1. Introduction to Quality Improvement in Practice
Shalani Raghavan
Susan Hannah
Scottish Government
Leading Improvement Team

4. Aims of this session
Brief introduction to the 3 Step Improvement Framework and the Model for Improvement
Invite you to consider how the Model for Improvement and its methodology can help you deliver on Quality Improvement – both strategically and operationally
Recognise your role in enabling and creating the conditions for Improvement
Raise awareness of the support available to you to implement the Model for Improvement in your area

5. Public Finances
Fall in Government expenditure

7. Changing the world – high level strategic view – includes understanding the evidence of what will work.
Creating the conditions – culture and leadership, six questions – includes measurement, also identifying correct changes.
Making the improvement – on the ground, start small – use model for improvement and other tools. Putting evidence into practice.

8. 1 2 3 4 5 6 Aim Correct changes Clear change method Measurement
The six questions to be asked of EVERY change programme… 1
Aim
Is there an agreed aim that is understood by everyone in the system? 2
Correct changes
Are we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact on our aim? 3
Clear change method
Does everyone know and understand the method(s) we will use to involve?
Effectively a Public Service ‘Bundle’ – the questions that have to be asked and answered to have a chance at introducing and sustaining a successful improvement to a system 4
Measurement
Can we measure and report progress on our improvement aim? 5
Capacity and capability
Are people and other resources deployed and being developed in the best way to enable improvement? 6
Spread plan
Have we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?

9. Leading Improvement Team – Our Key Objectives
To lead project-based, organisation wide programme of improvement activity addressing key organisational and policy challenges within Scottish Goverment.
A capability and capacity building programme to facilitate improvement across Public Services.
Our team was set up to act as a ‘guiding coalition’ – essentially we perform an internal consultancy service to SG – so we are there to help, facilitate and support people in their improvement efforts. We recognise we are not subject matter experts so the improvement has to come from those who work in and understand the system.

10. LIT: Current work Support for Early Years Collaborative and CPP’s
Education: Attainment, STEM
Health: Physical Activity
Justice: Building Safer Communities
Corporate: FOI
Awareness sessions and seminars
3 day training course

11. The Primary Drivers of Improvement
Having the Will (desire) to change the current state to one that is better
Will
Building Will
Motivating organisations to think beyond the status quo and imagine a better system and be ambitious – rather than doing more of the same we need to more
Harvesting Ideas
- Finding, cultivating, or inventing new approaches for better
delivery of public services
Getting Results (Execution of the ideas)
Providing the support, methods and tools for teams to take
action
Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas
Developing Ideas that will contribute to making processes and outcome better QI
Ideas
Execution

12. Improvement, whether it be about a particular problem/issue in relation to a specific process, or whole system, transformational change, is meant to be stretching.
This is an absolutely vital concept in improvement: improvement is not about doing more or adding additional work to an already overburdened team. It is about re-design.
Whatever improvement aim you set, it should not be achievable through hard work alone. If we all run a bit faster, we can make this improvement. Equally, it is not about blaming people, if only they’d run faster, we’d do this – the system is perfectly designed to get the results it produces.
It should require us to stop and think, understand the system, the user, the work we do – and how the work is done. In other words, it should be part of your work, rather than new or additional. If you’re seeing your project that way, or it’s making people feel like that, then more work is required to build the will and commitment – and there are strategies you can use to bring people on board by empowering them to test and try things out. 12

13. By what method? W. Edwards Deming
after you have established why you need the change this is the most significant question in improvement science: you must have a method and a way to measure to improve
W. Edwards Deming

14. "Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”
1941, William A. Foster 14 14

15. Improvement Science “There is no substitute for knowledge”
“Stamping out fires is a lot of fun, but it is only putting things back the way they were.”
“It is not necessary to change.
Survival is not mandatory.”
W Edwards DEMING ( )

16. No model is perfect, some are useful.

17. Drug & Alcohol Game
This is an improvement game which focuses on the flow of individuals into, through and out of drug + alcohol services or systems as part of their recovery. It addresses blockages, capacity, demand, interagency working, reviews and outcomes. It supports areas and services to think about what works, what doesn't and how to make improvements.

18. W. Edwards Deming Appreciation of the System Subject Matter Knowledge
Understanding Variation
Psychology
Theory of Knowledge

19. What is a System?
A system is an interdependent group of people, processes or items with a common purpose.

20. “Every system is perfectly designed to get the results it gets.”
Senge

21. Deming’s Concept of the Lens of Profound Knowledge
Deming provides a Lens through which to view a system.  
"One need not be eminent in any part of profound knowledge in order to understand it and to apply it. The various segments of the system of profound knowledge cannot be separated. They interact with each other. For example knowledge about psychology is incomplete without knowledge of variation." 21

22. Subject Matter Knowledge
Subject Matter Knowledge: Specialist knowledge and skills required to be a good practitioner
Subject Matter Knowledge
Improvement
Profound Knowledge
Profound Knowledge: The interaction of the theories of systems, variation, knowledge and psychology. 22 22

23. Different Types of Systems
So what do we need to do to stop the system from failing? And how do we go about making that a reality? We know that we can’t stop the system in its tracks.
Public Services!

24. “quality improvement”
The combined and unceasing efforts of everyone –professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to
better outcome, better system performance, and better professional development.
Fixing the plane while it’s flying!
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

25. So, in a chaotic world how can we get sustainable change that results in an improvement?
So in a chaotic complex world that is constantly moving, how can we support sustainable change?
We need a method for testing change that ensures it is right and reliable in a given situation

26. Use the Model for Improvement to test and implement changes
That’s where the Model for Improvement comes in. It hands the power back to front line and supports people to find processes that deliver
i.e. doing the right things right. A lot of the time we know what we need to do, we just don’t know how. This is the purpose of the Model – to help you develop the how; to turn ideas into tangible methods. What the model for improvement also highlights is that in order to make the ideas of change a reality, we need to enable those who are delivering services to find the “how”. The MFI gives them the power to make changes and to ensure the changes they make are fit for purpose in their own environment.
So the idea is that the model for improvement ensures that the improvements start at the grass roots level. This is an entirely different concept from what we have known before – its bottom up rather than top down. But Leaders still need to give people on the front line the permission and the support to make the changes to the system. 26

27. Our change theory A clear and stretching goal A method
SOON is not a time, SOME is not a number
A method
Predictive, iterative testing
Small tests of change, less risky, but quick results
HOPE is not a plan
These are the key elements of the MFI. If you don’t have a proper structure or a plan then it wont work – crossing our fingers and hoping that something will work out for the better isnt enough to introduce sustainable change. 27

28. The Model for Improvement28

29. Aim Measures Changes Execution The Improvement Guide, API Basics: Aims
Testing/Implementation
Execution
The Improvement Guide, API 29 29

30. “Aims create systems” Deming
So the idea that Deming was talking about is that where there is a common aim or purpose then a system will develop/follow that. Therefore when setting aims as an organisation then everyone has to be clear on what that aim is. You have to ensure that you bring people along with you and get them to engage and agree to meeting the aim. An aim is different from a strategic statement. It is something that can be focused on and met.
Deming

31. 1 2 3 4 5 6 Aim Correct changes Clear change method Measurement
The six questions to be asked of EVERY change programme… 1
Aim
Is there an agreed aim that is understood by everyone in the system? 2
Correct changes
Are we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact on our aim? 3
Clear change method
Does everyone know and understand the method(s) we will use to involve?
GO BACK TO OUR BUNDLE OF 6 QUESTIONS – YOU WILL SEE THE FIRST ONE IS FOCUSED ON THE CONCEPT OF AN AIM. SO THE QUESTION IS DOES EVERYONE IN THE SYSTEM KNOW WHAT YOU ARE TRYING TO DO? 4
Measurement
Can we measure and report progress on our improvement aim? 5
Capacity and capability
Are people and other resources deployed and being developed in the best way to enable improvement? 6
Spread plan
Have we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?

32. Aim
Aligned – provides a clear sense of what you are trying to accomplish
Numeric and Timed – How much, by when
Specific – who, where?
Unachievable by hard work alone
Non-negotiable (once set)
So order to ensure that the collective group meet aims. This is not a target. We need targets, but an aim is more ambitious than a target. And it doesn’t necessarily mean that you will meet the target. But it gives you something to stretch towards.

33. 100% of nurseries will be participating in Childsmile by June 2013
Aim Statements
To reduce infant mortality, i.e. deaths by 12 months of age (including stillbirths) by 15% by end-2015.
100% of nurseries will be participating in Childsmile by June 2013
The EYC will be a prominent agenda item at each CPP meeting by June 2013

34. Aim Statement Exercise: You Make the Call!34

35. Scotland, the best small country in the world
This is bad – it is not ‘how much, by when?’ and it is not specific
THE BAD 35

36. Our outpatient testing and therapy patient satisfaction scores are in the bottom 10% of the national comparative database we use. As directed by senior management, we need to get the score above the 50th percentile by the end of the 2ndQ of 2011.
Urrggh! Ugly! The first sentence is not necessary, the reason for doing it is shifted to ‘management have told us’, so it will not have ownership. Use of jargon
THE UGLY 36

37. By the end of 2012, hospital mortality will be reduced by 15% in Scotland
This is good as it ticks all the boxes for an aim statement, how much, by when and who/where
THE GOOD 37

38. Model for Improvement Q1: What are we trying to accomplish?
Take Aim
Take 5 minutes to think about a possible improvement aim for a project or policy that you are involved in.
Discuss it with the person next to you and give them feedback on theirs. 38

39. Exercise: Setting an Aim
Aim statement:
What will you do, how much and by when?
……………………………………………………………………………………………………………………………………
A clear stretch aim that is:
Is aligned directly to what you want to achieve (what)
Is quantifiable (how much)
Identifies a time frame for achieving the aim (by when)
Unachievable by hard work alone (change will be necessary) 39

40. Now we have an aim, we need a Driver Diagram!
What are the things that are going to influence the aim?
A useful tool to help us understand the system and organise our ideas and measures 40

41. Here’s what it looks like…
Theories about what will drive improvement
Aim Primary Drivers Secondary Drivers
Secondary factors which will
influence delivery of the
primary drivers
Key factors that will
Influence the aim
Aim statement:
general description
of desired
Improvement
(what, how much
by when)
Here’s a schematic view of a system – a ‘driver diagram’. On the left we depict the outcome in the red box. As we move right we drill down into the network of causes that drive the outcome, from ‘primary’ to ‘secondary’ drivers. On the right we depict the ideas for system changes that might ultimately impact the outcome.
This diagram represents our theory about how to modify the system to change the outcome. 41

42. Why a Driver Diagram?
Helps to organise theories about how to improve a system to meet the aim It displays visually our ideas on the areas we can improve to leverage the improvement we want to achieve – organises information with different levels of detail It helps a team to think critically about the issues that have the greatest impact on the desired outcome and which things will most influence those primary drivers. Shows several strategies for achieving the aim
There are various mechanisms for mapping out an improvement plan – this is helpful because it is visual and interactive – it is also fluid – the outcome aim should not change but processes and change ideas may be adapted/altered as the learning journey progresses. 42

43. Driver diagram
Primary Drivers
Key factors which you need to influence in order to move towards the aim. These drivers may act independently or in concert to achieve the overall goal.
Secondary Drivers
Underpinning factors affecting the associated primary driver(s). They can be used to create projects or a change package that will affect the primary drivers. 43 43

44. Draft physical activity driver diagram44

45. It’s ok if there are only 1 or 2 primary drivers
Now you drive…
Pick one of your aims from before.
Discuss and sketch out what would be the primary and secondary drivers for this aim
It’s ok if there are only 1 or 2 primary drivers

46. What Changes Can We Make? Understanding the System for Weight Loss
“Every system is perfectly designed to achieve the results that it gets”
Understanding Measurement for Quality Improvement • Sept 10&
© Richard Scoville & I.H.I. 46 46

47. How Will We Know We Are Improving
How Will We Know We Are Improving? Understanding the System for Weight Loss with Measures
Measures let us
• Monitor progress in improving the system
• Identify effective changes
Understanding Measurement for Quality Improvement • Sept 10& 47 47

48. Driver Diagram
Aim
Primary Drivers
Secondary Drivers 48 48

49. Measurement for Improvement49

50. Now back to this…. Aim Measures Changes Execution
Directly linked to the need for an aim, measures and change ideas which informes the 3 qustions in the thinking part.
The application of the cycle to test and measure the change ideas is crucial. Small incremental steps towards change, learning from each cycle, adapting the approach if necessary and testing it out in a variety of conditions to ensure it will be reliable when implemented as part of the system.
Linking the framework to the theory, any improvement project can be spotted by the following characteristics:
Focused on a well-specified, common aim
Guided by a deep understanding of the problem and the system that produces it
Disciplined by the rigour of improvement science
And networked, so that we can accelerate the learning, development, testing and refinement.
Execution
The Improvement Guide, API 50 50

51. Model for Improvement Q2: How will we know that a change is an improvement?
Improvement is not just about measurement However… without measurement you will never be able to answer the question! 51

52. Why Do You Need Data and Information?
To plan for improvement
For testing change
For tracking compliance
For monitoring long term progress and sustainability
To tell the story of your improvement journey 52

53. How Do We Know if a Change is an Improvement?
“If you can’t measure it, you can’t IMPROVE it” 53 53

54. Why Real Time Is Important for Measurement?
Improvement Science in Action
Why Real Time Is Important for Measurement?
Aggregate measures alone do not lead to predictions about future performance or insights to explain past variations
Displaying data over time (using run charts or control charts) allows us to make informed predictions, and thus make changes to create different results 54

55. Does this show an improvement?
Data for improvement?
Aggregated Data
Cycle time results for units 1, 2 and 3
Does this show an improvement?
Aggregated data doesn’t tell a story of the improvement work – often this is the high level data that management want for the board room – data looks good or better when looked at this way (masks the areas that are not really performing)

56. Data over time - dynamic data
Depends….
Which unit has improved?
Data over time - dynamic data
Unit 1
Unit 3
Unit 2
All these have the same before and after average as on the previous chart…
Unit 1 – the change has had an impact on the cycle time and for a few months the performance was better but something is causing further variation in this process and needs explored.
Unit 2 – was improvement anyway and the change has probably not been influential in the performance as this unit was moving in the right direction anyway
Unit 3 – The change has clearly had an impact on the performance and there was an impact on the cycle time, however you can see some deterioration in the performance creeping in again each month and this needs explored.
It is important for teams to understand and learn from their individual data as they try new ways of working and use the weekly/monthly measurement data to influence further testing and improvement activity. 56

57. This is what you need for a PDSA measure – nothing more57

59. What measures? Outcome measures – directly relates to the overall aim
what is the result?
how is the system performing?
Process measures – are the processes that contribute
to the aim performing as planned?
Balancing measures – assessing from different dimensions
unanticipated consequences, other
factors influencing the outcome 59

60. How do you measure up?
Looking at your driver diagram, can you identify any suitable measures that would help you to understand how you were progressing?
Just take 5 minutes to discuss…
Tabout possible outcome, process and hink balancing measures

61. Driver diagram with measures
Aim
Primary drivers
Secondary drivers
Tests of change
Track calories
Limit daily intake
Meals off
plan
Daily
calorie count
CALORIES IN
Plan meals
Substitute low
calorie
Weight,
BMI,
waist size
Drink water not coke
Limit alcohol
A NEW
HEALTHIER
ME!!
Average
drinks / week
Days between
workouts
Gym 5 x per week
Exercise
Calorie count
% of days
On bike
Exercise
CALORIES
OUT
Cycle to work
MEASURES
1. Rate of
weight loss / week
2. Reduction in units
of alcohol / week
3. Time spent
exercising / week
4. Feel good factor
Fidgeting
Chi balls
EFFECT 61 61
CAUSE

62. SSKS website