1. Building Bridges to Improvement
Learning Session 1

2. Learning Objectives
Describe a model to support change and improvement in your ECE program
So in this next session we are going to build on the work you all just did using your Program Systems Inventory and I’m going to introduce a way to help you think about and act on the opportunities for improvement you identified.

3. Quality Improvement is …..
What do you think of when you think of Quality?
Ask audience: What comes to mind when you think of the words “Quality”? Or “Quality Improvement?”
How about “change” – what words do you think of?

4. People embrace change at different rates depending on how important the issue is to them.
For example, some people are among the first to get the latest IPhone or Fitbit and others may have come along later down the road or decide it is not for them. I waited until the IPhone 4s before I jumped on the bandwagon.
This phenomenon is described by Everett Rogers in a book called The Diffusion of Innovation. In it he describes his theory for how, why, and at what rate new ideas are spread.

5. Roger’s Diffusion of Innovation Model
He defines categories to classify individuals response to adopting change. He found that people fall into the typical bell curve in their response to change.
Innovators- venturesome ones, always have a new idea, often see the work differently, often the ideas don’t succeed but they have to be ok with that- can be a lonely place to be and can be difficult to work with
Early Adopters-Risk Takers, opinion leaders, key to successful change, socially integrated (The innovator creates the idea and the early adopter makes it happen)
Early majority-Seldom are the Opinion Leader, Observant, Deliberate before signing on to a change, Socialites--interact frequently with peers (The early majority adopts the change after the early adopter demonstrates that it can work)
Late majority- Need peer pressure in order to change, Need a weight of evidence to change. (The late majority adopts the change after the early majority clearly demonstrates that the change is a better way)
Laggards or Traditionalists-Anchored to the past, historians, passionate about their issues, where we put our energy--need to put their resistance aside in making change
The spread of a new idea is influenced by innovation, communication, time and social connections. Recognize that people’s adaptation to change is very different but keeps things in balance.

6. Take a moment to read this cartoon describing the continuum of adoption of a new product

7. So while it is important to recognize that change is hard and that people initiate changes at different rates depending on their investment in it, David Jakes (and educator) said it well {read slide}
Notice the emphasis is on taking action – that is what I’m going to focus on in the rest of this session – giving you some QI tools to help you take action and then working through some examples to see how the tools can be put into practice.

8. Model For Improvement
So how does this relate to all of us in the room together?
We know that human beings have a basic desire to “do good work” thus, it can be very frustrating when despite our hard work and long hours we learn that that significant gaps exist. However, even more frustrating than identifying the problem is trying to figure out how to “fix” it. We often don’t know HOW to make changes, particularly in complex settings whether those be your centers or your community.
For the answer to this “HOW” we turn to a framework called The Model for Improvement.
The Model for Improvement combines the best of two approaches to change:
Understanding problems before trying to change them, and then
Systematic testing of ideas or interventions (real time science) to see what works.
The Model for Improvement can be thought of as a “trial‐and‐learning” method that will help you apply knowledge about what works in your office setting to improve care for your children and families.
The model has two parts:
Three fundamental questions;
What am I trying to accomplish, setting goals
How will we know a change is an improvement
What changes can we make that will result in an improvement
The Plan-Do-Study-Act (PDSA) cycle** to test changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement.

9. change is an improvement? make that will result in
Model for Improvement
Let’s look at the model…
The first question, “what are we trying to accomplish?” is about setting specific, measurable goals.
A goal for the improvement effort will guide and keep the effort focused.
A goal should state the accomplishments expected from your improvement effort and should be consistent with the overall aim of the project.
Creates a shared language and shared methods and activities
Supports accountability and understanding for team leaders and management
The second question is “how will we know if a change is an improvement?”
Collecting small amounts of data over time allows us to understand whether the changes we are testing are leading to improvements, having no impact, or making things worse.
The last question: “What changes can we make that will result in an improvement?” guides the generation of ideas about what can make a difference.
Ideas come from a variety of sources: critical thinking, creative thinking, observation, hunches, literature, or insight gleaned from a different situation.
Brainstorm and be creative about ideas that you would like to try on a small scale basis to see if they will lead to improvement
What are we trying to accomplish?
Goal
Measures
Change Ideas
How will we know that a
change is an improvement?
What changes can we
make that will result in
an improvement?

10. Plan-Do-Study-Act
The second part of The Model for Improvement is the Plan-Do-Study-Act cycle
We have all used this framework whether we were aware of it or not – think about making dinner last night:
First you had to plan a menu, shop for the ingredients, decide who was going to make the dinner and when
Then you had to execute your plan and cook the meal – this was your DO phase. While cooking, the phone rang and you got distracted and burned the rice.
Next, you take stock of what your family thought of the meal – is it one they want you to make again? Did the kids eat their vegetables? Are there enough left-overs for lunch tomorrow?
Finally, in the ACT phase – you decide whether to save the recipe to make it again soon, you might decide whether to share the recipe with friends or colleagues at work tomorrow, and you clean up the mess and start thinking about what is for dinner tomorrow night (ah, not chicken again mom….).
The use of PDSA cycles in very simple, in fact, it is probably how most of us think and process naturally, but it gets confusing when applied to complex settings

11. The PDSA Cycle “What’s happening now?
Let’s look at the steps of the PDSA
cycle
Plan- (read text) be purposeful about the scope of your test- keep it small, simple and manageable- this is the who, what , when and where process.
Do- (click and read text) try it out on a small scale, keep track of what worked, what didn’t and what was unexpected
Study- (click and read text) this is the step that often gets short-changed or overlooked completely- be purposeful to learn from what you did. This may be with your entire team at a weekly meeting or a simple quick meeting in the hall to discuss how things went, what you learned and are you going to refine the idea, throw it away of adopt it.
Act- (click and read) based on what you found and decide, move forward. PDSA cycles are not meant to be long and drawn out as a rigorous trial.
PDSA cycles are meant to be used for rapid cycle testing, trying something out- adjusting and moving on. By testing on small idea at a time, you learn what you need to know o decide if you should adapt the idea, toss the idea or adopt it.
“What’s happening now?
What will happen if we try something different?”
“What’s next: Try something else? Explore this further? Implement?”
“Did it work?”
“Let’s try it!”

12. PDSA Cycle PLAN What is your objective for this cycle?
What questions do you have?
What do you predict will occur?
Describe your plan for the test: Who? What? When? Where?
Plan for collection of data: Who? What? When? Where?

13. PDSA Cycle DO Carry out the change
Collect data and describe observations, problems encountered, and special circumstances

14. PDSA Cycle
Study
What were your results?
Summarize what was learned

15. PDSA Cycle Act Are you ready to adopt, adapt, or abandon the change?
What will you try next?
In a PDSA cycle, you begin by testing a particular change on a small scale, learn what you can, and then decide to adopt it, change it and test it again (i.e. adapt it) or abandon it (i.e. it was not a good idea, did not work out, or had unintended negative consequences)

16. Repeated Use of the PDSA Cycle
Changes That Result in Improvement A P S D D S P A A P S D
Repeated use of PDSA Cycles
Testing PDSA cycles in an iterative process. The completion of one cycle leads directly to the next on.
You study and learn form each test, what worked, what didn’t and what needs to be tweaked, and use this knowledge to plan your next steps.
Start small, keep it simple, measure just enough to inform your next step and ramp up the tests as you gain confidence they will lead to improvement.
DATA A P S D
Hunches Theories Ideas

17. Using Your Data for Change and Improvement
One way to share improvement data is to create a visual display – it allows you to communicate your results more effectively
This graph is an improvement over the table because the visual display is faster and easier for us to understand
However, we don’t know from this graph whether the improvement happened immediately (i.e. at cycle 1) or gradually. Further, we don’t have any sense of whether all teams did equally poorly (or well) or whether there was substantial variation.
In a run chart the x-axis is always time so that it provides a way for us to monitor a process over time.

18. Why Test
All improvement requires a change, but not all change is an improvement.
“Why it is a good idea to test changes?”

19. Why Test Increase belief the change is improvement
Provide opportunity for “failures” without impacting performance
Document degree of expected improvement
Read slide then…
Remember sometimes changes seem like they are making things worse before you see improvement

20. Why Test Learn how to adapt change to local conditions
Minimize resistance upon implementation
Evaluate side-effects
Sometimes the idea just won’t work. Some changes seem like a good idea and when you test them, you find they are not a good idea at all.

21. Use the PDSA Cycle for Testing or adapting a change idea
Implementing a change
Spreading the changes to the rest of your system

22. The Sequence for Improvement
Make part of routine operations
Sustaining improvements and Spreading a change to other locations
Test under a variety of conditions
Implementing a change
Act
Plan
Study Do
Identify a change idea
Discard, adapt, or adopt
When you start to test a change, wherever you start, think down a level until your plan is small in scope, easily and quickly tested.
State small, keep it simple, measure only enough to guide your next step. Test first on a really small scale – one child in one classroom
Increase the numbers as the idea is refined.
Test with people who are willing and happy to innovate.
Only implement the idea when you are confident that you have considered and tested all the possible ways of achieving the change.
Developing a change

23. Building, Changing, Improving …
Quality improvement is
what you do every day ….

24. Key Change Concept
It is important to remember that it’s not the size of the change that is important …
it’s the impact!!
The Improvement Guide

25. Key Changes The people you impact are small ….
The changes are important and can have a big impact.