North Tees and Hartlepool NHS Foundation Trust

Clinical Leadership Development Programme

Leadership and Improvement

All working life in NHSDiagnostic Radiographer and teacherImprovement roles since 1994

BPR Leicester Royal Infirmary 1994 - 1999National Patients ‘Access Team 1999 - 2002NHS Modernisation Agency 2002 – 2005NHS Institute for Innovation and Improvement 2005 -2008

Awarded OBE for services to NHS 2003Visiting professor University of Derby 2008

Jean.penny@btinternet.com Improvement: 17 years and still learning

Understanding the skill of improvement Linking strategic goals and frontline

improvements

What tools and techniques, knowledge and skills are needed to make good sustainable improvements?

If you are familiar with ‘Lean’ ‘LIPS’ ‘Productive Ward’’, what are the underpinning tools and techniques

Any improvement is a change◦not every change is an improvement◦but we cannot improve something unless

we change it

Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River

Press, Massachusetts

Any improvement is a change any change is a perceived threat to security◦there will always be someone who will

look at the suggested change as a threat

Eliyahu Goldratt

Any improvement is a change any change is a perceived threat to security

any threat to security gives rise to emotional resistance◦ you can rarely overcome emotional resistance

with logic alone

Eliyahu Goldratt

“Anyone who thinks you can

overcome emotional

resistance with logic was probably

never married”

Any improvement is a change any change is a perceived threat to

security any threat to security gives rise to

emotional resistance emotional resistance can only be

overcome by a stronger emotion

Eliyahu Goldratt

What to change?◦ Pin point the core problems

What to change to?◦ Construct (simple) practical solutions

How to cause the change?◦ Induce the appropriate people to invent such solutions ◦ they must own the problem

Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River

Press, Massachusetts

1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortable

Make the future attractive

3. Build Will•Plan for improvement•Set aims/allocate resources•Measure system

performance•Provide encouragement•Make financial linkages•Learn subject matter

5. Execute Change•Use Model for Improvement for

design and redesign•Review and guide key initiatives•Spread ideas•Communicate results•Sustain improved levels of performance

4. Generate Ideas•Understand organisation as a

system•Read and scan widely, learning

from other industries and disciplines

•Benchmark to find ideas•Listen to patients• Invest in research and

development•Manage knowledge

2. Establish the Foundation•Prepare personally•Choose and align the senior

team

•Build relationships•Develop future leaders

•Reframe operating values•Build improvement capability

Source: Robert LloydExecutive Director Performance Improvement

Institute for Healthcare Improvement January 16, 2007

Knowledge of Systems

Theory of knowledge

Knowledge about Variation

Knowledge of Psychology

W Edwards Deming (1994) The New Economics

4 equally important parts of improvement

Diagnostic tools e.g. Process and systems

thinking

Project and programme

management

User and public involvement

Change management

Discipline of improvement in health and social care (Penny 2003)

People Process

What

How

Diagnostic tools e.g. Process and systems

thinking

Project and programme

management

User and public involvement

Change management

Discipline of improvement in health and social care (Penny 2003)

People Process

What

How

Macro

Meso

Micro

©Profound Knowledge Products, Inc. 2008 All Rights Reserved

Ask yourself

•What are the problems that cause the bigger problem?

•What are you trying to achieve? (aim for each driver)

•How will you know a change is an improvement ? (outcome measures for each driver )

Drivers

Which in turn contribute directly to the ‘bigger’ aim

AimThe ‘big’ dots

Ask yourself

•What is the big (possibly strategic) problem you are addressing?

•What are you trying to achieve? (aim)

•How will you know a change is an improvement ? (outcome measures)

Ask yourself

What changes can you make that will result in the improvement you seek?

•What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing?

•How will you know a change is an improvement? (process measures for each intervention)

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Interventions The ‘small’ frontline dots

Contribute directly to the drivers

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

The interventions / change ideas that contribute directly to secondary drivers

Secondary Drivers:Contribute directly to

primary drivers

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

?

Primary Drivers:Contribute

directly to the strategic aim

The strategic aim (and

big problem)

Reducing harm in perioperative

care

Reduce surgical site infections

Improve team work and

communications

Appropriate use of prophylactic antibodies

Maintain normothermia

Maintain glycaemic control in known diabetes

Use recommended hair removal methods

Use of the WHOSurgical safety checklist

Primary Drivers Secondary Drivers

Ref. Patients Safety First

North Tees and Hartlepool NHS Foundation TrustCorporate strategy 2010 – 2015• Patient safety• Patient satisfaction• Staff satisfaction• Provider of choice• Quality of services• Governance and mandatory services• Financial stability • New facilitates• Care delivered closer to home

‘High level Aims and objectives’Pages 26 - 29

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

The interventions / change ideas that contribute directly to secondary drivers

Secondary Drivers:Contribute directly to

primary drivers

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

?

Primary Drivers:Contribute

directly to the strategic aim

The strategic aim (and

big problem)

The Model for Improvement breaks things down into small steps and works of the ‘little dots’ – at the frontline

These small steps should be part of the answer to the question of how to move the big dots

Align all improvement projects to strategy

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives

Measuring processes and outcomes

What have others done? What hunches do we have? What can we learn as we go along?Langley G, Moen R, Nolan K, Nolan

T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco

• The more specific the aim, the more likely the improvement

• Repeated clarification - without it aims drift

• Meet needs of external customers

Ishikawa (Fishbone) Diagrams

PPPP

People Place

Procedures Policies

‘The 80-20 Rule’ ‘The Law of the Vital Few’ For many phenomena,

80% of the consequences stem from20% of the causes

Observation that 80% of income went to 20% of the population

Vilfredo Pareto, 1906

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives

Measuring process, outcomes and balancing

What have others done? What hunches do we have? What can we learn as we go along?Langley G, Moen R, Nolan K, Nolan

T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco

Aspect Improvement Accountability Research

Aim Improvement of care Comparison, choice, reassurance, spur for

change

New knowledge

Methods:

• Test Observability

Tests are observable No test; merely evaluate current performance

Test blinded or controlled tests

• Bias Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

• Sample Size “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

• Flexibility of

Hypothesis

Hypothesis flexible, changes as learning takes

place

No hypothesis Fixed hypothesis

• Testing Strategy Sequential tests No tests One large test

• Determining if a Change is an Improvement

Run charts or control charts

No change focus Hypothesis, statistical tests (t-test, F-test, chi

square), p-vlaues

• Confidentiality of the Data

Data used only by those involved with improvement

Data available for public consumption and review

Research subjects’ identities protected

Robert Lloyd Executive Director IHI adapted from Solberg L, Mosser G, Mcdonald S (1997) Three faces of performance

measurement: Improvement, accountability and research Journal of Quality Improvement Vol. 3 No 3

540

550

560

570

580

590

600

610

2007 2008

300

350

400

450

500

550

600

650

Jan-07

Feb-07

Mar-07

Apr-07 May-07

Jun-07

Jul-07 Aug-07

Sep-07

Oct-07 Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08 May-08

Jun-08

Jul-08 Aug-08

Sep-08

Oct-08 Nov-08

Dec-08

Somethingvery important!

Lastmonth

Thismonth

What actionis appropriate?

21.6 23.9 23.3 22.6 28.8 22.7 23.822.8 28.7 22.9 24.2 23.3 28.6 22.8 23.9 23.2 23.7 28.5 23.2 23.5 23.1 27.7

What does this data tell us?What does this data tell us?

Mean = 24.4

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Wee

kly

pro

du

ctio

n v

olu

me

July Aug OctSeptWeek

What does this data tell us?What does this data tell us?

0102030405060708090

Day

1 4 7 10 13 16 19

Seco

nds

to

answ

er p

hon

e

Seven one side

Seven down (or up)

DO

Look for a run of seven points all above or all below the centre line or all increasing or all decreasing

Average length of pre-ward stayStroke Ward

from 01/2007 to 07/2007

0

0.5

1

1.5

2

2.5

3

3.5

1 2 3 4 5 6 7Months

Mike Davidge NHS Institute for Innovation and

Improvement

Average length of pre-ward stayStroke Ward

from 01/2007 to 07/2007

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Weeks

Patient length of pre-ward stay Stroke Ward

from 01/2007 to 07/2007

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Patients

North Tees and Hartlepool NHS

Foundation Trust

Corporate strategy 2010 – 2015

Strategic measures•Patient safety•Patient satisfaction•Staff satisfaction•Provider of choice•Quality of servicesEtc etc

Ask yourself

•What are the problems that cause the bigger problem?

•What are you trying to achieve? (aim for each driver)

•How will you know a change is an improvement ? (outcome measures for each driver )

Drivers

Which in turn contribute directly to the ‘bigger’ aim

AimThe ‘big’ dots

Ask yourself

•What is the big (possibly strategic) problem you are addressing?

•What are you trying to achieve? (aim)

•How will you know a change is an improvement ? (outcome measures)

Ask yourself

What changes can you make that will result in the improvement you seek?

•What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing?

•How will you know a change is an improvement? (process measures for each intervention)

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Intervention 1

Intervention 2

Intervention 3

Interventions The ‘small’ frontline dots

Contribute directly to the drivers

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives

Measuring processes and outcomes

Change ideas: What have others done? What hunches do we have? What can we learn as we go along?

Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco

Solution / change in

organisation A

Change principle Change principle

Solution / change in

organisation B

PDSA cycle for learning and improvement

Act

• what changes are to be made?

• next cycle?

Plan

•objective• questions and predictions (why)• plan to carry out the cycle (who, what, where, when)

Study

•complete the analysis of the data

•compare data to predictions

•summarise what was learned

Do

• carry out the plan• document problems and unexpected observations• begin analysis of the data

We planned to….. ( state the basic plan) In order to ….. (tie it back to the Aim)

What we did was….. (brief description of actions)

Looking at what happened, what we learned from this was….. ( lessons learned)

What we plan to do next is …. (state next plan)

© Paul Plsek

P

D

S

A

PDSA

PDSA

PDSA

PDSA

PDSA

Data Driven Change

Change in Team Culture

Hunches

Theories

Ideas

Aim•What am I trying to achieve?•How will I know a change is an improvement?•What changes can I make that will result in the improvement

Need to start small!!

Affection Trust

Distrust Respect

Extent to which I believe

you care about me

Extent to which I believe you are competent and capable

LOW

HIGH

HIGH

Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill

Think quietly by your self for a few minutes

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement