1. Making Better Decisions Making Better Decisions – WHAIP Info for Action course 4 November 2010 Presenter: Mike Davidge

2. Making Better Decisions Why do we analyse and present data? To understand the variation that lives within our data To help us make good management decisions in the way we react to that variation Source: Robert Lloyd IHI 2006

3. Making Better Decisions But often we have presented data in a different way...

4. Making Better Decisions The change in Merthyr is remarkable

5. Making Better Decisions Eco-friendly

6. Making Better Decisions Nomination for the Turner Prize

7. Making Better Decisions Every picture tells a story … Does it? Looks pretty – but cannot show change over time

8. Making Better Decisions Why do our processes vary? Mrs Jones runs a B&B establishment in a seaside town. She makes breakfast every morning for her guests before going off to do a cleaning job in the local factory. Recently she has been late and her supervisor has given her a verbal warning. What can she do to avoid being late in future? Her son has been measuring her finish times as part of a GCSE maths project. Let’s look at the results

9. Making Better Decisions Why does her finish time vary?

10. Making Better Decisions Walter A. Shewhart (early 1920’s, Bell Laboratories) While every process displays variation: some processes display controlled variation (common cause)  stable,consistent pattern of variation  constant causes/ “chance” while others display uncontrolled variation  pattern changes over time  special cause variation/“assignable” cause

11. Making Better Decisions Shewhart’s purpose Data contains both signal and noise. To be able to extract information, one must separate the signal from the noise within the data.

12. Making Better Decisions Upper process limit Mean Lower process limit A typical process control chart

13. Making Better Decisions The variation in Mrs Smith’s process Common Cause = Consistent over time & part of the process Special Cause = Irregular in time & indicates a changed process Group the causes into common & special Are there any that cannot be grouped?

14. Making Better Decisions So why run or control charts? One picture, one message Shows change over time Allows you to see variation Hospital X

15. Making Better Decisions Example #1: 2 data points MRSA at Hospital X Are we getting better? Measuring rare events

16. Making Better Decisions Have things improved during 2005? Hospital collecting the date of specimen (event) for each MRSA specimen from January 2005 to February 2006 Improvement this quarter?

17. Making Better Decisions We have 2 quarterly data points - is this an improvement? Higher is better

18. Making Better Decisions Are we assuming something like this?

19. Making Better Decisions But it could be like this...

20. Making Better Decisions Or this...

21. Making Better Decisions Or this!

22. Making Better Decisions How have I analysed the data? I have calculated the gap between successive specimen events in days  For example if the first event was on 1 Jan 2005 and the second was on 17 Jan 2005 then the gap is 16 days I have plotted the gaps on a run chart to see whether there is evidence of a change over time If MRSA is becoming less prevalent then the gaps between occurrences will get larger If MRSA is becoming more prevalent then the gaps between occurrences will get smaller

23. Making Better Decisions Hospital X Setting the baseline Using the first 25 gaps Average is 5 days But could have gaps of upto 18 days Data plotted shows that performance is predictable within the limits

24. Making Better Decisions Performance over the year Hospital X Baseline period

25. Making Better Decisions Hospital X Performance over the year A more unstable period with a large gap typically followed by a short one

26. Making Better Decisions Hospital X Performance over the year In January 2006, a series of events one after the other suggesting a worsening in performance

27. Making Better Decisions Questions What caused the unstable period in the second half of 2005?  Was it simply that having found 1 event people were more active in spotting another?  Did one event cause the next?  Was it a data collection issue? Did things really get worse in 2006?  We don’t have quite enough points on the chart to be certain but the question is worth asking as the pattern of events does seem to have changed

28. Making Better Decisions The MBFC Index You will need a coin And two free hands! Just how competitive can you get?

29. Making Better Decisions Sustainable processes You need about 6 data points to confirm a change You need to continue measuring to assure yourself that the change is sticking “In God we trust, all others bring data” W Edwards Deming Percent using SBAR

30. Making Better Decisions X X X X X X X X X LCL UCL MEAN X X X X X X X X X X LCL UCL MEAN X Point above UCL Point below LCL SPECIAL CAUSES - RULE 1

31. Making Better Decisions MEAN Seven points above centre line SPECIAL CAUSES - RULE 2 LCL UCL LCL UCL X X X X X X X X X X X X X X X X X X X X X Seven points below centre line

32. Making Better Decisions MEAN Seven points in a downward direction SPECIAL CAUSES - RULE 2 LCL UCL LCL UCL X X X X X X X X X X X X X X X X X X X X X Seven points in an upward direction

33. Making Better Decisions SPECIAL CAUSES - RULE 3 X X X X X X X X X X X X X X X X X X X X Cyclic pattern X X X X X X X X X X X X X X X X X X X LCL UCL LCL UCL Trend pattern

34. Making Better Decisions SPECIAL CAUSES - RULE 4 Considerably less than 2/3 of all the points fall in this zone X X X X X X X X X X X X X X X X X LCL UCL X X X X X X X X X X X X X X X X X X X X X X X X X X LCL UCL Considerably more than 2/3 of all the points fall in this zone

35. Making Better Decisions Rules for special causes Rule 1 Rule 2 Rule 3 Rule 4 Any point outside one of the control limits A run of seven points all above or all below the centre line, or all increasing or all decreasing Any unusual pattern or trends within the control limits The number of points within the middle third of the region between the control limits differs markedly from two-thirds of the total number of points

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38. PROCESS 3 X X X X X XX X X X X X X X X X X X X X X PREDICTABLE? YES / NO / NOT SURE RULE 1 2 3 4

39. Making Better Decisions PROCESS 4

40. Making Better Decisions

42. SPC tools BP chart  Type BP Chart.xls into Google Baseline  See handout Winchart from Prism Europe  http://www.winchart.net/ Chartrunner from PQ Systems  http://www.pqsystems.com/products/SPC/CHARTrunner/CH ARTrunner.php

43. Making Better Decisions Useful references Donald Wheeler. Understanding Variation. Knoxville: SPC Press Inc, 1995 Donald Wheeler. Making sense of data. SPC for the service sector. Knoxville: SPC Press Inc, 2003 WE Deming. Out of the crisis. Massachusetts: MIT 1986 American Society for Quality www.asq.org/about/history/shewhart.html Donald M Berwick. Controlling variation in health care: a consultation from Walter Shewhart. Med Care 1991; 29: 1212-25. Walter A Shewhart. Economic control of quality of manufactured product. New York: D Van Nostrand 1931.

44. Making Better Decisions Example #2: How often? Barnsley stroke pathway time in hospital before getting onto stroke ward

45. Making Better Decisions Monthly data shows improvement

46. Making Better Decisions Weekly data tells a different story

47. Making Better Decisions Example #3: Link to change SPI project Medicines management

48. Making Better Decisions % medicines reconciled UHW MAU Form piloted Form printed Letter from CDs Pharmacy included