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Improvement Next Steps . Susan Hannah Pat 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 K nowledge - PowerPoint PPT Presentation

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Improvement Next Steps

Susan HannahPat OConnor

Purpose of this sessionCurrent 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 townOutside 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, APIAimMeasuresChangesTesting & Implementation

44MFI in 2 parts thinking part 3 Questions.. doing part the PDSA cycle for testing changes

4 basic aspects: aims, measures, changes and testing for implementation

Plan Do Study ActWhat will happen if we try something different?Lets try it!Did it work?Whats next? Northwest Improvement Initiative R. Scoville & I.H.I.Four parts of the cycle:Plan:Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen? Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test. Do:Carry out the change. Study:Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test?Act:Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?

Cycles of Tests Build Confidence

Proposals, theories, hunches, intuitionChanges that will result in improvementLearning from dataNorthwest Improvement Initiative R. Scoville & I.H.I.31Working our way up to implementation is a matter of building belief in the effectiveness of a change. First tests are small scale, under optimal conditions: changes that fail here are discarded quickly.If they succeed, we explore them in more detail: by replication under other circumstances, with different actors, in different locales, etc. If the change looks robust, it will gather the approval it will need for implementation. Along the way, were building confidence in the change.Sequence for improvementDevelop a changeTest a changeImplement a changeSustain & spread a change to other locationsSupport with data and consideration of peopleTheory &predictionTest under avariety of conditionsMake partof routineoperationsStudyActPlanDo71 client1 day1 case1 worker

Move to 3,5,7. as confidence grows

Start SmallIf you think we can test the change in a month, what can you test a day from now?

Small scale, quick teststeams are most effective when they move quickly to testing changes (& maintain momentum)best to first test innovative changes on a small scaleokay to test multiple changes at oncetest under a variety of conditionsimportance of linking tests of change dont try to get buy-in or consensus for tests (but will be necessary for implementation)

8Smaller Scale Tests: Shrink It!rapid cycles of learningYearsQuartersMonthsWeeksDaysHoursMinutesDrop down next two levels to plan test cycle!Northwest Improvement Initiative R. Scoville & I.H.I.When youre in your meeting, thinking about a change you want to test. listen for a time frame. Move down two levels to do a test.

If you hear quartersAsk what test can we do by the end of next week?If you hear weeks, what can do in the next hours. You wont get the change all tested but gets people moving.

This formula helps people rethink the time frame.

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

101010So in the theory of improvement this is what this looks like the vital combination of expertise in the subject and profound knowledge of the system and all the variables that interact and influence one another, impacting on the ability to achieve the desired outcomeViewing the System to plan for Quality ImprovementMacro 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

Systems are large and complex, it is important to consider the different levels that exist within the system so that you can consider what improvement work can be focussed at each level

Macro: is it.CPP collaborative progress meetingsLeadership walkrounds

Meso: Implementation of 27- 30 month reviewsAccess to Education and Health services nursery & primary school, speech and language therapy service, dental services etc

Micro: Effective communication/info sharing between agencies and teamsInfluencing increased uptake in healthy vitamins, child development activities in nursery

11Appreciation of a system Understanding VariationTheory of KnowledgePsychology ValuesThe 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. 12The Syspem of PK provides us with a lens through which we can view and consider our systems.You do not need to be eminent in every aspect of the lens however you need to have some knowledge of how the system functions and appreciate how the relationships and interactions influences the overall function and effectiveness of the system.

Im sure glad the hole is not in our end!People unclear on the concept of a system!If each part of a system, considered separately, is made to operate as efficiently as possible, then the system as a whole will not operate as effectively as possible. Ackoff (1981)

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 changeUnderstanding 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

14Appreciation for a System

Psychology Theory of Knowledge Understanding Variation How does the Lens of Profound Knowledge look in your system?SIS Course December 2012A System for Planning: Integrate Planning for Improvement with Other Organisation Planning ProcessesPlan to OperateFinancialPlanningDeveloping OperatingBudgetDevelopingCapitalBudgetOperate and improve the OrganisationPlan to ImproveOperationsPlanningHuman Resources PlanningProduct/ServiceDevelopmentPlanningProjectPlanningMarketPlanningDepartment and Functional PlanningTrainingPlanningINPUTS FOR PLANING Purpose of the Organisation Market Analysis Customer Research Supplier Input Technology Information Economic Forecasts Business needs RegulationsFutureScenariosStrategicPlanningProcessBusinessPlanningProcess Key measures of the system Customer feedback Employee suggestions Status of plansAnnuallyQuarterly1 to 5 yearsAnnually1 to 5 yearsthere will be a vast breadth of ideas for change and improvement and a number of things in the system to consider

.. how do you prioritise where to invest time and energy that is most likely to impact on the workstream aims of the collaborativeSetting Priorities: Process Condition and Strategic Impact Diagram654321

Strategic Impact (total rating)Process Condition0 5 10 157842531916610 12111514921181High leverage processes: develop improvement charters to address theseThis tool can help identifying the number of possible improvement ideas and current activities and considering the likelihood of impact of the activity you can prioritise the high leverage processes and develop improvement plans for testing. Therefor your time and energy is going into working on processes that will most likely progress you towards the aims of the collaborative.

Thanks to EdinburghNice example of work being taken forward in Edinburgh clearly defining a 6 step approach for embedding 27-30 month reviews18Use System Theory to Improve OutcomesMeasurement for ImprovementIf I had to reduce my message to just a few words, Id say it all had to do with reducing variation.

Dr. W. Edwards DemingIn essence this project is about elimination of variation between teams and within teamsWhy Do You Need Data and Information?To plan for improvementFor testing changeFor tracking complianceFor determining outcomesFor monitoring long term progressTo tell their storyThree Types of MeasuresOutcome 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. una