1. “Mind the Gap” The Journey
24/11/2016

2. Theory of Improvement PDSA cycles. (we all do…) Clear objectives.
Test of change.
Continuous audits and data gathering.

3. Reasons to Test Changes
To decide which of several proposed changes will lead to the desired improvement and whether they will work in the environment of interest.
To evaluate how much improvement can be expected from the change.
To decide which combinations of changes will have the desired effects on the important measures of quality.
- To minimize resistance upon implementation.

4. Run Charts Complex statistical tools
Study time to understand statistical analysis
Help you test the changes made
Help to quantify improvement / worsening
Easy to understand graphics
Sigma limits (Random & Non-random)
To improve a process we must reduce variation

6. Highlight previous data to keep track of progress
Safety cross help to visualize performance at a glance
Account time of administration missed
Highlight previous data to keep track of progress

9. People dependent process!!
NR Occurrences
NR Occurrences
Trans. resp
Mind the gap & safety cross
Segregated data (21.5)
Name and shame
Handover checks(3.8%)
Back to old shifts (4.15%)
Transfer of responsibility
Handover checks
Staff meeting (12.97%)
New poster
(10.5%)
Transfer of responsibility
Reduced Variation
OP!!
Safety cross stopped! (19.44%)
Safety cross back (5.16%)
Error reporting (14.3%)
Name and shame stopped!
People dependent process!!

10. Implementation Advice
Nursing team must take lead and accountability.
Pharmacy in supporting role (data analysis)
It is a cultural change so will take time
Little changes may go a long way…
Use small but significant sample to start with
The more data the better!! (3+ years of weekly audits)
Praise / challenge appropriately
Avoid spreading too early!

11. Results so Far… Reduction of blank boxes 40% (80% AIB)
Time consuming but can be rewarding (sometimes!!!)
Scared of my green pen and pink highlighter 
Currently transferred to nursing team (still counting though)