1. Scottish Improvement Skills
Leading change:
From testing to implementation

2. System of Profound Knowledge
Appreciation for a System
Understanding Variation
Theory of Knowledge
Psychology
In this module we need to consider all four components of Profound Knowledge:
Variation, because we need to interpret our data to help us decide whether we are ready to move on to the next stage of our improvement journey.
Psychology, because we’re talking about how we lead people through an improvement journey, from one project stage to another
Theory of Knowledge and Appreciation for a System because our progress depends on having a good understanding of our context and the features of our system.
All of them because we are continually working through PDSA cycles.
Deming 2000

3. 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.
Learning outcomes – Lead facilitator read out or participants read.
Leading and managing improvement projects is a huge area – we worked on some issues in Workshop 1 eg influencing, communications, stakeholder management.
Today we are going to focus on some issues directly relating to data and measurement for improvement:
The improvement journey – we’ll look in more depth at PDSA cycles and the role they play at different stages of an improvement project

4. An improvement journey
A P S D
Identify opportunity for change
Plan
Test
Sustain the change
Implement
Hold the gains
Spread
DISCOVERY
Aim
Participants can list the stages in an improvement journey and identify at any point in their project which stage they are at.
Key messages
Stages of an improvement journey, as in this slide and next.
Features of the three key stages
Timing
15 – 20 minutes (through to end of testing, implementation, spread activity)
- 5 minutes (Improvement journey, Examples)
10 minutes (testing, implementation, spread activity)
Materials
Arrange the furniture so that there is space for all participants to stand in the middle, and to go to three different areas for the testing, implementation, spread activity.
Corner labels TIC
Blu tac
Features of testing, implementation, spread
Lead facilitator
These are some of the steps that you may go through on an improvement project. Depending on the initial objectives of an improvement project, and their relevance beyond the team that initiated the project, you may go through some or all of these.
Last time we focussed on the first 3 steps. Now we are briefly going to look at some of the others.
PDSA cycles are a feature of ALL stages in the journey.

5. An improvement journey
A P S D
Identify opportunity for change
Plan
Test
Sustain the change
Implement
Hold the gains
Spread
Now we’re going to look at some of the broad differences between these 3 stages in the journey, before looking at testing and implementation in some more detail.

6. Examples of change: medicines reconciliation
Testing
Implementation
Spread
3 nurses on one ward use a new reconciliation and order form
All 30 nurses on the unit use the new medication and order form
Nurses from the ‘pilot’ unit assist all nursing units in the organisation to adopt or adapt the change
Lead facilitator
Examples – briefly talk through slide.
Refer to these examples during the following ‘features’ task.
Decide if each of the following features of an improvement journey is Testing, Implementation, or Spread (could be more than one)

7. Testing? Implementation? Spread?
Failure is a useful, natural part of the improvement process.
PRACTICE
Lead facilitator
Do this example in plenary while still seated.
Is this a feature of Testing, Implementation, or Spread – or more than one of these?
Elicit responses and ask participants to give reasons.
Then all participants stand in the middle of the room.
Facilitators put corner labels up ready for the next item – as far apart as possible in parts of the room that are accessible, where a large cluster of participants can gather
Lead facilitator read out the feature. Participants go to the stage label where you think it most applies.
You can be between labels if you think the feature is common to more than one.
Discuss with others in the same place – do you have the same reasons for being there?
Plenary debrief.
Facilitators
If a participant is on their own at any point, a facilitator join them and ask them to explain their reasons.
Then bring all participants to the middle again, and repeat with the next item.
It is unlikely that you will need to use all 7 items. 3 or 4 are usually enough. Decide which ones to use based on the discussion generated by previous items.
At the end of the activity give out the Features document. Make sure that issues highlighted during this activity are consistent with this summary document.
Ask participants to have a quick look at it and ask questions if anything is not clear.

8. Testing? Implementation? Spread?
The change becomes part of the routine operation of the unit.

9. Testing? Implementation? Spread?
Work out how to explain the benefits of a change beyond the unit.

10. Testing? Implementation? Spread?
Use PDSA cycles.

11. Testing? Implementation? Spread?
Learn what works in your system.

12. Testing? Implementation? Spread?
Change is not permanent.

13. Testing? Implementation? Spread?
Develop infrastructure (eg policies, job descriptions, SoPs) to maintain the improvement.

14. 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
DISCOVERY
Aim
Participants can recognise when their project (or one change idea in the project) is ready to move from testing to implementation
Key messages
Three criteria for implementation
Timing
7 minutes, including PDSA ramps
Lead facilitator
Now looking in more detail at Testing, and Implementation.
Once your have Studied your data in each PDSA test cycle, your Act stage should include a decision to take action in one of these ways.
Your decision will depend on 3 things: see next slide

15. 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.
Lead facilitator
If these criteria are all true, you are ready to move on to the implementation stage.
This slide is a summary – the next slide goes into more detail.

16. 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
Lead facilitator
Expand on the previous slide
Moving to Implementation should only be considered if these 3 criteria apply:
The team has a high degree of belief that the change will result in improvement
The cost of failure is small ie risk is low, losses from a failed test are not significant
The organisation is ready to make the change.
Implementing a change includes (summarise some of the issues arising from T/I/S activity)
Makes the change part of routine for the whole unit
Continues to use PDSA cycles
Requires more time than testing
More people are involved, so challenges are often related to people’s reactions to change
Adapted from: The Improvement Guide p146

17. Sequential building of knowledge
A P S D
Implementation cycles
Learning and Improvement
Wide scale tests
Test new conditions
Follow up tests
For one change idea, we would expect to go through a series of PDSA cycles before we are ready for implementation.
This is called a ‘ramp’ of PDSA cycles.
Each change idea will have its own ramp.
Some may never reach implementation, if you learn that this change doesn’t lead to the improvement you are looking for.
Small scale test
Very small scale test
Develop a change

18. 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
To contextualise an example of ramps: ICU Length of Stay
Refer back to the module Planning with PDSA case study and project: we looked in detail at some PDSA cycles relating to staff training.
Now we are going to look at how we might work on that and the other two change ideas highlighted here - more information about this on the following slide – PDSA ramps.

19. 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
Key messages
To increase the pace of change test 2 or more change ideas at the same time – the different ramps may be at different stages ie one may reach implementation before others
Collecting data for too many measures can reduce the time people have to devote to testing changes – so collect just enough data.
Collect qualitative as well as quantitative data, particularly during very small scale tests - V small scale means that changes in quantitative measures may be v small

20. 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?
PROJECT (OPTIONAL)
Aim
Participants think through these questions in relation to their own project
Timing
10 minutes
Materials
Ask participants to bring their own project documents including driver diagram and PDSA reports, and stakeholder analysis or communications plan
Facilitators
Check in with each participant to make sure their thinking will help move their project forward.
If no time: this provides questions to consider about your own project, once back at work.

21. Components of Implementation
Standardisation eg policies, procedures
Documentation eg job descriptions
Training
Measurement
Resourcing eg equipment purchases
PRACTICE
Aim
Participants can list the tasks to be carried out as part of implementation
Key messages
PDSA cycles continue
A lot of work still to be done
Increasing importance of attention to Psychology as more people get involved
Timing
minutes
Materials
Implementation planning template
Example of this implementation planning sheet, completed.
Implementing change People issues
Lead facilitator
These are the components of implementation that need to be addressed in all improvement projects, for any change idea.

22. 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
We are going to look at an example based on this case study, for the ‘hand gel’ change idea
Leadership training for team leads
People
Staff engaged in health and wellbeing practices
Offer Bereavement support programme for managers

23. Components of Implementation
Standardisation eg policies, procedures
Documentation eg job descriptions
Training
Measurement
Resourcing eg equipment purchases
Lead facilitator
Participants work in groups of 3 - 4
Read the different items on the example that need action. Discuss:
- Sequence – what are the interdependencies, what would need to be done before some others could be done?
(depending on time available, you might ask for numbering of PDSA cycles across the whole list)
- What issues would you need to consider, particularly with respect to the People issues, and how would you deal with these?
Allow time for everyone to read the example, then elicit immediate ideas on sequencing, as an example of the kind of thing that groups should be discussing.
Facilitators
Monitor the room, respond to any participant queries, check in from time to time and intervene as necessary.
Plenary debrief.
Focus debrief on:
Practical issues re sequence – what did participants identify?
What are the key people issues, and how would participants deal with them?
It may be too early in some participants’ projects to be applying this now, but highlight that they should start considering whether they are ready for this with a single change idea.
Optional Activity if time and if participants are expected to be moving on to implementation soon:
Use the Planning template to act as a checklist
PDSA reports for each ramp that you identify.
For example use the sequence of 5 PDSAs for the ICU case study (used in module Planning with PDSA case study and project), and the ramps above
In pairs or small groups, use these to develop an implementation plan.
Use the planning template, and refer to the example and Implementing a change docs.
Do one example in plenary to get them started.

24. Leading change: from testing to implementation: summary
An improvement journey
Criteria for implementation
PDSA ramps
Components of implementation
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
2 – 5 minutes, depending on time available
Lead Facilitator
Elicit what content was covered for each of the bullets eg:
What are the key stages in an improvement journey?
What are the three criteria for implementation? How many of them need to apply to move on to implementation?
How many PDSA ramps might you work on at the same time? (more than 1)
What are the five components of implementation that you need to work on?
How many PDSA cycles are you likely to need during implementation? (lots)