1. Scottish Improvement Skills
What are we trying to accomplish?
Focussing our aim
SIS Group B Project Aims, Theories of Change, Change ideas: Module – What are we trying to accomplish? Focussing our aim: Facilitator

2. System of Profound Knowledge
Discovery
Developing our aim, we are mainly in this part of the System of Profound Knowledge: refining our Theory of Knowledge.
Deming 2000

3. Model for Improvement The Improvement Guide Langley J et al 2009
We are in the ‘thinking part’ of the Model for Improvement.
The Improvement Guide Langley J et al 2009

4. 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?
We are going to start with a brief look at the first question, although that isn’t necessarily where you will always start.
The three questions are so interwoven that it may be difficult to really know which one you are considering to start with, but before you start to plan what your are going to do or to collect data (in the doing part) you need to have an answer to all three.

5. Focussing your aim By the end of this session you will be able to:
name key components of an aim statement
explain the importance of an effective aim statement for a project
formulate an effective aim statement to guide your improvement work.
Aim
To start applying practical tools to an improvement project.
Participants start to apply improvement thinking to their work project (not the personal improvement they’ve been talking about up to now).
To shape their own project idea from a general idea to a focussed aim, realistic and achievable.
Key messages
Importance of spending time on defining this clearly
It has a purpose – so must be expressed in a way that is useful
To be useful it needs to be specific
Timing
45 minutes
Lead facilitator
Talk through learning outcomes, or ask participants to read them.

6. Why is an aim statement important?
Framework
Focus
Scale
Team membership
Communications.
Lead facilitator
Constructing an aim statement helps us to answer the first question in the Model for Improvement: What are we trying to accomplish?
It provides a framework to think through all aspects of the proposed improvement project
It keeps improvement activity focussed on the original purpose
It makes clear the scale of improvement expected from this project
It helps to select suitable team members for the improvement work
Communications – make it as easy as possible for everybody (including/particularly senior leaders) to understand what you are trying to achieve. And you need to think about communications from the beginning – who needs to know what, why and when?

7. Constructing an aim statement (1)
Specific
Timebound
Aligned
Numeric.
Aim
Participants to have a memorable framework for an aim statement
Key messages
Important to think through all four of these components of an aim statement
Lead facilitator
As you go through each of the four elements, elicit ideas on what this may include and why.
What do you need to consider when constructing an aim statement?
Specific
It won’t be useful unless it’s specific. It should include the following:
Boundaries
Which part of the healthcare system do you want to improve? A boundary may relate to:
a structure, such as a particular ward or a patient’s entry into a service’s building
time, for example calls to a clinic on a Monday morning
a patient population, based on a geographic area or gender or age group.
Outcome
The aim should be stretching. You should feel at least a bit uncomfortable about the idea of trying to achieve it. This also links directly to ‘numeric’.
(consider linking this back to the QI and why it matters module: transformational change and being audacious)
Timebound
Setting a timeframe for achieving the goal provides a clear statement of intent to review progress, and a reason to reinforce the aim by repeating it until the end of the timeframe is reached.
Aligned
This is a useful check to ensure that your improvement idea will gain the support of senior managers or leaders.
There are many possible areas for improvement that you could choose to work on – you need to be able to justify why you have chosen this particular one.
Consider strategic priorities at national and Board level, as well as local strategic objectives for your service.
Operational goals may be contained in your organisation’s Local Development Plan or Business Plan. What is your Chief Executive talking about right now?
Numeric
This helps to focus the improvement work, and provides a starting point for identifying a change idea and developing measurement plans.
This does not mean that qualitative data is not of value – it just ensures that we use quantitative data.
A statement including all of this in one sentence would be very unwieldy. To keep the focus, it must include two features that answer the questions: How good? By when? (ie specific/numeric, timebound). The other things must be on record eg in a project charter, and used in reporting to some stakeholders, but may not be essential day to day.
[STAN – with thanks to April Masson in East Ayrshire (Early Years Collaborative)]
A query may come up about why use STAN rather than SMART, which may be familiar to many of the participants. Response: use whatever will help you to make sure that your aim serves the purposes outlined under ‘Why?’ in the earlier slide.
Depending how you use and think about SMART, there is a risk that some of the thinking about improvement may be lost or distorted. Eg:
Specific – must include boundary as well as outcome
Measurable – fits with Numeric
Agreed or Achievable – Agreed could be considered to fit with ‘Aligned’; Achievable risks the aim not being stretching enough.
Relevant or Realistic – again, Relevant could be considered to fit with ‘Aligned’, while Realistic risks the aim not being stretching enough
T - Timebound

8. Constructing an aim statement (2)
By March 2015, 95% of endoscopy patients at the Queen Mary Hospital return signed postal consent forms, in line with the Global Rating Scale for Endoscopy, which states: 1.7 All consent signatures are obtained outside the procedure room.
Aim
This provides an example, and practice for the next activity.
Lead facilitator
This has all four components - elicit each of them, and which words or phrases apply to each one, then go to next slide to confirm.

9. Constructing an aim statement (2)
By March 2015, 95% of endoscopy patients at the Queen Mary Hospital return signed postal consent forms, in line with the Global Rating Scale for Endoscopy, which states: 1.7 All consent signatures are obtained outside the procedure room.
Answer Key
S – boundaries = endoscopy patients / at QMH; outcome – return signed postal consent forms
T – by March 2015
A – in line with the Global Rating Scale etc
N – 95%
But it’s rather a mouthful. So – move on to next slide.

10. Constructing an aim statement (3)
By March 2015, 95% of endoscopy patients return signed postal consent forms. How good, by when?
Lead facilitator
Day to day within the team and with local stakeholders, this would be fine.
On next click: While we need to be mindful of the rest, it’s How good, by when? that is key to keeping us focussed.

11. Constructing an aim statement (4)
Offer all patients registered with the practice same-day access to a GP within 12 months.
Key messages
It is possible to get most components into a concise statement.
Lead facilitator
Another example – elicit which of the 4 components of STAN are in this one.
S: boundary – patients registered with the practice; outcome – same day access
T: 12 months from now – briefly discuss risks of this wording compared with giving a specific date: better to say eg by December 2016; less risk of slippage.
A: (not in this statement)
N: all = 100% - briefly discuss which of these is more useful

12. Aim statements
Aim
To embed thinking about the four components of an aim statement by reviewing aims for other projects than participants’ own. To recognise the components when present and notice when absent.
Material
Aim statements worksheet
Timing
12 mins including debrief
Lead facilitator
Some of the aim statements on this sheet are more or less useful than others.
To be useful an aim statement needs to be specific enough to be able to work with it and for everyone to have shared understanding.
So, is it useful/specific enough? Why? Which components are included? Any other features that are helpful or not?
Work individually first, then compare notes in pairs.
Decide if each one is useful, definitely not useful, or somewhere in between (referring to the emoticons).
Move on to the next slide, so participants can refer to this while using the task sheet.
Facilitators
Monitor and support as needed.
Plenary debrief using the following slides – show the statement, and elicit responses.

13. Constructing an aim statement (1)
Specific
Timebound
Aligned
Numeric.
Leave this up while participants are working on the task.

14. Aim statements
All written information on the Physiotherapy unit is available in two languages other than English by August 2015, as stated in the CHP business plan.
Lead Facilitator
Debrief from these slides.
Participants do not have these slides in their slide set as they have the statements in the worksheet.
No ‘answer’ is given using the emoticons, to allow for all to be possible, so long as people can justify their views.
Comments in these notes must be included in the debrief – other issues will also be raised.
Good but could be improved by saying which languages – otherwise why 2, not 1 or 3?
What does ‘written information’ mean? Posters, leaflets, appointment letters?

15. Aim statements
Reduce the incidence of hospital acquired pressure ulcers by 50%.
Includes ‘how good’ but nothing else.
Elicit: what problems could occur in a project with this aim statement?
(eg no sense of urgency because no timeline, different expectations in relation to scope eg one ward or the whole hospital?)

16. Aim statements
Improve the service provided by the Radiology clinic by getting feedback from all patients.
Getting feedback is a task to get information to help work towards improvements. It isn’t an improvement in itself – unless you are able to define in advance what you will do with it, which is unlikely – if you could do that you wouldn’t need the feedback in the first place.

17. Aim statements
To transfer every patient from the ICU to an inpatient bed within 4 hours of the time the patient is assessed as ready to move from the ICU.
This has a time as part of the Specific outcome (within 4 hours), but is not timebound. Ie by when do you want to achieve this?

18. Aim statements
Our day case rate for hernia repair is 20% below British Association of Day Surgery benchmark. As directed by senior management, we need to meet or exceed that benchmark by December this year.
Includes how good (meet or exceed benchmark) by when (December this year). However:
‘as directed’ suggests that it may be difficult to engage the staff concerned, so unlikely to succeed.
It isn’t expressed in a way that is very stretching – exceed by how much?

19. Project work: aim statement
Specific
Timebound
Aligned
Numeric
Aim
Participants to draft an aim statement that will inform the rest of their project work during this workshop.
They might revise it again during the workshop.
Key messages
They will need to consult key stakeholders to agree the aim statement once back at work.
It is highly likely that their aim statement will change slightly at that stage.
Usually, importance of creating this in consultation with project sponsor and project team members.
Timing: 10 minutes (participants may go through several revisions during this time).
Lead facilitator
Create the aim statement for your own project that you are going to work on through this whole programme. With reference to:
The project idea that you identified and agreed with your colleagues before today
Features of the system that you are working in
The interests of different people with a stake in your services (not just patients)
The components that we need in a specific, useful aim statement.
Facilitators
Monitor and support as needed. Depending on the number of facilitators it may be appropriate for each facilitator to stay at one table, moving around to support each participant at that table.
This provides a useful opportunity to steer participants towards an aim that is person-centred rather than process driven or eg based on a task that they have been assigned by a key stakeholder. Or depending how participants are getting on, it may be better to use this opportunity to apply the four components of STAN, then completely revise the aim statement once they begin drafting a driver diagram (in the next module).
Brief plenary debrief depending on issues arising – but don’t simply pre-empt the summary on next slide.
How good, by when?

20. Focussing our aim: summaryT A N
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 – 2 minutes
Lead Facilitator
Elicit what each component of the acronym reminds us of ie:
Specific: boundaries, outcome
Timebound
Aligned
Numeric
Elicit reasons for ensuring we have a specific, focussed aim.