Model for improvement Two phases: a planning period, followed by carrying out the project and assessing results. Planning involves designing structured project aims and a change measurement plan; projects are then structured around ‘plan, do, study, act’ (PDSA) cycles. The use of driver diagrams to understand key factors influencing aims (primary drivers) and downstream features (secondary drivers) is an equally important component. A considered diagram aids careful selection of outcomes, including those related to the process of improvement, as well as balancing measures (‘off target effects’) stemming from the primary drivers. Its advantages are that it is simple and easy for non-experts to adopt, and is practical for small, local or poorly resourced projects.

Plan Do Study Act SMART objective Outcomes Driver diagram What change can we make to improve? Driver diagram How will we know if a change is an improvement? Outcomes What are we trying to accomplish? SMART objective Plan Do Study Act

Driver diagrams

Lean Give the customer what they want: do we know what this is? Maximise flow Minimise waste

Lean The Lean system is known for being conceived and applied at Toyota, and involves understanding and targeting customer needs, whilst eliminating waste by ensuring that every process in the system adds value. In manufacturing terms the aim is to ensure flow of product to the consumer. In healthcare Lean has most often been used in secondary care settings and in specific locations or departments (such as the productive ward), however the greatest benefits have been seen in the few places which have attempted to apply Lean across their whole organisation. Whilst the focus on waste reduction and maintaining flow seems suited to secondary care, where duplication (and thus waste) is often an issue within a hospital and in a region systematic focus on customer values and needs is harder to address accurately with the current level of NHS data collection around patient experience. D'Andreamatteo et al (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197-1209.

Six sigma Much more popular in the USA than UK Involves the whole workforce at varying levels Tends to be very data driven

Six sigma Six Sigma is a data driven approach in which problems are defined, measured and analysed (acronym DMAIC). A potential advantage is complete involvement of the staff in an organisation in improvement, and thus potential to truly embed an improvement culture A review of Six Sigma implementations in healthcare found most were in specialised settings and many were of poor quality In the NHS a potential problem of using this approach is the lack of digital maturity of many organisations, which limits their capacity to collect and provide data to improvement teams Deblois, S., & Lepanto, L. (2016). Lean and Six Sigma in acute care: a systematic review of reviews. Int J Health Care Qual Assur, 29(2), 192-208.