1. QI Presentation: Skills and Examples
Dr David Gozzard
Senior Fellow, Institute for Healthcare Improvement, Boston US

2. Objectives of the Session
Understanding of relationship between structure and process
Introduction to process mapping
Driver diagram development
PDSA worked examples

3. System Design
Every system is perfectly designed to achieve exactly the results it gets

4. The Healthcare System 133 People to take care The Patient
of the patient
The Patient

5. STRUCTURE +
PROCESS =
OUTCOME

6. PROCESS MAPPING

7. Why Map Processes?

8. Dealing with a non-functioning lamp
A Simple Flowchart
Dealing with a non-functioning lamp

9. Another Simple Flowchart
Waking up in the morning

10. Process Maps

12. A New Tool – Driver Diagrams
A tool to help us understand the messiness of life!

13. What changes can we make?
Primary Drivers
System components which will contribute to moving the primary outcome
Secondary Drivers
Elements of the associated Primary Driver. They can be used to create projects or a change package that will affect the Primary Driver.

14. Stroke Driver Diagram Improve the outcome for people following stroke
First hours bundle
Start aspirin
Confirmation of diagnosis
Rapid recognition tool e.g. ROSIER
First day bundle
Swallow screen
Admission to co-located beds
CT scan
First 3 days bundle
Physiotherapy assessment
Nutritional assessment
Manual handling assessment
36h continuous monitoring
First 7 days bundle
Information sharing with patients/carers
MDT goal setting meeting
OT assessment commenced
Reduce the number of episodes of avoidable harm
Interventions identified by the Global Trigger Tool analysis

15. Driver Diagram Exercise
Establish stakeholder group
Objectives
Discussion regarding concerns (group)
Flipchart exercise (smaller groups)
Sticky notes exercise (individual)
Coffee!!
Whilst this is taking place the notes are “themed”
Stakeholders view themes (primary drivers)
Group exercise to format driver diagram

19. Projects Anaemia Management Driver Diagram Better anaemia management
Education
Training packages
Communication
Disseminating pathway guidelines
Core Processes
Hospital
Treatment options
Guidelines/Protocols
Referral pathway
Finances
Business cases
Commissioning
Patient
Satisfaction/outcome
Service design
Involvement
Primary care
Responsibilities
Engagement
Anaemia Management
Driver Diagram
Projects

20. How Will We Know We Are Improving
How Will We Know We Are Improving? Understanding the System for Weight Loss with Measures
Here is a theory about the drivers that impact my current weight loss campagin
[BUILD1] Of course, every system is perfectly designed to achieve…
[BUILD2] What would it take to achieve a NEW ME? Describe the drivers (alcohol drives both intake and outflow, the latter because it discourages exercise). Points to make:
Secondary drivers have a clear impact on the outcome
Selection of secondary drivers to work on depends on where we start: if we’re already working out 5 days a week and fit, we’ll probably concentrate on intake; if we don’t drink, then we don’t need to consider that driver.
Effective changes are idiosyncratic
[BUILD3] Mention Donabedian’s categories, relate to the diet
Measures let us
• Monitor progress in improving the system
• Identify effective changes

21. Group Work
Working in pairs, for an improvement aim arising from a national audit define the following:
Primary drivers
Secondary drivers
Possible projects
Allow 10 minutes for this exercise

22. Guidance for testing a change concept
A test of change should answer a specific question!
A test of change requires a theory and a prediction!
Test on a small scale and collect data over time.
Build knowledge sequentially with multiple PDSA
cycles for each change idea.
Include a wide range of conditions in the test sequence.
Don’t confuse a task with a test! 29

23. The Model for Improvement
Define the question
Gather information and resources (observe)
Form hypothesis
Generate new hypothesis and retest
Analyze and interpret data
Perform experiment and collect data

24. Why Test? Why not just implement then spread?
Increase degree of belief
Document expectations
Build a common understanding
Evaluate costs and side-effects
Explore theories and predictions
Test ideas under different conditions
Learn and adapt

25. Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement? A P
What change can we make that S D
will result in improvement?
DATA D S
Implementation of Change P A A S P
Wide-Scale Tests of Change D
Hunches Theories Ideas A P
Follow-up Tests S D
Very Small Scale Test

26. The Sequence for Improvement
Make part of routine operations
Spreading a change to other locations
Test under a variety of conditions
Implementing a change
Act
Plan
Study Do
Testing a change
Theory and Prediction
Developing a change

27. Group Work
Working in pairs, devise a PDSA cycle to test an idea based upon a problem arising from a national audit.
Note – your driver diagram exercise will have developed some ideas for testing!
Allow 10 minutes for the exercise

28. Thank You Any Questions?