Improvement Next Steps

Susan HannahPat O’Connor

Purpose of this session• Current position of the work so far… life in the fast

lane • Revisit the Science of Improvement • Consider your local work through the Lens of

Profound Knowledge • What is your data telling you… your measures

sampling and groups of work (segments) are crucial • Bringing it all together on the driver diagram • Next steps

Back at the Ranch

• Early years work is not the only game in town• Outside the SECC life goes on • Where are your bright spots and how does

everyone know about them

Discuss at your table and find out one new connection or a piece of work that is going well (5 mins)

The Improvement Guide, API

Aim

Measures

Changes

Testing & Implementation

Plan Do Study Act

“What will happen if we try something different?”

“Let’s try it!”“Did it work?”

“What’s next? ”

Cycles of Tests Build Confidence

AP D

S

AP

D S

APD

SA P

DS

Proposals, theories, hunches, intuition

Changes that will result in improvementLearning

from data

Sequence for improvement

Develop a change

Test a change

Implement a change

Sustain & spread a change to other locations

Support with data and consideration of people

Theory &prediction

Test under avariety of conditions

Make partof routineoperations

Study

Act Plan

Do

• 1 client• 1 day• 1 case• 1 worker

Move to 3,5,7…. as confidence grows

Start Small

Smaller Scale Tests: Shrink It!rapid cycles of learning

• Years• Quarters• Months• Weeks• Days• Hours• Minutes

Drop down next “two levels” to plan

test cycle!

Subject Matter Knowledge

Subject Matter Knowledge: Specialist knowledge and skills required to be a good practitioner

Profound Knowledge: The interaction of the theories of systems, variation, knowledge and psychology.

Profound Knowledge

Improvement

Viewing the System to plan for Quality Improvement

Macro – systems : e.g. Local Authority localities, Health Boards

The CPPs

Meso – system :e.g. Education Dept, Social Work Service Primary Care Service

Micro- system :e.g. Nursery School, Local Social Work Team Health Visiting Team

Appreciation of a system

Understanding Variation

Theory of Knowledge Psychology

Values

The Science of Improvement

“The aim of this chapter is to provide an outside view – a lens – that I call a System of Profound Knowledge. It provides a map of theory by which to understand the organisations that we work in.”

I’m sure glad the hole is not in our end!

People unclear on the concept of a system!

What insights might be obtained by looking through the Lens of Profound Knowledge?

Appreciation for a System• Interdependence of sub systems • Processes and interactions• System must have an aim and plan for improvement• Whole is greater than sum of the parts

Psychology• Interaction between people• Motivation• Values, beliefs, assumptions • Will to change

Understanding Variation• Knowledge of baseline• Variation is to be expected• Common or special causes• Reliability

Theory of Knowledge• Learning from theory and experience• Operational definitions • Expert prediction • MFI / PDSA for learning and improvement

Appreciation for a System• • •

Psychology• • •

Theory of Knowledge• • • •

Understanding Variation • • • •

How does the Lens of Profound Knowledge look in your system?

A System for Planning: Integrate Planning for Improvement with Other Organisation Planning Processes

Plan to Operate

FinancialPlanning

Developing OperatingBudget

DevelopingCapitalBudget

Operate and improve the Organisation

Plan to Improve

OperationsPlanning

Human Resources Planning

Product/ServiceDevelopmentPlanning

ProjectPlanning

MarketPlanning

Department and Functional Planning

TrainingPlanning

INPUTS FOR PLANING• Purpose of the Organisation• Market Analysis• Customer Research• Supplier Input• Technology Information• Economic Forecasts• Business needs• Regulations

FutureScenarios

StrategicPlanningProcess

BusinessPlanningProcess

• Key measures of the system• Customer feedback• Employee suggestions• Status of plans

Annually

Quarterly

1 to 5 years

Annually1 to 5 years

Setting Priorities: Process Condition and Strategic Impact Diagram

6

5

4

3

2

1

Strategic Impact (total rating)

Proc

ess

Con

ditio

n

0 5 10 15

7

8 4 2 5

3 19

16610 12

11

15 14 9

21

18 1

High leverage processes: develop improvement charters to address these

Thanks to Edinburgh

Use System Theory to Improve OutcomesMeasurement for Improvement

“If I had to reduce my message … to just a few words, I’d say it all had to do with reducing variation.”

Dr. W. Edwards Deming

Why Do You Need Data and Information?

• To plan for improvement• For testing change• For tracking compliance• For determining outcomes• For monitoring long term progress• To tell their story

Three Types of Measures• Outcome Measures: Voice of the customer or patient. How is

the system performing? What is the result?

• Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?

• Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome)

Fundamental Questions for Measurement

1. How can we monitor the real-time behavior of the system of care, steer it to avoid crashes, and maintain it’s operational reliability?

2. Over time, where are the gaps in practice that indicate a need for system change (i.e. improvement)?

3. In our efforts to improve, what’s working? What changes are improvements? Are we on track to meet our aims?

Look at the Relationships % high CO women referred to Smoking Cessation services

Cessation intervention delivered

Clinical attendance

Rate of pregnant women smokers

21/1

/13

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nursery nurses talking to parents about reading at pick

up time

Reading Bedtime StoriesNu

mbe

r of c

hild

ren

who

had

bed

time

stor

yLittle Stars Nursery

Anytown

Speak to your neighbour

• Where are you in relation to your testing plans in each of the work stream areas?

• Where are you in relation to data and results?

• What are the prevailing challenges you are facing?

What could a family of measures for WS2 look like?

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0102030405060708090

100Percent of 30mth Reviews Completed

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What could a family of measures look like for your area of work

Can you link your activity and potential measures to a driver diagram?

Summary • Improvement links to the big aims (driver

diagrams)• Data and measurement – dashboard of measures• Use of run charts • Annotations• Integration • Local support structure • Leadership removing barriers