Introduction to Improvement for Safety
Day 2
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Your facilitators today are:-
Amanda HuddlestonImprovement Lead: MSc,QN, HV, RN.
&Wendy Stobbs
Improvement Lead: MA, MSc, RGN.
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Agenda Day 2 9.00 Registration & Coffee 9.30 Evaluation Feedback & Review of Day 1 – Driver Diagrams10.00
Engaging People in Improvement – Change Models and Stakeholders
11.15 Coffee11.30 Engaging Teams in Improvement - Tools12.30 Lunch13.00 Measurement for Improvement 15.00 Coffee15.15 PDSA Cycles16.00 Summary of the day, homework & evaluation16.30 Close
Evaluation Feedback• Cold room• PDSA• More group work to include all team members• More focus on root cause than solutions• Handouts pre session
Evaluation Feedback• Good content• Enjoyed project focused learning• Balanced and useful day• Informative• Practical
Learning Objectives for Day 2• Review of your driver diagrams• Understand how human factors may impact
your initiative• Have a basic understanding of measurement
for improvement and how it applies to your initiative
• Understand how PDSA cycles can aid your initiative testing.
Day 1 Recap
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if achange is an improvement?
CHANGE: What changes can we makethat will result in improvement?
Model for Improvement
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Setting an Aim• What are you trying to accomplish?• What? By how much? By when?
SafeTimelyEffectiveEfficientEquitablePatient
Centred Crossing the Quality Chasm: A New Health System for the 21st Century, 2001 Institute of Medicine
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Driver Diagrams- 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
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90% of patients in Bay 1 receive their
lunch of choice
everyday by 12.30 by July
2013
Know what patients want / need for lunch
Lunch & equipment arrives on time
Ward Staff are available to give
out lunch
Patients are available to receive
lunch
Menu cards distributedChoices recorded &
communicated
Diet requirements understood
Numbers established & communicated
Time for delivery agreed
Access to ward available
Allocate lunch dutyComplete other tasks prior to
lunch arrival
Staff appropriately trained
Schedule inpatient appts appropriately
Appropriately positioned
Maintained at appropriate temperature
Aim / Outcome Primary Drivers Secondary Drivers
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Engaging people in your Improvement Project
Understand human responses to change
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Change is situational: new site, new boss, new team roles, new policy.
Transition is the psychological process people go through to come to terms with new situations
William Bridges
Change is different from transition
Change can be instant, transition takes time.20
William Bridges
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Marathon Model
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Winners?
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Heroes or villains?
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What is a stakeholder?
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What is a stakeholder?• A stakeholder can be defined as any person, or
group, who has an interest in the project or could be potentially affected by its delivery or outputs.
• Correct stakeholder identification is a critical component of the initial scoping phase.
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Identifying Stakeholders• Who is influential in this area?• Who will be affected by any decisions on the issue
(individuals and organisations)?• Who runs departments with relevant interests?• Who else is influential on this issue?• Who can obstruct a decision if not involved?• Who has been involved in this issue in the past?• Who has not been involved, but should have been?
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Stakeholder GridIn
flu
en
ce o
r P
ow
er
Interest
Key Player
Meet Needs
Inform Consider
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Readiness for Change – Influencing
Source: NHS III
• Identify who might be for, or against your project and proposed changes.
• You can then plan necessary influencing activities.
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Understand their perspective
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Acknowledge Behaviours• Sceptics & cynics• Reflectors & rationalisers• Quiet & cautious• Anger Vs apathy• Beware zealots & welcome laggards • A point of view that challenges can prevent an
issue further on
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Coffee Break
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Engaged teams…. • Have shared goals• Feel valued• Trust each other• Are trusted• Review progress, goals & issues regularly & together• Are multi-skilled/multidisciplinary• Communicate & collaborate• Have autonomy & are empowered• Support improvement & will make changes!
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Communicate• Clarify any confusion, assumptions and
misunderstandings about your project• Make sure that someone is responsible for each
task, timescales etc• Identify who needs to be communicated with for
each task• Prevent duplication of effort-yours & theirs• Proactively plan to unearth issues, gaps in
responsibility, misunderstanding, miscommunication
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Engaging – Tell the story, share your vision
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Frame it for them:• Aims• Bring it to life• Current state - problems, issues, facts,
figures• Future state - expectations, evidence• Learn to Listen
Why People Engage
• Regulatory mandate• Risk management issue• “If you knew, or should
have known, and don’t act…”
• Evidence• Data• Logic• Business case—
Return on Investment
• Stories—recent, local, real
• Videos? Bring a patient along?
• “How many people will be affected?”Source: Reinertsen
Lift Speech• 30 second speech to explain project to others.• Snappy….so it’s remembered!• Should reflect the Aim• Used consistently
Have a go!
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Engagement and Stakeholder Management Tools
For engagement– WIIFM– De Bonos 6 thinking hats
• For organisation– RACI
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WIIFM?
Key people or group
What’s In It For Me (WIFM)? What could they do
to support or prevent the
improvement initiative?
What could/should we do to reduce non-compliance
activities or support compliant
ones?
+Impact
-Risk
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RACI Matrix
ActionsRoles/names
RACI: R = responsible A = accountable C = consulted I = informedIndicate on the matrix which of your stakeholders are accountable for the action,
responsible for the action, need to be consulted about the action or need to be kept informed of the action
RACI Matrix
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De Bono’s 6 Thinking Hats
Managing the thinking process: Could you summarise finding so far?
Information / data needs: What are the facts
Ideas: Is there a different way of looking at this?
Benefits / positives: Can we list them?
Negatives / risk: What can go wrong?
Emotion / gut feeling: What is your gut feeling?
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References and resources• http://www.immi.gov.au/about/stakeholder-engagement/_pd
f/stakeholder-engagement-practitioner-handbook.pdf• http://www.kotterinternational.com/• http://www.mindtools.com• http://www.changemodel.nhs.uk/pg/dashboard• http://www.businessballs.com/• http://www.advancingqualityalliance.nhs.uk
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Introduction to Measurement
The Model for Improvement
© AQuA Academy 49
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if achange is an improvement?
CHANGE: What changes can we makethat will result in improvement?
How Do We Know if a Change is an Improvement?
“You can’t fatten a cow by weighing it”- Palestinian Proverb
• Improvement is NOT about measurement
• However…
“If you can’t measure it,
you can’t IMPROVE it”
Measurement in ContextAspect Improvement Accountability Research
Aim Improvement of care Comparison, choice, reassurance, spur for
change
New knowledge
Methods:• Test Observability
Test observable No test, evaluate current performance
Test blinded or controlled
• Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small sequential samples
Obtain 100% of available, relevant data
“Just in case” data
• Flexibility of Hypothesis
Hypothesis flexible, changes as learning takes
place
No hypothesis Fixed hypothesis
• Testing Strategy Sequential tests No tests One large test
• Determining if a change is an improvement
Run charts or Shewhart control charts
No change focus Hypothesis, statistical tests (t-test, F-test, chi square),
p-values
• Confidentiality of the data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
The Measurement Trinity1. Defining your measures
What am I going to measure and why?
2. Measurement and data collection planHow will I collect data?
3. Reporting planHow am I going to present my data?
The Measurement Journey
Attributes of Project Measures
© AQuA Academy 55
• Small number (<8) of key measures that refer to the project goals
• Balance – together describe a great system of care• Suggested goals based on current system,
improvement agenda, ‘state of the art’• Clearly defined for common data collection and
reporting
Thinking at Two Levels• Measures & goals are linked to drivers – track team progress
on outcomes and key processes.
• You will report project-level measures to your sponsor and your teams:
Clinical outcome & process measures (e.g. Average of team values, Percent of teams achieving goals, etc.)
Ratings of team project participation and progress (Percent of teams with sponsor, Percent participating in calls, etc.)
• Teams select measures to report based on their aim
• Measures should align with team aim
• Teams also collect local ‘change’ measures to track progress on testing and changes
Project Level
Team Level
Types of Measures• Outcome Measures
– Where are we ultimately trying to go?– Point to qualities that are valuable to stakeholders i.e. how
is the system performing? What is the result?• Process Measures
– Are we doing the right things to get there?– Track that steps in the system are performing as planned. – Help identify if changes are leading to improvement.
• Balancing Measures– ……………….
When thinking about balancing measures
• To patients• But also other parts of the
healthcare system• Balancing Measures help us
‘keep an eye on’ other aspects of the system as we focus on improving one part
Unintended Consequences
Group Work
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Plans & Definitions
How Big is Your Banana?
1. Create a step-by-step guide to capture the concept of “banana size” using the equipment in the envelope
2. Measure your banana according to your guide, write down the result (on a different piece of paper) and keep it secret!
3. Put your guide, the equipment and banana in the envelope. Keep your result, facilitator will now move bananas!
4. Measure the new banana using equipment and guide in envelope and record.
What did the Banana Say?• You need an intimate understanding of team your
working with. • Understand what they are trying to achieve and how
it relates to patients.
This will help team to determine; – what to measure– how to design a simple & effective measurement
tools– provide guidance on collection, interpretation and
representation of data
Defining / Naming Measures• Names of measures should be objective statements
about what is actually being measured – percent of missing charts– wait time to see the doctor– the number of ED visits – length of stay for a particular DRG
• Avoid placing goals and targets in the name of the measure, unless you’re counting ‘defects’ against some quality standard– percent of patients with antibiotics administered within 1
hour of surgery
An Operational Definition...… is a procedural description of what to measure and the steps to follow to measure it consistently.
• Gives communicable meaning to a concept• Tells what you need to count or measure• Specifies measurement methods and equipment• Identifies criteria and exclusions
… is the basis for reliable measurement ND
IHI Measurement Planning Form MeasureType Outcome Process BalancingWhy is this measure needed in our project?
Operational Definition
ExclusionsUseful StratifiersData Collection & Sampling Method
DisplayGoal Source
Aim:90% of patients in Bay 1 receive their lunch of choice everyday by 12.30 by July 2013
Measures Definition Sample Accountable Collection Schedule
Start Date
Numerator Denominator
Chart
Outcome Measures
Percentage of patients receiving lunch of choice
Number of patients receiving their meal of choice in bay 1 each day recorded as a proportion of occupied beds.
Process Measures
Percentage of patient menu cards completed each day
Number of days when lunch arrived on time
Number of cards completed for patients in bay 1 each day recorded as a proportion of occupied beds.
Total days each month when lunch arrived by agreed time.
Balancing Measures
Additional Staffing Costs?
Reduction in food waste
Staffing costs for bay 1 in £s
Number of meals returned by patients in bay 1
Group Work
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Sampling & Data
Sample sizes for QI-
Data Collection Plan• DATA COLLECTION PLAN• Who is responsible for actually collecting the data?• How often will the data be collected? (e.g., hourly, daily,
weekly or monthly?)• What are the data sources (be specific)?• What is to be included or excluded (e.g. only inpatients are to
be included, or only stat lab requests should be tracked).• How will this data be collected?• Manually ______ From a log ______ From an automated
system• Are these data:• Attributes data? ______ or Variables data? ______
Data Collection Plan Cont.....• BASELINE MEASUREMENT• What is the actual baseline number?
______________________________________________• What time period was used to collect the baseline?
___________________________________• TARGET(S) OR GOAL(S) FOR THIS MEASURE• Do you have target(s) or goal(s) for this measure?• Yes ___ No ___• Specify the External target(s) or Goal(s) (specify the number, rate or
volume, etc., as well as the source of the target/goal.)• Specify the Internal target(s) or Goal(s) (specify the number, rate or
volume, etc., as well as the source of the target/goal.)
Coffee Break
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PDSA Cycles
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if achange is an improvement?
CHANGE: What changes can we makethat will result in improvement?
Model for Improvement
© 2013 AQuA
PDSA Cycles
Consensus &
Buy In!
© 2013 AQuA
Reasons to test changes
• To increase your belief that the change will result in improvement. • To decide which of several change ideas will lead to the desired
improvement. • To evaluate how much improvement can be expected from the
change. • To decide whether the proposed change will work in the actual
environment we are working in. • To see which ideas didn’t work and why. • To evaluate costs, social impact, and side effects from a proposed
change. • To minimise resistance upon implementation-uses staff to test
change so they see for themselves.• To see if what we assume is correct
We’ve all done at least one!
Ever tried a PDSA cycle?
PDSA In Action!
Pace & pressure!• Smaller Scale Tests: One patient, one staff, try it once to
get started, talk it through before trying• Test Multiple Drivers: Assign individual responsibility for
testing changes• Test Multiple Change Ideas: Work in parallel to
accelerate learning• Use Volunteers: Don’t waste time persuading!• Instant feedback: PDSA means you know if it worked &
you don’t need to wait 2 weeks for someone to tell you!
How long will a PDSA test take?• Years• Quarters• Months• Weeks• Days• Hours• Minutes
Always plan to drop down “two levels” to plan a Test Cycle!
Failure (or is it…?)A. Be sure to distinguish the reason:
– Change was not executed– Change was executed, but not effective
B. If the prediction was wrong – not a failure!– Change was executed but did not result in
improvement– Local improvement did not impact the secondary
driver or outcomeC. In either case, we’ve improved our understanding
of the system!
You aren’t the only ones
"I did not fail one thousand times; I found one thousand ways how to not
to make a light bulb.” Thomas Edison
Testing or implemented?• Testing
– Trying and adapting ideas and knowledge on small scale.– Learning what works in your system.
• Implemented– Making this change a part of the day- operation of the
system – a permanent change in how work is done – Would the change persist even if its champion were to
leave the organisation?– The change is permanent - need to develop all support
infrastructure to maintain change– High expectation to see improvement (no failures)
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PDSA Pilot PDSA Implementation
Support needed = LOW
Support needed = HIGH
Tolerance for failure = HIGH
Tolerance for failure = LOW
People involved = FEW People involved = MANY
Time = SHORT Time = LONGER
F B+
Questions?
I. Start to plan your tests of changeII. Think small: 1 change idea, I area, 1 member of
staff, 1 patient.III. Repeat if successful: 1 change idea 1 area, 2 staff, 2
patients,IV. Still successful? Roll out wider:1 area, 3 staff, 3
patients
References• http://www.ihi.org/Pages/default.aspx• https://www.aquanw.nhs.uk/• http://www.healthcareimprovementscotland.
org/welcome_to_healthcare_improvem.aspx• Google
Home Work• Ensure your project has a
• A set of measures• A set of operational definitions (for each measure)• Ideas for some things that you may start to change to
make improvements
We will be looking to share some of these at the next session• If you have any visual data for your project bring it along• We would encourage you to complete your ‘Reflective log’• And your i-Resilience
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