Scottish Improvement Skills

Scottish Improvement Skills
Workshop 1 Day 2 Scottish Improvement Skills Workshop 1 Day 2 Facilitator slides and notes

Day 1 Quality Improvement and why it matters Improvement principles
Focussing your aim Project charters Developing theories for change Leading local change This is what we have done so far. Warmer: In 2s or 3s Find out one thing that the other person is going to share with their project team from the first day of the workshop Aim Possibly getting to know someone else here, refreshing memory on Day 1, and starting to think about action planning

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 By the end of today you will have: Generated some change ideas for your project selected a priority change idea to work on established outline measures for your project discussed some of the issues around testing changes.

Developing change ideas using diagnostic tools
Process mapping Service user feedback Brainstorming frameworks We are going to look at 3 different approaches to generating change ideas.

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. Lead facilitator read through briefly, or ask participants to read.

System of Profound Knowledge
Key messages Process mapping is one tool that can help us to identify the best way to achieve our aim Importance of context – the same process may work well in one context, but not in another. People who map the current state and proposed future state must be familiar with the context. Lead facilitator With all diagnostic tools, we are in this part of the System of Profound Knowledge: Theory of Knowledge. Generating ideas for possible changes, we are developing our knowledge around change, answering the Model for Improvement Question 3: What change can we make that will result in improvement? Often we tend to jump in to an improvement project with an idea for change, without thinking through in detail whether that is the best way to achieve our aim. This may be because we’ve had the idea ourselves, or we’ve heard about it being used elsewhere, or if our work is linked to an SPSP collaborative, or an organisation-wide programme, they have already done much of this work for us. However, every context is different and we need to identify a number of potential changes for our setting, and then prioritise the ones likely to bring the most benefit. Deming 2000

Lean principles Specify value Map the value stream Make the value flow
Pull Eliminate waste. Discovery Aim For those new to Lean have a brief background to process mapping To find out and acknowledge who in the room is already familiar with Lean Key messages Process mapping originates in Lean thinking. Lean thinking involves determining the value of any given process by distinguishing value added steps from non-value-added steps, and eliminating waste so that every step adds value to the process. Timing Max 5 minutes for this slide Lead facilitator Process mapping is a tool associated with Lean. Elicit – who has experience of Lean? How have you use it, and in what context? What has been the impact of using it? Talk through the 5 principles briefly: First, establish value – what is it in the eyes of your service users? Then, map the total value stream. To do this, you map your process first, then assign values. What is a process map? A series of actions. Start by mapping your current state – what actually happens, not what is supposed to happen. Depending what kind of process it is, physically walking through the steps can be very revealing. Mapping the value stream then assigns a value to each step (in the eyes of your service users), and a time for each step. Next, make improvements to create a future state map. To do this, you look for ways to: Make value flow with no interruptions: analyse the obstacles that prevent the process from flowing freely For example the flow of patients through the hospital or clinic should be continuous. To achieve continuous flow of patients, Lean tries to: load level patient demand; bring services to the patient just when they are needed; and stop the process when problems occur. Healthcare has been described as having 7 flows: flow of patients, clinicians, medication, supplies, information, equipment, and flow of process engineering. - Pull what you want when you want it: rather than eg pushing patients from one queue to another and creating blockages - Search for perfection with no waste – a waste is any step that does not add value (as you have defined value in the eyes of your service users).

Waste Transportation Inventory Movement Waiting Overproduction
Overprocessing Defects. Staff Aim Participants to be able to list different kinds of waste in the context they work in (not necessarily using the terms on the slide) Key messages Waste is a symptom, not a cause, of a problem. We need to find the causes of waste in our system, and eliminate those causes. Timing 5 minutes, or longer if you use local examples and/or elicit. Lead facilitator Talk through this briefly – the following provide some examples you may wish to use, but there is no need to go through all this detail. OR use examples from your own context, if participants are all from the same organisation or workstream. OR if more time available, elicit examples from participants, filling any gaps with these or your own examples. Animation – one bullet comes up on each click, and a further click for ‘staff’ Transportation Moving a patient to an inpatient bed for review at post-op ward round and then to another ward for discharge Moving a patient for tests or to see the physiotherapist. Moving ‘stuff’ – any kind of equipment, medication etc eg patient records from one place to another, information leaflets, paper for printers. Inventory (ie stock) Using inpatient beds for patients who are waiting for tests but could be discharged safely Ordering excess material because the supply is unreliable Retaining material beyond its useful life eg an audiology unit may have 6000 moulds, many of which are useless because they shrink over time. Movement – unnecessary movement of staff eg around a room, from room to room, from building to building Waiting Patients waiting in queues at the surgery Patients or staff waiting for tests Making sure all the equipment is ready for an operating list Overproduction Requesting tests and referrals to outpatient clinics ‘just in case‘ Carrying out tests/assessments in order to cut waiting lists, but not having capacity to follow through once results of tests/assessments are available. Overprocessing Things we find ourselves doing that don’t add value for the patient eg re-testing, chasing late paperwork Defects – Things that are not right and need fixing in orthopaedics you may have prostheses that are damaged or missing or don’t fit/wrong. This is the standard list of Lean ‘wastes’. Some people add another: Staff – ie untapped potential Staff having the capacity to work in a more effective way, but the system (structures, processes, culture) doesn’t allow them to do that.

Making a cup of tea Aim To apply these ideas to an example
To discuss an example of an everyday process that everyone is familiar with, before showing a more complex healthcare example later. To ensure participants are actively engaged following 10+ minutes of input/trainer talking. Key messages Features of a process map: start/finish points; actions; decision points A process doesn’t have to be scary; it’s a way of representing how we do something, and provides a basis for discussion. Timing Quick pace – about 6-7 mins Aim is for this to be a quick intro, then spend much more time on the Portering example. Materials 1. Making a cup of tea process map 2. Questions on whiteboard sheet or flip chart prepared earlier. Is this how you make tea? What wastes are there? Which steps don’t add value? How could you improve it? Lead facilitator First, looking at a non-healthcare example. Elicit: Do you drink tea? Anyone who doesn’t, ask what they do drink. Likely to be similar process. A process = sequence of actions There are many different ways to represent a process. These are some common conventions: Square/rectangle = action Diamond = decision point – always ask a yes/no question Curved shapes – beginning/end Elicit: How many action steps are there here? (10) How many decision points are there here? (5) Give handout. Show questions on flipchart/whiteboard. Return slide to previous Waste slide Discuss in pairs/tables. Support Facilitators Light touch facilitation around the room – participants may have some questions initially eg about the shape conventions. Apart from that, leave them to it. Debrief in plenary Elicit responses re: wastes, value, improvements. Highlight importance of being clear about your criteria eg here criteria are probably time and quality – need to reduce time as much as possible without compromising quality. Benefits of using a process map here: If I had asked you to identify possible wastes in making a cup of tea, do you think you would have come up with as many ideas?

High level process map: a patient journey
Aim To provide a context for the Portering process map later To show different levels of process map, and different designs (appropriate to the level of analysis) Key messages Focus on the interests of service users Timing This sequence of 5 slides (before Portering Process) is designed to be quick – just a few minutes to provide context and person-centredness. Lead facilitator Process maps can be used at different levels. To ensure that our focus is always on improvements that will be of interest to patients, we should start by looking at patient journeys. Another reason to start with a high level map is to make sure that we are aware of the potential for improvement of many parts of a process – the first part of a process that we think of working on in detail may not be a priority for our service users. At this level we normally start with a simple sequence of actions. In this example, we’re looking at Susan’s journey from identifying a healthcare need to completion of treatment in response to that need. We could do an analysis at this level, looking at patient flow, and wastes, and for example information about patient satisfaction relating to different steps in the journey. The arrows at both ends indicate that this is a section of an ongoing patient journey - for the individual, this is in the context of health issues before and after too – but this is a chunk that we may look at depending on where we fit in in relation to it.

Value adding activities
Does the service user experience it? Do they want it to happen? Would they care if you changed it? Aim After introducing the idea of value as one of the 5 Lean principles, this looks at value in more detail – criteria to identify whether a process step is of value to our service users. Key messages Focus on what is of value to service users. These three questions provide one way to find out what that is. Timing 2 mins Lead facilitator For a step in a process to be value adding, each of these questions should get a ‘yes’ answer. So, we should be looking to remove as many steps as possible that are not directly experienced by service users. If they don’t want something to happen, or if they would like it to be changed, it is a suitable focus for improvement. Of course there are some activities in health and social care systems that are not directly experienced by service users that we cannot eliminate completely. Those can also be targets for change – to reduce wastes relating to those steps. From the high level process map of Susan’s journey, we need to focus down on something that she would want to happen differently or would like to be changed (go to next slide)

Mid-level process map Lead facilitator
We can take one of the steps in the high level map – one that has been identified as having steps that include wastes, and that do not add value. Here, looking at the day surgery step (the blue box). We now break this down into more detailed steps, in sequence, and look to work on one that includes wastes or activities that do not add value. (However, remember that all these are interdependent, so changing one may involve changing others too). A question may be asked about why the convention of different boxes is not used in this series of process maps. If so, point out that the aim of these higher level maps is to ensure that we are focussing on the right area/priority, before looking at a process in detail.

Detailed process map Aim
This slide is only to indicate which of the steps in the mid-level process map we are going to look at in detail. Lead facilitator Let’s work on this one.

Aim To put the swim-lane process map in context – to show how it would have been developed Key messages Process mapping as a collaborative process Timing 1 – 2 minutes Lead facilitator In real life, mapping a process might start like this. This is an example of a process map being developed by a team (for example at a Rapid Improvement Event), before it’s all recreated neatly using appropriate software. Benefits of creating a process map collaboratively: Different perspectives Find out what actually people actually do, not what procedures, protocols etc say they should do Get buy in of key stakeholders, as they are involved in mapping the desired future state as well as the current state. Tips: Start with post it notes – you’re likely to need to move them around a lot Before you take it away, use clear sellotape to stick the post it notes down, as here (this one is in the process of being packed away) Continue with another example on the next slide.

Aim To show there is not just one way to create a process map. The different stages – process mapping and value stream mapping Timing 1 – 2 minutes Lead Facilitator Here the process map has been created with pale yellow post its. Then the value stream has been mapped using different colour post its – here orange, pink and blue will each represent a measure of value or waste.

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? Practice Aim To gain some familiarity with how process maps are organised. To practise applying some of the principles of process mapping and improvement. Key messages Use the process map to identify activities in your system that do not add value. Then use your deeper understanding of the system to generate change ideas. Importance of not doing this alone. Include subject matter experts – people familiar with the context. Timing 10 – 15 minutes Material 1. Portering process map – this is adapted from real ‘current state’ portering process maps from NHS hospitals. 2. Whiteboard sheet or flipchart sheet prepared earlier – list of Wastes Lead facilitator This process map uses ‘swim lanes’. Each swim lane represents a person or department. You might start creating a process map knowing that you are going to use swim lanes (in which case, indicate these on the background paper you put the post its on), or the usefulness of swim lanes may emerge as you build the process map. Elicit: When would swim lanes not be useful? (eg if only a single person following the process eg making yourself a cup of tea) Analyse this ‘current process’ using the questions on the slide. Work along for a few minutes, thinking about all the questions. Then discuss in pairs or 3s. In 10 minutes I’ll ask you to share your change ideas, and explain your reasoning. Facilitators Monitor around the room and support as necessary. Lead facilitator: plenary debrief: Either: Elicit some responses to the questions – it is not necessary to go through each question separately as the answers will overlap. OR Elicit some ideas for changes to improve this process, with reasons

Portering change ideas
? Capacity and demand ? Resource management Process Increase Porter productivity (time spent on jobs despatched) to 70% by end September 2016 Porter morale ? Dispatch time ? Practice Aim To wrap up the Portering process map activity, and possibly deepen the debrief by requiring participants to commit to an opinion. To create a visual representation of a ‘theory of knowledge’ by linking the change ideas to secondary drivers. Timing 5 – 10 minutes Materials Cards for driver diagram (aim, primary and secondary drivers) either already on the wall from Developing theories of change, or put up on wall before this activity. Cards with change ideas, in two sets: Set 1 – link to the ‘improved process’ primary driver Set 2 – link to the ‘resource management’ primary driver Lead facilitator Distribute Set 1 cards amongst participants. Ask them to put them up next to the relevant secondary driver (and add arrows, if you are using them) Support Facilitators One or more facilitators at the wall, with Set 2 cards. Once all the Set 1 cards are up, in agreed positions, distribute Set cards and facilitate discussion as participants decide where to put them. OR If two or more facilitators are available, consider giving both Sets 1 and 2 out together, and one facilitator each to focus on the two sections of the driver diagram. As with the Developing theories of change driver diagram activity, allow for different matches from those in the key, so long as a good justification is provided. Pick up time

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) Project Optional slide and activity If you are doing a series of modules using other diagnostic tools as well as process mapping all within a day or two, you may prefer to leave project work until after you’ve looked at all the diagnostic tools, as in the full Scottish Improvement Skills programme. Aim For participants to start thinking about applying this tool in the context of their own project. Timing 5 minutes Materials Plain A3 paper or flip chart sheets – one per participant Sticky notes – small and medium sizes, multiple colours, total approx 1 pad per participant Lead facilitator Now think about how you might use process mapping in your own project. Take a few minutes to work through these questions. Remember the ‘principle of the system boundary’ (Senge – see Improvement Principles): consider the ‘interactions that are most important to the issue at hand, regardless of parochial organizational boundaries’ – this will affect your choice of people to work with you on this. Support Facilitators Facilitate around the room. Respond to any queries that arise, or intervene if you notice people rushing to detailed processes.

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 Aim To briefly recap the session content: - to support a sense of learning and accomplishment - to aid memory of the session later An opportunity for participants to ask any outstanding questions from any part of the session. Timing 1 – 5 minutes, depending on time available Lead Facilitator Elicit what content was covered for each of the bullets eg: What are the 5 Lean principles? What are the 7 wastes? And the 8th one that we added? What does a rectangle represent? A diamond? An oval? What are the two options coming off a decision point? What are the 3 questions we should ask to find out if an activity adds value for service users? Why shouldn’t we create a process map alone? (other perspectives, find out what really happens vs what is supposed to happen, get buy-in by involving key stakeholders) Why should we start with a high level process map, not go straight to detail?

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. Still generating change ideas. There are many different tools you can use to generate change ideas. We are giving you an opportunity to try some out and think about whether they may work for you. Now: Service user feedback

Service User Feedback Aim
To keep focus on the needs and wants of service users. To begin to think about how to find out what those needs and wants are. To see examples of and think about differences between qualitative and quantitative data before this comes up in the context of measurement later (probably Day 3) Key messages One size does not fit all Involve different people eg respondents to include carers and family members as well as patients themselves Also consider service users who are internal to your organisation eg if you have a facilities role Which staff and partner organisations are stakeholders and would usefully be involved eg multidisciplinary practice staff, pharmacists? Use small sample qualitative questions to generate quantitative questions for larger population sample Timing Discovery 15 mins Practice 15 mins Material 3 examples of service user feedback forms Service user feedback task Discovery Lead facilitator Elicit a couple of examples: In the area that you work in, who are your service users, and what feedback do you get from users of your services? How do you get feedback? When? Why? Task: Q1 – what do you like about them? Have a look at them on your own and jot down a few thoughts. Then discuss in groups. Q2 and 3 – qualitative vs quantitative data; compliments Discuss in groups Plenary debrief, include: Qualitative data – may give whole new ideas Quantitative data – helps prioritise Compliments – we need to know what people like so we don’t change by stopping doing it. As well as to share with staff re morale Practice Q4 – Primary Care Access Half the room, in groups, each work on one of the primary drivers – facilitator assign. Plenary debrief – share some of thinking from each group : How would you collect feedback from service users? What are some of the issues you would need to take into account? Plenary debrief – elicit some responses relating to both parts of the driver diagram. Facilitators Monitor the room and support as required.

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? Project Aim Participants think about getting feedback from their own service users. Timing 10 mins Lead facilitator Who are your service users? – not just patients, may be internal staff or partner organisations How might you draw on them to help you generate change ideas? Refer to your driver diagram Facilitators Monitor the room and support as required. Brief plenary – elicit some of the immediate actions participants are going to take when they go back to work.

Service User Feedback: Summary
Why What How When Who Aim To briefly recap the session content: - to support a sense of learning and accomplishment - to aid memory of the session later An opportunity for participants to ask any outstanding questions from any part of the session. Timing 1 – 5 minutes, depending on time available Lead Facilitator Elicit what content has been covered for each of the bullets eg: Why do we need service user feedback? What format might be collect it in? eg paper, online, face to face How – what are the logistics, constraints etc When – importance of doing this at an early stage in your project Who – who in the project team and beyond needs to be involved in this?

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. There are many different tools you can use to generate change ideas. We are just looking at a few. Chances are that you will become comfortable with some tools that work for you. We are giving you an opportunity to try out a few brainstorming frameworks and think about whether they may work for you.

Brainstorming Principles Logistics Frameworks Forcefield Analysis
Human factors Driver Diagram Signalling slide – this is what we are going to look at – some of the principles of brainstorming, and then how starting with an appropriate framework can help us.

Brainstorming Principles of Idea Collection
Aim People generally think they know about brainstorming, but some of these principles are often forgotten, so worth reminding. Key messages As on slide Timing 2 mins Lead facilitator Briefly talk through the following: Clearly state the problem or topic Each person presents their ideas Record each idea exactly as given No criticism or judgement, no questions Produce quantity Don’t mind stating the obvious Don’t fear repetition Combine and improve on others. Produce quantity – NB from the ‘change is good’ video if used already in the Leading Local Change module:, ‘The best way to get a good idea is to get lots of ideas.’ (Linus Pauling) Then in the assessment phase, criticise the idea, not the person.

Brainstorming Logistics
Lead facilitator Talk through the following briefly: Individually or as a group Captured by each person or a ‘recorder’ Paper, post-its, flip chart Serially, concurrently Framework Frameworks – brainstorming is most effective if you don’t just start with a blank sheet of paper. Use a framework that will give you a starting point for generating ideas. There are many possible frameworks.

Forcefield analysis Forces for change Forces against change
Present state Desired state Forces for change Forces against change Aim Brief recap of a tool introduced in Day 1, module Leading Local Change. Timing 2 mins Lead facilitator Refer back to having looked at this before. Elicit what it was used for then: (You used it then to help you analyse your change context and identify potential resistance to change.) You may find this is useful at different levels. eg you have just got a driver diagram and no change ideas yet. OR, you have some change ideas but no idea where to start with tests of change – this approach can help you select which tests of change to start with. So, it can contribute to both generating change ideas and identifying your priorities, particularly if you use a scoring system. We’ll be looking at other approaches to prioritise change ideas in the next module. Lewin 1943/1997

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) Discovery Aim A very very brief introduction to Human Factors to ensure that everyone is aware of the field and knows where to go for more information. To have an opportunity to think briefly about the wide range of features of systems that can impact on health and social care outcomes, and hence the potential for change in these areas to improve the quality of services. Ie thinking about systems in more depth than when introduced to the System of Profound Knowledge previously. Key messages The breadth of the field Given its aim, we should all be using HFE thinking – it is relevant for all improvement projects. Timing 2 mins Lead facilitator The next framework for brainstorming that we’re going to look at comes from the field of Human Factors and Ergonomics. The aim of the HFE approach is to improve to the highest possible level human wellbeing, and system performance. HFE thinking encompasses …. Anthropometry is the science that defines physical measures of a person's size, form, and functional capacities

We are in Theory of Knowledge because working on generating change ideas we are looking at increasing our knowledge through making predictions and testing our theories. In practice we do that by testing change ideas. We are also in Appreciation for a System, because HFE is all about getting an in-depth understanding of our system, based on the reality of work. Gaining a better understanding of our system will help us develop and test our theories. Application of HFE thinking is key to improving the wellbeing of both patients and staff. First, let’s think about patients. Patients Lead facilitator Elicit: What % of patients admitted to hospital do you think are unintentionally harmed? It is now widely accepted that about 10% of all patients admitted to hospital will be unintentionally harmed in some way. Elicit: And in primary care? In primary care, there is less research available – Some studies do, however, point to the potential size and nature of the safety problem. For example, in a small review of a sample of 500 randomly chosen electronic patient records, evidence of unintentional harm (mostly of low-to-moderate severity) was found in 9.5% of cases. About 40% were judged to have been avoidable Bowie, P. 2010? Research on unintentional harms in hospital shows that half of these could be avoided if rigorous HFE thinking is routinely applied. Scottish Patient Safety Programme Elicit: How much do you think it costs NHSS each year in extra treatment and hospital days? It is estimated that adverse events cost the NHSS £200 million each year (look at this in relation to total budget of around £12 billion). Also other costs, such as suffering of patients, their families and the health care workers involved. Error and success are two sides of the same coin – you can do the same thing, and on most occasions everything goes well, but on one occasion it goes badly. People have to vary the work they do to cope with varying conditions – usually this ensures a good outcome. What is important is how you react on the occasions when there is a bad outcome. Application of HFE principles, relating to systems and design, is key to reducing adverse events in healthcare, improving staff and patient wellbeing, and performance of the system (whether thinking of the system in terms of organisation, department, team etc). It is about modifying the design of a system to better aid people (OR to take into account human failings). We started thinking about systems as a component of the System of Profound Knowledge. We use HFE principles in relation to interactions between humans, as well as between humans and machines and other elements in the environment. HFE is about designing systems that are resilient to unanticipated events. Its range extends from individuals to a whole organisation. We are not going to look at HFE in detail here – there are many other resources available for you if you want to investigate it in detail. Example of how thinking in terms of HFE can help you identify change ideas that may have been far from your original thinking: In a study in Holland (source – Mark Johnston, NES), patients on a ward were becoming very dehydrated, more than on other wards. What might the cause have been (elicit possibilities)? Eg staff not providing enough water, not helping patients to drink? No, the study found that there was always plenty of water by the bedside of each patient (somewhere they could reach it if able), and staff reminded them and offered to aid drinking. Eventually they found out, through talking to patients, that the cause was the design of the ward toilet. Elicit suggestions for how design of the toilet might lead to dehydration. Then continue: The loo roll holder was poorly positioned, so it was difficult for patients to reach. Because they couldn’t reach the loo roll, they didn’t want to go to the loo, so they drank as little as possible. So the improvement idea turned out not to be to do with availability of water or helping to drink, but placing 2 loo rolls, one on either side of the loo, the locations decided in consultation with a patient group. Deming 2000

Applying an HFE framework
Who What When How Where Why Aim To start thinking about systems in HFE terms. Key messages HFE can be thought of as ‘the evaluation of work’. Asking questions using these question words is one way to evaluate work. Don’t jump to solutions (change ideas) without thinking through these questions thoroughly. Timing 30 minutes Materials This slide is animated: 0 – question words 1 – People/Activity/Environment Applying a Human Factors framework - handout Discovery Lead facilitator Now moving on to look at how we can use HFE principles to help us to understand why things go wrong (or what could go wrong in future), what features of our systems threaten the wellbeing of our staff and patients. When thinking in terms of HFE, what we are doing is evaluating human work. It can be helpful to ask questions, working through these words (Who etc). Scenario 1 (in plenary): Patient harm or near misses due to blood matching errors ie the wrong blood being selected for a blood transfusion. A project aiming to reduce these errors had decided to provide nurses (who carry out the transfusions) with training. The training included an introduction to patient safety, to make sure that the nurses understood the importance of patients receiving the correct blood match. Elicit: Is training to understand the importance of the correct blood match likely to be helpful? Do you think they don’t understand this already? Use these words to think about what might be causing the errors. Start with lead facilitator asking some of the questions to elicit a range of answers. As participants get the idea, elicit questions from them, using the question words on the slide as prompts. egs Who is in the system where this blood mismatch takes place? Eg age, height, weight, psychology (a small person – may have ‘reach’ problems; a larger person may have ‘clearance’ problems) What actually happens when these mismatches occur, or nearly occur? (‘Observable data’ in Ladder of Inference terms – Day 3) What is going on around them when they do this? What can they and others observe? Eg lots of other activity on the ward When do most of the errors occur? Eg time of day/night, day of week, beginning/end of shift, [when particularly busy] Where does the transfusion, or selection of blood take place? How is the blood selected? Why does the error (or near-error) occur on some occasions and not others? Why do they select the wrong blood? [response re this project was: They get interrupted by colleagues, or distracted by other things going on around them] So, we’ve explored contributory factors. Now, move on to think of some change ideas. Elicit ideas. eg who needs to do something differently – are we sure it’s the nurses who select the blood and administer the transfusion? To not be interrupted by colleagues eg education for all on ward about not interrupting How could they know when they shouldn’t interrupt? Eg wear coloured tabard (like a drug round), but this may be a one off/brief activity selecting the blood and connecting it to the line so other ideas? Eg different way of organising blood in fridge, matching coding to line? Practice Now do the same with two other scenarios. Assign one scenario each to half the room. Consider dividing the room into clinical/non-clinical? Causes of the problem – using Who etc questions again minutes only. Scenario 2 Nurse or HCSW is off sick or can carry out limited tasks due to musculoskeletal problems (back) either due to repeated lifting or a single incident (evidence that even standard guidance on correct lifting technique is damaging). Notes for facilitators eg: Nurse can’t find lifting equipment No space for lifting equipment Feel they are being heroic Quote from a nursing online forum: How long will it take for a Hoyer lift to arrive, and who will pay for it? Patients need to move when they say they need to move; not 20 minutes from that time, not days, weeks or months. Right then. Ideas eg having suitable equipment easily accessible and manouverable in the space; reducing falls so less lifting required. Scenario 3 You want to reduce Presenteeism – There is evidence that staff attendance at work when sick damages the wellbeing of themselves, their colleagues and the performance of the organisation. Cost is higher than cost of absenteeism. Causes eg personal money troubles, worries about job security/redundancy; work-related stress, perceived pressure from managers; pressure from colleagues – feeling guilty for taking sick leave; staff not discouraged from coming to work while ill; not aware of employer support around sickness absence. [Also eg ‘leavism’ – using annual leave to catch up on work] Leads to : reduced general staff morale; longer recovery periods from illness; higher levels of stress-related absence and mental health issues; colleagues catching illnesses from each other. Ideas eg implementation of sickness absence policies; role of line managers in tackling workplace stress. Must put employee health above operational demands – how to do this when op demands are about supporting public with their health needs? Wellbeing strategy – discourage presenteeism. Then (after about 10 minutes?) introduce the idea of the three categories from enhancedSEA - Refer participants to handout. SEA = Significant Event Analysis The previous SEA framework was used in a way that allowed a ‘blame response’. This enhanced version aims to shift the focus to the system in which the significant event occurred. Groups continue discussion, using the prompts on the handout. Which of the categories/subcategories are implicated, and how? (ie continuing to think about causes) Then feed in next question: Based on the possible causes you’ve identified, what might you want to change in the system concerned? Plenary debrief (or mix groups up to do this in groups) Groups share their thinking re the two different scenarios. People Activity Environment

Aim: promote staff wellbeing
Aim  Driver  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. Environment ? A workplace that is safe for staff ? Activity ? Materials Staff wellbeing cards on wall: title, aims, drivers Change ideas cards – split into two sets, one HFE, one the rest. Blu tac, velcro or pins to put them up Scenario 4 Staff wellbeing driver diagram on wall Distribute change idea cards (HFE) to go up on wall One facilitator by driver diagram to facilitate Once all those are up, distribute the other change ideas for this scenario, to go up on wall. One facilitator by driver diagram. People Staff engaged in health and wellbeing practices

Project work: Applying an HFE framework
Who What When How Where Why Project Aim To apply HFE thinking to a project To generate change ideas for a project Timing 5 – 10 minutes Materials Post it notes First think about the possible causes of the problem, then work from that to change ideas, don’t jump to ideas immediately. Individuals use the handout and question prompts to explore contributory factors and then generate change ideas for their own projects. Make notes on questions and answers. Write change ideas on the Post It notes to add to driver diagram. Plenary debrief – elicit a couple of examples of how this thinking has been useful for them (if time) To next slide to wrap up. People Activity Environment

Human Factors and Ergonomics
“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 Key messages Human error is usually a symptom, not a cause of problems/failures in a system. Summing up, to have a way to summarise what HFE is about. Here are two definitions of human factors: a technical definition from the International Ergonomics Assciation, and the everyday language version by Martin Bromiley, an airline pilot, whose wife died due to complications during a routine operation. He has been at the forefront trying to introduce HF training into healthcare. The Clinical Human Factors Group was set up by him in The group aims to improve patient safety by placing the understanding of HFE at the heart of it. “Making it easy to do the right thing” Bromiley M. 2011

Driver diagram Aim 1 Driver 2 Driver Change ideas
A new healthier me! Lose 7 pounds by end July 2015 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 Use stairs not lift Walk to a daily step target Swim at least twice a week Calories in Calories out Another framework to use for brainstorming Discovery Materials Slide animation: 0 – Aim and drivers 1 – red dot 2 – all change ideas together Lead facilitator Using our driver diagram as a framework for generating change ideas. 1. Remind of aims and drivers. 2. Red circle comes up. Elicit some change ideas – brainstorm from drivers – one driver at a time (not all of them) 3. Then show Change Ideas column Depending what cropped up in previous modules with driver diagram, talk about the iterative process – may start anywhere. It may even be that you start with a change idea. But rather than doing that without thinking through if that’s the best change idea to try, use it to build the driver diagram backwards, then generate more change ideas. Then work out which to start with – it may not be the one you thought of first. Even if it is that one, now you will be able to provide a rationale (we’ll be looking at prioritising shortly in the next module).

Organising theories for improvement
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 Secondary Drivers Change ideas The changes or proposed interventions that can be tested out to achieve the secondary drivers We looked at this in the driver diagrams session – this is just to reiterate that change ideas are part of our theory.

Project work: change ideas
? Use the ‘driver diagram’ approach to generate some change ideas. Project Aim Each participant to end with a driver diagram + change ideas Timing 30 mins Materials Driver diagram (aim, primary and secondary drivers) created by participants previously Post it notes Blank Aims Drivers Change Ideas Measures Work on individual driver diagrams + change ideas with post its. This may involve a review of drivers. Binning ideas is part of the process – but you may like to hold on to all your notes as they may come in useful later. Facilitators Monitor and support as needed. This may mean spending up to 10 minutes with individuals. Plenary debrief: Remind of importance of involving a range of stakeholders, getting different perspectives and buy-in: Who will you need to involve? What action from you will this require? ?

Brainstorming frameworks: summary
Brainstorming principles and logistics Frameworks Forcefield analysis Human Factors and Ergonomics Driver diagram Aim To briefly recap the session content: - to support a sense of learning and accomplishment - to aid memory of the session later An opportunity for participants to ask any outstanding questions from any part of the session. Timing 1 – 5 minutes, depending on time available Lead Facilitator Elicit some key messages from the session eg: What are some of the key principles of brainstorming? Why use these frameworks rather than a blank sheet of paper? When might Forcefield analysis be a particularly useful framework? (when you want to take into account potential resistance to change) In which part of the System of Profound Knowledge does Human Factors and Ergonomics mainly sit? (Appreciation of a System) What is the aim of Human Factors and Ergonomics? (to optimise individual well being and overall system performance) What does a Human Factors approach stop us doing (seeking to apportion blame before investigating systems) If you already have some change ideas, should you still create a driver diagram (yes, once you’ve thought through your Aim and Drivers, you may come up with other change ideas that will also be useful to test.) When will you laminate your driver diagram? (never)

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. Before starting this session, put up change ideas for the other case studies on the wall. Eg returning from the break, one facilitator at each of the remaining case studies give each participant a card to put on the wall, and facilitate as required. Lead facilitator read out or ask participants to read.

A project charter sets out your understanding of your project and its context, through the lens of all four components of Profound Knowledge Deming 2000

Prioritisation Impact/difficulty matrix Pareto chart Aim
For participants to use a tool to prioritise change ideas in their own project, and think about how they’ll do this back at work. Key messages Different requirements of each, including: Matrix – involve other people/ people issues Pareto – what data do you have/might be useful? Use not only for prioritisation but also as another diagnostic tool Lead facilitator We have lots of ideas for change, but how do we decide where to start? Still working on Question 3 of Model for Improvement, and developing our theory of change. We now need to apply appropriate techniques to prioritise our ideas. Some of the tools we’ve already looked at for generating ideas will also help us to prioritise eg Forcefield analysis, service user feedback. These are the 2 tools we’re going to look at now.

Prioritisation Impact/difficulty matrix Pareto chart
Starting with the matrix. It’s subjective, but that doesn’t mean it isn’t useful. It means it’s important to work through it with other people who may bring different perspectives on the issue.

Matrix: impact vs difficulty
High Low Easy Hard Difficulty DISCOVERY Aim Participants to be able to use a Difficulty/Impact matrix to prioritise drivers and/or change ideas in their own project, working with appropriate stakeholders. Key messages There are many possible 2x2 matrices to help prioritise. We can use them with drivers or change ideas (one or the other, don’t mix them) Timing 5 minutes to work through the example and principles Lead facilitator Highlight the two dimensions on the matrix: Dimensions: difficulty, impact Each divided in two: easy/hard, low/high

Driver diagram Aim 1 Driver 2 Driver Change ideas
A new healthier me! Lose 7 pounds by end July 2015 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 Use stairs not lift Walk to a daily step target Swim at least twice a week Calories in Calories out Key message Different perspectives – even just comparing views with one other person. Lead facilitator Looking at an example using the New Healthier Me scenario. We need to decide which change idea to start with. In pairs, discuss briefly, if this was you, which of these change ideas would be easiest and hardest for you, and how much impact do you think those two ideas would have? Very brief plenary debrief: elicit a couple of examples, and ‘what surprised you, in that discussion?’

New, healthier me! Impact High Low Easy Hard Difficulty
Easy Hard Difficulty Cook from scratch Lead facilitator Looking now at one person’s application of the matrix: Cook evening meal from scratch Don’t know how much this would help – don’t want to be counting every calorie and how to compare? Hard, and possibly not helpful.

Easy Hard Difficulty Reduce portion size Cook from scratch Reduce portion size If did it regularly, would have big impact, but difficult. Particularly when eating pre-prepared food – don’t want to throw stuff away.

Easy Hard Difficulty Reduce portion size Keep to shopping list Cook from scratch Easier, though it seems a shame to miss out on all those offers

Easy Hard Difficulty Reduce portion size Keep to shopping list Cook from scratch Replace biscuits with fruit Relatively easy (if don’t buy biscuits), but low impact. I don’t eat a huge number of biscuits anyway.

Easy Hard Difficulty Reduce portion size No alcohol Mon – Thurs Keep to shopping list Cook from scratch 1 soft drink / day Replace biscuits with fruit Soft drink – how many calories in a soft drink? Alcohol – recent research found that many people don’t include alcohol in their calorie counts – don’t realise how high in calories many alcoholic drinks are, so high impact. These examples help to highlight the need for an evidence base relating to impact. Although difficulty is subjective, in this scenario for impact you need to know something about calories – both taken in and used during different activities.

Easy Hard Difficulty Reduce portion size Swim twice / week No alcohol Mon – Thurs Keep to shopping list Cook from scratch 1 soft drink / day Replace biscuits with fruit Swim

Easy Hard Difficulty Reduce portion size Swim twice / week No alcohol Mon – Thurs Keep to shopping list Cook from scratch 1 soft drink / day Increase steps Replace biscuits with fruit Increase steps

Easy Hard Difficulty Reduce portion size Swim twice / week No alcohol Mon – Thurs Keep to shopping list Cook from scratch 1 soft drink / day Increase steps Replace biscuits with fruit Use stairs at work. As you can see as we’ve been building this up, ‘difficulty’ is quite subjective. For this particular case, only one individual is involved, but for a work project there will be more. Important to involve people – this will also help you to learn about how people feel about the change project you’re working on. And it’ll help you to diagnose what support different people will need as you work through the change. ‘impact’ should not be subjective – you can refer to the evidence eg here calories in or out associated with each idea. Elicit: Which quadrant contains the change ideas or drivers that you would probably test first? Easy and high impact – go to next slide AFTER eliciting a response Use stairs at work

Matrix: impact vs difficulty
High Low Easy Hard Difficulty Key messages The blue segment is the one that it makes most sense to prioritise. But there will be good reasons to work with change ideas in other segments too. This helps to consider change management issues eg motivation – and balance potential impact against motivation. So eg you may want to work on changes in the ‘easy/low’ segment for some quick wins and build motivation to work on changes that will be harder to achieve.

Prioritisation Impact/difficulty matrix Pareto chart
We’ve looked at the matrix. Now moving on to look at how a Pareto chart can help us. In contrast with the matrix, this is an objective tool, but it doesn’t take into account how people respond to change. We need to collect data, and then create a chart to help us to analyse the data. Once we’ve got the data, because this is an objective tool we can create the chart without other people, then use the chart to influence others.

80:20 What is a Pareto chart? Aim
To introduce the principles and use of Pareto charts in small bites with lots of examples. Many people find it tricky, so break up the different elements of the chart. Key messages What kind of change idea you can use it with – what data you need. Creating and analysing the chart isn’t difficult – we analyse a few here, and provide step by step guidance for creating a chart in your folders. The hardest part is getting hold of the data you need in the first place, and that may affect whether you choose to use this tool. Timing 10 minutes to work through the example slides Material 1 long ruler Lead facilitator The Pareto chart is a particular type of bar chart. It is an illustration of the 80/20 rule. Vilfredo Pareto was an Italian economist working in the early 20th century. He noted that 80% of the income at that time in Italy went to only 20% of the population. Joseph Juran, a management theorist, adapted this thinking and popularised the notion (the Pareto Principle) that much could be achieved by focusing on the 20% of circumstances in which 80% of problems occur. So, we want to focus our improvement efforts on the circumstances in which 80% of the problems occur. The Pareto chart helps us with that. (the chart here is tilted because it isn’t here for analysis, just as a brief indication of what a Pareto chart looks like) Source of this image:

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 to Use a Pareto Chart When analysing data about the frequency of problems or causes in a process. When there are many problems or causes and you want to focus on the most significant. When analysing broad causes by looking at their specific components. When communicating with others about your data you can show people the data behind selection of your change idea.

Access to primary care Before showing the Pareto chart – this is about deciding what we might use a Pareto chart for. Looking at this driver diagram, how might a Pareto chart be useful? What data might you want to analyse? Elicit a few ideas then show the next slide

Primary care practice X: reasons given by patients for not attending
This bar chart is looking at data relating to ‘Did Not Attends’. Imagine you’ve collected data from patients on the reason why they missed an appointment. On the horizontal axis we have different reasons. (read across some of the categories here) On the vertical axis we have the number of patients giving each of those reasons. For a Pareto chart, the first thing we have to do is sort the categories so that they are in order from biggest to smallest. That has already been done here.

Number % cumulative % Unable to contact to cancel 35 24% Forgot 26 18% 43% Unaware of appointment 23 16% 59% Confusion about appointment time 19 13% 72% Inconvenient day 12 8% 80% Other 9 6% 87% Unwell 6 4% 91% Inconvenient time 4 3% 94% No value in appointment 97% Working 3 2% 99% No transport 1 1% Unable to afford time off work 100% Total 143 Then we need to switch from thinking about the number of times each reason was given to thinking about the percentage each reason contributes to the whole. Percentage column: Adding all the percentages together has to add up to ? Elicit: 100% Cumulative percentage column: It adds up the percentage that each category of reason contributes to the total. Talk through the first few examples of adding together the first two, etc. Once you’ve added them all, you get the total of 100% NB some of the calculations don’t seem quite right here because they are rounded to whole numbers.

We create a second chart, that shows us the cumulative percentage. Then, we put the two charts together (next slide)

This is the Pareto chart. We want to focus our improvement efforts on the causes of 80% of the effects Use a long ruler to slide up from 0% to 80% - depending on the size of the screen, it may be best to have another facilitator with a second ruler, to make it long enough to reach the blue line. Elicit: Which of these reasons would you address changes at? (the first four) NB if someone asks about red/dotted lines at 80% (which are sometimes used but not here)- they can be used but are not part of the chart – just something we might add in to make clear how we’re reading across from 80% 2. What action might you take from here? (eg move on to a matrix and consider difficulty) This example demonstrates how a Pareto chart might not only help to prioritise but actually identify change ideas (ie generate change ideas and prioritise at the same time).

Central Hospital Ward F: Percentage of meals returned, by meal type (2013)
PRACTICE Here’s a different context. A ward looking at reducing waste from meals returned uneaten. Elicit: Which meal types should change efforts target? Use ruler against slide to check. (Red meat, Poultry) Elicit: what would you do next? Eg find out why people are returning Red meat and Poultry more than the other meals Speculate eg it could be that Red meat and Poultry are used as default when for some reason a patient does not choose their own meal, whereas Vegetarian will be a positive choice so is more likely to be eaten. Or, could it be to do with the quality if cooking? Or, it could be that the measure is not useful, or not clear enough – would it be more useful to know ‘meals returned as a % of that meal type’? What would you next? Find out more – what, how, why?

Ward X: Adverse drug events - causes
Another example Which causes of adverse drug events should be targetted? Use ruler on slide to check. The first four, and possibly including ‘extra dose given’ Action? NB is this the correct measure? Would it also be helpful to look at data about the severity of the adverse drug events?

Hospital X: SAB cases by ward (SAB = Staphylococcus aureus bacteraemia)
Another example Optional – if time and if participants seem to need or want another one. This is a useful example to demonstrate the importance of considering local context, and not ‘sheep dipping’ the same solutions everywhere - it may not be best use of resources to require Wards 3, 5 and 4 to work on improving in this area. On the other hand, it may be that you could investigate processes and structures in these wards as examples of good practice, and consider whether these may be worth trying in the wards with higher incidence.

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 When to Use a Pareto Chart – briefly recap earlier slide When analysing data about the frequency of problems or causes in a process. When there are many problems or causes and you want to focus on the most significant. When analysing broad causes by looking at their specific components. When communicating with others about your data you can show people the data behind selection of your change idea. Pareto Chart Procedure (in addition) Decide what categories you will use to group items. Decide what measure is appropriate. Decide what period of time the Pareto chart will cover: One work cycle? One full day? A week? Collect the data, recording the category each time. (Or assemble data that already exists.) Elicit in plenary 1-2 examples of when participants have used Pareto charts – what for, how did it help, any particular challenges/issues?

Pareto chart examples For this project, what data could a Pareto chart be used with? Which driver(s) or change idea(s) is this Pareto chart related to? Which categories would you focus your improvement efforts on? What action would you take based on this chart? PRACTICE Timing 15 mins Materials One A3 Pareto chart and one ruler for each case study Divide into 4 groups, each with a facilitator. Each go to one case study (driver diagram + change ideas on the wall). Facilitators One facilitator go to each case study and facilitate the discussion. Discuss Q1. When Lead facilitator clicks onto the rest of the questions: All facilitators hold up the chart prepared earlier. Discuss Qs 2, 3, 4. The ruler is to help with Q3. Suggested issues to consider in each group: Portering productivity: Find out which departments contribute most of the ‘not ready for transport’ and ‘equipment needed’ and focus efforts on them. ICU Length of Stay: Large number of components of bundle mean that there are more processes within the 80%, so this Pareto chart doesn’t narrow options down as much as for the other examples. It might be helpful then to use the next technique – matrix – just with the categories that are within the 80% Staff incidents – NB the cumulative % has a decimal point because the data included decimal points. Out of hours Asthma – As with the ICU example, when working with a care bundle, this demonstrates the importance of having data for, and understanding compliance with each component of the bundle.

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. PROJECT Timing 15 mins Material 2x2 matrix template Small sticky notes Lead facilitator Instructions: To consider re Pareto chart: How could you get data? Ie: Does it already exist? Who owns it? How could you or a project team colleague get hold of it? If not, how could you collect it? For the purposes of this workshop, use the Impact vs Difficulty matrix to identify the change idea that you will continue to work with (on subsequent modules or in the workplace) over the next few days. You may prefer to use the sticky notes, so that you can adjust later. Plenary debrief: Brief discussion of issues arising re use of both these tools to projects. And we’re giving you guidance on how to create a Pareto chart on Excel.

Prioritisation: summary
Impact/difficulty matrix Pareto chart Aim To briefly recap the session content: - to support a sense of learning and accomplishment - to aid memory of the session later An opportunity for participants to ask any outstanding questions from any part of the session. Timing 1 – 5 minutes Lead Facilitator Elicit key messages eg: Which tool is more objective? (Pareto chart) In a matrix, which options will you prioritise (high impact, low difficulty) Who will you work with? For a Pareto chart, what’s the minimum amount of data you need (30 observations total over all items)

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. Learning outcomes: Read out, or ask participants to read. This is a brief introductory overview, with much more on measurement in future modules.

Understanding variation Elicit/recap what this is about: identifying random vs non-random variation, and understanding the cause of any non-random variation. Deming 2000

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? In the Model for Improvement, we are now looking at this question.

Measurement: why? Safe Effective Person- centred
To make improvement visible To plan To monitor progress To tell an improvement story To use a shared language. Safe Effective Person- centred DISCOVERY Aim Participants to be able to describe why we need data to support improvement work. Key messages We measure so that we can know whether a change we have introduced into our system is an improvement. Measurement is not an end in itself – we should spend as little time as possible dealing with measurement, but enough time to get the information Timing 10 mins Lead facilitator On heading only: Lead facilitator briefly outline their personal improvement project, focussing on the variation features. If this is the same Lead Facilitator who introduced Variation in the module Improvement Principles, it will just need a minute, if a different facilitator and example, then it may need more than this. This is just as an example before participants look at their own: Get out your Profound Knowledge notes. In pairs, find out what your partner measures out of work, and why. Eg do they run, are they learning a language or some other skill, or supporting a child to get better grades? Does anything strike you as particularly useful, not useful, or do you have any suggestions about other measures they may like to use? 2-3 mins. Longer will be required if participants did not attend Improvement Principles, or if it was a long time earlier. In plenary invite participants to share some of their examples, and discuss why we measure. Click (brings up bullets): now thinking about healthcare: Compare with and build on what participants said. What does ‘better’ look like? We need to know at all stages. So we can plan for it, and so we will recognise it when it happens. “Measurement as a language helps translate complex and often nebulous concepts into a more precise form” (Kaplan & Norton The Balanced Scorecard) Click (brings up box) Above all we must not forget that our aim is improvement, not measurement. We are measuring in order to make healthcare more safe, effective and person centred. Measurement is not an aim in itself, so we should always look for ways to use measurement that will minimise the time we take away from other elements of our day to day work, including other aspects of improvement, and delivering patient care.

What is measurement for improvement?
Accountability Research Purpose New knowledge Understanding of process Evaluation of change Comparison Reassurance Hypothesis Flexible – hypothesis changes as learning takes place No hypothesis Fixed 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 current Long and past Confiden-tiality Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected Timing 5 mins Lead Facilitator Talk through the slide – focus mainly on the Improvement column, using the others for brief comparison and to help respond to any queries. Accountability refers to what many people typically refer to as ‘audit’ (but the literature often uses the term ‘accountability’, which is why we use it here) Key messages (in bold) The aim of measurement for improvement is to improve healthcare systems, processes and outcomes, in the local healthcare context Collect data to test if a change is an improvement Also: to help get useful ideas for improvement And: to find out if an improvement has been maintained In improvement projects we do not work with a fixed hypothesis; data helps us to adjust a hypothesis as we work towards improvement We try to develop measures from data that is already available, or easy to obtain. That way data collection can easily be integrated into the daily work routine, and if we find that the change is an improvement, it is easier to embed in the culture. Usually people collect data for improvement projects within the healthcare department or organisation where they work. You need to see variation in data over time to know if a change is an improvement. Link the improvement to ‘the way we do things around here’, so it becomes part of the culture. Make it EASIER TO DO THE RIGHT THING Things we do NOT do: Data for measurement is NOT used to evaluate performance If bias exists in the process that we are measuring, we assume it is there all the time. We aim to design data collection so that any biases are stable. You can observe the impact of a change while testing. When we measure for improvement, we assume that any biases are stable. The small scale of each test of change reduces risk as each test is based on learning from the previous one. Many people are persuaded by data – each small test of change generates data that can be used to persuade more people to get involved. Key is not just what you measure but HOW you use that data.... Measurement for improvement requires a fundamental cultural shift from ‘sort it’ to ‘how can we help’.

Access to primary care We’re going to look at some different measures relating to this scenario.

Three types of measure Outcome
Tells a team whether the changes it is making are helping to achieve the stated aim The aim in structuring and sequencing the slides this way is to introduce each of the three types of measure separately – not to introduce them all at once. So, at this stage don’t refer to Process or Balancing measures. The next slide is designed to raise the need for the other measures before introducing them. Timing 10 mins max for this series of 4 slides Lead facilitator Outcome measure This is the voice of the patient or other service user. This measure is essential to justify the resources being put into a project. Almost all improvement projects should include one or more outcome measures.

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 Lead facilitator Imagine that for the last 3 months you’ve been doing work to achieve this aim. Elicit: What measure do you think you might use? [eg % of patients offered an appointment within 24 hours] You’ve been collecting data for this measure, and it’s showing no improvements at all. Why do you think this might be? Groups discuss for 2 mins. Plenary debrief should include: There hasn’t been enough time yet to see an impact on outcomes Our theory is wrong – we haven’t made the right change that will enable us to accomplish this The changes that we have made might be the right changes, but we haven’t applied them in a reliable way.

Three types of measure Outcome Process
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 What we need is process measures, as well as outcome measures. Process This is the voice of the system. It addresses how key parts of the system are performing. It should be logically connected to achieving the outcome(s), and directly related to changes you are making in your system. Process measures generally show improvement before the outcome measure does. They provide an earlier indication of whether a change is an improvement. Process measures are the only way to tell if failure to achieve improvements in our outcome is due to the wrong theory, (or not reliably applying the change.) Often compliance with a process is key to achieving the desired outcome, so process measures help us to identify whether changes in a process help to make it easier for people to do the right thing. Process measures should be simple to collect. Elicit a couple of examples of process measures for the Access to Primary Care scenario. Material It may be helpful here to provide some copies of the Access to Primary Care driver diagram for participants to refer to while thinking about this question.

Three types of measure Outcome Process Balancing
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 Lead facilitator All improvement is change, but not all change is improvement. Ie we need to know whether our change, which may seem to be an improvement, has resulted in any negative effects anywhere else in the system. NB the interdependence of elements of a system. Balancing A change is not an improvement if it has a negative effect elsewhere in the system. Balancing measures help us to detect unintended consequences. They look at the system from a different perspective. Sometimes they help to identify other factors that may explain an improvement. When planning a test of change, it is helpful to try to anticipate one or two balancing measures; others may emerge once the test of change is under way. An unintended consequence may be negative or positive. Involving people from all parts of your system will help you identify potential negative balancing measures before doing, and actual ones once project under way. Elicit a couple of examples for the Access to primary care scenario. eg if systems become more automated, might this favour particular tech-savvy patients?

A New Healthier Me Aim A new healthier me!
Time taken to prepare meals Cost of Mon-Thurs meals 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 Drivers Secondary 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 Use stairs not lift Walk to a daily step target Swim at least twice a week Change ideas Family perception of new lifestyle Number of items bought not on shopping list Daily Calorie intake Fruit replaces cake/week Days between cakes Key messages: You have to work out what is the most suitable measure for your project – usually there is more than one possibility. We’ll look at that in more detail in future modules. You will normally have one (maybe 2) outcome measures, several process measures, and one or two balancing measures. Don’t become a data factory – only use the measures and collect the data that you really need. The measures you choose will also depend on whether you have the tools/resources needed for that particular measure. (If operational definitions crop up, cover briefly – planning to do this in detail in another module Timing A New Healthier Me – 5 mins ICU measures – 10 mins Lead facilitator Examples of different measures: One category at a time, elicit some possible measures, then show the examples and discuss. Click 1 – outcome measures Click 2 – process measures Click 3 – balancing measures (top left hand of slide) If participants hadn’t had many ideas before you showed them the examples at each click, elicit more examples before moving on. Participants may query the different outcome measures – eg why have measures that are different from the aim? Point out that while at the ‘thinking’ stage (the three questions in Model for Improvement), we might adjust our aim based on our thinking about measurement. The Three Questions are iterative, so this may lead to other changes in the driver diagram too. Eg our scales may be unreliable or broken, so we decide to use a different measure. PRACTICE Material ICU types of measure ICU types of measure KEY Categorise each measure as O, B, or P Do the first one as an example in plenary. Elicit answers and discuss if more than one answer given. Participants do the rest individually, then compare answers in pairs. Facilitators Light touch monitoring – intervene if people are struggling. Plenary debrief. The measures are numbered, so it isn’t necessary to read out the whole measure. Weight BMI Body Fat Waist Size Jeans fit Flights of stairs climbed/day Calories Burned/day

Create measures: Staff Wellbeing
1 outcome measure 3 process measures 1 balancing measure Aim To start thinking about how to define a measure. Timing 10 – 15 mins Material Measures Staff Wellbeing Lead facilitator Do the outcome measure in plenary. Process measures: If five groups/tables of participants, assign one Secondary Driver (and its associated change ideas) to each table, or similar. Work together to create 3 process measures (these could include more than one measure for the same change idea), and one balancing measure. Facilitators Monitor and support as required. Optional Materials Wall cards – Staff Wellbeing measures If time, or for early finishing groups – an initial ‘debrief’ to guide their learning, Facilitators distribute cards for walls, matched to the tables working on those processes. They compare with their own, then put the cards on wall next to the relevant process. Balancing measures to side or below. Debrief (this could be plenary or if enough facilitators, each work with one table to debrief) – based on issues arising. Eg reinforce that it’s ok if their measures were different from the ones on cards, so long as they can justify (more detail on this in later module(s).

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 PROJECT Aim Participants to begin drafting their own measures so that when they work on measurement planning in more detail, including operational definitions, they aren’t starting from a blank sheet of paper. Timing 5 – 10 mins Lead facilitator These are just to be rough outlines – you will work on these again in a future module. Facilitators monitor and support as required. If time very short, participants could do this after the session and before the Planning Measurement module.

Introduction to measurement: Summary
Aim To briefly recap the session content: - to support a sense of learning and accomplishment - to aid memory of the session later An opportunity for participants to ask any outstanding questions from any part of the session. Timing 1 – 5 minutes, depending on time available Lead Facilitator Elicit what content was covered eg: Why is measurement in an improvement project? [to know whether a change is an improvement] What’s the measure called that relates to our aim? [outcome] What’s the measure called that relates to our change ideas? [process] Why do we need balancing measures? [to check whether our change is having an impact on other parts of our system]

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) Lead facilitator will read through the learning outcome or ask the participants to read

Model for Improvement The Improvement Guide Langley J et al 2009
Key message In terms of the Model for Improvement, we are now moving away from the ‘thinking’ part of the Model for Improvement on to the ‘doing’ part of Model for Improvement – the PDSA cycle Timing 1 minute Lead facilitator Remind everyone where THE PDSA cycle fits with Model for Improvement The Improvement Guide Langley J et al 2009

Key messages In terms of the SoPK, the PDSA cycle involves consideration of all components of the System of Profound Knowledge: You are testing your theory of knowledge You need to consider how to engage people in your test You collect and analyse data, taking into account your understanding of your system. Timing (intro slides) 2 minutes Lead facilitator The PDSA cycle involves all components of the System of Profound Knowledge Deming 2000

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? DISCOVERY Aim Participants to be able to describe the key components and structure of the PDSA approach. Timing minutes for the three slides using the ‘New Healthier me’ example of a PDSA cycle Key messages: State the aim for the overall project, and specific aim for this test based on the change idea that you are testing. Have a clear link from your project aim, through change idea to test of change Be clear about what questions you want to answer. Material PDSA template (one copy here to make notes on) Lead facilitator We are going to use the ‘New Healthier Me’ example, where Vanessa wants to lose 7lbs to look at how we use the PDSA framework. We are using a standard template to plan and record the different stages of this PDSA framework, and that is what we will see on the next three slides Lead facilitator talk through this slide and the following 2 slides, as Vanessa’s story, to demonstrate how the different components of the PDSA framework work.

Plan Person responsible When to be done Where to be done
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 Key messages What do you predict will happen when you carry out this test – your theory? How will you know if your prediction succeeds – importance of measures. Importance of prediction to learn from your tests and build knowledge Note that numbering predictions is threaded throughout the rest of the pdsa template Note that a change may mean needing to stop doing something usually done as well as start doing something different You need to plan your test- what tasks are required, when, where and by whom? Lead facilitator Lead facilitator talks through this slide

Describe what happened when you ran the test.
Do Describe 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. Key messages Do - What happened when you ran the test? This should include anything relevant, including things you may not have included in your plan. Study – what were the results of your test and how did they compare with your predictions? Act – Based on what you have learned from this test what will you do next time? Lead facilitator talk through this slide

Scale and sequence of tests
On Mon & Weds, eat apples for snacks. Lose 10lb in three months. On Mon, Tues, Weds & Thurs, eat apples for snacks. Tomorrow, eat an apple instead of biscuits. Within one month replace all biscuit snacks with apples. Aim Participants apply ‘how good, by when?’ aims to their project at different levels. Participants start tests of change at an appropriate scale, and scale up appropriately. Key messages Start with small scale tests e.g test one time, with one patient Gradually increase the scale of your tests as you learn from previous tests. NB You learn something from every test. If a test ‘fails’, your scale may go down for the next cycle. Timing 5 minutes Lead facilitator We are still looking at Vanessa’s weight and health project, a New Healthier Me. Elicit: On this list, which of these is a test of change? Answers - a, c, d Elicit: What are the other items on the list? Answers: b – project aim e – this is an example of an aim that is somewhere between a project aim and an aim for a test of change. It’s sometimes called a ‘process aim’ – it refers to one particular change idea (process). Elicit: Which of the three tests of change would you expect to do first, second, third and why? 1 – d 2 – a 3 – c

Prediction Aim Participants don’t plan PDSA cycles in isolation, but have some idea of what they will test next, depending on the outcome of the current cycle. Key messages It can be tempting to Plan – Do – Plan – Do and omit the Study and Act elements of the cycle Have a rough idea of where you are going with testing and be prepared to change if current tests do not go to plan Predict in detail one step at a time to support learning and don’t predict further until you have some data to analyse and are starting to plan the next test of change. Many tests of change fail and you can learn a lot from this. Timing 5 minutes Lead Facilitator Talk through the slide to illustrate different results that may arise following initial tests and what different options for next steps could be be depending on results of these tests

PDSA Simulation Aim: In the fastest possible time, pass the ball to each person in the group. DISCOVERY Aim Participants experience rapid cycle testing Key messages Aim of simulation is: In the fastest possible time, pass the ball to each person in the group. Practical steps in simulation Key messages for the simulation/whole module activity, are as on the Simulation: key points slide. Timing 10 minutes to set up the activiity Materials: 1 tennis ball per group. Timer per group. (Group facilitator) Pen and pad to record times. (Group facilitator) Name tags if participants are unknown to each other. Space to spread out. Lead Facilitator This exercise is intended to work with groups of (not counting the facilitator). Find out if any participants have done this activity before. If they have, they could either take on all or part of the group facilitator’s role (recording discussion and data), or they could become a general observer – go from group to group finding out what is being done at each. Divide participants into groups, each with a facilitator, in a given space. Support facilitator The support facilitator should arrange the group into a wide circle before outlining the rules of the exercise. Avoid suggesting the circle layout is a requirement (it’s not), just arrange them into a wide circle. Put the aim of the exercise to the group. (They should already be in a wide circle at this point) “In the fastest possible time pass the ball to each person in the group”. You have to achieve this by:-must be thrown diagonally away from the starting point to another person in the group. One person becoming the starting point The starting point must call out the intended recipient’s name (the catcher), as they throw the ball. This works best if the group facilitator demonstrates the first throw as part of the group, to seed the idea. The catcher must receive the ball and select another person to throw it toward, calling out the next recipient’s name, and so on…..until all members of the group have received and sent the ball once. The timer starts when the ball is first thrown, and stops when the starting point catches the ball again. Your final completion time will then be recorded. Then move on to the next slide - The Rules. On completion of the first round either ask them to attempt it again to improve the time (preferred) or ask that they discuss how they can improve the completion time. If the group struggles to improve remind them of the rules, ask how the rules restrict improvement.

The Rules The ball must be thrown diagonally. You may not throw the ball to the person next to you. You must call out the name of the person you are throwing it to. Each person must receive the ball once. If someone drops the ball you must start again from the beginning. The timer will not be stopped. If you restart the process, the ball must follow the same order of passing as the previous attempt. The last person to receive the ball must be the starter. This is when the process and timer will stop. If you break any of these rules you must start again. The timer will not be stopped. Lead facilitator Move the slides on Support facilitators (in group) Talk through the rules, and respond to any questions.

What we will do next time
Record keeping Test Aim 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 Aim Participants work through all four stages of the PDSA cycle, not just PDPDPDPD Key messages Require a theory to achieve objective Make prediction about the result Actual time to be recorded Learning to be recorded and inform actions next time Support facilitators (in groups) Explain the different columns, and that they will be recording what is discussed, and data collected, in the group. Ask the group to start the first cycle. Step back to let the group get on with their planning. Intervene to ensure that they follow the rules (and make sure that the group doesn’t find the best solution in the first round). On completion of each round either ask them to attempt it again to improve the time (preferred) or ask that they discuss how they can improve the completion time. If the group struggles to improve remind them of the rules, ask how the rules restrict improvement. Timing 15 minutes for all groups to go through about 5 cycles Lead facilitator Monitor the room and let the support facilitators know when they should wind up the activity.

PDSA Simulation Aim: In the fastest possible time, pass the ball to each person in the group. Key messages As below and on next slide Timing 10 minutes for debrief, including next slide Lead facilitator Bring up this slide as a backdrop for the plenary debrief. Ask groups for their fastest time. Ask the group that had the fastest time what their theory was. This is an example of best practice. Also note that sometimes best practice teams show signs of competition and are resistant to sharing. If groups stayed in a circle, there may be an assumption that is a rule and they are anchoring that as a false requirement. o Note the energy level and engagement as team members are all involved in planning, testing, and results review. o Note that each test may provide various ideas for testing and each one can be tested to learn. Including when two team members have different change ideas. o Note how a change may improve one measure but not another. Importance of having a family of measures including process and balancing. (eg dropping the ball could be considered to be a balancing measure). o Enquire why participants were not visiting other teams to learn from them and bring the learning back to their team. Highlight this is the key value of a collaborative learning and a common missed opportunity . Ask support facilitators to share their observations.

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. Lead Facilitator Deming points out that without theory and prediction it is difficult to create profound learning. In addition, measurement supports our learning and helps us understand variation and the impact of our changes. • Knowledge is gained through testing (not through planning or brainstorming). • Tests should be small, rapid, and sequential. • Theory and prediction preceding every test Review following the test is essential – having data is not enough – you must analyse it • Learning from other teams can accelerate learning and understanding. • Measurement does not have to be hard, and aids learning.

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 Aim Opportunity to recap key points from all PDSA content. To briefly recap the session content to support a sense of learning and accomplishment and to aid recall following the session Provide the opportunity for participants to ask any outstanding questions Timing 1- 5 minutes depending on questions asked Lead Facilitator Elicit the content covered in each of the bullet points, for example: How is PDSA associated with the Model for Improvement? What does abbreviation PDSA stand for? Why is prediction important? What elements of the PDSA cycle is it easy to omit? What can you tell me about the scale of first tests?

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 This is what we’ve looked at today. Overnight task (create in the morning as you get up?) Process map – hand-draw or use small post its – your morning routine from waking up to leaving the house. You will be looking at it with others at your table. And: Overnight task if not done earlier: create OPB measures for own project (see earlier slide).

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 e.pdf Systems thinking ety:_Ten_Principles/Presentation Enhanced Significant Event Analysis

References and further resources
Pareto chart

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