1. Quality Education for a Healthier Scotland Scottish Improvement Skills Workshop 1 Day 2

2. Quality Education for a Healthier Scotland Day 1 Quality Improvement and why it matters Improvement principles Focussing your aim Project charters Developing theories for change Leading local change

3. Quality Education for a Healthier Scotland Day 2 Developing change ideas using diagnostic tools Prioritising change ideas Introduction to measurement Using the Plan-Do-Study-Act framework to plan a test of change

4. Quality Education for a Healthier Scotland Developing change ideas using diagnostic tools Process mapping Service user feedback Brainstorming frameworks

5. Quality Education for a Healthier Scotland Developing change ideas using process mapping By the end of this session you will be able to: demonstrate how to use process mapping to generate, capture and use others’ ideas and apply them to improvement work apply process mapping principles to identify potential ideas for change in your system.

6. System of Profound Knowledge Deming 2000

7. Lean principles Specify value Map the value stream Make the value flow Pull Eliminate waste.

8. Waste Transportation Inventory Movement Waiting Overproduction Overprocessing Defects. Staff

9. Making a cup of tea

10. High level process map: a patient journey

11. Value adding activities Does the service user experience it? Do they want it to happen? Would they care if you changed it?

12. Mid-level process map

13. Detailed process map

14. Quality Education for a Healthier Scotland

16. Portering process Which steps in the process do not add value? What kind of wastes are there? Which steps would you want to eliminate? Which steps could you speed up? Would a change in sequence help? What change ideas would you try?

17. Portering change ideas Increase Porter productivity (time spent on jobs despatched) to 70% by end September 2016 Resource management Process Capacity and demand Dispatch time Porter morale Pick up time ? ? ? ?

18. Quality Education for a Healthier Scotland Project work What processes in your system may have steps that do not add value for your service users? Start mapping the high level process or pathway that your service users experience. Who do you need to work with you on this? (in your immediate team and others)

19. Quality Education for a Healthier Scotland Process mapping: summary 5 Lean principles Wastes Conventions: process steps, decision points Value from the perspective of service users Collaborative process: current state to future state High level to detail

20. Quality Education for a Healthier Scotland Developing Change Ideas using Service User Feedback By the end of this session you will be able to: Demonstrate how to use service-user feedback to generate, capture and use others’ ideas and apply them to improvement work Collect and analyse service-user feedback to identify potential ideas for change in your system.

21. Service User Feedback

22. Project Work: Service User Feedback Who would you ask? Would you use a paper form or another method of collecting feedback? How would you develop your questions? Who should be involved? What kind of questions would you ask? How would you engage service users to provide this data?

23. Service User Feedback: Summary Why What How When Who

24. Quality Education for a Healthier Scotland Developing change ideas using brainstorming frameworks By the end of this session you will be able to: demonstrate how to use a range of brainstorming frameworks to generate, capture and use others’ ideas and apply them to improvement work apply a number of brainstorming frameworks to identify potential ideas for change in your system.

25. Principles Logistics Frameworks Forcefield Analysis Human factors Driver Diagram Brainstorming

26. Brainstorming Principles of Idea Collection

27. Brainstorming Logistics

28. Forcefield analysis Forces for changeForces against change Present state Desired state Lewin 1943/1997

29. Human Factors and Ergonomics Aim: to optimize human well-being and overall system performance Encompasses: Design Engineering Psychology Organisational Management (including quality) Human Sciences (anatomy, physiology, biomechanics, anthropometry)

30. System of Profound Knowledge Deming 2000

31. Applying an HFE framework Who What When How Where Why People Activity Environment

32. Aim: promote staff wellbeing Aim 1  Driver 2  Driver Change ideas Promote the physical, mental and emotional wellbeing of staff. By March 2017: (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. A workplace that is safe for staff Staff engaged in health and wellbeing practices Activity People Environment ? ? ? ?

33. Project work: Applying an HFE framework Who What When How Where Why People Activity Environment

34. Human Factors and Ergonomics “Making it easy to do the right thing” Bromiley M. 2011 “Human Factors is the scientific discipline concerned with the understanding of inter- actions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance” International Ergonomics Association

35. Driver diagram Aim A new healthier me! Lose 7 pounds by end July 2015 Calories in Calories out Leisure activity Calories in meals Calories in drinks Calories in alcohol Work activity Calories in snacks No alcohol Monday to Thursday Max 1 x juice or soft drink per day Reduce portion size Cook evening meals from scratch Replace biscuits/cakes with fruit Keep to shopping list Get up from desk to talk, instead of phone or email Use stairs not lift Walk to a daily step target Swim at least twice a week 1  Driver2  Driver Change ideas

36. Organising theories for improvement Secondary Drivers Aim Aim statement: A general description of the desired improvement. (what, how much, by when) A network of factors that drive the outcome/ aim Primary Drivers Secondary factors which will influence delivery of the primary drivers Change ideas The changes or proposed interventions that can be tested out to achieve the secondary drivers

37. Project work: change ideas Use the ‘driver diagram’ approach to generate some change ideas. ? ?

38. Quality Education for a Healthier Scotland Brainstorming frameworks: summary Brainstorming principles and logistics Frameworks o Forcefield analysis o Human Factors and Ergonomics o Driver diagram

39. Quality Education for a Healthier Scotland Prioritisation By the end of this session you will be able to: use a 2 x 2 matrix (eg Difficulty vs Impact) to prioritise change ideas or drivers Identify opportunities to use Pareto charts, and analyse Pareto charts to generate and prioritise change ideas.

40. System of Profound Knowledge Deming 2000

41. Prioritisation Impact/difficulty matrix Pareto chart

42. Prioritisation Impact/difficulty matrix Pareto chart

43. Matrix: impact vs difficulty Impact High Low EasyHard Difficulty

44. New, healthier me! Impact High Low EasyHard Difficulty Cook from scratch Reduce portion size Keep to shopping list Replace biscuits with fruit 1 soft drink / day No alcohol Mon – Thurs Swim twice / week Increase steps Use stairs at work

45. Matrix: impact vs difficulty Impact High Low EasyHard Difficulty

46. Prioritisation Impact/difficulty matrix Pareto chart

47. What is a Pareto chart? 80:20

48. When to use a Pareto chart When you can categorise items that have the potential to contribute to the improvement you are considering When you want to analyse data about the frequency of problems

49. Access to primary care

50. Primary care practice X: reasons given by patients for not attending

51. ReasonsNumber%cumulative % Unable to contact to cancel3524% Forgot2618%43% Unaware of appointment2316%59% Confusion about appointment time1913%72% Inconvenient day128%80% Other96%87% Unwell64%91% Inconvenient time43%94% No value in appointment43%97% Working32%99% No transport11%99% Unable to afford time off work11%100% Total143100%

52. Primary care practice X: reasons given by patients for not attending

54. Central Hospital Ward F: Percentage of meals returned, by meal type (2013)

55. Ward X: Adverse drug events - causes

56. Hospital X: SAB cases by ward (SAB = Staphylococcus aureus bacteraemia)

57. When to use a Pareto chart When you can categorise items that have the potential to contribute to the improvement you are considering When you want to analyse data about the frequency of problems When you have at least 30 observations across the categories (vertical axis) Consider: measure, period, existing data

58. Pareto chart examples 1.For this project, what data could a Pareto chart be used with? 2.Which driver(s) or change idea(s) is this Pareto chart related to? 3.Which categories would you focus your improvement efforts on? 4.What action would you take based on this chart?

59. Project work: prioritise Would a Pareto chart be useful for your project? If so, what data would you need, and how could you get it? Use the Impact vs Difficulty matrix to identify your top priority for change.

60. Prioritisation: summary Impact/difficulty matrix Pareto chart

61. Quality Education for a Healthier Scotland Introduction to measurement By the end of this session you will be able to: describe why data is needed to support improvement work describe 3 types of measure and explain why it is important to use all of them.

62. System of Profound Knowledge Deming 2000

63. Quality Education for a Healthier Scotland Three questions What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

64. Measurement: why? To make improvement visible To plan To monitor progress To tell an improvement story To use a shared language. Safe Effective Person- centred

65. What is measurement for improvement? ImprovementAccountabilityResearch Purpose New knowledge Understanding of process Evaluation of change Comparison Reassurance New knowledge Hypothesis Flexible – hypothesis changes as learning takes place No hypothesisFixed Testing Small, sequential tests Observable tests No tests One large test Tests blinded/controlled Data Gather just enough data to learn in each cycle Large amounts of data Gather as much data as possible ‘just in case’ Timescale Short and currentLong and past Confiden- tiality Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected

66. Access to primary care

67. Three types of measure Outcome Tells a team whether the changes it is making are helping to achieve the stated aim

68. Three types of measure Aim At primary care practice X increase by 20% the % of patients offered an appointment within 24 hours, by end December 2014

69. Three types of measure Outcome Tells a team whether the changes it is making are helping to achieve the stated aim Process Tells a team whether a specific process change is having the intended effect

70. Three types of measure Outcome Tells a team whether the changes it is making are helping to achieve the stated aim Process Tells a team whether a specific process change is having the intended effect Balancing Makes sure that changes to improve one part of the system are not causing problems in other parts of the system

71. A New Healthier Me Aim A new healthier me! Lose 7 pounds by end July 2015 Calories in Calories out Leisure activity Calories in meals Calories in drinks Calories in alcohol Work activity Calories in snacks Primary DriversSecondary Drivers No alcohol Monday to Thursday Max 1 x juice or soft drink per day Reduce portion size Cook evening meals from scratch Replace biscuits/cakes with fruit Keep to shopping list Get up from desk to talk, instead of phone or email Use stairs not lift Walk to a daily step target Swim at least twice a week Change ideas Weight BMI Body Fat Waist Size Jeans fit Daily Calorie intake Calories Burned/day Flights of stairs climbed/day Number of items bought not on shopping list Family perception of new lifestyle Cost of Mon- Thurs meals Time taken to prepare meals Fruit replaces cake/week Days between cakes

72. Create measures: Staff Wellbeing 1 outcome measure 3 process measures 1 balancing measure

73. Quality Education for a Healthier Scotland Project work: create measures For your aim and highest priority change idea, create measures 1 outcome measure 2 process measures (for the same change idea) 1 balancing measure

74. Quality Education for a Healthier Scotland Introduction to measurement: Summary

75. Quality Education for a Healthier Scotland 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)

76. Quality Education for a Healthier Scotland Model for Improvement The Improvement Guide Langley J et al 2009

77. Quality Education for a Healthier Scotland System of Profound Knowledge Deming 2000

78. Aim (overall goal for this project) Lose 7 lbs Change idea Apples instead of biscuits Aim for this test of change What questions do you want answered for this test of change? Tomorrow, eat an apple instead of biscuits 1. How will I feel emotionally before, during and after eating the apple? 2. How will I feel physically after eating the apple?

79. Plan Predict what will happen when the test is carried out. Measures to determine if prediction succeeds 1. I’ll feel pleased that I did it. 2. I’ll still feel hungry. 3. I’ll eat the apple. Emotional state on a 1-5 scale Energy level on a 1-5 scale Number of apples eaten List the tasks needed to set up this test of change. Person responsible When to be done Where to be done a. Buy apple b. Don’t buy biscuits c. Don’t accept biscuits offered by colleagues Me Before work All day Corner shop Anywhere

80. DoDescribe what happened when you ran the test. Ate 1 biscuit, then thought I might as well eat another. Ate another. Study Describe the measured results and how they compared to the predictions. 1. Felt miserable before. Didn’t enjoy biscuits. Felt guilty after. 2. A bit buzzy. 3. No apples eaten Act Describe what modifications in the plan will be made for the next cycle from what you learned. Eat one apple and one biscuit tomorrow.

81. Scale and sequence of tests a.On Mon & Weds, eat apples for snacks. b.Lose 10lb in three months. c.On Mon, Tues, Weds & Thurs, eat apples for snacks. d.Tomorrow, eat an apple instead of biscuits. e.Within one month replace all biscuit snacks with apples.

82. Prediction

83. PDSA Simulation Aim: In the fastest possible time, pass the ball to each person in the group.

84. The Rules 1.The ball must be thrown diagonally. You may not throw the ball to the person next to you. 2.You must call out the name of the person you are throwing it to. 3.Each person must receive the ball once. 4.If someone drops the ball you must start again from the beginning. The timer will not be stopped. 5.If you restart the process, the ball must follow the same order of passing as the previous attempt. 6.The last person to receive the ball must be the starter. This is when the process and timer will stop. 7.If you break any of these rules you must start again. The timer will not be stopped.

85. TestAim of test Theory/ plan Prediction (time) Actual time Observations What we will do next time 1 To pass the ball to every member in the group in the least possible time, sticking to the rules 2 3 4 5 Record keeping

86. Simulation: key points Knowledge is gained through testing Tests should be small, rapid, and sequential Theory and prediction must precede every test Review following the test is essential Learning from other teams can accelerate learning Measurement does not have to be hard Data aids learning.

87. Quality Education for a Healthier Scotland Planning a Test of Change Using the PDSA Framework: Summary Where to use PDSA Framework Elements of PDSA Framework Scale and sequence of tests Planning future tests

88. Quality Education for a Healthier Scotland Day 2 Developing change ideas using diagnostic tools Prioritising change ideas Establishing measures Using the Plan-Do-Study-Act framework to plan a test of change

89. Quality Education for a Healthier Scotland References and further resources Lewin K., 1943, Defining the "Field at a Given Time" Psychological Review. 50: 292–310. Republished in Resolving Social Conflicts & Field Theory in Social Science, Washington, D.C.: American Psychological Association, 1997 The Science of Human Factors: Separating fact from fiction http://www.nes.scot.nhs.uk/media/2407888/human_factors_articl e.pdf Systems thinking http://skybrary.aero/index.php/Toolkit:Systems_Thinking_for_Saf ety:_Ten_Principles/Presentation Enhanced Significant Event Analysis http://www.nes.scot.nhs.uk/media/2407430/enhanced_sea_pers onal_booklet.pdf

90. Quality Education for a Healthier Scotland References and further resources Pareto chart http://www.ihi.org/resources/Pages/Tools/ ParetoDiagram.aspx