1. Scottish Improvement Skills
Workshop 2
Scottish Improvement Skills Full Programme Workshop 2 Participant slides

2. Housekeeping

3. Workshop 1
By the end of the workshop, you will have planned a first test of change to carry out in the workplace, taking into account the work context and priorities for improvement, and the needs of stakeholders.

4. Project work By the time your return for Workshop 2, you will have:
reviewed the Three Questions with your team
collected data to help you identify your priority for change
collected baseline data
carried out several tests of change
collected qualitative and quantitative data

5. Find someone who ...

6. Workshop 2
By the end of the workshop, you will have created run charts with your own project data, and practised talking about your data with your team or other stakeholders.

7. Workshop 2 Content Interpretation of run charts
Creating run charts on MSExcel
An improvement journey: from testing to implementation
Talking about data in run charts

8. Improvement principles
By the end of this session you will be able to:
apply Deming’s System of Profound Knowledge to help you understand the complexity in your improvement project.

9. System of Profound Knowledge
Deming 2000

10. Aim: promote staff wellbeing
Aim  Driver  Driver Change ideas
Staff complete safety climate survey
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
Action planning from survey
Lean visual management of cupboards, notice boards etc
A workplace that is safe for staff
Activity
Use and location of hand gel dispensers
Staff able to focus as required
Schedule regular team huddles
Leadership training for team leads
People
Staff engaged in health and wellbeing practices
Offer Bereavement support programme for managers

11. System of Profound Knowledge
Deming 2000

12. System of Profound Knowledge
Which of the 4 components are you finding most challenging in your project right now? Is this reflected in what you’ve included, or in there being gaps?
What would you advise the project team to work on?

13. System of Profound Knowledge
Deming 2000

14. Analysing data: interpretation of run charts
By the end of this session you will be able to:
Explain the importance of using annotation to help interpret run charts
Discuss how the type of median used affects interpretation of signals from run charts and impacts on decision making
Explain use of phasing, stratification, and what to do with extreme values on run charts.

15. Analysing data: Interpretation of run charts
Annotation
Median
Phasing
Extreme values
Stratification

16. Aim: promote staff wellbeing
Aim  Driver  Driver Change ideas
Offer Bereavement support programme for managers
Promote the physical, mental and emotional wellbeing of staff. Within 12 months (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month.
A workplace that is safe for staff
Flyer on staff health and wellbeing programmes
Staff education
Hold staff health fairs
Smoking cessation campaign
Staff engaged in health and wellbeing practices
Set up walking groups
Healthy lifestyle programmes for staff
Improve staff diet at work
Offer lunchtime yoga
Enable cycling to/from work

17. Annotation Hours lost through sickness absence
Median 5.2
Fit Note introduced
Goal

18. Median (1) Women walking 10,000 steps
Baseline median Extended median
Pedometers issued
Challenge announced

19. Median (2) Women walking 10,000 steps
Signal detected here
Pedometers issued
Challenge announced

20. Median (1) Women walking 10,000 steps
Baseline median Extended median
Signal detected here
Pedometers issued
Challenge announced

21. Creating a baseline median
Use historical data if available
Collect new baseline data before introducing a change, if this makes sense in your context
If no baseline data is available, create a baseline median using the first 10 data points.

22. Phasing Women walking 10,000 steps
Pedometers issued
Challenge announced

23. Interpretation of run charts
Each run chart can be improved to make the data easier to interpret. Possible improvements may relate to:
Type of median line used
Measure used
For each chart, decide what improvements would be most useful, and why.
Annotation
Design

24. Extreme values Frequent events Rare events
More than half the data falls on the median line
More than half the data is at ‘extreme’ values eg 0 or 100 on percentage scale

25. Extreme values (1) Compliance with hand hygiene

26. Extreme values (2a): Number of needlestick incidents per month

27. Extreme values (2b): Number of patients seen between needlestick incidents

28. Stratification (1): Inpatient requests for MRI

29. Stratification (1): Inpatient requests for MRI

30. Stratification (1): Inpatient requests for MRI

31. Stratification (2) Staff walking 10,000 steps (men and women)
Median 35.25
Challenge announced
Pedometers issued

32. Stratification (2) Staff walking 10,000 steps (women)
Median 29
Pedometers issued
Challenge announced

33. Stratification (2) Staff walking 10,000 steps (men)
Median 41
Pedometers issued
Challenge announced

34. Interpretation of run charts
Each run chart can be improved to make the data easier to interpret. Possible improvements may relate to:
Type of median line used
Measure used
For each chart, decide what improvements would be most useful, and why.
Annotation
Design

35. Analysing data: Interpretation of run charts: summary
Annotation
Median
Phasing
Extreme values
Stratification

36. System of Profound Knowledge
Deming 2000

37. Visual display of data: using Excel to create run charts
By the end of this session you will be able to:
Create annotated run charts with baseline and extended medians using Excel
Create an annotated run chart showing phasing with Excel

38. A New Healthier Me Aim 1 Driver 2 Driver Change ideas
Lose 7 pounds in 3 months
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

39. Visual display of data Basic run chart
Run chart with baseline and extended median
Run chart with phasing
Run charts with your data
Annotations.

40. Leading change: from testing to implementation
By the end of this session you will be able to:
Describe typical stages in an improvement journey - testing, implementation and spread
Make decisions based on learning from PDSA cycles and data analysis
Demonstrate understanding of when to move from testing to implementation
Draft an implementation plan.

41. System of Profound Knowledge
Deming 2000

42. An improvement journey
A P S D
Identify opportunity for change
Plan
Test
Sustain the change
Implement
Hold the gains
Spread

43. Test cycles: Act on your learning
Abandon the change
Modify the change
Increase the scope of the change
Test the change under different conditions
Stop collecting data
Implement the change

44. Three criteria for implementation
High degree of belief that a change will result in improvement
Small cost of failure
The organisation is ready to make the change.

45. From testing to implementation
Cost of failure
Current commitment within the organisation
None
Some
Strong
Degree of belief that change idea will lead to improvement
Low
Large
Very small scale test
Small
Small scale test
High
Large scale test
Implement
Adapted from: The Improvement Guide p146

46. Sequential building of knowledge
A P S D
Implementation cycles
Learning and Improvement
Wide scale tests
Test new conditions
Follow up tests
Small scale test
Very small scale test
Develop a change

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

48. PDSA Ramps A P S D A P S D A P S D Education package RASS scoring tool
Develop content
Restructure content – 2 staff nurses
Test with 1 staff nurse
Revise wording – 1 nurse
Test with all staff
Education package
A P S D
Develop tool
Amend tool (colour) & test at 1 bed space
Test at 1 bed space
Test at 2 bed spaces
Amend tool (wording) & test at 1 bed space
RASS scoring tool
A P S D
Develop poster
Move poster so not obscured when doors opened
Display outside ward
Layout of poster more readable
Size poster to fit space
Poster for families

49. Building knowledge: your project
How could you increase your degree of belief?
What different conditions could you test your change under?
Which change ideas could you work on at the same time?
How could you minimise the cost of failure?
How could you better make your department/organisation ready for the change?

50. Components of Implementation
Standardisation eg policies, procedures
Documentation eg job descriptions
Training
Measurement
Resourcing eg equipment purchases

51. Aim: promote staff wellbeing
Aim  Driver  Driver Change ideas
Staff complete safety climate survey
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
Action planning from survey
Lean visual management of cupboards, notice boards etc
A workplace that is safe for staff
Activity
Use and location of hand gel dispensers
Staff able to focus as required
Schedule regular team huddles
Leadership training for team leads
People
Staff engaged in health and wellbeing practices
Offer Bereavement support programme for managers

52. Components of Implementation
Standardisation eg policies, procedures
Documentation eg job descriptions
Training
Measurement
Resourcing eg equipment purchases

53. Leading change: from testing to implementation: summary
An improvement journey
Criteria for implementation
PDSA ramps
Components of implementation

54. Communicating improvement stories: A framework for talking about data
By the end of this session you will be able to:
list key components of an effective improvement story
describe 4 steps in talking about data.

55. System of Profound Knowledge
Deming 2000

56. Communicating improvement stories
Stakeholder analysis
Planning communications
Talking about data
Writing reports
Sharing success

57. Communicating improvement stories: key stages
Why this project
Changes
Results
Lessons learned
Next steps

58. Talking about data: 4 steps
The 4 Ws
Horse and Cart
Dimensions
GEE

59. Step 1: The 4 Ws Where, Who, What, When
Median 41
Pedometers issued
Challenge announced

60. Step 2: Horse and Cart

61. Step 2: Horse and Cart

62. Step 2: Horse and Cart
Median 41
Pedometers issued
Challenge announced

63. Step 3: Dimensions Horizontal axis Vertical axis Data points
Median line

64. Step 3: Dimensions
Median 41
Pedometers issued
Challenge announced

65. Step 4: GEE Generalisation
Example
Exception
Summarise what the chart is saying Point out data that illustrates the generalisation Draw attention to any exceptions

66. Step 4: GEE
Median 41
Pedometers issued
Challenge announced

67. Talking about data: 4 steps
The 4 Ws
Horse and Cart
Dimensions
GEE

68. Talking about data: staff who smoke
Support group launched
Re-launch
Free fruit
Buddies

69. Communicating improvement stories: A framework for talking about data: summary
Key stages
Why this project
Changes
Results
Lessons learned
Next steps
4 Ws
Horse and cart
Dimensions
GEE

70. Communicating improvement stories: Talking about your data
By the end of this session you will have created and an improvement story based on your project data, and talked about it using the four-step framework.

71. Communications plan Stakeholders Purpose of communication
Key messages to be communicated
Timing of communication

72. Prepare to talk about your data
Paste your run chart into a Powerpoint slide, and annotate. Create 1 – 2 other slides if necessary.
Plan what you are going to say using the report structure:
Why this project
What changes you tested
Results
Lesson learned
Next steps

73. Talk about your data Small groups
Up to 4 minutes – start by telling your audience who they are
‘Audience’ will note some comments and questions
2 minutes for discussion

74. Feedback
What questions might you have as target audience? What do you like about the way the data is presented? Suggest one way this talk could be improved.

75. Commmunicating improvement stories: Talking about your data: summary
Prepare

76. Next steps Online evaluation Project charter
Action planning, including actions that demonstrate:
Working with your team on developing and testing changes
Use of run charts to display and analyse your project progress
Communications within and outwith the project team

77. And finally …
Workshop 3

78. References and further resources
VProvost Lloyd P & Murray S (2011)
The Health Care Data Guide: Learning from Data for Improvement
Jossey-Bass
Online learning module: Measurement for improvement: Presenting data