1. Driver Diagrams

2. Why use driver diagrams?
Breaks down any broad aim, graphically, into increasing levels of detailed actions that must or could be done to achieve the stated aim
Helps to focus on the cause and effect relationships that exist in complex situations.
Well defined drivers that can form the focus of improvement efforts.

3. What are the component parts?
Aim or goal of the improvement effort
Primary drivers - system components that contribute directly to the chosen aim or goal. Processes, rules of conduct, structure
Secondary drivers - elements of the primary drivers and which can be used to create change projects. Components and activities
Relationship arrows - show the connection between the primary and secondary drivers. A single secondary driver may impact upon a number of primary drivers
Primary drivers describe the “what” and secondary drivers describe the “how”

4. An example of a driver diagram
Secondary drivers
An example of a driver diagram
Appropriate use
of ITU services
Identification of pt severity and wishes with respect to EOLC
Timely referral to palliative care / hospice options
Identification of provider responsible for coordination
Hand off management
Execution of a shared treatment plan (all providers and patient and family)
Assist patient and family to establish goals and intention
Preparation of family caregivers to cope with exacerbation
24 hour access to appropriate services
Availability of providers
Availability of resources
Primary drivers
Hospital care
Aim
Coordination of care
Aim to improve the use of resources in end of life care (EOLC)
Relationship arrows
Pt and family support
Primary drivers
Provider availability
Effect
Cause

5. An example of a driver diagram with identified measures
Appropriate use
of ITU services
Identification of pt severity and wishes with respect to EOLC
Timely referral to palliative care / hospice options
Identification of provider responsible for coordination
Hand off management
Execution of a shared treatment plan (all providers and patient and family)
Assist patient and family to establish goals and intention
Preparation of family caregivers to cope with exacerbation
24 hour access to appropriate services
Availability of providers
Availability of resources
% of patients with ELO care needs who are cared for in their preferred place of care
Hospital care
% of patients with ELOC needs who have an identified care co-ordinator
Coordination of care
Aim to improve the use of resources in end of life care (EOLC)
% of patients with EOLC needs with shared treatment plans
Pt and family support
% of family caregivers who report they are well prepared to cope with an exacerbation
Provider availability
% of EOLC referrals made to care providers which were made available to service users

6. Your chance to apply the tool
Allow 1.5 hours for a project team workshop that involves the team and subject matter experts
Ask your team to come prepared with appropriate research literature and any good practice guidance relating to the project area (which may help you identify some of the drivers in your system)
Ensure you have a supply of post-it notes, some flipchart paper and a suitable wall space for posting up notes

7. Don’t get hung up on the detail, this is just a tool to help identify improvement projects. It is not a thesis!
When identifying drivers or testing them for completeness do not get too hung up on finding every driver or determining if it is a primary or secondary driver. The purpose here is to help you identify improvement opportunities and be able to show a clear, defensible logic for how your improvement projects contribute to achieving your main aim or goal.
It is also entirely possible for two teams to construct their driver diagrams differently. This is fine as the driver diagrams are shaped by the language we use and our thought processes in creating them. They are a tool to help you on the improvement journey, not a test or academic exercise.

8. Applying the tool
Write down your aim statement and ensure the group is agreed on the aim. If necessary write down multiple aims if it is sensible to handle them all at the same time.
Divide your wall space into two parts. Label the left side Primary Drivers and the right side Secondary Drivers.
Spend minutes brainstorming potential primary drivers using the sticky notes. Place them under the Primary Drivers heading. The question you are answering here is “What are the main system factors that will impact upon achievement of my aim?”. Try to keep this high level.
Go through your list of potential primary drivers and apply the two questions given on the next sheet to test to see if you have actually identified some secondary drivers and whether you have a complete set of primary drivers. These questions are:

9. Is this driver I’ve identified a primary or secondary driver?
Ask yourself ……. “If I made an improvement in this driver
what would it achieve?”
If your answer directly describes your aim then you probably have a primary driver. If it describes something else then that “something else” is probably the primary driver (and you have identified a secondary driver).
ii) Are my primary drivers complete?
Ask yourself …… “If I could influence (or improve) against all of these drivers is there anything else that could go wrong and prevent me achieving my aim?”
If you can think of something else it should be considered as another potential primary driver. The same logic applies to testing secondary drivers and whether another factor exists that will influence the relevant primary driver.

10. Applying the tool (cont’d)
Agree your list of primary drivers.
For each primary driver spend minutes brainstorming potential secondary drivers using the sticky notes. Place them under the Secondary Drivers heading adjacent to the relevant primary driver. The question you are answering here is “What are the main system factors that will impact upon this primary driver?”.
For each primary driver go through your list of potential secondary drivers and test whether they directly influence the primary driver and whether you have a full set of secondary drivers. Modified versions of the questions used in step 4 may help.
After doing steps 6 and 7 for each primary driver you should now have a complete set of secondary drivers. Your driver diagram is complete.
The driver diagram will help you set your priorities for improvement work. You may therefore want to start picking out some of the most important primary or secondary drivers and begin identifying relevant measures.

12. Scottish Patient Safety Programme Critical Care Driver Diagram
Primary Drivers
Processes, Rules of
Conduct, Structure
Secondary Drivers
Components, Activities
Outcomes
Reliable Process of Care:
Prevent ventilator complications
Prevent CL complications
Reduce complications from PVC’s
Prevent Inf. & cross contamination
Proper Sepsis Rec. and Rx
Involve Pt./Family into Goal
Setting Process
Communications Team & Family
Clarify care wishes and EOL planning
Appropriate Infrastructure to Provide Reliable, Evidence Based Care
Improve ICU throughput
Competent staff with knowledge in QI Work
Reliable planning, communication and collaboration of a multi disciplinary team
Provide reliable, timely, care using evidence-based therapies
Improved
Patient
Outcomes
(Reduced Mortality,
Infections
(VAP, CVC, SAB’s)
and Other
Adverse Events)
Integrate patient and family into care
Develop infrastructure that promotes
quality care
Create a
collaborative team
and safety culture