Scottish Improvement Skills Workshop 1 Day 3 Scottish Improvement Skills Full Programme Workshop 1 Day 3 Participants

System of Profound Knowledge Deming 2000

Day 3 Planning a test of change using the Plan-Do-Study-Act framework Creating measurement plans Using run charts to tell an improvement story Influencing colleagues and other stakeholders Bringing it all together – sharing your knowledge

Planning a test of change using the PDSA framework By the end of this session you will be able to: explain all stages of the PDSA framework to others (planning, including theory and prediction; analysing results; applying learning to next cycles) use all stages of the PDSA cycle in your improvement work.

System of Profound Knowledge Deming 2000

ICU Length of Stay Aim Primary Driver Secondary Driver Change idea Reduce average length of stay in Central General ICU by 20% by March 2015 Assessment and management of sedation and agitation Improved management of delirium Validated sedation tool Appropriate sedation Incidence of acute cognitive dysfunction Structured daily sedation breaks Staff information leaflets Staff training sessions Improve multidisciplimary team communication Assess sedation and agitation using the RASS tool (Richmond Agitation Sedation Scale) Use ear plugs to improve sleep Use Dexmedetomidine as alternative to benzodiazipines Develop and follow guidelines for daily sedation breaks Assess for delirium using CAM-ICU (Confusion Assessment Method for ICU patients) Investigate and correct underlying causes Include delirium as part of safety brief Medical staff and family jointly keep an ICU diary Improved identification of delirium Validated delirium tool Staff education Care bundle initiated within 2 hours of diagnosis Engage with patient/family/carer Mobilise patients earlier and more frequently

Testing change: ICU examples Sequence the 5 PDSA reports What links do you identify from one cycle to the next? What do you notice about the scale of the tests? How many different measures were used? How did theory change through the cycles? How did qualitative data inform subsequent tests?

Qualitative and quantitative data “Why did you use the hand gel?” “Because it’s the start of my shift – I’ve just come from home.” Which of the following are occasions when you use hand gel? At the start of a shift Between patients After lunch etc On what percentage of occasions do you use hand gel at the start of your shift? 0 – 20 21 – 40 41 – 60 61 – 80 81 - 100

Project work: plan a test of change Create an aim for your first test of change: how good, by when? Start small Match your questions to your predictions and measures Plan tasks Complete who/when/where

Model for Improvement The Improvement Guide Langley J et al 2009

System of Profound Knowledge Deming 2000

Planning measurement By the end of this session you will be able to: Create operational definitions for your measures that others can follow reliably to collect data Create a measurement plan for your improvement work.

How big is your banana?

Operational definitions Define the specific components of the measure If it is an average, specify the calculation for deriving the average If it is a score (eg patient satisfaction score), describe how the score is derived. If it is a percentage or a rate, specify the numerator and denominator Describe any special equipment needed Describe the criteria to determine concepts such as ‘accurate’ or ‘complete’.

Project work: measurement planning Pick one of your measures Create an operational definition Consider exclusions and stratifiers Provide outline data collection method

Planning measurement: summary

Data analysis By the end of this session you will be able to: Explain why it is important to measure data over time Interpret run charts using rules to differentiate between random and non-random variation Use run charts to explain outcomes of improvement work to others Use and explain the importance of using a family of measures.

Understanding Variation Random variation – affects everyone and all outcomes over time Non-random variation – does not affect everyone or not part of the system all the time; arises because of specific circumstances.

Analysing data: before and after ‘When you have two data points, it is very likely that one will be different from the other.’ W Edwards Deming

Data analysis: Introduction to run charts Weight (lbs)

Data tells a story: New healthier me!

Introduction to run charts A ‘time series’ chart tells a story. Baseline data helps us to see whether a change is an improvement. Any changes made are shown on the chart.

What is a run? Vanessa’s Weight

Run charts: signals that identify non-random variation Six or more data points in a run (all above or all below median) Five or more consecutive data points all increasing or decreasing Too many or too few runs An ‘astronomical’ data point A shift A trend See table Consider

Run charts: Rule 1 – a shift

Run charts: Rule 2 – a trend

Run charts: Rule 3 (a) Too few or too many runs

Run charts: Rule 3 (b) Total useful data points Total data points For the chart below: Useful observations Lower number of runs Upper number of runs 15 5 12 16 13 17 18 6 14 19 20   Calculate the number of ‘useful’ observations (subtract the number of data points on the median from the total). Find this number in the first column. Count the number of runs. If this number is below the lower limit or above the upper limit, the chart is demonstrating special cause. 21 7 22 23 24 8 25 26 9 27 10 28 29 30 11 Total useful data points Total data points

Run charts: Rule 4

Applying the rules (4)

Baseline data How urgent is a change? Is it necessary to identify whether the system has any non-random variation before introducing a change? What is the source of historical data? If there is existing data, make use of it. If there is no existing data, decide whether to start collecting data before introducing the change.

Project work: baseline data Does baseline data exist somewhere? If so, how can you access it? If you are going to collect it, how long will you collect baseline data for before introducing a change? Why?

Data analysis: Introduction to run charts: summary Data tells a story Look for signals of non-random variation Rules: Shift Trend Too few or too many runs Astronomical point Baseline data

System of Profound Knowledge Deming 2000

Influencing colleagues and other stakeholders By the end of this session you will be able to: Apply frameworks to identify key stakeholders and gain understanding of their needs Plan for positive influencing using reflection, advocacy and inquiry.

Stakeholder analysis: RACI matrix Responsible Accountable Consulted Informed

Title of project, or change idea, or test of change RACI matrix: template Title of project, or change idea, or test of change Name Task 1 Task 2 Task 3 Task 4 Task 5 Task 6

Pulmonary Rehabilitation Programme: Patient Education Materials RACI matrix: example Pulmonary Rehabilitation Programme: Patient Education Materials John Sue Kiran Alex Lyn Anna Write material A R C I Arrange design and print Distribution to GP practices Data collection AR Data analysis Reporting

Planning communications Stakeholders Purpose of communication Key messages to be communicated Timing of communication How to communicate Who is responsible for communication.

Influencing: Ladder of Inference

Your Story Something similar has happened to all of us. What’s your story?

Example Hand hygiene

Example: Hand Hygiene In a corridor near the door to a clinic. A handwash gel dispenser is on the wall by the door. Liz approaches the door. Chris is just beyond the door, along the corridor, holding a clipboard. Liz uses the gel dispenser and rubs a dose of gel into her hands. She steps towards the door. Chris says ‘Excuse me, can I …’. Liz says ‘Sorry, I’ve been bleeped,’ and goes t through the door.

Actions Beliefs Conclusions Assumptions Meanings Data I select Observable Data Data I select Meanings Assumptions Conclusions Beliefs Actions I’ll show them. I won’t give anyone a reason to find fault. I’ll use the gel – as usual. I won’t talk to her about it. They treat us like children. They don’t trust us to do the right thing. There’ll be trouble if people don’t use the gel. It’s an audit on use of handgel. A clipboard means collecting data. We’re supposed to use the hand gel before going through the door. Chris is standing in the corridor holding a clipboard. The gel dispenser is on the wall by the door.

Example: Hand Hygiene In a corridor near the door to a clinic. A handwash gel dispenser is on the wall by the door. Liz approaches the door. Chris is just beyond the door, along the corridor, holding a clipboard. Liz uses the gel dispenser and rubs a dose of gel into her hands. She steps towards the door. Chris says ‘Excuse me, can I …’. Liz says ‘Sorry, I’ve been bleeped,’ and goes t through the door.

Actions Beliefs Conclusions Assumptions Meanings Data I select Observable Data Data I select Meanings Assumptions Conclusions Beliefs Actions

Actions Beliefs Conclusions Reflexive Loop Assumptions Meanings Observable Data Data I select Meanings Assumptions Conclusions Beliefs Actions Reflexive Loop

Your Own Example What action did you take, or what did you say? What beliefs was that action based on? What conclusions led you to those beliefs? What assumptions did you make? What meanings did you add? What data might have been available that you selected out?

Actions Beliefs Reflection Conclusions Advocacy Inquiry Reflexive Loop Observable Data Data I select Meanings Assumptions Conclusions Beliefs Actions Reflexive Loop Reflection Advocacy Inquiry

Influencing colleagues and other stakeholders: summary RACI matrix Communications plan Ladder of Inference: Reflection Advocacy Inquiry

Knowledge sharing Make a note of a particular challenge you are facing in your improvement work ‘Challenge owner’ describe your situation Others give advice, from your own experience Challenge owner note down ideas – action you could take in future based on this advice

People Connect

People Connect

Project charter A summary of what you expect to achieve from the improvement project Helps to maintain focus Answers the 3 questions Identifies appropriate team members

Learning Journal Reflections on learning 10 - 15 minutes

Workplace learning Online learning modules and videos Ongoing project work Online learning events Project charter

Project work By the time your return for Workshop 2, you will have: Completed your project charter Collected data to help you identify your priority for change Collected baseline data Carried out several tests of change Collected qualitative and quantitative data

References and further resources Provost Lloyd P & Murray S (2011) The Health Care Data Guide: Learning from Data for Improvement Jossey-Bass Senge, Peter M, 1994 The Fifth Discipline Fieldbook: Strategies for Building a Learning Organisation Nicholas Brealey Publishing