measure4improve.pdf

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M easurement fo r improvement

Improvement Leaders Guide to

Measurement for improvement

For f ur ther info rmat ion seewww.modern .nhs .uk

AcknowledgementsThe development of t h is guide for

Improvement Leaders has been a trulycol laborative process. We would l ike to

thank everyone who has contr ibuted by

sharing h is or her experiences, kno w ledge

and case studies.

Design Team : Sally Batley, Helen Bevan,

Kevin Cottrel l , Debbie Christ ian,

M ike Davidge, Jim Easton , Richard Green,

Jud y Hargad on , Jul ie Harries, Ruth Kenned y,

M ike M cBride, Nicki M cNaney, Steve ONeil l ,Jean Penny, Neil Riley, Guy Rotherham,

Kate Si lvester, Neil Westw oo d.

Our thanks to Darent Valley Hospital and

Gravesend M edical Centre, Kent fo r th ei r

cooperat ion wi th the photography.

2 0 0 2 Cro w n Co p yr ig h t

Designed by Redho use Lane, 020 7 291 4646

Published by Ancient House Print ing Group,

Ipsw ich , 0147 3 23 2777


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M easurement for improvement

www.modern .nhs.uk / improvementgu ides 1

Forew ord

I am pleased to present t his guide on e of a series fo rIm provem ent Leaders in th e NHS.A key objective for al l of us in the NHS, whatever our role, is to continual ly

look f or w ays to im prove the exper ience and care of pat ients. M anyimprovements have been achieved already, whether as part of a large national

program m e, or on a much smal ler scale, through t he comm itment of a smal l

team of healthcare staff. Everyone involved in such projects has gained so much

know ledge about in i t ia t ing and sustain ing these imp rovements.

The aim of t h is set of guides is to gather th is know ledge into a summ ary of

current th ink ing. Weve put them together in response to a huge demand for

too ls and techniques to support im provement in p at ient care. Al l the gu ides

include useful, practical advice that can be applied in healthcare sett ings.

Written by experienced healthcare staff, they are aimed at al l Improvement

Leaders in the NHS by which w e mean everyone w ho w ants to improve the

care and experience of pat ients, w hether a m anager of a smal l team in general

practice, a director of modernisation for a large Trust, or the cl inical leader of a

team of doctors, nurses or therapists.

As I said, the gu ides are based on current learning and think ing bu t th is is

constantly changing. I f youve found this printed version useful, keep checking

the w ebsi te on www.modern.nhs.uk/ improvementguides

Here the guides wil l be regularly updated as we learn more and have new thingsto share.

Improvement and modernisation is real ly just beginning. I t s an excit ing t ime,

and a g reat o pport uni ty to develop and share new ski l ls and understanding so

w e can t ru ly make th ings bet ter for our p at ients.

David Fi l l ingh am , Director NHS M odernisat ion A gency

Apr i l 2002


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www.modern .nhs.uk / improvementgu ides 3

The Improvement

Leaders Guides

Col lect ively the Imp rovemen t Leaders Gu ides fo rm a

set of pr inciples for creat ing the best condit ions for

imp rovemen t in health care. The greatest ben efi t is w hen

they are used to supp ort a prog ramm e of t ra in ing in

improvement techniques.

Where should I start?The seven guides are not sequential and ideal ly you should read them al l at an

ear ly stage in your im provement project , to be aw are of the t ools and

techniques in a l l the g uides. How ever there are som e th ings w e w ould sugg est

you should do f irst, as you develop your plan based on local needs and

experience.

Each guide includes

som e background in fo rmat ion on t he top ic some activi t ies which you, as an Improvement Leader, may f ind useful to help

the team s you w ork w i th und erstand t he basic pr inc ip les

quest ions that are f requent ly asked abou t t he to pic and suggested w ays to

answ er them

guidance on w here to go for m ore inform at ion. Sources inc lude th e excel lent

toolk i ts that have been produced to supp ort imp rovement program m es in

specific services, such as Cancer, Critical Care, M ent al Health an d Clin ical

Govern ance. Useful bo oks, papers and w ebsites are also l isted


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6 www.modern .nhs.uk / improvementgu ides

Take the th ink ing forw ard.

The websi te wi l l be a dynamic

medium . Please contr ibute t o th e

discussion i f you can. We would

w elcom e and value your experience

Have fun .

M any have said that leading an

improvement project has been on e of

the m ost enjoyable and f u l f i l ling ro les

of their careers!

Le t us know w hat you th ink o f

the guides.

We w ant your comm ents and

thoughts about the Improvement

Leaders Guides. Our aim is to keep

improv ing them so le t us know w hat

you th ink .

how can we im prove the guides? Is

there anything w e have lef t out?

have you f oun d th em u seful? If so

w hich guide in par t icular and w hich

section?

how have you used them? Can you

tell us any stories?

i f there w ere to b e other guides,

w hat top ics shou ld they be on?

have you visited the web site? How

can we im prove it? is there any thing else you would

l ike to te l l us abou t th e

Improvement Leaders Guides

Emai l us now on

[email protected]

A few addit ional thoughts

The guid es are based o n current

th ink ing and experience.

Be aware th at th is is constant ly

changing. Check updates on the

Improvement Leaders Guides website,

www.modern .nhs .uk / improvement

guides w h ich w i ll be updated o f ten as

we test out and learn f rom new

techniques.

Be aw are of your ow n exper ience.

If this f ield is total ly new to you, plan

how you can f ind ou t m ore th rough

fur th er reading or developm ent

courses. If you are m ore fam il iar w ith

leading service imp rovem ents, can

you share you r experiences and

know ledge w i th o thers in your

heal thcare communi ty and the

w ider NHS?

M ake con tac t w i th o thers w ho have

improvement ski l ls.

M any people in heal thcare have had

tra in ing in th e improvem ent sk i lls

contained in these guides. Their

t ra in ing w i ll m ost l ike ly have been fo r

a particular service such as primary

care, derm atolo gy or cancer. M akecontact w i th them to fo rm a hea lth

comm uni ty improvement ne tw ork to

suppo rt and learn f rom each ot her.

Try it for yourself.

These guides dont represent the only

w ay to do th ings, but th ey provide a

good star t ing point . Create your own

case stu dies and then share you r

experiences.

M easurem ent fo r im provem ent


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M easurement for improvement M easurement for improvement

8 w w w .m o dern .n h s.u k /im pro vem en tgu ides w w w .m o d ern .nh s.u k /im p ro vem en tg u id es 9

The f irst st ep is to m easure w hat ever

can be measured easily. This is OK asfar as it goes. The second step is to

disregard th at w hich cant easi ly be

measured or to give i t an arbitrary

qu ant itat ive value. Th is is artif icial an d

misleading. The third step is topresume that what can t be measured

easily really isnt important. This is

blindness. The fourth step is to say

th at w hat can t easi ly be m easured

really doesnt exist. This is suicide.Ch arles Hand y

Conten ts

1. Int rod uct ion

2. M easurement fo r im provement

3. W hat m easures to choose

4. Presentin g you r dat a5. Act iv it ies to supp ort m easurement for im provement

6. Frequent ly asked qu est ion s and answ ers

7. Case study: Developing measurement for improvement

8. Useful reading fo r mo re info rmat ion and ideas

9. Glossary of t erms

1. Int rodu ct ion

You are about t o set of f on your journ ey of improvem ent . You h ave agreed

your overal l aims and objectives and an outl ine project plan. You have

contacted key stakeholders and got thei r supp ort . You m ay have produced

your f i rst p rocess map and are beginning to real ly und erstand the w hole

patient s jour ney. www.modern.nhs.uk/ improvementguides/process

Before you d o anyth ing else, just t ake a l i t t le t ime to imagine yoursel f at t heend of you r journey:

a long that jou rney, you w i ll have m ade many changes, ones wh ich w orked

and some th a t d idn ' t !

how w i ll you know w h ich a re the impo r tan t ones?

how w i ll you know that th e changes you have made have resul ted in an

imp roved service?

If you did no t col lect th e r ight inform at ion to measure progress, you w i l l not

have the evidence to b ack up your g ut f eeling th at th ing s have got bet ter.

So how do you g o abou t col lect ing the evidence to dem onstrate the im pact

you've had? How can you im press colleagues w i th g raphical representat ions

o f imp rovement?


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16 www.modern .nhs.uk / improvementgu ides www.modern .nhs.uk / improvementgu ides 1 7


3.4 Establishing your baselineIt is very im portant that t he per iod you

choose for your baseline is

representative. In the f igure below, the

DNA rate is very variable from month

to m onth . Taking the w hole six m onth

period, the average is just under 9%

but i t had been as li t t le as 0% and as

high as 20% . You w i ll get very var iable

rates w hen the actual num bers

involved are sm all .

This graph show s the danger of

making a measure for judgement .

M easur ing a t m onth 1 and then a t

month 5, i t would be easy to

conclude, wron gly, that there had

been a vast imp rovement in th e DNA

rate.

In an ideal wo rld, you n eed at least six

points on the graph to make an

assessment of th e baseline, and at

least 2 4 to have any understanding ofthe variat ion in the system. But

remember, this is in the ideal world

dont use i t as an excuse to stop

measur ing.

0

2

4

6

8

10Target num ber

Actua l number

Nov00

Dec00

Jan

01

Feb

01

M

ar01

Apr01

M

ay01

Jun

01

Jul01

Aug

01

Sep

01

Oct01

Nov01

Dec01

Jan

02

Feb

02

M

ar02

Apr02

M

onth

Num

berofdays

5 .64 .7

0

4 .23

0 0 0 0

3

0

50

100

150

200

Target number

Actua l number

Nov00

Dec00

Jan

01

Feb

01

M

ar01

Apr01

M

ay01

Jun

01

Jul01

Aug

01

Sep

01

Oct01

Nov01

Dec01

Jan

02

Feb

02

M

ar02

Apr02

130

110 105103

7 0

42 42

21

7 7

M

onth

Num

berofdays

Examp le DNA rates with large variat ion

0

5

10

15

20

25

M o n t h

Perce

ntage

1 2 3 4 5 6

Average = 8 .7%Heart Failure A ccess Outp atients

Case Stu dy: Echo cardiograph y Service in Londo n

The team m easured the t ime in d ays f rom request ing echocardiography to

th e t im e th e results are available for the cl inicians. There w as a great

di f ference for inpat ients and o utp at ients. The team w orked hard and

drastical ly reduced the delay for both groups of patients.

Heart Failure A ccess Inpatients


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Preparation

col lect a selection of run charts,

some showing improvement , someshowing th ings get t ing worse, some

show ing f luctuat ing resul ts , som e

show ing targets a lready

be ing m et and some w i th

inadequate labels

paper and pens for al l part icipants

par t icipants wo rk in smal l groups of

5-8, preferably on round tables in

cabaret style each group has a selection of

run char ts

Instructions to part icipants

consider each run chart in turn

consider the fo l low ing qu est ions:

is t h is ru n ch ar t d em o n st ra t in g

improvement ? Yes or No

w hat ar e t h e reaso n s f o r t h e

improvement , or the reasons wh yno im provement is being

demonstrated?

ho w co u ld t h e ru n ch ar t b e

improved?

Learning point s

the use of run char ts to show

improvements

the need to m easure over t im e the impac t o f the da ta on the

run char ts

the im portance of correct label ling

on a run char t

www.modern .nhs.uk / improvementgu ides 2 5


W hy is this important?

Som e of us take to th e idea of change

more easi ly than others. Some l ike to

develop ideas through activi t ies anddiscussions, w hile oth ers prefer t o

have t ime to th ink b y them selves. W e

are al l dif ferent and need to be valued

for our d i f ferences. The Improvement

Leaders Guide to M anaging the

Hum an Dimensions of Ch ange gives

ideas of h ow to ensure the best

possib le ou tcome w hen w ork ing w i th

di f ferent people.www.modern .nhs .uk /

improvementguides/human

5.1 The m essages of run charts

Objective

to improve the understanding of theuse of run char ts in measur ing fo r

improvement

Benefit

easy to do, bu t you need to b e qui te

c lear about the m easures and t he

detai ls behind th e run char ts for

discussion

Time required

30 minu tes

24 www.modern .nhs.uk / improvementgu ides


5. A ct ivi t ies to sup po rt m easurem ent f or

improvement

Befo re organising an y act ivi ty, consider th e fo l low ing:

w ho is the aud ience?

what is thei r pr ior knowledge?

are the locat ion and t iming of the act ivi ty correct?

recognise and value th at par t icipants w i ll w ant t o w orkand learn in di f f erent w ays. Try to provide info rm ation

and act ivi t ies to suit al l learning preferences


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