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Driver
Diagrams
Wendy Jamieson – Manager Clinical Leadership and Improvement Program
Clinical Excellence Commission [email protected] Mob 0434 - 078 026 Twitter @wendyejamieson
About this Workshop
• Lots of content in some slides For you to refer back to when you are doing your project
• Some staff will have solid knowledge and others not – be patient!
• Chatham House Rules – what’s said in the room stays in the room
• Ask questions any time
• Mobiles on silent
• Pre-Post Knowledge Survey
Driver Diagram - Overview
• A Driver Diagram (DD) is a powerful tool that helps you translate a problem into an improvement project using an:
Aim Statement Primary & Secondary Drivers Relationship Arrows Solutions Measures
• It is used to scope a project and to clarify the plan for reaching the desired aim
• It captures an entire improvement project in a single diagram which can be reviewed / updated at every team meeting.
• Originally developed by IHI in USA & used by the NHS Reference: http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/GoldmannDriver.aspx
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers & R’ship Arrrows
Secondary Drivers & Arrows Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions & Arrows Impact: High Implementation: Easy
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Team Members: • David • David’s wife • David’s children • etc • Project Sponsor – Davids Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Priority PDSA
Process Measure: • How much: Reduce Calorie
intake by 30% • By when: 2 months
Process Measure: How much: Increase by calories burnt by 40% By when: 2 months
Aim Statement with measurable
Stretch goal Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Measures
CAUTI Driver Diagram
Within 6 months, 100%
of patients admitted to
the ward from ED will have a documented indication for their catheter.
Improve catheter documentation in
medical record
Increase communication re catheters to admitting
medical teams
Discuss indications for in-situ catheter with ward
nurse
Include catheter indication in ward handover notes
100% of medical orders for catheterisation are
documented (not verbal)
More thorough history taking on Admission at ED.
Ensure completeness of documentation of
catheter insertion ie: no gaps in information
Design & implement an AMO handover checklist
Provide Education to ED medical officers re: handover
of catheters
Include catheters indication on Nursing handover checklist
Provide ward nurse with print out of catheter obs from First
Net.
Insert a field for catheter indication on ward handover
notes.
ED to complete catheter insertion record sticker at
time of insertion and provide to ward nurse at handover.
Provide Education to ED medical officers re:
documenting orders for catheter insertion
Enable ward with electronic access to First Net
ED to document catheter insertion & indication in paper
medical record.
Make catheter insertion obs compulsory fields on First Net.
Impact: High Implementation: Hard
The Problem: Do not know WHY patients from ED have catheters in place.
Team Members: • Nurse educator – Ward & ED • ED med director • Ward NUM
• ED Clinical NUM
Increase communication re: Catheters at
clinical handover btw staff
Increase access to documentation on First
Net.
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Measure: • How much: • 100% documented • By when: 6 months Impact: High
Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Measure: How much: 100% of ED staff will discussed catheters during handover By when: 3 months.
Measure: How much: 100% of catheterised patients will have documentation in their healthcare record about their catheter insertion at the time of their transfer. By when: 6 months.
Measure: How much: All ward AMOs will be made aware that their patient is being transferred with catheter within 1 hour of the transfer being booked By when: 2 months.
Measure: How much: 80% of nursing staff on the ward will be trained on how to use eMR to find catheter information By when: 3 months.
Measure: How much: A complete catheter insertion record will be available in the notes of all catheterised patients By when: 4 months.
CAUTI Driver Diagram
Within 6 months,
reduce # of pts admitted to
ward with an IDC by 30%
Reduce the # of pts with existing
(chronic) IDCs who are transferred out
of ED.
Increase equipment availability
ED discharge nurse checks for IDCs that can be removed more frequently before
transferred
Always document planned IDC removal in Med Rec.
Increase # of bladder scanners
Increase supply of in/out catheter
Increase awareness & use of in/out catheters
100% of ED Medical Officers will be
credentialed in IDC competency
Increase the % of pts with an existing IDC that
have a review for on-going clinical need
Include IDC on transfer / HO checklist
EMR Alert in First Net to check after 4 hrs
Use catheter insertion labels
Document in Power chart
Stock take of bladder scanners in Hospital & pool
Repair /trade in broken bladder scanners
Seek funding from Exec for more bladder scanners
Ensure regular stock of in/out catheters in ED
Implement the pre-insertion decision support tool
Medical Educator to provide catheter workshop
Implement Urethral catheter insertion competency
assessment
ED CNE to provide catheter workshop
Include credentialing in ED orientation
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Hard
The Problem: Ward is receiving from ED too many patients with a In Dwelling catheter inserted.
Team Members: • Team Leader – Ward NUM • ED NUM • ED Medical officer • Continence CNC • ED CNE Educator • Consumer – Past patient
100% of ED staff will be credentialed in IDC competency
Increase communication re:
IDC at handover
100% of ED Nursing staff will be credentialed in IDC
competency
Measure: How much: ED will reduce number of patients discharged with a catheter in situ by 15% By when: 2 months
Measure: How much: 100% of patients will have catheter insertion history included in their ward handover notes By when: 4 months
Measure: How much: Increase purchasing volume of in/out catheters by 75% By when: 2 weeks
Measure: How much: 90% of ED staff will be credentialed in insertion competency By when: 1 month
Measure: • How much: 30%
reduction • By when: 6 months
Measure: How much: Increase purchasing volume of in/out catheters by 75% By when: 2 weeks
CAUTI Driver Diagram
Within 6 months, 100% of patients will
have appropriate
catheterisation
Increase availability of equipment
Improve staff awareness of appropriate indications eg:
• NOF • Trauma • Stroke
Better management of falls risk patients
Improve work flow priorities and staff time
management
Increase availability of cleaning
Increase awareness of pts toileting
Improve ward knowledge of correct indications
Labs have clear guidelines on urine collection
Nursing in-service
Doctor in-services
Implement CEC decision support tool
HETI e-learning module
Implement CEC Competency assessment tool
ED Assessment nurse to review Falls risk
Review environmental design of ED for falls risk pts
Medically ordered catheterisations
Establishment of a cleaning trolley in ED
Ensure stock of incontinence supplies
Implement CEC urine specimen collection tool
Implement hospital Urine collection guidelines (see MoH
guideline)
Revise lab order on Power Chart
Impact: High Implementation: Easy
The Problem: ED is inserting too many Catheters
Team Members: • NUM • Dr (Consultant) • CNC continence • ED CNE • Jnr nurse • Consumer
100% of staff have knowledge
of appropriate indications
ED staff need to increase awareness of appropriate
specimen collection Measures: • Number of
catheters inserted
Measure: • How much: 100% of staff • By when: 1 month
Measure: • How much: 100% of time
bladder scanners accessible • By when: 3 months
Measure: • How much: 100% availability of in
/ out catheters • By when: 3 months
Increase awareness of ID recommendations for
specimens prior to antimicrobial therapy
Ensure supply of in / out catheters
Ensure access to bladder scanner
Measure: • How much: Bladder scanner can
be accessed within 5 minutes. • By when: 3 months
Measure: • How much: 100% of staff have
passed a competency assessment on indications
• By when: 3 months
ID to provide information guidance regarding
Therapeutic Guidelines
Place standing order for in / out catheters
Purchase bladder scanner for ED or borrow for another unit
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Hard
CAUTI Driver Diagram
Within 6 months, increase rate of
appropriate antibiotic use for
UTI to 90%.
Outcome Measure: How much? By when?
Improve the accuracy of attitudes and beliefs about
appropriate antibiotic commencement among staff
Measure: How much? 50% of staff
have a changed attitudes and beliefs
By when? Within 3 months
Measure: How much? 100% of teams
in the unit
By when? By the end of 6 months
Measure: How much? 50%
improvement in diagnostic accuracy for UTI
By when? By the end of 3
months
Improve the integrity and completeness of the diagnostic process
Improve coordination of the multidisciplinary teams
working in the unit
Increase rate of appropriate testing and
investigations for UTI
Measure: How much? Increase rate by 70%
By when? By the end of 6
months
Eliminate myths associated with UTIs in older patient populations
Deconstruct myths that antibiotics are harmless medicines
Improve perception regarding the usefulness, cost and time burden associated with UTI investigations
Increase the number of rounds per week that is attended by both ward
pharmacist and medical team
Increase availability of clinical microbiologist for advice
Increase time spent on differential diagnosis prior to prescribing ABx
Increase awareness of potential alternative diagnoses for UTIs signs or
symptoms
Remove barriers that preclude appropriate testing for UTI diagnosis
Increase education on how to interpret UA results
Improve language used and recommendations provided on
microbiology reports
Clinical microbiologist and AMS pharmacist to provide
myth busting inservices
Ward pharmacist trained in academic detailing regarding
antibiotic use
Run poster campaign on truth vs myths in antibiotics
Ward pharmacist to be paged by medical team at beginning
of ward round
3 ward rounds a week are pre-booked in MDT’s calendars
Clinical microbiologist to offer dedicated times to provide
advice
Clinical microbiologist is provided with on-call pager for unit
Allocate time for differential diagnosing in rounding
checklist
New policy to institute documentation of differential diagnosis in healthcare record
Implement CEC’s decision support tool for urine specimen collection
Preformat lab order form
Provide nursing and medicine staff with clinical skills training
Clinical microbiology team to review and update micro
reporting templates
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: Low Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Hard
Team Members: • Team Leader s– AMS pharmacist
+ CNE • NUM of unit • Snr Registrar • JMO • Registrar • Snr Clinician • Clinical microbiologist / ID MO • Ward pharmacist • Consumer
The Problem: According to AMS pharmacist, our Rehab Unit has a high rate of unnecessary commencement of antibiotics for UTIs
Outcome Measure: How much? By when?
Improve understanding and interpreting of
investigations relating to UTI
Measure: How much? 70% of staff demonstrate improved understanding By when? By the end of 6 months
Clinical microbiology team to provide cheat sheet on how to
interpret urine results
Driver Diagram Steps 1. Define the problem
2. Project Team & Sponsor
3. SMART Aim Statement
4. Literature Review
5. Flow Chart the current process
6. Brainstorm the ‘causes’ of the problem
7. Affinity diagram - Categorise the ‘causes’
8. Define Primary & Secondary Drivers
9. Devise Measures
10. Brainstorm Solutions
11. Assess Priority of Solutions
12. PDSA Cycles
13. Data Collection & Measuring Impact
14. Sustain the Gains & Spread the Idea
15. Regularly update your Driver Diagram
Learning Outcomes
Participant's will be able to:
Develop a SMART Aim Statement
Flow Chart a process
Brainstorm the ‘causes’ of a problem using ‘post it notes’
Develop an Affinity Diagram
Draw up a Driver Diagram with Drivers, Relationship Arrows & Solutions
Graph Outcome, Process & Barrier measures
Develop and Prioritise Solutions
Plan PDSA cycles
Plan to Sustain & Spread project
Evaluation: Let me know if the learning outcomes were not met.
Use the CEC cheat sheet for Driver Diagrams
Source: NSW Health GEM Workstar – CPI module.
https://gem.workstar.com.au/public/index.cfm?action=l
ogin&returnTo=/
Beware of jumping from a problem to a solution
A Driver Diagram assists you to thoroughly diagnose the causes of the problem and devise relevant solutions & measures. Example
A patient arrives in ED with back pain. What do you do?
a) Presume Kidney stones – send straight to theatre
b) Presume Orthopaedic – send straight to theatre
c) Methodically examine the patient and thoroughly investigate to fully diagnose the cause of the back pain.
David is overweight.
He weighs 130kg.
Steps to develop a Driver Diagram
Example
• What is the problem?
David is overweight as he is 130kg (Nov 2015)
• Check that your problem is an issue worth solving?
• Is it a significant issue? Yes, 130kg is overweight
• Does anyone else think it is a problem? Yes, his famous wife thinks so…
• Is there supporting evidence that it’s a problem (qualitative/quantitative)? Yes, 130kg
• Common mistake: Don’t select a solution to implement
It must be a ‘problem’ to investigate / ‘area to improve’
• Document the ‘problem’ in the DD (top left corner)
Step 1: Define the problem you want to fix
Driver Diagram
The Problem David is over
weight as he is 130 kg
(Nov 2015)
• Gather people with the right expertise
People from all areas of the process under review
Ensure its an Interdisciplinary team
Include a consumer
Appoint a Team Leader
Consider inviting ‘challenging’ characters onto your team
• Appoint a Project Sponsor
• Pre-book regular meetings
• Document the Project Team in the DD
(bottom left corner)
Step 2: Form a Project Team
Driver Diagram The Problem: David is over weight as he
is 130kg (Nov 2015)
Team Members: • David • David’s wife • David’s children • etc … • Project Sponsor - Mother
First Team Meeting
• Ratify the problem
Do all Team members & your Project Sponsor agree on the problem?
Work on 1 problem at a time
• Beware: Gaining the teams agreement on the ‘problem you are trying to solve’ can be a stormy time
Step 2: Form a Project Team
Step 3: Develop a SMART Aim Statement with a measurable Stretch Goal
• The first team meeting is used to decide exactly what the team is trying to achieve
• They need to AGREE on:
a) the exact problem they are trying to solve, and
b) the goal/aim/objective they want to work towards
• This is recorded as an Aim Statement
Step 3: Develop a SMART Aim Statement with a measurable Stretch Goal
Warning
• Developing an Aim statement can take a while
• It may take time to get the teams consensus on:
What is the actual problem you are trying to solve?
What is the specific Aim and how will you measure it?
• The Aim Statement should meet the SMART criteria:
Specific - objective, scope & criteria
Measurable - quantifiable data
Achievable / Appropriate - can be done & should be done
Result Oriented - stretch goal
Time scheduled - date to be completed
Step 3: Develop a SMART Aim Statement with a measurable Stretch Goal
Step 3: Develop a SMART Aim Statement with a measurable Stretch Goal
Aim Statement
• State clearly what are you trying to accomplish
• Focus on a measurable outcome
• Include a ‘Stretch Goal’ – a measurable target that is achievable
but also a challenge to obtain
• David’s Example:
‘Stretch Goal’ David losing 40 kg - wont be easy, but it can be done.
Within 12 months,
David will lose 40 kg
Step 3: Develop a SMART Aim Statement
Check - Does your Aim statement have a:
1. Timeframe = Within 12 months
2. Stretch goal = lose 40kg (he currently weighs 130kg)
3. Criteria - What are you trying to fix? = David’s weight
4. Scope ie Target population = David
Double check:
The aim statement relates to the original problem
You have NOT put solution in your aim statement?
The scope isn’t too big? ie can you achieve your project with in the timeframe?
You included a specific, measurable stretch goal – do NOT use words like lose ‘some’ weight or lose weight ‘soon’ – be specific
Within 12 months,
David will lose 40 kg
Driver Diagram
Within 12 months, David will lose 40 kg
The Problem:
David is over weight as he is
130kg (Nov 2015)
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
1. By 30 September 2016, the need for ongoing catheter use will be assessed daily for 100% of catheterised patients .
2. Within 6 months, 90% of urinary catheters inserted in emergency department will be for an appropriate clinical indication.
3. Within 3 months, all catheterised patients discharged from the ED will have a completed catheter insertion sticker included in their medical record.
4. In 8 months’ time no more than 5% of urine specimens collected from catheterised patients in this unit will be inappropriately indicated.
5. By 31st July, the average catheter dwell time in xxxx Unit will be less than 60 hours.
6. Reduce inpatients catheter days by 25% before 31 January, 2016.
7. The number of indwelling catheters used in this emergency department will be reduced by 50% within the next 12 months.
8. Reduce CAUTIs incidence rate to 0 in the next 24 months.
9. Within 3 months, a catheter removal order will be documented in the medical record of 80% of catheterised patients.
10. Reduce the number of unnecessary urine cultures ordered for catheterised patients by 30% before 1 September, 2016.
Step 3: Develop a SMART Aim Statement - CAUTI Examples
Step 3: Develop a SMART Aim Statement Other Clinical Examples
• “Within 1 year, 100% of elective surgical patients will be screened for anaemia pre-
operatively.”
• “Within 6 months, 100% of patients with VRE will be triaged and admitted to a ward bed within four hours”
• “100% of all autologus products collected by the blood Service will meet the Patient Blood Management Guidelines by 1st July.”
• “Within 1 year, 90% of patients suitable for discharge, will be discharged from the ward before 11am”
• “Within 6 months, reduce the number of unnecessary pathology tests in the ED by 50%”
• “Within 12 months, decrease the rate of infections in joint replacement surgery to zero.”
• “Within 8 months, decrease the number of admissions with a primary diagnosis of asthma by 50%.
Step 4: Plan a Literature Review • A literature search is essential if you are to:
identify best practices for the problem under review
prevent reinventing the wheel
• Time efficiency - 1 or 2 team members perform this task
• Decide key words for the search
Resources:
• CIAP - On line Journals & Articles at ‘Clinical Information Access Program’ www.ciap.health.nsw.gov.au
• Search engines www.google.com.au or ww.scholar.google.com
• ACI Innovation Exchange www.aci.health.nsw.gov.au/ie
• Hospital Library / Librarians
Step 4: Plan a Literature Review • Key words for literature search on David’s problem
Causes of obesity
Weight loss
BMI
Diet & nutrition etc
Step 5: Flow Chart the Current Process On Butchers paper, construct a Flow Chart of the CURRENT process From start to finish
Every step & every decision
Ask at each step ‘Does this
usually happen?’
REMEMBER: Current process
Step 5: Flow Chart the Current Process
Why bother
• So there is a shared understanding by the team of the current process
• It is a way of gathering information / intelligence / facts about the problem
• There is open criticism of the current process Helps to identify bottle necks
• The complexity of the process can be identified and managed in the future
• A better process maybe identified which may later become the NEW / improved process
David’s Day
7am David wakes up
Breakfast: Coco Pops, 2 x p/butter toast, coffee
8.30am drives 5kms to wrk.
9am Sits at desk all morning. Drinks coke &
coffee. Snacks on chocolate.
Lunch: 2 x Big Mac & fries
5.30pm drives home
11.30pm bed
Sits at desk all afternoon & snacks: chocolate & coke.
7pm Dinner (takeaway) & beer
Week day or
weekend?
Week day Weekend
Breakfast: Coco Pops, 2 x p/butter toast, fried eggs, sausage & bacon, coffee.
6pm watches TV with a beer
Watches more TV & more beer
Saturday or
Sunday?
Saturday Sunday
9am Drives kids to sport. Reads paper.
Lunch: KFC (8 pieces)
All afternoon - Sits & watches TV /
Movies.
Lunch: 2 pizzas from Pizza Hut
10am might go to the Gym (usually once a month)
Takes lift to level 3.
Patient comes to the ED Patient is seen by triage nurse Patient history and obs are taken Medical assessment undertaken
Is a consult
required? YES NO
Is hospital admission required?
YES NO
Patient is sent home
Is a diagnostic
investigation required?
YES
NO
Is a urine specimen required?
NO
Other diagnostic investigations are performed
Has an IDC been
medically ordered?
YES Insert an IDC and collect specimen if
required
YES
Get patient admitted to the ward
Transfer patient to ward
ED nurse hands over patient to ward nurse
Ward nurse takes baseline obs and checks paperwork
CAUTI flow chart example
Patient arrives in the ED
Patient is seen by triage nurse
Patient is allocated to a bed/area
Patient registration is done
Patient is assessed Assessed as 1-2 priority Assessed as 3-5 priority
Patient placed in high acuity area
Patient placed in low acuity area
Patient assessed by senior clinician Patient assessed by clinician Differential diagnosis is made
Clinical investigations undertaken
Diagnosis made
Treatment commenced
Is immediate
surgery required?
YES NO IDC inserted if needed Patient transferred to the OT
for surgery Insert catheter if needed
Reassess patient
Document patient management plan
Does the patient
need to be admitted?
NO
YES
Discharge patient
Admit patient to ward
CAUTI flow chart example
Step 6: Team Brainstorms the ‘Causes’ of the Problem
Team members write on ‘post it notes’ all the reasons / causes they can think of, that contribute to the problem:
Done in silence, to cut through the authority gradient
One idea per ‘post it note’
Use as many ‘post it notes’ as needed
Ideas need to be specific (phrases)
Do NOT brainstorm ‘solutions’ – focus only on ‘causes’ of the problem
Stick the ‘post it notes’ on a flat surface (eg: wall or table)
Step 6: Team Brainstorms the ‘Causes’ of the Problem
Brainstorm: What is ‘causing’ David to be overweight? The Flow Chart will highlight many of the ‘causes’
• Team members arrange the ‘causes’ (post it notes) into
Logical Categories and
Assign a Heading to each category
Affinity Diagram – generally have btw 2 to 5 categories
• Remove duplicates: Re-read all the ‘post it notes’ and remove any absolute double ups.
Step 7: Categorise the ‘Causes’ & assign headings
Category Headings = Primary Drivers
Causes = Secondary
Drivers
• Word the ‘Category Headings’ (Primary Drivers) as measurable improvement / action statements ie: How to ‘improve’
• Use words such as
Increase / Decrease
Improve …
More / Less
Start / Stop etc
Step 8: Define each Primary & Secondary Driver
Within 12 months,
David will lose 40 kg
Aim Statement
• Reword each cause (post it note) into measurable action statements to form true Secondary Drivers ie:
=
=
Eat less fried food
Go to gym more
Step 8: Define each Primary & Secondary Driver
Reduce volume of food eaten
Eat more low calorie food
=
=
Driver Diagram
Within 12 months, David will lose 40 kg
The Problem: David is over weight as he is 130kg (Nov 2015)
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers & Relationship Arrows
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
Driver Diagram
Within 12 months, David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Secondary Drivers & Arrows Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at desk at work
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
Team Members: • David • David’s wife • David’s children • Etc • Sponsor - Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Primary Drivers & Relationship Arrows
Check
Are your Drivers complete – have you forgotten any?
• Ask your team:
“Is there anything else that could improve / impact our aim?”
“What else do we need to do to reach our goal? “
“Is there anything else that could go wrong to prevent us reaching our aim?”
Step 8: Define each Primary & Secondary Driver
3 types of Measures
1. Outcome (impact) Measures
2. Process Measures
3. Balancing / Barrier / Side Effect Measures
Step 9: Devise Measures
How will you know that a change is an improvement?
Outcome (impact) Measures
• Have a direct impact on the aim
Kgs lost
BMI reduced
Process Measures
• Indirect impact on the aim
Calories burnt
Calories consumed
Barrier / Balancing / Side Effect Measures
• Side effects (knock on effects) as a consequence of changes
If staff say “You can’t do that because … this will happen”
NB: Can add ‘Barrier Measures’ after ‘Solution’ stage
Step 9: Devise Measures Within 12 months,
David will lose 40 kg
• How will you know that a change is an improvement?
• Devise specific measures for the Primary Drivers How much
By when
Step 9: Devise Measures
Measure: • How much: Reduce calorie
intake by 30% • By when: 2 months
Measure: • How much: Increase calories burnt
by 40% • By when: 2 months
• Measures can be tweaked at team meetings - they are not set in stone!
Driver Diagram
Within 12 months, David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers & R’ship Arrows
Secondary Drivers & Arrows Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at desk at work
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
Process Measure: How much: Reduce by 30% By when: 2 months
Process Measure: How much: Increase by 40% By when: 2 months
The Problem: David is over weight as he is 130kg (Nov 2015)
Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Step 10.1: Brainstorm Solutions (change concepts) Brainstorm Solutions (change ideas / interventions) for each secondary driver
• For each secondary driver, the team brainstorms (or researches from
literature) specific ideas/solutions to address the driver
WHAT exactly are you going to do next week / next month &
HOW exactly are you going to do it?
• Place solutions in DD and draw arrows to relationships
Sit less at work desk
Secondary Drivers Solution (change concept)
Move to a adjustable / standing desk.
Stand for 2 hrs + a day
Reduce volume of food eaten
Serve meals on small/side plate
Gastric Banding Surgery
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers
Secondary Drivers Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Team Members: • David • David’s wife • David’s children • etc • Sponsor – Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Process Measure: How much: Reduce by 30% By when: 2 months
Process Measure: How much: Increase by 40% By when: 2 months
Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers
Secondary Drivers Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Process Measure: How much: Increase by 40% By when: 2 months
Process Measure: How much: Reduce by 30% By when: 2 months
Actions Effect / Impact
Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers
Secondary Drivers Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Process Measure: How much: Increase by 40% By when: 2 months
Process Measure: How much: Reduce by 30% By when: 2 months
Actions Effect / Impact
Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Step 10.2: Brainstorm Solutions then Barrier Measures
Barrier Measures • Side effects (knock on effects) as a consequence of solutions
(change concepts)
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Solution
Barrier Measure: How Much: David arrives at work, on time (9am) 100% of time. By when: 1 Month
• What can go wrong? David might be late to work… often !
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers
Secondary Drivers Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Process Measure: How much: Increase by 40% By when: 2 months
Process Measure: How much: Reduce by 30% By when: 2 months
Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Barrier Measure: How much: Arrive at work on time (9am) 100 % of time . By when: 1 month
Step 11: Assess Priority of Solutions
• You have many Solutions – which ones will you test / implement first?
Assess each solution for:
Ease of Implementation – will it be Easy or Hard to implement? • Will it cost a lot $$$ ? • Can it be done next week? • Will it take: hours, weeks or months to embed? • Will many people have to be re-trained / educated?
Impact on the Aim – will it have High or Low impact on the Aim
Statement? • How much will the solution effect the:
Problem Aim statement Outcome measures
Sit less at work desk
Secondary Drivers Solution (change concept)
Move to a adjustable / standing desk.
Stand for 2 hrs + a day
Reduce volume of food eaten
Serve meals on small/side plate
Gastric Banding Surgery
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Priority
Impact: High Implementation: Easy
• Solutions that you predict will have high impact & are easy to implement should be tested as a priority using a PDSA Cycle.
Step 11: Assess priority of solutions
Step 11: Assess priority of solutions
• Any solution that has an impact on 2 or more Secondary
Drivers should also be a priority Look for 2 or more Relationship Arrows from a Solution
Secondary Drivers Solution (change concept) Priority
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers
Secondary Drivers Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions Impact: High Implementation: Easy
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Team Members: • David • David’s wife • David’s children • etc • Sponsor – Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Priority PDSA
Process Measure: How much: Reduce by 30% By when: 2 months
Process Measure: How much: Increase by 40% By when: 2 months
Proces Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Outcome Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Outcome Measure: • How much: Reduce BMI by
20% • By when: 12 months
Barrier Measure: How much: Arrive at work on time (9am) 100 % of time . By when: 1 month
“The most successful improvement projects are those that get into testing -
PDSA – the quickest” Don Berwick - IHI
PDSA - AKA – “Rapid Cycle Testing”
In summary
the steps of a Driver Diagram
are …
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers & R’ship Arrrows
Secondary Drivers & Arrows Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions & Arrows Impact: High Implementation: Easy
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to work M-F: ride bike, walk/jog,
(don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Team Members: • David • David’s wife • David’s children • etc
The Problem: David is over weight as he is 130kg (Nov 2015)
Priority
Process Measure: • How much: Reduce Calorie
intake by 30% • By when: 2 months
Process Measure: How much: Increase by calories burnt by 40% By when: 2 months
Aim Statement with measurable
Stretch goal Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Measure: • How much: Reduce BMI by
20% • By when: 12 months
Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Measures
• A DD is a living document • Each Team meeting you can review your DD and add or re-word:
Aim Statement Primary & Secondary Drivers Relationship Arrows Measures Solutions
• Don’t get too hung up on detail Its NOT a Thesis It’s a practical tool to help you improve
Remember: Don’t put a ‘solution’ into your Aim Statement The Primary & Secondary drivers start to hint at ‘change
concepts’ or solutions.
In Summary
Outcome for David after 12 months
1. Define the problem you want to fix – See scenario on your table. Start DD on butchers paper – document the problem.
2. Form a Project Team (interdisciplinary & include a consumer) – Who would you have in your team and as Project Sponsor?
3. Develop a SMART Aim Statement with a measurable stretch goal
4. Plan a Literature Review – What key words would you search?
5. Flow Chart the CURRENT Process: On butchers paper, draw steps & decisions from start to finish of the CURRENT process. (Choose 1 unit and flow chart its current process)
6. Team brainstorm the ‘causes’ of the problem (in silence with ‘post it notes’) NB: focus on ‘causes’ NOT solutions.
7. Affinity Diagram - Categorise the ‘causes’: Sort the ‘causes’ (post it notes) into logical categories and assign a ‘heading’ to each category
Primary Drivers = category headings
Secondary Drivers = the ‘causes’ under each category heading
8. Define each Primary & Secondary Driver
Re-word each post it note as a measurable action statement (driver) – use words such as increase/decrease; more/less; start/stop; extend/reduce etc
Place Primary & Secondary drivers in the DD and draw Relationship Arrows from right to left to corresponding relationships.
9. Devise Measures: State how you will measure relevant drivers & solutions: ‘How much & by when’.
10. Brainstorm Solutions (change ideas / interventions) for each secondary driver and draw in Relationship Arrows. Then devise “Barrier Measures”.
11. Assess Priority of Solutions: Assess each solution for a) Impact (high/low) & b) Ease of Implementation (easy/hard). Also prioritise solutions which impact 2 or more drivers. Prioritise which solutions to test using a PDSA cycle.
12. PDSA Cycles: Test high priority solutions via a PDSA cycle and report progress at team meetings
13. Data Collection & Measuring Impact: Develop data collection tools, collect data and graph results. Regularly report at team meetings.
14. Plan to Sustain the Gains & Spread the idea
15. Regularly update your Driver Diagram - A Driver Diagram is live document that should be reviewed (added to / amended) at each team meeting.
Your turn - Work shop a CAUTI problem
Plan Do Study Act (PDSA) Cycle
• Test high priority solutions via a PDSA cycle and report progress at team meetings
Testing a ‘change’ / ‘intervention’ is not always easy:
Things may happen that were not planned
The change may not impact the measures
There may be unwanted side effects
Step 12: PDSA Cycles
Step 12: PDSA Cycles
1. Plan your change: What you are going to change,? Who is going to do it? When & where will it be done? Data: How will you measure it?
2. Carry out your change and observe & measure
3. Study the data & anecdotes
4. Act on the data: What will you do next?
One priority solution at a time
Driver Diagram
Within 12 months,
David will lose 40 kg
Decrease Calorie intake
Increase Exercise to burn more
calories
Primary Drivers
Secondary Drivers Eat less fried food
Reduce alcohol intake
Reduce drinking coke
Drink less coffee & use skim milk
Reduce volume of food eaten
Eat more fresh fruit
Stop eating chocolate between meals
Eat more low calorie food
Ride bike more
Go to gym more
Sit less at work desk
Use stairs more
Eat less dessert
Start a regular sport
Stop driving car to work
Wear pedometer more
On Sunday, plan meals for week Low cal, 1 fried dish, < dessert.
Solutions Impact: High Implementation: Easy
Only drink Alcohol on Fri & Sat night (2 std drinks )
Stop drinking coke - Carry a water bottle everywhere
Buy only Skim Milk and reduce coffee to 2 a day
Serve meals on small/side plate
Buy fruit bowl for work. Only eat fruit btw meals (at least 2 pcs a day)
Eat berries for dessert
Move to a adjustable / standing desk. Stand for 2 hrs + a day
On Sunday plan how to get to / from work M-F: ride bike, walk/jog, (don’t drive car)
Play soccer all year round
Buy Fitbit, wear everyday and monitor steps. Aim >15,000 steps
Only take stairs (don’t use lift)
Personal trainer at gym x 2 week
Gastric Banding Surgery
See GP & a dietician
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: Low Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Hard
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Impact: High Implementation: Easy
Team Members: • David • David’s wife • David’s children • etc • Sponsor - Mother
The Problem: David is over weight as he is 130kg (Nov 2015)
Priority
Process Measure: How much: Reduce by 30% By when: 2 months
Process Measure: How much: Increase by 40% By when: 2 months
Aim Statement Process Measure: • How much: Reduce alcohol
intake by 80% • By when: 1 month
Process Measure: • How much: Meet 100% of
weekly exercise goals. • By when: 1 month
Measure: • How much: Reduce weight
by 40 kg • By when: 12 months
Measure: • How much: Reduce BMI by
20% • By when: 12 months
Barrier Measure: How much: Arrive at work on time (9am) 100 % of time . By when: 1 month
Step 12: PDSA Cycles On Sunday plan how to get to/from work M-F: ride bike,
walk/jog, (don’t drive car) Getting to/from work – Week 1 & 2
PLAN: First 2 weeks, plan (goal) to walk 5kms to work in the morning: Mon, Wed & Fri and catch train home in evening. Drive car other days. (Ease himself into new exercise regime) Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight, BMI.
DO: Carry out plan (above). • Collect exercise achievements
in a Tally Sheet.
STUDY: Every Sunday review past weeks exercise data. • Were the goals achieved?
ACT: After reviewing the data, act on the results. • If he did reach his
predicted goal, can he exercise more next week?
• If goals not reached, why not & what can be done?
Step 12: PDSA Cycles On Sunday plan how to get to work M-F: ride bike,
walk/jog, (don’t drive car) Getting to/from work – Week 3 & 4
PLAN: Weeks 3 & 4, plan (goal) to walk 5kms to work in the morning 5 days a week. Catch train home in the evening. Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight.
DO: Carry out plan (above). Collect exercise achievements in a Tally Sheet.
STUDY: Every Sunday review past weeks exercise data. Were the goals achieved?
ACT: After reviewing the data, act on the results. If he did reach his predicted goal, can he exercise more next week? If goals not reached, why not & what can be done?
Step 12: PDSA Cycles On Sunday plan how to get to work M-F: ride bike,
walk/jog, (don’t drive car) Getting to/from work – Week 5 & 6
PLAN: Weeks 5 & 6, plan (goal) to walk & JOG part of the 5kms to work, 5 days a week. Catch train home in the evening. Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight.
DO: Carry out plan (above). Collect exercise achievements in a Tally Sheet.
STUDY: Every Sunday review past weeks exercise data. Were the goals achieved?
ACT: After reviewing the data, act on the results. If he did reach his predicted goal, can he exercise more next week? If goals not reached, why not & what can be done?
Step 12: PDSA Cycles On Sunday plan how to get to work M-F: ride bike,
walk/jog, (don’t drive car) Getting to/from work – Week 7 & 8
PLAN: Weeks 7 & 8, plan (goal) to walk & jog part of the 5kms to work on Mon, Wed & Fri. Tue & Thur ride BIKE to & from work. Data / Measures: Kms travelled, Exercise goals met, Calories burnt, Weight.
DO: Carry out plan (above). Collect exercise achievements in a Tally Sheet.
STUDY: Every Sunday review past weeks exercise data. Were the goals achieved?
ACT: After reviewing the data, act on the results. If he did reach his predicted goal, can he exercise more next week? If goals not reached, why not & what can be done?
Step 12: PDSA Cycle Ramp
Week 1&2: walk 5kms to work on Mon, Wed & Fri AM
Week 3 & 4: walk to work 5 mornings a week.
Weeks 5 & 6: walk & jog part of the 5kms to work 5 mornings a week
Week 7 & 8: walk & jog M,W,F. Ride bike to & from work Tu & Th.
David Getting to/from work
• The completion of each PDSA cycle leads directly into the start of the next cycle
• A team learns from the test:
what worked
what didn’t work
what should be kept, changed, or thrown out and
new knowledge to plan the next test
• People are far more willing to test a change if they know that changes can and will be amended as needed (call it a trial / pilot).
Step 12: PDSA Cycles
“The most successful improvement projects are those that get into testing -
PDSA – the quickest” Don Berwick - IHI
PDSA - AKA – “Rapid Cycle Testing”
Step 12: PDSA Cycles
Low calorie meals
Getting to / from Work
Personal trainer
Measurement
Process Measures: • Kms walked / jogged / cycled per week • % daily exercise goals met per week • Calories burnt
But …. So what! Do the process measures impact the Aim?
• Did David lose weight? Outcome Measures
• Weight Kgs • BMI
Step 13: Data Collection & Measuring Impact
Step 13: Data Collection & Measuring Impact
Outcome Measure - Annotated Run Chart
70
80
90
100
110
120
130
David's Weight (kgs) (Outcome/Impact Measure)
Davids Kgs Stretch goal 90 kg
Kgs
Stretch Goal = 90 kg
Started walking to
work 5 days M-F
Started walk / jog
M-F
Started walking to
work 3 days M,W,F.
Hurt leg - no exercise
Davids Son's wedding
celebrations
Meals on side plate to reduced
volume
Started bike T&Th, walk / jog
M-F
Menu plan: Started low
calorie diet & reduced alcohol
Standing desk at work
Take stairs at work
Personal Trainer
PRESENTATION NAME – MONTH YYYY PRESENTER NAME
77
Mon Tue Wed Thur Fri Sat Sun
Numerator:
# daily exercise
goals met
Denominator: Total number
of daily exercise goals
for week
% daily exercise
goals met for week
Total Kms for
week
Week 1 (3 goals)
Walk to
work
Walk to
work
Walk to
work 2 3 67% 10
Week 2 (3 goals)
Walk to
work
Walk to
work
Walk to
work 3 3 100% 15
Step 13: Data Collection & Measuring Impact
Tally Sheet Legend: Achieved goal
Did NOT
achieve goal
Step 14: Sustaining the Gains & Spreading the Improvement
Some of the practices that help make improvements permanent (sustained) in an organisation are:
1. Standardisation
2. Documentation
3. Measurement
4. Training
Periodic self-audits can be useful in determining whether these practices are being followed
Beware:
• Many people make improvements only to discover later that things have somehow returned to the old level or that some new problem has been created.
PRESENTATION NAME – MONTH YYYY PRESENTER NAME
79
Step 14: Sustaining the Gains & Spreading the Improvement
British National Health Service Sustainability Model • Complete the British NHS Sustainability Survey and score your project? • The closer the score to 100, the better chance of successful sustainability
Score of 55 or higher offers reason for optimism. Score of 45 or lower suggests reason for concern.
Step 14: Sustaining the Gains & Spreading the Improvement British National Health Service Sustainability Model
1) Benefits beyond helping patients - Improves efficiency and makes jobs easier 2) Creditability (to affected staff) of benefits from improved process - Benefits are immediately obvious, supported by evidence and believed by stakeholders 3) Adaptability of improved process - The process can be adapted to organisational changes and there is a system for continually improving the process 4) Staff involvement and training to sustain the process - Staff have been involved from the beginning and adequately trained to sustain the improved process 5) Staff attitudes toward sustaining the improved process - Staff feel empowered and believe the improvement will be sustained 6) Senior leaders responsibility taking and staff action toward the leader - Organisational leaders take responsibility for efforts to sustain the process, and staff generally share information with and actively seek advice from the leader.
PRESENTATION NAME – MONTH YYYY PRESENTER NAME
81
Step 14: Sustaining the Gains & Spreading the Improvement British National Health Service Sustainability Model
7) Clinical leaders responsibility taking and staff action toward the leader - Clinical leaders take responsibility for efforts to sustain the process, and staff generally share information with and actively seek advice from the leader 8) Effectiveness of the system to monitor progress of the improvement - A system monitors progress using evidence, acts on it and communicates results. 9) Fit with the organisation ion's strategic aims and culture - There is a history of successful sustainability; improvement's goals are consistent with organisation's strategic aims. 10) Infrastructure to sustain (staff, facilities, equipment etc) - Staff, facilities and equipment, job descriptions, policies, procedures and communication systems are appropriate to sustaining the improved process.
Spreading the Improvement Do you have a plan to roll out your project in other
areas?
ACI Innovation Exchange http://www.aci.health.nsw.gov.au/ie
Quality Awards
Present at conference
Poster
Journal article
Step 14: Sustaining the Gains & Spreading the Improvement
Step 14: Sustaining the Gains & Spreading the Improvement
Review of your project 12+ months on after ‘completion’ Project Sustainability
Have you been able to sustain the gains made in your project? Do you conduct regular measurement regarding your project?
Project Spread
Have you rolled out your project in other areas? Was your project summary uploaded into the ACI Innovation
Exchange http://www.aci.health.nsw.gov.au/ie Did you submit your project into a Quality Award? Have you presented your project at a conference?
Building capacity in your LHD
Have you been involved or led any additional improvement projects?
Step 15: Regularly update your Driver Diagram
• A Driver Diagram is live document that should be reviewed at each team meeting
more drivers maybe discovered and the literature may reveal more drivers and solutions to test
• Remember: Not all Team Driver diagrams will be the same – different teams will find different drivers.
Questions
• You Tube videos from NHS:
Driver Diagrams Lesson 1 of 3 Introduction https://www.youtube.com/watch?v=2mBpJIzzYI8
Driver Diagrams- Lesson 2 of 3- Reasons to use driver diagrams https://www.youtube.com/watch?v=xXRym4aFLa4
Driver diagrams Lesson 3 of 3 How to develop a driver diagram https://www.youtube.com/watch?v=BhY-rw9ejDk
• Driver Diagram References:
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html#sthash.GNk7SHIo.dpuf
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html#sthash.Kfs7TJjL.dpuf
http://www.kingsfund.org.uk/projects/pfcc/driver-diagrams
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html
• PDSA References:
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
More information on Driver Diagrams & PDSA
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Links to other Clinical Quality & Safety Websites: State: • Clinical Excellence Commission: www.cec.health.nsw.gov.au • Agency for Clinical Innovation: www.aci.health.nsw.gov.au • Bureau of health Information: www.bhi.nsw.gov.au National: • Australian Commission on Quality and Safety: http://www.safetyandquality.gov.au/ • Australian Association for Quality in Health Care (AAQHC): https://www.aaqhc.org.au/ • Authoritative information and statistics to promote better health and wellbeing http://www.aihw.gov.au/data/ International: • Institute for healthcare Improvement resources http://www.ihi.org/resources/Pages/default.aspx or do you
just want www.ihi.org • Intermountain healthcare (transforming
healthcare) https://intermountainhealthcare.org/about/transforming-healthcare/ • Agency for Healthcare research and quality: www.ahrq.gov • National Patient Safety Agency: www.npsa.nhs.uk • Institute for Innovation and improvement: www.institute.nhs.uk • Scottish Patient Safety Programme: www.patientsafetyalliance.scot.nhs.uk • Healthcare Improvement Scotland www.healthcareimprovementscotland.org • Koawatea Healthcare system innovation and improvement: http://koawatea.co.nz • The International Society for Quality in Healthcare: http://www.isqua.org/home
Driver Diagram Template
Outcome Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Team Members: • Team Leader – • Consumer • Xx • Xx • xx • xx • Project Sponsor -
The Problem:
Outcome Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Driver Diagram Template
SMART Aim
Statement with stretch
goal
Outcome Measure: How much? By when?
Primary Driver
Process Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Primary Driver
Primary Driver
Primary Driver
Process Measure: How much? By when?
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Secondary Driver
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Solution
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Impact: High Low Implementation: Easy Hard
Team Members: • Team Leader - • . • . • . • . • . • Consumer – • PROJECT SPONSOR -
The Problem: xxxxxx
Outcome Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Process Measure: How much? By when?
Barrier Measure: How much? By when?
1. Define the problem you want to fix – See scenario on your table. Start DD on butchers paper – document the problem.
2. Form a Project Team (interdisciplinary & include a consumer) – Who would you have on team & as a Project Sponsor?
3. Develop a SMART Aim Statement with a measurable stretch goal
4. Plan a Literature Review – What key words would you search?
5. Flow Chart the CURRENT Process: On butchers paper, draw steps & decisions from start to finish of the CURRENT process. (Choose 1 unit and flow chart its current process)
6. Team brainstorm the ‘causes’ of the problem (in silence with ‘post it notes’) NB: focus on ‘causes’ NOT solutions.
7. Affinity Diagram - Categorise the ‘causes’: Sort the ‘causes’ (post it notes) into logical categories and assign a ‘heading’ to each category
Primary Drivers = category headings
Secondary Drivers = the ‘causes’ under each category heading
8. Define each Primary & Secondary Driver
Re-word each post it note as a measurable action statement (driver) – use words such as increase/decrease; more/less; start/stop; extend/reduce etc
Place Primary & Secondary drivers in the DD and draw Relationship Arrows from right to left to corresponding relationships.
9. Devise Measures: State how you will measure relevant drivers & solutions: ‘How much & by when’.
10. Brainstorm Solutions (change ideas / interventions) for each secondary driver and draw in Relationship Arrows.
11. Assess Priority of Solutions: Assess each solution for a) Impact (high/low) & b) Ease of Implementation (easy/hard). Also prioritise solutions which impact 2 or more drivers. Prioritise which solutions to test using a PDSA cycle.
12. PDSA Cycles: Test high priority solutions via a PDSA cycle and report progress at team meetings
13. Data Collection & Measuring Impact: Develop data collection tools, collect data and graph results. Regularly report at team meetings.
14. Plan to Sustain the Gains & Spread the idea
15. Regularly update your Driver Diagram - A Driver Diagram is live document that should be reviewed (added to / amended) at each team meeting.
Driver Diagram Steps