994 - 1999
National Patients ‘Access Team 1999 - 2002
NHS Modernisation Agency 2002 – 2005
NHS Institute for Innovation and Improvement 2005 -2008
Awarded OBE for services to NHS 2003
Visiting professor University of Derby 2008
Jean.penny@btinternet.com
 Who
are you?
 Where
 Which
are you from?
of the 10
work streams are
you working on
1. Set Direction: Mission, Vision and Strategy
Make the future attractive
Make the status quo uncomfortable
4. Generate Ideas
3. Build Will
•Understand organisation as a
system
•Read and scan widely, learning from
other industries and disciplines
•Benchmark to find ideas
•Listen to patients
•Invest in research and development
•Manage knowledge
•Plan for improvement
•Set aims/allocate resources
•Measure system performance
•Provide encouragement
•Make financial linkages
•Learn subject matter
5. Execute Change
•Use Model for Improvement for
design and redesign
•Review and guide key initiatives
•Spread ideas
•Communicate results
•Sustain improved levels of
performance
2. Establish the Foundation
•Reframe operating values
•Build improvement capability
•Prepare personally
•Choose and align the senior
team
•Build relationships
•Develop future leaders
Source: Robert Lloyd
Executive Director Performance Improvement
Institute for Healthcare Improvement
January 16, 2007
6
Knowledge of
Systems
Theory of knowledge
Knowledge about
Variation
Knowledge of
Psychology
W Edwards Deming (1994) The New Economics
8
4 equally important parts of
improvement
People
What
How
User and public
involvement
Diagnostic tools
e.g. Process and
systems
thinking
Change
management
Project and
programme
management
Process
Discipline of improvement
in health and social care (Penny 2003)
People
What
How
User and public
involvement
Diagnostic tools
e.g. Process and
systems
thinking
Change
management
Project and
programme
management
Process
Discipline of improvement
in health and social care (Penny 2003)
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make
will result in improvement?
that
Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The
Act
Plan
Study
Do
improvement guide: a practical
approach to enhancing
organisational performance 2nd ed,
Jossey Bass Publishers, San
Francisco
Understanding
the problem.
Knowing what
you’re trying to
do - clear and
desirable aims
and objectives
Measuring
processes and
outcomes
What have
others done?
What hunches do
we have? What
can we learn as
we go along?
Tools to find out the current status and position
of an organisation or individual in relation to their
environment and current role.
Use as a basis for future planning and strategic
management.
Prioritisation – ‘something considered to be more
important than other things’ (PMMI, 2006)






Political – what are the key political drivers of
relevance?
Economic – what are the important economic
factors?
Social – what are the main social and cultural
aspects?
Technological - what are current technology
imperatives, changes and innovations?
Legal - what current and impending legislation
factors?
Environmental - What are the environmental
considerations, locally and further afield?

Using PESTLE take stock of the position of
your improvement topic
then

Use PESTLE to map the things that will
influence the way your service is delivered
Macro
Meso
Micro
©Profound Knowledge Products, Inc. 2008 All Rights Reserved
Aim
The ‘big’ dots
Drivers
Interventions
The ‘small’ frontline dots
Ask yourself
Ask yourself
Ask yourself
•What is the big (possibly strategic)
problem you are addressing?
•What are the problems that cause
the bigger problem?
What changes can you make that will result in the
improvement you seek?
•What are you trying to achieve?
(aim)
•What are you trying to achieve?
(aim for each driver)
•How will you know a change is an
improvement ? (outcome measures)
•How will you know a change is an
improvement ? (outcome measures
for each driver )
•What are the change ideas / interventions/
solutions to test with PDSA cycles before
implementing?
Which in turn contribute
directly to the ‘bigger’ aim
•How will you know a change is an improvement?
(process measures for each intervention)
Contribute directly to the drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
The
strategic
aim (and
big
problem)
Primary Drivers:
Contribute
directly to the
strategic aim
Secondary Drivers:
Contribute directly to
primary drivers
The interventions / change ideas that
contribute directly to secondary drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
?
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Primary Drivers
Secondary Drivers
Appropriate use of
prophylactic antibodies
Maintain normothermia
Reduce surgical site
infections
Reducing harm in
perioperative care
Ref. Patients Safety First
Maintain glycaemic control
in known diabetes
Use recommended hair
removal methods
Improve team work
and communications
Use of the WHO
Surgical safety checklist
To provide
accessible
rented housing
Make effective use
of existing public
housing
•Percentage dwellings empty
•Relet intervals for all public housing
•Percentage housing stock in good repair
Work with registered
social landlords to
develop public
housing
•Total number of dwellings available
Manage housing
benefit effectively
•Speed of processing claims
•Accuracy of processing claims

Consider the position of your improvement
topic in a driver diagram

Is it a primary or secondary driver?

What would your driver diagram look like?



The Model for Improvement breaks things
down into small steps and works of the ‘little
dots’ – at the frontline
These small steps should be part of the
answer to the question of how to move the
big dots
Align all improvement projects to strategy

Process Mapping
The patient journey

Other (sub-) processes

An example
Process Map:
◦ Who does what to the patient?
◦ Define which group of patients
◦ Define the scope (beginning
and end)
◦ Identify everyone involved
◦ Together, write it down or draw
it
◦ Transport
◦ Communication
26






How many steps?
How many hand-offs?
What is the approx. time of or between each
step?
Where are possible delays and why?
Where are the problems for users, carers and
staff?
How many steps do not “add value”?
WASTE!
Ask why 5 times!!
“Lean thinking is not a manufacturing tactic or a
cost reduction programme, but a management
strategy that is applicable to all organisations
because it has to do with improving
processes. All organisations – including health
care organisations – are composed of a series
of processes, or sets of actions, intended to
create value for those who use or depend on
them (customer/patients)”
IHI: Going Lean in Health Care 2005
Eliminating Non Value Add has a major impact on
Quality, Cost and Service Delivery
Processing waste – “stuff” we have
to do that doesn’t add value.
E.g continuing to care for patients
in hospital when they
could be discharged
Motion – unnecessary
movement e.g having
to walk up and down
the ward to obtain
appropriate supplies
Inventory
– “stuff” waiting to be
worked on
e.g patients
on a waiting list
What is Waste?
Lean Principles
Overproduction
– too much “stuff”
e.g. requesting unnecessary
tests and X-rays
Waiting
– people
waiting for
“stuff” to arrive
e.g waiting
for a ward
round
Defects – “stuff” that is not right and
needs fixing e.g a leaky tap
Injuries
– damage
to people
e.g stress
Transportation
– moving “stuff” e.g
moving patients
from ward to ward
Mark Rahman NHS Scotland
For each step ask ‘does it add value?’. If not
ask:
◦
◦
◦
◦
◦
◦
◦
Can it be eliminated?
Can it be done in some other way?
Can it be done in a different order?
Can it be done somewhere else?
Can it be done in parallel?
Can any “Bottlenecks” be removed?
Is it being done by the most appropriate person?
Ishikawa (Fishbone) Diagrams
People
Place
PPPP
Procedures
Policies
31




‘The 80-20 Rule’
‘The Law of the Vital Few’
For many phenomena,
80% of the consequences stem from
20% of the causes
Observation that 80% of income went to 20%
of the population
Vilfredo Pareto, 1906
33
• The more
specific the aim,
the more likely the
Model for Improvement
improvement
What are we trying to
accomplish?
• Repeated
clarification without it aims
How will we know that a
change is an improvement?
drift
• Meet needs of
external
customers
What change can we make
will result in improvement?
that
Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The
Act
Plan
Study
Do
improvement guide: a practical
approach to enhancing
organisational performance 2nd ed,
Jossey Bass Publishers, San
Francisco
Understanding
the problem.
Knowing what
you’re trying to
do - clear and
desirable aims
and objectives
Measuring
processes and
outcomes
What have
others done?
What hunches do
we have? What
can we learn as
we go along?

Have you defined the problem and agreed
the aim for your improvement topic?


Can you verbalise it in order to communicate?
Use a fishbone diagram to start to identify
the causes of the problem
35
4 equally important parts of
improvement
User and public
involvement
Change
management
Diagnostic tools
e.g. Process and
systems
thinking
Project and
programme
management
Discipline of improvement
in health and social care (Penny 2003)
Ways of helping others to change:
 Building trust and relationships
 Creating rapport
 Managing conflict
 Negotiation
 Effective communication
No rights or wrongs
just differences!
Value (and learn about) the differences
What are your fears about change?
Personal styles How do you behave under stress?
Controls
emotions
Analytical
Driver
•formal
•measured + systematic
•seek accuracy / precision
•dislike unpredictability and surprises
•business like
•fast + decisive
•seek control
•dislike inefficiency and indecision
Ask
Amiable
•conforming
•less rushed + easy going
•seek appreciation
•dislike insensitivity and impatience
Tell
Expressive
•flamboyant
•fast + spontaneous
•seek recognition
•dislike routine and boredom
Shows
emotions
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
Personal styles
Controls
emotions
Analytical
Driver
•formal
•measured + systematic
•seek accuracy / precision
•dislike unpredictability and surprises
•business like
•fast + decisive
•seek control
•dislike inefficiency and indecision
Ask
Amiable
•conforming
•less rushed + easy going
•seek appreciation
•dislike insensitivity and impatience
Tell
Expressive
•flamboyant
•fast + spontaneous
•seek recognition
•dislike routine and boredom
Shows
emotions
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
Analytical
•not enough information
•making a wrong decision
•being forced to decide
Amiable
•damaged relationships
•confrontations
•not being recognised
for efforts
Driver
•loss of control
•failure
•lack of purpose
Expressive
•being ignored
•being asked for detail
•being linked with failure
Merrill D, Reid R (1991) Personal Styles and
Effective Performance, CRC Press, London
Analytical
Driver
•will withdraw
•will become
autocratic
Amiable
Expressive
•will submit
•will become
offensive/sarcastic
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
Personal styles
Analytical
Controls
emotions
•Highly detail orientated
•Can have difficulty making decisions
without all the facts
•Tend to be highly critical
•Very perceptive
Driver
•Objective focused
•Know what they want and how to get there
•Sometimes tactless and brusque
•Hardworking, high energy. Does not shy
from conflict
Ask
Tell
Amiable
•Kind hearted people who avoid conflict
•Can blend into any situation
•Can appear wishy-washy and have
difficulty with firm decisions
•Can be quiet and soft spoken
Expressive
•Natural sales people and story tellers
•Warm and enthusiastic but can be
competitive
•Good motivators and communicators
•Can exaggerate, leave out facts and details
Shows
emotions
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
The Driver: Command Specialist
Perceived positively as:
Perceived negatively as:
Decisive
Independent
Practical
Determined
Efficient
Assertive
A risk taker
Direct
A problem solver
Pushy
One man/woman show
Tough
Demanding
Dominating
An Agitator
Cuts corners
Insensitive
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
The Expressive:
Social Specialist
Perceived positively as:
Perceived negatively as:
Verbal
Inspiring
Ambitious
Enthusiastic
Energetic
Confident
Friendly
Influential
A Talker
Overly dramatic
Impulsive
Undisciplined
Excitable
Egotistical
Flaky
Manipulating
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
The Amiable: Relationship Specialist
Perceived positively as:
Perceived negatively as:
Patient
Respectful
Willing
Agreeable
Dependable
Concerned
Relaxed
Organized
Mature
Empathetic
Hesitant
Wishy Washy
Pliant
Conforming
Dependent
Unsure
Laid Back
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
The Analytical: Technical Specialist
Perceived positively as:
Perceived negatively as:
Accurate
Exacting
Conscientious
Serious
Persistent
Organized
Deliberate
Cautious
Critical
Picky
Moralistic
Stuffy
Stubborn
Indecisive
Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London
Another way
of looking at it
Task focus
Analytical
Driver
Get it
right
Get it
done
Aggressive
Passive
Get Get
along appreciation
Expressive
Amiable
People
focus
Indicate
◦ A person’s interests &
priorities
◦ Behaviour and actions
◦ Strengths and weaknesses
Use this insight to
◦ Choose effective ways to
communicate ideas
◦ Know how to work better
with that person
Think about
• Your team strength
• How the team can
be more effective
• The style of the
individual who may
cause most difficulty
51
HIGH
Affection
Trust
Adapted
from P
Scholtes
(1998) The
Extent to
which I
believe
you care
about me
Distrust
LOW
Leaders’
Handbook;
Respect
McGraw Hill
HIGH
Extent to which I believe you are competent and
capable
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?
Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The
Act
Plan
Study
Do
improvement guide: a practical
approach to enhancing
organisational performance 2nd ed,
Jossey Bass Publishers, San
Francisco
Understanding
the problem.
Knowing what
you’re trying to
do - clear and
desirable aims
and objectives
Measuring
processes and
outcomes
What have
others done?
What hunches do
we have? What
can we learn as
we go along?
Aspect
Improvement
Accountability
Research
Aim
Improvement of care
Comparison, choice,
reassurance, spur for
change
New knowledge
Methods:
Tests are observable
No test; merely evaluate
current performance
Test blinded or controlled
tests
Accept consistent bias
Measure and adjust to
reduce bias
Design to eliminate bias
• Sample Size
“Just enough” data, small
sequential samples
Obtain 100% of available,
relevant data
“Just in case” data
• Flexibility of
Hypothesis flexible,
changes as learning takes
place
No hypothesis
Fixed hypothesis
• Testing Strategy
Sequential tests
No tests
One large test
• Determining if a
Change is an
Improvement
Run charts or control
charts
No change focus
Hypothesis, statistical
tests (t-test, F-test, chi
square),
p-vlaues
• Confidentiality of
the Data
Data used only by those
involved with
improvement
Data available for public
consumption and review
Research subjects’
identities protected
• Test Observability
• Bias
Hypothesis
Robert Lloyd Executive Director IHI adapted from
Solberg L, Mosser G, Mcdonald S (1997) Three faces of performance
measurement: Improvement, accountability and research Journal of
Quality Improvement Vol. 3 No 3
56
610
600
590
580
570
560
550
540
2007
2008
650
600
550
500
450
400
350
300
Jan- Feb- Mar- Apr-07 May- Jun- Jul-07 Aug- Sep- Oct-07 Nov- Dec- Jan- Feb- Mar- Apr-08 May- Jun- Jul-08 Aug- Sep- Oct-08 Nov- Dec07
07
07
07
07
07
07
07
07
08
08
08
08
08
08
08
08
08
What action
is appropriate?
Something
very important!
Last
month
This
month
What does this data tell us?
21.6
22.8
22.8
23.1
23.9 23.3 22.6 28.8 22.7 23.8
28.7 22.9 24.2 23.3 28.6
23.9 23.2 23.7 28.5 23.2 23.5
27.7
What does this data tell us?
30
Weekly production volume
25
20
15
10
Mean = 24.4
5
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22
Week
July
Aug
Sept
Oct
Seconds to answer phone
Seven one side
90
80
70
60
50
40
30
20
10
0
Average based on first 10 days
DO
1
4
7
10
Day
13
16
19
Seven down (or up)
Look for a run of seven points all above or all below
the centre line, or all increasing or all decreasing
Mike Davidge
NHS Institute for Innovation and Improvement
3.5
Average length of pre-ward stay on Barnsley
Stroke Ward
from 01/2007 to 07/2007
3
2.5
2
1.5
1
0.5
0
1
2
3
4
Months
5
6
7
The chart shows
the average
monthly length of
time before
patients got to the
Stroke ward
Average length of pre-ward stay on Barnsley
Stroke Ward
from 01/2007 to 07/2007
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
Weeks
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
1
0.0
Aim
The ‘big’ dots
Drivers
Interventions
The ‘small’ frontline dots
Ask yourself
Ask yourself
Ask yourself
•What is the big (possibly strategic)
problem you are addressing?
•What are the problems that cause
the bigger problem?
What changes can you make that will result in the
improvement you seek?
•What are you trying to achieve?
(aim)
•What are you trying to achieve?
(aim for each driver)
•How will you know a change is an
improvement ? (outcome measures)
•How will you know a change is an
improvement ? (outcome
•What are the change ideas / interventions/
solutions to test with PDSA cycles before
implementing?
measures for each driver )
Which in turn contribute
directly to the ‘bigger’ aim
•How will you know a change is an improvement?
(process measures for each intervention)
Contribute directly to the drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3

Think about Question 1 of The Improvement Model
and the primary and secondary drivers of your
improvement work
 What ARE you trying to achieve?
 How will you KNOW that a change is an improvement?

How can you display measures for improvement on
run charts to share with others – the big dots and
the little dots?
Link improvement measures to
strategic measures
68
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?
Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The
Act
Plan
Study
Do
improvement guide: a practical
approach to enhancing
organisational performance 2nd ed,
Jossey Bass Publishers, San
Francisco
Understanding
the problem.
Knowing what
you’re trying to
do - clear and
desirable aims
and objectives
Measuring
processes and
outcomes
What have
others done?
What hunches do
we have? What
can we learn as
we go along?
Change principle
Change principle
Solution /
change in
organisation A
Solution /
change in
organisation B
P
D
S
A

We planned to….. ( state the basic plan)
In order to ….. (tie it back to the Aim)

What we did was….. (brief description of actions)



Looking at what happened, what we learned
from this was….. ( lessons learned)
What we plan to do next is …. (state next plan)
© Paul Plsek
Having an
experience
Reviewing the
experience
Planning the
next steps
Concluding
from the
experience
Honey & Mumford,
1992
72




Where will the
change ideas come
from?
How will you gather
them?
How will you test
them?
Go back to your
driver diagram

Ideas for change:
Yours and others
Experience
Brainstorming
Evidence
Steal ideas shamelessly
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?
Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The
Act
Plan
Study
Do
improvement guide: a practical
approach to enhancing
organisational performance 2nd ed,
Jossey Bass Publishers, San
Francisco
Understanding
the problem.
Knowing what
you’re trying to
do - clear and
desirable aims
and objectives
Measuring
processes and
outcomes
What have
others done?
What hunches do
we have? What
can we learn as
we go along?
Macro
Meso
Micro
©Profound Knowledge Products, Inc. 2008 All Rights Reserved
1. Set Direction: Mission, Vision and Strategy
Make the future attractive
Make the status quo uncomfortable
4. Generate Ideas
3. Build Will
•Understand organisation as a
system
•Read and scan widely, learning from
other industries and disciplines
•Benchmark to find ideas
•Listen to patients
•Invest in research and development
•Manage knowledge
•Plan for improvement
•Set aims/allocate resources
•Measure system performance
•Provide encouragement
•Make financial linkages
•Learn subject matter
5. Execute Change
•Use Model for Improvement for
design and redesign
•Review and guide key initiatives
•Spread ideas
•Communicate results
•Sustain improved levels of
performance
2. Establish the Foundation
•Reframe operating values
•Build improvement capability
•Prepare personally
•Choose and align the senior
team
•Build relationships
•Develop future leaders
Source: Robert Lloyd
Executive Director Performance Improvement
Institute for Healthcare Improvement
January 16, 2007
76
4 equally important parts of
improvement
User and public
involvement
Change
management
Two sides of improvement
Helps ‘what’ and ‘how’
Diagnostic tools
e.g. Process and
systems
thinking
Project and
programme
management
Discipline of improvement
in health and social care (Penny 2003)
Knowledge of
Systems
Theory of knowledge
Knowledge about
Variation
Knowledge of
Psychology
W Edwards Deming (1994) The New Economics
“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.”

Do you / your organisation currently use
improvement tools and techniques?

What are you going to do next?

One thing you will do as a result of today

One thing you have learnt / Ah-ah moment
79


Boaden, Harvey, Moxham Proudlove (2008) Quality
Improvement: theory and practice in healthcare
NHS Institute for Innovation and Improvement
Improvement Leaders’ Guides
General
Improvement Skills

Process and
systems
thinking
Personal and
organisational
development
NHS Evidence specialist collection on innovation and
improvement www.library.nhs.uk/IMPROVEMENT
Please complete your feedback forms for us
At Improvement workshop 2
 Be prepared to share
◦ What you have done
◦ What you wish you had done differently
◦ What you have learned about improvement

Next time
◦
◦
◦
◦
Managing transitions
Variation
Engaging others
Sustainability and spread