1. Scottish Improvement Skills
Workshop 1
Day 3
Scottish Improvement Skills Full Programme Workshop 1 Day 3 Participants

3. System of Profound Knowledge
Deming 2000

4. Day 3 Planning a test of change using the Plan-Do-Study-Act framework
Creating measurement plans
Using run charts to tell an improvement story
Influencing colleagues and other stakeholders
Bringing it all together – sharing your knowledge

5. 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)
use all stages of the PDSA cycle in your improvement work.

6. System of Profound Knowledge
Deming 2000

7. ICU 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

8. Testing change: ICU examples
Sequence the 5 PDSA reports
What links do you identify from one cycle to the next?
What do you notice about the scale of the tests?
How many different measures were used?
How did theory change through the cycles?
How did qualitative data inform subsequent tests?

9. Qualitative and quantitative data
“Why did you use the hand gel?”
“Because it’s the start of my shift – I’ve just come from home.”
Which of the following are occasions when you use hand gel?
At the start of a shift
Between patients
After lunch
etc
On what percentage of occasions do you use hand gel at the start of your shift?
0 – – – –

10. Project work: plan a test of change
Create an aim for your first test of change: how good, by when?
Start small
Match your questions to your predictions and measures
Plan tasks
Complete who/when/where

11. Model for Improvement
The Improvement Guide Langley J et al 2009

12. System of Profound Knowledge
Deming 2000

13. Planning measurement By the end of this session you will be able to:
Create operational definitions for your measures that others can follow reliably to collect data
Create a measurement plan for your improvement work.

14. How big is your banana?

15. Operational definitions
Define the specific components of the measure
If it is an average, specify the calculation for deriving the average
If it is a score (eg patient satisfaction score), describe how the score is derived.
If it is a percentage or a rate, specify the numerator and denominator
Describe any special equipment needed
Describe the criteria to determine concepts such as ‘accurate’ or ‘complete’.

16. Project work: measurement planning
Pick one of your measures
Create an operational definition
Consider exclusions and stratifiers
Provide outline data collection method

17. Planning measurement: summary

18. Data analysis By the end of this session you will be able to:
Explain why it is important to measure data over time
Interpret run charts using rules to differentiate between random and non-random variation
Use run charts to explain outcomes of improvement work to others
Use and explain the importance of using a family of measures.

19. Understanding Variation
Random variation – affects everyone and all outcomes over time
Non-random variation – does not affect everyone or not part of the system all the time; arises because of specific circumstances.

20. Analysing data: before and after
‘When you have two data points, it is very likely that one will be different from the other.’
W Edwards Deming

21. Data analysis: Introduction to run charts
Weight (lbs)

22. Data tells a story: New healthier me!

23. Introduction to run charts
A ‘time series’ chart tells a story.
Baseline data helps us to see whether a change is an improvement.
Any changes made are shown on the chart.

24. What is a run? Vanessa’s Weight

25. Run charts: signals that identify non-random variation
Six or more data points in a run (all above or all below median)
Five or more consecutive data points all increasing or decreasing
Too many or too few runs
An ‘astronomical’ data point
A shift
A trend
See table
Consider

26. Run charts: Rule 1 – a shift

27. Run charts: Rule 2 – a trend

28. Run charts: Rule 3 (a) Too few or too many runs

29. Run charts: Rule 3 (b) Total useful data points Total data points
For the chart below:
Useful observations
Lower number of runs
Upper number of runs 15 5 12 16 13 17 18 6 14 19 20
Calculate the number of ‘useful’ observations (subtract the number of data points on the median from the total).
Find this number in the first column.
Count the number of runs.
If this number is below the lower limit or above the upper limit, the chart is demonstrating special cause. 21 7 22 23 24 8 25 26 9 27 10 28 29 30 11
Total useful data points
Total data points

30. Run charts: Rule 4

31. Applying the rules (4)

32. Baseline data How urgent is a change?
Is it necessary to identify whether the system has any non-random variation before introducing a change?
What is the source of historical data?
If there is existing data, make use of it.
If there is no existing data, decide whether to start collecting data before introducing the change.

33. Project work: baseline data
Does baseline data exist somewhere? If so, how can you access it?
If you are going to collect it, how long will you collect baseline data for before introducing a change? Why?

34. Data analysis: Introduction to run charts: summary
Data tells a story
Look for signals of non-random variation
Rules:
Shift
Trend
Too few or too many runs
Astronomical point
Baseline data

35. System of Profound Knowledge
Deming 2000

36. Influencing colleagues and other stakeholders
By the end of this session you will be able to:
Apply frameworks to identify key stakeholders and gain understanding of their needs
Plan for positive influencing using reflection, advocacy and inquiry.

37. Stakeholder analysis: RACI matrix
Responsible
Accountable
Consulted
Informed

38. Title of project, or change idea, or test of change
RACI matrix: template
Title of project, or change idea, or test of change
Name
Task 1
Task 2
Task 3
Task 4
Task 5
Task 6

39. Pulmonary Rehabilitation Programme: Patient Education Materials
RACI matrix: example
Pulmonary Rehabilitation Programme:
Patient Education Materials
John
Sue
Kiran
Alex
Lyn
Anna
Write material A R C I
Arrange design and print
Distribution to GP practices
Data collection AR
Data analysis
Reporting

40. Planning communications
Stakeholders
Purpose of communication
Key messages to be communicated
Timing of communication
How to communicate
Who is responsible for communication.

41. Influencing: Ladder of Inference

42. Your Story Something similar has happened to all of us.
What’s your story?

43. Example
Hand hygiene

44. Example: Hand Hygiene
In a corridor near the door to a clinic. A handwash gel dispenser is on the wall by the door. Liz approaches the door. Chris is just beyond the door, along the corridor, holding a clipboard. Liz uses the gel dispenser and rubs a dose of gel into her hands. She steps towards the door. Chris says ‘Excuse me, can I …’. Liz says ‘Sorry, I’ve been bleeped,’ and goes t through the door.

45. Actions Beliefs Conclusions Assumptions Meanings Data I select
Observable Data
Data I select
Meanings
Assumptions
Conclusions
Beliefs
Actions
I’ll show them. I won’t give anyone a reason to find fault. I’ll use the gel –
as usual. I won’t talk to her about it.
They treat us like children. They don’t trust us to do the right thing.
There’ll be trouble if people don’t use the gel.
It’s an audit on use of handgel.
A clipboard means collecting data. We’re supposed to use the hand gel before going through the door.
Chris is standing in the corridor holding a clipboard. The gel dispenser is on the wall by the door.

46. Example: Hand Hygiene
In a corridor near the door to a clinic. A handwash gel dispenser is on the wall by the door. Liz approaches the door. Chris is just beyond the door, along the corridor, holding a clipboard. Liz uses the gel dispenser and rubs a dose of gel into her hands. She steps towards the door. Chris says ‘Excuse me, can I …’. Liz says ‘Sorry, I’ve been bleeped,’ and goes t through the door.

47. Actions Beliefs Conclusions Assumptions Meanings Data I select
Observable Data
Data I select
Meanings
Assumptions
Conclusions
Beliefs
Actions

48. Actions Beliefs Conclusions Reflexive Loop Assumptions Meanings
Observable Data
Data I select
Meanings
Assumptions
Conclusions
Beliefs
Actions
Reflexive Loop

49. Your Own Example What action did you take, or what did you say?
What beliefs was that action based on?
What conclusions led you to those beliefs?
What assumptions did you make?
What meanings did you add?
What data might have been available that you selected out?

50. Actions Beliefs Reflection Conclusions Advocacy Inquiry Reflexive Loop
Observable Data
Data I select
Meanings
Assumptions
Conclusions
Beliefs
Actions
Reflexive Loop
Reflection
Advocacy
Inquiry

51. Influencing colleagues and other stakeholders: summary
RACI matrix
Communications plan
Ladder of Inference:
Reflection
Advocacy
Inquiry

53. Knowledge sharing
Make a note of a particular challenge you are facing in your improvement work
‘Challenge owner’ describe your situation
Others give advice, from your own experience
Challenge owner note down ideas – action you could take in future based on this advice

54. People Connect

55. People Connect

56. Project charter
A summary of what you expect to achieve from the improvement project
Helps to maintain focus
Answers the 3 questions
Identifies appropriate team members

57. Learning Journal
Reflections on learning
minutes

58. Workplace learning Online learning modules and videos
Ongoing project work
Online learning events
Project charter

59. Project work By the time your return for Workshop 2, you will have:
Completed your project charter
Collected data to help you identify your priority for change
Collected baseline data
Carried out several tests of change
Collected qualitative and quantitative data

60. References and further resources
Provost Lloyd P & Murray S (2011)
The Health Care Data Guide: Learning from Data for Improvement
Jossey-Bass
Senge, Peter M, 1994 The Fifth Discipline Fieldbook: Strategies for Building a Learning Organisation Nicholas Brealey Publishing