Introduction to
Improvement
Day 1
2
Your facilitators today are:Amanda Huddleston
Improvement Lead: MSc,QN, HV, RN.
&
Wendy Stobbs
Improvement Lead: MA, MSc, RGN.
3
Agenda Day 1
9.00
9.30
10.00
Registration & Coffee
Housekeeping and Introductions
Setting the scene for Barts and AQuA work
QI Theory & Context – Quality & Improvement
Coffee
11.00
11.15
QI Theory & Context – Change & Human Factors
Lunch
12.30
13.15
Diagnosing your Problem
14.00
Aim Statements
Coffee
14.45
15.00
Driver Diagrams
16.15
Summary , Homework & Evaluation
16.30
Close
4
Setting the Scene
for the Safety work
at Barts
AQuA Quality Improvement
Training
Setting the Context
Dr. Charlotte Hopkins
Context
• First do no harm
• Don Berwick
‘….routinely collect, analyse and respond to local measures that serve
as early warning signal of quality and safety problems such as the voice
of the patients and the staff, staffing levels, the reliability of critical
processes and other quality metrics. These can be smoke detectors as
much as mortality rates are, and they can signal problems earlier than
mortality rates do’
How do we know care is safe?
Quality and Safety: the challenges
• CQC ratings of ‘Inadequate’ for Whipps Cross, Newham and The
Royal London plus the Margaret Centre at Whipps Cross
• Trust placed in Special Measures
• CQC found a lack of safety focus across the organisation. For
example:
 The application of early warning systems to assist staff in
the early recognition of a deteriorating patient was varied.
 The National Early Warnings System (NEWS) had not yet
been implemented consistently.
Safe and compassionate – our improvement plan priorities
• Safe and effective care: making safety an absolute priority at all times
• Workforce: making sure we have the right number and mix of staff across
our services at all times
• Outpatients and medical records: making our systems more reliable so
they support staff to do their jobs and patients to get the care they need
• Emergency pathway and patient flow: making sure patients get care and
treatment in a timely way
• Compassionate care and patient experience: making sure patients are
always treated with dignity and respect
• End of life care: making sure there are appropriate care plans for those
patients nearing the end of their life
• Leadership and organisational development: strengthening the way the
Trust is run and making sure staff have all the support they need
Our Quality and Safety Priorities
• To further embed safety into our culture.
• Provide support and opportunity for staff in developing their
capability and capacity in quality improvement.
• Quality Improvement Collaborative to share good practice,
accelerate improvement across the Trust and build a quality
improvement system based on a core methodology.
• Sepsis, Preventing Acute Kidney Injury, Falls, Failure to Rescue,
Pressure Ulcers, VTE, 5 stage WHO checklist
A framework for the measurement and monitoring of safety
Has patient care been safe in the past?
Ways to monitor harm include:
• Safety Cross data
• Number of hospital visits due to harms
• Reporting of incidents by staff members
Are our clinical systems and
processes reliable?
Ways to monitor reliability include:
• Use of a falls checklist
• percentage compliance with all
elements of the pressure ulcer
care bundle.
Are we responding and
improving?
Sources of information to learn
from include:
• How are you using the
information in Quality & Safety
meetings?
• Can you demonstrate
improvement over time?
Is care safe today?
Ways to monitor sensitivity to operations
include:
• safety walk-rounds
• meetings, handovers
• day-to-day conversations
• staffing levels
• patient or carers interviews to identify
threats to safety.
Will care be safe in the future?
Possible approaches for achieving
anticipation and preparedness include:
• safety culture analysis and safety
climate analysis
• safety training rates
• sickness absence rates
Source: Vincent C, Burnett S, Carthey J.
The measurement and monitoring of safety.
The Health Foundation, 2013
The different levels of capability within an organisation
Staff who show
enthusiasm and
talent will be given
opportunities to
progress through
these levels to
continually build
expertise and skills
To work in partnership with expert
organisations to develop our own
experts and faculty and talent spot
within the organisation
Identify and develop new
improvement roles working
alongside teams
The partner organisation will
train 3 full time staff members
to develop our own internal
sustainable resource
Basic introduction to
QI – half day course
Why partner?
Who are AQuA
Who are AQuA?
Advancing Quality Alliance
• North West health improvement organisation
• Membership: Acute, Primary care, Community, CCG,
Mental health and Ambulance trusts across North
West England
• Its mission is to stimulate innovation, spread best
practice and support local improvement in health
and in the quality and productivity of health services
17
Working Together to Improve
AQuA is unique to the NHS.
It has not been established by
a central edict but as a result
of NHS staff and organisations
working together to bring
about improvements for
patients.
As a membership organisation,
AQuA’s success relies on strong
and active engagement from
its members.
18
AQuA’s Key Principles
• We can achieve more by working together than in
isolation
• Improvements must be owned from front line staff to
Boards and leaders
• Use robust evidence based improvement methods
• As a membership organisation we will only succeed
with active and engaged members
Values Banner?!
19
Skills Escalator for Safety
Introduction to Improvement
for Safety (I2I4S)an Overview
Programme Aims
Aim- for delegates to achieve Level 1 / Novice level of the Academy
Skills Escalator.
Objectives are for individuals:
• To appreciate the foundations of theory of quality improvement for
safety and the how this is relevant in the current NHS context
• To provide delegates with tools, techniques and concepts which will
help them:
– Plan an improvement initiative
– Engage people in an improvement initiative
– Deliver an improvement initiative
– Evaluate an improvement initiative
– Sustain and spread an improvement initiative
– To provide an opportunity for delegates to practically apply the
tools to an organisational relevant improvement initiative
22
Programme Expectations
AQuA
• Core facilitators/link names
• Copies of presentations via
email
• Support to develop
improvement initiative
• Evaluations acted upon
You
• Attendance at all 3 workshops
• Print out all materials required
• Development of your
improvement project
• Submission and delivery of
completed project case study
• Evaluations and reflective log
completed
• Consider how Links to PDP &
skills development framework
23
Learning Objectives for the Day
 To introduce you to the theory and context of
quality improvement in the NHS
 To provide an understanding of how to plan and
refine an improvement initiative
 To allow you to practically apply this to your own
initiative
24
Available in
the Tool Kit
Available on
AQuA Portal
Reflection
point
25
Initiative Rationale
What is the evidence to support
the need?
Who has an interest in this area?
Would they be on your expert
panel?
How is it aligned to your
organisation’s quality and safety
strategy?
Who are your stakeholders?
How will it impact patient care,
staff satisfaction & involvement
and the wider health economy?
26
Getting to Know You
Please take a post-it note from your desk and write a
random fact about yourself on it – it can be work or
non-work related and the more random the better!
You must be willing to share your fact during the
course, and it must be something that can be shared in
public but please keep it secret for now!
Please write your name at the bottom, fold it up and
give it to one of the facilitators 
28
QI Theory & Context
- Quality & Safety
What does quality mean?
•
•
•
•
•
To you as a consumer?
To you as an employee?
To your organisation?
To your patients/clients/service users?
Describe it – what does it
look/feel/sound/smell like?
30
QI Isn't A New Thing,
It’s the Right Thing
Scuatari Barracks
Hospital Turkey
1854
Florence Nightingale (1859)
Notes on Hospitals
32
150+ years later…
“.. patient safety is of paramount importance in
terms of quality of care and to delivering
better health outcomes ... long history of
efforts to embed patient safetymore
systemically in the NHS, widely recognised
across the health system that the pace of
change is too slow…..’cultural barriers’ to
ensuring that patients are as safeas they
could be.”
The NHS Outcomes Framework 2011/12 p29
33
Francis.
Feb 13
Berwick.
Aug 13
Keogh.
July 13
5 Yr FV
2014
Maintaining Safety in our Current
Climate
6 Dimensions of Quality Healthcare
Quality Healthcare
Safe
Timely
Equity
Effective
Efficient
Patient
Centered
Sustainability
Improvement science and profound knowledge
IOM (2001) Crossing the Quality Chasm
Sustainability was added: Future Hospital Commission (2013)
36
Future Hospital: Caring for Medical Patients
6 Dimensions of Quality Healthcare
Quality Healthcare
Safe
Timely
Equity
Effective
Efficient
Patient
Centered
Sustainability
Improvement science and profound knowledge
THE DARZI ‘3’
5 YEAR FORWARD
IOM (2001) Crossing the Quality Chasm
Sustainability was added: Future Hospital Commission (2013)
37
Future Hospital: Caring for Medical Patients
The Quality Pioneers
W Edwards
Deming
1900-93
American engineer,
statistician, professor,
author, lecturer, and
management
consultant
Scientific pioneer of
quality control.
Walter
Shewhart
1891-1967
American physicist,
engineer and
statistician
Father of statistical
quality control.
Invented the Shewhart
Cycle
Romanian born
American management
consultant and
engineer
Advocate of quality &
quality management
Joseph
Juran
1904-2008
38
Two Types of Knowledge
Subject Matter
Knowledge
Subject Matter Knowledge:
Knowledge basic to the
things we do in life.
Professional knowledge.
Profound Knowledge: The
interaction of the theories
of
systems,
variation,
knowledge, and psychology.
Profound
Knowledge
40
Deming’s System of Profound
Knowledge
Appreciation for a System
• Interdependence, dynamism
• World is not deterministic
• Optimization, interactions
• Containing systems, subsystems
Psychology of change
• Interaction between people
• Motivation
• Beliefs, assumptions
inferences
Understanding Variation
• Variation is to be expected
• Common or special causes
• Ranking, tampering
• System capability
Theory of Knowledge
• Prediction
• Learning from theory,
experience
• Operational definitions
• PDSA for learning and
improvement
41
From L. Provost
Deming’s System of Profound
Knowledge
Appreciation
of a System
Theory of
Knowledge
Subject Matter
Knowledge
Psychology
Knowledge
for
Improvement
Understanding
Variation
The aim of this chapter is to provide an outside view – a lens – that I
call a system of profound Knowledge. It provides a map of theory by
which to understand the organizations that we work in.”
(Deming 1993 p. 92)
42
Quality Improvement
for Safety
Old Way versus the New Way
Action taken
on all
occurrences
Threshold
Action
taken
here
No
action
taken
here
Better
Quality
Worse
Old Way
(Quality Assurance)
Better
Quality
Worse
New Way
(Quality
Improvement)
45
Improvement ScienceWhat is it?
Improvement science is an emerging field of study focused on the methods,
theories and approaches that facilitate or hinder efforts to improve quality
and the scientific study of these approaches.
Source: The Health Foundation, Improvement Science Evidence Scan, Jan
2011
‘We propose defining it as, the combined and unceasing efforts of
everyone – healthcare professionals, patients and their families,
researchers, payers, planners and educators – to make the changes that
will lead to better outcomes (health), better system performance (care)
and better professional development (learning).’
Paul Batalden & Frank Davidoff 2007
Improvement Science
What is it?
Improvement science is an emerging field of study focused on the methods,
theories and approaches that facilitate or hinder efforts to improve quality
and the scientific study of these approaches.
How do we make
things better?
Source: The Health Foundation, Improvement Science Evidence Scan, Jan 2011
‘We propose defining it as, the combined and unceasing efforts of
everyone – healthcare professionals, patients and their families,
researchers, payers, planners and educators – to make the changes that
will lead to better outcomes (health), better system performance (care)
and better professional development (learning).’
Paul Batalden & Frank Davidoff 2007
Quality Improvement Leaders
Don Berwick
Previous Administrator
of the Centers for
Medicare and
Medicaid Services &
CEO of IHI
Paul Batalden
Professor The
Dartmouth Institute
for Health Policy and
Clinical Practice
Helen Bevan
NHS Improving
Quality
48
Change Concepts
Change the Work Environment
Eliminate Waste
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Eliminate things that are not used
Eliminate multiple entry
Reduce or eliminate overkill
Reduce controls on the system
Recycle or reuse
Use substitution
Reduce classifications
Remove intermediaries
Match the amount to the need
Use Sampling
Change targets or set points
Improve Work Flow
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Synchronize
Schedule into multiple processes
Minimize handoffs
Move steps in the process close
together
Find and remove bottlenecks
Us automation
Smooth workflow
Do tasks in parallel
Consider people as in the same system
Use multiple processing units
Adjust to peak demand
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
Give people access to information
Use Proper Measurements
Take Care of basics
Reduce de-motivating aspects of pay system
Conduct training
Implement cross-training
Invest more resources in improvement
Focus on core process and purpose
Share risks
Emphasize natural and logical consequences
Develop alliances/cooperative relationships
Enhance the Producer/customer
relationship
38.
39.
40.
41.
42.
43.
44.
45.
Listen to customers
Coach customer to use product/service
Focus on the outcome to a customer
Use a coordinator
Reach agreement on expectations
Outsource for “Free”
Optimize level of inspection
Work with suppliers
Manage Time
Optimize Inventory
23
24
25
26
Match inventory to predicted demand
Use pull systems
Reduce choice of features
Reduce multiple brands of the same
item
46.
47.
48.
49.
50.
Reduce setup or startup time
Set up timing to use discounts
Optimize maintenance
Extend specialist’s time
Reduce wait time
Manage Variation
51.
52.
53.
54.
55.
56.
57.
58.
Standardization (Create a Formal
Process)
Stop tampering
Develop operation definitions
Improve predictions
Develop contingency plans
Sort product into grades
Desensitize
Exploit variation
Design Systems to avoid mistakes
59.
60.
61.
62.
Use reminders
Use differentiation
Use constraints
Use affordances
Focus on the product or service
63.
64.
65.
66.
67.
68.
69.
70.
Mass customize
Offer product/service anytime
Offer product/service anyplace
Emphasize intangibles
Influence or take advantage of fashion
trends
Reduce the number of components
Disguise defects or problems
Differentiate product using quality
dimensions
Added for 2nd Edition
71. Change the order of process steps
72. Manage Uncertainty, Not Tasks
Reference: The Improvement Guide, 2nd Ed. Langley, Nolan, Nolan, Norman Provost, Appendix A; pgs. 357-408
Model for Improvement
AIM: What are we trying to accomplish?
MEASURES: How will we know if a
change is an improvement?
CHANGE: What changes can we make
that will result in improvement?
Act
Study
A P
S D
Plan
Do
51
Empathy the Human
Connection to Patient Care
Video
The Wigan Empathy video
52
Coffee
Break
53
Do you have an initiative in mind?
What does your initiative mean to
people (patients, staff, carers,
family, friends)?
54
Initiative Rationale
What is the evidence to support
the need?
Who has an interest in this area?
Would they be on your expert
panel?
How is it aligned to your
organisation’s quality and safety
strategy?
Who are your stakeholders?
How will it impact patient care,
staff satisfaction & involvement
and the wider health economy?
55
Exercise: Building the Components of
Profound Knowledge
Consider the system that you will seek to improve.
• Discuss the issues related to the project that arise from
each component of the System of Profound Knowledge:
– which systems will your project impact?
– what variation do you know about or expect?
– how will your project impact people (colleagues, team
members, other depts)?
– what beliefs do you have about your project and how
will you test them?
• And what do you bring to it personally?
56
Deming’s System of Profound
Knowledge
Appreciation for a System
• Interdependence, dynamism
• World is not deterministic
• Optimization, interactions
• Containing systems, subsystems
Psychology of change
• Interaction between people
• Motivation
• Beliefs, assumptions
inferences
Understanding Variation
• Variation is to be expected
• Common or special causes
• Ranking, tampering
• System capability
Theory of Knowledge
• Prediction
• Learning from theory,
experience
• Operational definitions
• PDSA for learning and
improvement
57
From L. Provost
Change
What does change
mean to you?
59
Change
• To cause to be different
• To give a completely different form or appearance to;
transform
• To give and receive reciprocally
• To exchange for or replace with another
• To lay aside, abandon, or leave for another; switch: change
methods; change sides.
• To put a fresh covering on
• To become different or undergo alteration
• To undergo transformation or transition
• To go from one phase to another
60
http://www.thefreedictionary.com/change
Why do we need to change
things anyway?
61
“Every system is perfectly designed
to get the results it achieves”
Paul Batalden
Dartmouth Medical School,
New Hampshire, USA.
62
Systems and Processes
Input
Action
Output
Input
Action
Output
Input
Action
Output
Input
Action
Output
63
Systems and Processes
Process
System
• Series of steps that are
connected and achieve an
outcome
• Definitive start and end
point (scope)
• Defined user group/product
• Usually links to other
processes
• A collection of processes
organised around a purpose
• Impact on those above,
below or embedded
• Coordinated activity
between each system
• Think ripples on a pond
64
65
Reactive vs Proactive
Reactive change
Proactive change
• Made to solve immediate
problems or react to a
special circumstance.
• Often result in putting the
system back to where it was
sometime before.
• Result is usually felt
immediately or in the near
future
• Initiate changes before
problems occur
• Causing something to
happen rather than waiting
for it to happen
• Result felt later on-not
always obvious
67
Human Factors
Definition
Human factors encompass all those factors that can
influence people and their behaviour. In a work
context, human factors are the environmental,
organisational and job factors, and individual
characteristics which influence behaviour at work.
Implementing human factors in healthcare
Patient Safety First “How to guide” 2010 version
70
Everywhere………
71
Why are Human Factors so Important?
Human error is estimated to account for:
• 70% of aviation disasters
• 70% of shipping incidents
• 85% of shuttle incidents at NASA
In healthcare?
• 80% of healthcare errors
72
Buses analogy
What’s your data telling you?
66 seats
73
Even more alarming……..
HEALTH CARE
74
Why are errors happening
Traditional approach to human error:
– The sources of error are bad people
– Seek out and apportion blame
– Remove individual from system = improve patient
safety
– Fails to learn lessons
77
Traditional responses for reducing Error
1. Telling people to “make fewer mistakes” is not
effective at reducing error
2. Writing new detailed policies is not necessarily
effective at reducing error
3. Punishing individuals for making mistakes is not
effective at reducing error
4. Remove individual from system = improve patient
safety
78
Reducing Error
Studies have shown that the best way of reducing error
rates is to target the underlying systems failures, rather
than take action against individual members of staff
• the perfection myth: if people try hard enough, they will
not make any errors;
• the punishment myth: if we punish people when they
make errors, they will make fewer of them.
79
Or maybe…
1. Redesigning systems to protect against error
2. Educating staff about the causes of error, error
detection and error correction
3. Educating patients about personal hospital safety
…are more effective approaches to reducing error???
Admission video link
80
Failure
• In any complex system faults, errors and failures are
inevitable
• This applies to equipment / technology and to human
beings
• Most of these are of relatively little consequence and do
not result in adverse consequences
• Serious adverse incidents are usually the result of a
sequence of lesser failures and errors
• Critical systems need to be designed to cope with errors
or failures
81
When everything slots into place…….
Understaffed
Distraction
Poor
Guidelines
Adverse /
Never
Event
James Reason’s Swiss Cheese Model
© AQuA Academy
82
Causes of Failure
• Latent conditions
– Organizational failures & systems design
– Present in all systems for long periods of time
– Increase likelihood of active failures
• Active Failures
– Errors at the time of the event
– Unsafe acts (errors and violations) committed at the
“sharp end” of the system
– Have direct and immediate impact on safety, with
potentially harmful effects
83
Latent Conditions
•
•
•
•
•
•
•
Exist within organisation, systems and processes
Poor design of equipment or systems
Poor guidelines or lack of guidelines
Adverse environmental factors
Poor working conditions
Lack of resources (e.g. understaffing)
Poor training and education
84
“Active Failures”
Violations
Intended
actions
Mistakes
Routine Reasoned
Reckless
Malicious
Rule Based
Knowledge Based
Basic Error
Types
Unsafe
acts
Lapses
Skill based errors
Memory failures
Slips
Skill based errors
Attentional failures
Unintended
actions
85
Top tips – Combatting Error
Reduce potential for error:
• Good education and training
• Reduce distractions and workload
• Appropriate staffing and resources
• Appropriate and understandable procedures
• Accessible, easy to use SOPs
• Proper equipment
• Appropriately designed technology
87
Remember – Safety vs Efficiency
• Efforts to Improve efficiency often look to remove
steps considered to be “wasteful”
• This can also improve safety as processes with
more steps have a higher risk of failing
• However, safe systems also have redundant steps
(steps which may detect and error or failure)
• Caution not to remove important redundant steps
88
Diagnosing your Problem
90
Sometimes its obvious when things
need to change…
91
Three Modes of Thinking
• Creative thinking, which results in new ideas
• Logical positive thinking, which is concerned with
how to make a new idea work
• Logical critical thinking, which is focused on finding
problems in the new idea
It is usually better for a group to engage in one
type of thinking at a time
Improve or Innovate?
Improvement – small
incremental changes. Doing
the same thing but doing it
better
Innovation – an idea
that breaks with the
usual way of thinking
Solution V’s Problem
© 2014 AQuA
But before we start…………do you
really understand the problem??
Solution vs Problem
How do you know what needs
improving?
Quantitative data
Qualitative data
We benchmark poorly
Patients who complain
We’re failing our target
Patients we interview
Our Outcomes are poor
Staff feedback
5 Whys
• This could take any number of “whys” to get to the
root cause of the problem
• Do not stop until you reach what you believe is a
“cause” and not a “symptom”
• If you reach a cause that cannot be controlled, such
as weather, go back one level and see if eliminating
that cause will help
© AQuA Academy
97
Why, why, why?!
‘Results indicate that when preschoolers ask "why"
questions, they're not merely trying to prolong
conversation, they're trying to get to the bottom of
things.’
http://www.sciencedaily.com/releases/2009
/11/091113083254.htm
Frazier et al. Preschoolers' Search for
Explanatory Information Within Adult-Child
Conversation. Child Development, 2009;
80 (6): 1592 DOI
© 2014 AQuA
Process Maps
Process
Map
Value
Stream
Map
© 2014 AQuA
Diagrams
Fishbone
Spaghetti
© 2014 AQuA
Fishbone Diagram
A systematic and structured method for identifying
potential root causes of failures
– Classifies potential causes for a failure into
five separate categories
– Very logical and analytical method of
determining potential causes for failures
© AQuA Academy
103
Group
Work
104
Analysing qualitative data
Construct a story
around typical
findings
Thematic analysis:
Look for the
common themes
The power of a
good quote
The Patient Perspective
106
108
Resources/references
• http://www.bbc.co.uk/news/uk-england-london-18814487
• http://www.pickereurope.org/improvingpatientexperience
• http://www.institute.nhs.uk/productives/15stepschallenge/15stepschallenge.
html
• http://www.institute.nhs.uk/
• http://www.patientexperiencenetwork.org/
• http://www.nhsconfed.org/priorities/Quality/Pages/Delivering-great-patientexperience.aspx
• http://www.ihi.org/knowledge/Pages/IHIWhitePapers/AchievingExceptionalPa
tientFamilyExperienceInpatientHospitalCareWhitePaper.aspx
• http://www.patientvoices.org.uk/
• http://www.mindtools.com/CommSkll/ActiveListening.htm
110
References/resources
Patient opinion 2010; What Patients think about our NHS
The Intelligent Board, 2010; Patient Experience; Dr Foster Intelligence
NHS west Midlands Aug 2009; A guide to capturing and using patient, public and service user feedback
effectively
Brown H, Davidson D, Ellins J (2009) Real-time Patient Feedback. Birmingham: Health Services
Management Centre, University of Birmingham (for NHS West Midlands)
Institute for innovation and improvement; The rough guide to experience and engagement for GP
Consortia
NHS Institute for Innovation and Improvement, Experience Based Design, approach guide and toolkit,
www.institute.nhs.uk/quality_and_value/introduction/experience_based_design.html
Department of Health, 2008, High Quality Care for All, London
Department of Health, 2008, The Operating Framework for the NHS in England 2009/10, London
Department of Health, 2009, The NHS Constitution, London
Department of Health, 2007, World Class Commissioning: Competencies, London Cabinet Office, 2009,
Working together: public services on your side, London Department of Health, 2008, ‘Measuring the
experience of patients/users’,
www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/NationalsurveyofNHSpatients/DH_087516
Department of Health 2009b Improving Patient Experience. Transforming services using patient
experience feedback.www.dh.gov.uk/ppe
Department of Health 2009 Understanding what matters: A guide to using patient feedback to
transform services
111
Healthcare Commission, 2007, Is anyone listening? A report on complaints handling in the NHS
Planning your Improvement
Initiative
Setting Aims
Why do we need an Aim?
• Improvement requires setting aims.
• An organisation will not improve without a clear
and firm intention to do so.
Adapted from
114
Model for Improvement
AIM: What are we trying to accomplish?
MEASURES: How will we know if a
change is an improvement?
CHANGE: What changes can we make
that will result in improvement?
Act
Study
A P
S D
Plan
Do
115
Do you have an initiative? Why did
you choose that topic
There:
• Is a gap between science and practice
• Are examples of better performance
• Is a good “business case” to change
• Is there a safety concern?
116
Initiative Idea Rationale
What is the evidence to support
the need?
Who has an interest in this area?
Would they be on your expert
panel?
How is it aligned to your
organisation’s quality and safety
strategy?
Who are your stakeholders?
How will it impact patient care,
staff satisfaction & involvement
and the wider health economy?
117
Link to Quality
Safe
Timely
Effective
Efficient
Equitable
Patient Centred
Crossing the Quality Chasm: A New
Health System for the 21st Century,
2001 Institute of Medicine
118
Setting an Aim
•
•
•
•
What are you trying to accomplish?
By how much?
By when?
For whom(or what system)?
119
Aim Statement
Good
Bad
We aim to reduce harm and improve patient safety for all of our
internal and external customers.
By June of 2012 we will reduce the incidence of pressure ulcers in the
critical care unit by 50%.
Our outpatient testing and therapy patient satisfaction scores are in the
bottom 10% of the national comparative database we use. As directed
by senior management, we need to get the score above the 50th
percentile by the end of the 1st Quarter of 2012.
We will reduce all types of hospital acquired infections.
According to the consultant we hired to evaluate our home health
services, we need to improve the effectiveness and reliability of home
visit assessments and reduce rehospitalisation rates. The board agrees,
so we will work on these issues this year.
Our most recent data reveal that on the average we only reconcile the
medications of 35% of our discharged inpatients. We intend to increase
this average to 50% by 1/4/12 and to 75% by 31/8/12.
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Aim Statement
• Team name: Lunch time – on time
• Aim statement
(What’s the problem? Why is it important? What are
we going to do about it?)
90% of patients in Bay 1 receive their lunch of choice
everyday by 12.30 by November 2014
• Whom will it affect? Patients in Bay 1
• By how much? 90% will receive choice by 12.30
• By when? November 2014
Adapted from
121
Aim Statement
• Team name:___________________________
• Aim statement
(What’s the problem? Why is it important? What are we going to do about it?)
• Whom will it affect?_____________________
• By how much?____________________________
• By when?______________________________
Adapted from
122
Coffee
Break
123
Driver Diagrams
Driver Diagrams – why use them?
• Breaks down any broad aim, graphically, into increasing
levels of detailed actions that must or could be done to
achieve the stated aim
• Helps to focus on the cause and effect relationships that
exist in complex situations.
• Well defined drivers that can form the focus of
improvement efforts.
NHS Tayside
125
What are the component parts?
•Aim or goal of the improvement effort
•Primary drivers - system components that contribute
directly to the chosen aim or goal. Processes, rules of
conduct, structure
•Secondary drivers - elements of the primary drivers and
which can be used to create change projects. Components
and activities
•Relationship arrows - show the connection between the
primary and secondary drivers. A single secondary driver
may impact upon a number of primary drivers
NHS Tayside
126
127
Aim / Outcome
90% of
patients in Bay
1 receive their
lunch of
choice
everyday by
12.30 by
November
2014
Primary Drivers
Secondary Drivers
Technology-
Menu cards distributed
Know what
patients want /
need for lunch
Choices recorded &
communicated
Materials-
Diet requirements understood
Numbers established &
communicated
Lunch & equipment
arrives on time
Time for delivery agreed
Process-
Allocate lunch duty
Ward Staff are
available to give
out lunch
Complete other tasks prior to
lunch arrival
PeoplePatients are
available to receive
lunch
Access to ward available
Staff appropriately trained
Schedule inpatient appts
appropriately
Appropriately positioned
Maintained at appropriate
temperature
131
Developing Primary Drivers
• Dedicate time for team and subject matter experts – ask
them to come prepared!
• Revisit your aim statement.
• Brainstorm potential Primary Drivers & check
– ’If I made an improvement in this driver what would it
achieve?’
– ’If I could influence (or improve) against all of these
drivers is there anything else that could go wrong and
prevent me achieving my aim?’
NHS Tayside
133
134
Developing Secondary Drivers
• Look at your Primary Drivers and ask
– What are the main system factors that will impact
upon this primary driver?’
– What changes will be made to impact on this?
• Brainstorm potential Secondary Drivers & check
– ’If I made an improvement in this driver what would it
achieve?’
– ’If I could influence (or improve) against all of these
drivers is there anything else that could go wrong and
prevent me achieving my aim?’
•
Add relationship arrows
NHS Tayside
135
Aim / Outcome
90% of
patients in Bay
1 receive their
lunch of
choice
everyday by
12.30 by July
2013
Primary Drivers
Secondary Drivers
Know what
patients want /
need for lunch
Menu cards distributed
Lunch & equipment
arrives on time
Ward Staff are
available to give
out lunch
Patients are
available to receive
lunch
Choices recorded &
communicated
Diet requirements understood
Numbers established &
communicated
Time for delivery agreed
Access to ward available
Allocate lunch duty
Complete other tasks prior to
lunch arrival
Staff appropriately trained
Schedule inpatient appts
appropriately
Appropriately positioned
Maintained at appropriate
temperature
136
Group
Work
137
138
Home Work
• Work through the toolkit and
ensure your initiative has an:
• Aim
• Driver Diagram
• Give thought to how the patients and staff will be
affected and involved
• If you have any measures from your project bring them
along
139
Learning Objectives for the Day
By the end of this session you will:
• Theory & Context
– Have a comprehension of the foundations for quality
improvement
– Have a basic awareness of the impact of human factors in
healthcare
• Planning your Improvement Initiative
– Be able to develop the building blocks for delivering an
improvement initiative through the application of
Improvement Tools – including Aim Statements, Driver
Diagrams, Problem Solving and Diagnostic Techniques
140
Contact AQuA Via:
• The website at:
www.advancingqualityalliance.nhs.uk
• The Member Web Portal at:
www.aquanw.nhs.uk/users/sign_in
• Email your project lead at Barts:
rachel.huck@bartshealth.nhs.uk
•
•
@AQuA_inform
AQuA-Advancing-Quality-Alliance
141