wave 6 improvement science in action - east london nhs
TRANSCRIPT
Morning Reflection
QI
Improving access to C&H adult mental health services
Project lead: Andrew Horobin
Project team: Andrew Haynes, Amrus Ali, Mark Salter, Charlie Kennedy Scott, Auzewell Chitewe, Maria Lee, Jen Taylor-Watt Priscilla Kent Mark Salter
Project sponsor: David Bridle
Background
We chose this project following concerns that patients in C&H were waiting too long for their first assessment by our adult mental health service.
December 2014: 30% patients seen within 28 days (required target 95%).
Why does this matter?
• This will address the needs of the patient in a timely manner and therefore improve patient experience (and carers).
• Will reduce risks to patients.
• Will improve staff satisfaction.
• Will meet KPI targets.
• Improving GP satisfaction.
• Meets commissioning requirements.
AIM: 95% of patients to be given an appointment
for face-to-face contact with any HCP within non-
specialist services in City & Hackney within 28
days by April 2017.
Background
UCL
LCL
0%
10%
20%
30%
40%
50%
60%
Oct-
14
No
v-1
4
De
c-1
4
Ja
n-1
5
Feb-1
5
Ma
r-1
5
Apr-
15
Ma
y-1
5
Ju
n-1
5
Ju
l-1
5
Au
g-1
5
Se
p-1
5
Ap
po
intm
en
ts s
ee
n w
ith
in 2
8 d
ays
/ %
C&H CMHT % seen within 28 Days - P Chart
Baseline Data
What system are you focused on?
Referral Received
Information Screening
Referrals Meeting
Initial Assessment (face-to-face)
Assessment DNA
Assessment appointment
booking
High level process:
Current change ideas are targeted here.
Detailed Flow Chart
Driver Diagram
By 1st April 2017 we
Pre-Testing Task 1: Data cleansingIs the data correct? : administration processes
Pre-Testing Task 2: Process MappingWhat is the process from receipt of referral to assessment appointment
Pre-Testing Task 4: Caseload cleansingDuty Dr, creation of referral database
Pre-Testing Task 3:Demand/capacity – extra clinic assessment capacity, GP realignmentUnderstanding of process; audit of each step
Pre-Testing Tasks & Activities
PDSA: Daily allocation meeting
A P
S D
A P
S D
Cycle 1: Run daily referrals allocation meetings at CHAMRAS each day, to
review new referrals received. (T)
Cycle 2: Re-run the PDSA with just the North Recovery Team
consultants. Study & act on process measures weekly (NB: Outcome measure can only be seen a month later after 28 days). (T)
Cycle 3: Extend PDSA to include South Recovery
Team Consultants. (T)
Ramp 1: Daily Allocation MeetingDaily referrals meetings to remove the inbuilt 1-7days wait that comes from weekly referrals meetings.
Key:
• Plan to test (P)
• Are currently testing (T)
• Are or have implemented (I)
• Abandoned (A)
PDSA Cycle Strategy
OUTCOME MEASURES:Wait Times: Average wait time from referral to first face-to-face appointment (internal and external referrals and includes DNAs and cancellations)Seen in 28 days: % of patients who are referred to the service who are seen face-to-face within 28 days (clock reset on DNA or Cancellation) (under construction)
PROCESS MEASURES: Breach Assessments: Number of patients seen by CHAMRAS team due to long waits to be seen by allocated Dr/team (we replaced this with the overspill clinic) (under construction)Other: Specific process measures will arise with each test
BALANCING MEASURES:%DNAs: DNAs before first face-to-face contact / total number of appointments booked (excluding cancellations) Referrals: No. of referrals into the team (internal and external)
Measures
Charts
Data Cleaning
On-call Dr Assessments
Daily Referrals Meeting
Diary Management
Centralized Booking
1st Class Stamps
SMS Reminders
49% Reduction
July August September
1st Appointment DNAs 25% 26.43% 33.3% 29.12% ↗
Assessment within 28 days 95% 92.65% 95% 96.3% ↗
Latest Data
Data Cleaning
On-call Dr Assessments
Daily Referrals Meeting
Diary Management
Centralized Booking
1st Class Stamps
SMS Reminders
128% Increase
Learning• Its hard to engage teams in subjects like this as no teams have ever looked
at their performance in this way before
• Inter disciplinary conflict
• Data Quality (in = data out)….what are we really reporting to our staff/ patients/ commissioners
• Project linked to KPIs so voice of customer is the commissioners
• Getting “buy in” to test new ways of working has been difficult
• Centralising the appointment booking process has been challenging
• Meeting to talk about the project is a challenge.
• We didn’t know/ understand the whole system until we tried to define it…. We are still not 100% clear on exact capacity in the system. Work is ongoing.
• The complexity and size of the project needs to be considered carefully and resource allocated
• Giving project high profile sponsors such as Clinical Director helps move project forward
What next?
• Separate DNA QI project
• ‘Deep dive’ into 28 day breaches
• Service user involvement
• Refreshing referral criteria.
• Revisiting previous change ideas and ensuring they are implemented and the system can still support them.
OK…
time to
WAKE
UP!
Definition of a System
“A group of items, people, or processes working together toward a common
purpose.”
Langley, et al. The Improvement Guide,
Jossey-Bass Publishers, 2009: pages 77 -79.
Role of the System
The discipline of seeing interrelationships graduallyundermines older attitudes of blame and guilt. We begin tosee that all of us are trapped in structures, structuresembedded both in our ways of thinking and in theinterpersonal and social milieus in which we live. Ourknee-jerk tendencies to find fault with one anothergradually fade, leaving a much deeper appreciation of theforces within which we all operate.
This does not imply that people are simply victims ofsystems that dictate their behavior. Often, the structuresare of our own creation. But this has little meaning untilthose structures are seen. For most of us, the structureswithin which we operate are invisible. We are neithervictims nor culprits but human beings controlled by forceswe have not yet learned how to perceive.
Peter Senge, The 5th Discipline
Characteristics of a System
• A system has an aim or purpose
• The network of factors that lead to outcomes of value to stakeholders
• Factors comprise structures, processes, culture, personnel, geography, and much more.
• Dynamic: The “thing in motion”
• The system is perfectly designed to achieve the results it gets!
• Improving outcomes requires understanding the dynamics of the system
“Every system is perfectly designed to achieve
the results that it gets”
Courtesy of Richard Scoville
Atlanta’s infamous “Spaghetti Junction”
XWhere you
want to go!
25
Step 1:
Pick a number
from 3 to 9
Step 2:
Multiply your
number by 9
Step 3:Add 12 to the
number from step 2
Step 7: Write down the
name of a country
that begins with
your letter
Step 4:
Add your 2
digits together
Step 5:Divide # from step 4
by 3 to get a 1
digit number
Step 6:Convert your
Number to a letter:1=A 2=B 3=C
4=D 5=E 6=F
7=G 8=H 9 = I
Step 8: Go to the next
Letter: A to B,
B to C, C to D,
etc.
Step 9: Write down the name
of an animal (not bird,
fish, or insect) that
begins with your letter
from Step 8
Step 10:
Write down
the colour of
your
animal
Do
you have
a 2-digit
Number?
Result:
Colour__________
Animal________
Country________
Does the system determine the outcome?
26
A Grey Elephant in Denmark
Inputs Processes Outcomes
Materiel
Participants
Equipment
Stakeholders
© Richard Scoville & I.H.I.
InputsInputs Processes(Voice of the Process)
Outcomes(Voice of the
Customer)
Components of a System
Process = a sequence of decisions and actions that delivers value to stakeholders
What principle characterizes a system?
29
Levels of the System
Whole Trust
Directorate
Single team
Macro-systems
(e.g. a hospital, multiple hospitals, a state, a region)
Meso-systems
(e.g. a division, a clinical department, pathology, IT)
Microsystems
(e.g. a ward or unit, a clinic, home care nurses
S + P + C* = O
Structure + Process + Culture* = Outcomes
Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment. Ann
Arbor, MI, Health Administration Press, 1980.
Drivers of the System
*Added to Donabedian’s original formulation by R. Lloyd and R. Scoville
Defining your messy system
The Driver Diagram is a tool to help us
understand the system we wish to improve
It helps you focus on Outcomes and
the Processes that drive the outcomes
AIM
Primary
driver
Primary
driver
Secondary
driver
Secondary
driver
Secondary
driver
Secondary
driver
Secondary
driver
Change
1
Change
2
Change
3
How might you Improve the System?
AIM:Lose 5kg
in 3 months
Calories
in
Calories
out
Limit daily
intake
Substitute
low calorie
food
Avoid
alcohol
Exercise
Fidgeting
Track
calories
Plan meals
Drink water,
not Coke
Work out 3
times a week
Cycle to
work
Hacky sack
in office
Example: Building a new me!
Two Main Categories
Primary Drivers
System components that impact your
Outcome(s)
Secondary Drivers
• Components of the associated Primary
Drivers
• Can align to projects or a change package
that can affect the Primary Drivers and
ultimately your Outcome(s)
To improve the inpatient
experience for adult female
inpatients on a mental health unit in order to increase
satisfaction by 25% in 10 months
Ward Environment
Bed occupancy
Stop sleep outs
Multidisciplinary Ward Team Process
Nursing input
Pharmacy input
Family support
Patient Choice
Ward round
Complaints
Ward ActivitiesOT programme
Add senior OT to project team
Review of delays at weekly bed meetings
AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS
Rewrite protocol
Offer pharmacy advice to every patient during
stay
Ensure daily 1:1 time with named nurse
Change concept of large MDT ward round
meetings
Train one staff member on each ward to use
support skills
To change OT programme content
Improving quality of care on an inpatient female psychiatric ward
37
Driver Diagram Tip 1
Drivers and Processes are Linked!
Primary
DriversOutcome
Secondary
Drivers
Ideas for
Changes
AIM:
A New
ME!
Calories In
Limit daily
intake
Track
Calories
Calories
Out
Substitute
low calorie
foods
Avoid
alcohol
Work out 5
days
Bike to
work
Plan
Meals
Drink H2O
Not Soda
Exercise
Fidgiting
Hacky
Sack in
office
List days
cooking v.
leftovers
List dishes
to prepare
List
ingredients
Ingredient
on hand?
Add item to
list
Shop from
listNO
YES
Set aside for
meal
Improving the reliability,
consistency, usability or
efficiency of processes is
central to improving system
outcomes.
Source: Richard Scoville & I.H.I.
38
Driver Diagram Tip 2
Don’t forget about the timing of change!
Primary
DriversOutcome
Secondary
Drivers
Ideas for Process
Changes
AIM:
A New
ME!
Calories In
Limit daily
intake
Track
Calories
Calories
Out
Substitute
low calorie
foods
Avoid
alcohol
Work out 5
days
Bike to
work
Plan
Meals
Drink H2O
Not Soda
drives
drives
drives
drives
drives
drives
drives
drives
Exercise
Fidgiting
Hacky
Sack in
office
Source: Richard Scoville & I.H.I.
Outcomes
Outcome
measures
change
more slowly
Process measures
change more quickly
Processes
39
ExerciseDriver Diagram
• Review the Driver Diagram you developed for your project.
• Is your Driver Diagram reflecting a macro, meso or micro level system?
• Do your primary drivers adequately capture the ‘big buckets’ that drive the outcomes?
• Which secondary drivers will your change ideas be working on?
Demo
Stop and Think
Is your aim so huge that it’s just too big to contemplate?
Do you need to drill down a level?
41
Driver Diagram Tip 3
Cascade your driver diagram by drilling down
42
Most
cascades
start at the
top!
And,
trickle
downward…
A typical top-down cascade
Board &
CEO
Executive
Team
Single Teams
Directorates
The Big Dots
Mesosystem
Macrosystem
Microsystem
Think about reversing the
cascade!
Inverted PyramidsTraditional
Pyramids
Adapted from the work of Dr. Gene Nelson, Dr. Paul Batalden and Marjorie Godfrey
Quality By Design: A Clinical Microsystems Approach, Jossey-Bass, 2007.
So, think about building an inverted pyramid
Micro: Single Teams
Meso: Directorates
Macro
Level 1
Level 2
Level 3
Adapted from R. Lloyd & G. Nelson, 2007
Micro Level
Macro Level
Start with the Little Dots
You begin the adequate treatment
within four weeks
The diagnosis and treatment with ’best
method’ is offered
The best possible health promotion
measures and efficient screening
program is offered
Equally good palliative care is provided
no matter of the place of residence
Prevention
Early detection
Investigation/Treatment
Investigation/Treatment
Patient’s Involvment
Multi-disciplinary Collaboration
Palliation
Our promise to
patients with colon
cancer
Good health care
Regional cancer center should
Prioritise patient-oriented research in
oncology
Interactive research approach in
several parts of the project
You are well informed / involved in the
entire healthcare chainPatient’s involvment
The primary effect
"What?
Secondary effect
"How?’’
Goal/
objectives
Improving Care for Colon Cancer Patients
You begin the adequate treatment
within four weeks
The diagnosis and treatment with ’best
method’ is offered
The best possible health promotion
measures and efficient screening
program is offered
Equally good palliative care is provided
no matter of the place of residence
Prevention
Early detection
Investigation/Treatment
Investigation/Treatment
Patient’s Involvment
Multi-disciplinary Collaboration
Palliation
Our promise to
patients with colon
cancer
Good health care
Regional cancer center should
Prioritise patient-oriented research in
oncology
Interactive research approach in
several parts of the project
You are well informed / involved in the
entire healthcare chainPatient’s involvment
The primary effect
"What?
Secondary effect
"How?’’
Goal/
objectives
Patient
Involvement
Newham Centre for MH OT pathway
Change IdeasSecondary DriversPrimary DriversAIM
Increase the effectiveness of planning and implementation of OT intervention following admission to NCMH:
* Accurate identification of needs at admission
* For intervention crucial to successful admission or discharge, that these are implemented in a timely
way and recorded to match
* For other interventions to be prioritised planned
and clearly recorded
Admission information, process & pathway
Accurate information
MDT assessment
Changes to pathway post initial plan
OT Triage and screening Triage OT capacity
Caseload monitoring tool/management
process
OT intervention delivery
SU outcome measure
SU satisfaction measure
Review standards for delivery
Service user knowledge and engagement
MDT discharge planning
Ward round
Bed management meeting
OT senior at bed management meeting
Panel processesKnowledge and access
to community resources
Community information
Locality OTs
OT goals embedded on Rio
Change IdeasSecondary DriversPrimary DriversAIM
By December 2015
100% of service users
admitted to NCMH
will be screened for
OT need by a senior
OT each month.
NCMH admission report (Reporting
Services)
Updated daily
Screening OT daily
Wider team respond
OT Triage spreadsheet
Time to transfer data
Develop spreadsheet and
data transfer process
Simple daily accuracy check by
countAdmin staff
Senior OT staff (Screening rota)
New sheet ready each month
Time to screen
Screening process training
Knowledge of service structure
IT access
Time for accuracy check
Shared approach to screening
Newham Centre for MH OT pathway
ExerciseDriver Diagram
• Use the Driver Diagram you just reviewed.
• Review the Secondary Drivers you identified on this initial Driver Diagram.
• Select one of the Secondary Drivers and make it the Outcome of your new Driver Diagram.
• Identify the Primary and Secondary Drivers of this new outcome.
• Do you need to cascade down another level
Time to Set Some!
Imp
ort
an
tUrgent Not Urgent
1(Manage)
Urgent and Important
Do it now!
2(Focus)
Important but not urgent
Decide when to do it!
Quadrant of Necessity Quadrant of Quality &Personal Leadership
No
t Im
po
rta
nt
3(Avoid)
Urgent but not important
Delegate it!
4
(Avoid)
Not important andnot urgent
Drop it!
Quadrant of Deception Quadrant of Waste
Stephen
Covey’s 4
quadrants of
time
management
Imp
ort
an
t
Urgent Not Urgent
1(Manage)
• Crisis• Medical emergencies• Pressing problems• Deadline-driven projects• Last-minute preparations for
scheduled activities
2(Focus)
• Preparation/planning• Prevention• Values clarification• Exercises• Relationship building• True recreation/relaxation
Quadrant of Necessity Quadrant of Quality &Personal Leadership
No
t Im
po
rta
nt
3(Avoid)
• Interruptions, some calls• Some mail & reports• Some meetings• Many “pressing” matters• Many popular activities
4(Avoid)
• Trivia, busywork• Junk mail• Some phone messages/e-mail• Wasting time• Escape activities• Watching mindless TV shows
Quadrant of Deception Quadrant of Waste
What’s Next?Prioritise Your Drivers!
Adapted from Richard Scoville.
Limitations of resources, attention, and will
usually mean we cannot work on everything.
• Which drivers do we believe will deliver the
biggest impact?
• Which ones will be easiest to work on?(Factors include personnel, culture, resources)
• What is our current level of performance on
these drivers?
• What is your level of ambition?
56
Oral Health Clinic Project
Source: Richard Scoville, Ph.D.
At OHC over 16 months, we will
1) increase the % of pts completingcaries control within 2 month by
X% and
2) decrease the % of “riskmanagement” pts who need
treatment for new caries by Y%
(active pt = 18+ w/ >=1 visit in past 2years, not withdrawn)
Risk Management
(no active caries)
Timely Scheduling ofAppointments
Caries Control
(all active cariesrestored)
Treatment Planning & Execution
Patient Education & Support
Risk assessment, communicationof risk status
Patient Self Management (hygiene& preven. Products)
Patient Sense of Urgency,Acceptance of Protocol
Ability/Willingness to Pay
Population Management
Patient Diet
Risk-based preventive care(cleaning, etc)
Timely restorative care for newcaries
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLow Impact
Process WELL
defined
Process NOT
defined
Oral Health Care Prioritisation
0 1 2 3 4
5
58
Oral Health Clinic Project
Source: Richard Scoville, Ph.D.
At OHC over 16 months, we will
1) increase the % of pts completingcaries control within 2 month by
X% and
2) decrease the % of “riskmanagement” pts who need
treatment for new caries by Y%
(active pt = 18+ w/ >=1 visit in past 2years, not withdrawn)
Risk Management
(no active caries)
Timely Scheduling ofAppointments
Caries Control
(all active cariesrestored)
Treatment Planning & Execution
Patient Education & Support
Risk assessment, communicationof risk status
Patient Self Management (hygiene& preven. Products)
Patient Sense of Urgency,Acceptance of Protocol
Ability/Willingness to Pay
Population Management
Patient Diet
Risk-based preventive care(cleaning, etc)
Timely restorative care for newcaries
59
What’s The Status of This Driver/Process?
LEVEL DEFINITIONAPPROXIMATE
RELIABILITY
0Driver is not defined or status is unknown
1
There is an informal understanding about the driver
by some of the people who do the work. No widely
recognized or formal written description of the driver.50%
2
Driver is documented. driver description includes allrequired participants (including families where
appropriate). The driver is understood by all.80%
3
The driver is well-defined, and enacted reliably.
Quality measures are identified to monitor outcomes of
the driver and may be in use by few/some.90%
4
Ongoing measures of the driver are monitored
routinely by key stakeholders and used to improve the
driver. Documentation is revised as the driver is
improved.
95%
5
driver outcomes are predictable. driveres are fully
embedded in operational systems. The driver
consistently meets the needs and expectations of all
families and/or providers.
99%
DRIVER STATUS
.
D
Driver outcomes are predictable. Drivers are fully
embedded in operational systems. The driver
consistently meets the needs and expectations of all
families and/or providers.
Driver is documented. Driver description includes all
required participants (including families where
appropriate). The driver is understood by all.
P.48
60
What Is It’s Predicted Impact?
LEVEL DEFINITION
0This driver has no impact or does not apply to our system
of care
1
This driver has only minimal or indirect impact on patient
services and outcomes
2
This driver will improve services for our patients, but
other driveres are more important
3
This driver has significant impact on outcomes for our
patients
4
This driver is necessary for delivering patient services It
has a major, direct impact on the outcomes.
5
This driver is absolutely essential for achieving results.
Improvement in this driver alone will have a direct,
immediate impact on outcomes
PREDICTED IMPACT
This driver has no impact or does not apply to our system
of care.
This driver has only minimal or indirect impact on patient
services and outcomes.
This driver will improve services for our patients, but other
drivers are more important.
This driver has significant impact on outcomes for our
patients.
This is necessary for delivering patient services. It has a
major, direct impact on the outcomes.
This driver is absolutely essential for achieving results.
Improvement in this driver alone will have a direct,
immediate impact on outcomes.
P.49
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLow Impact
Process WELL
defined
Process NOT
defined
Oral Health Care Prioritisation
0 1 2 3 4
5
Scheduling
Results of OHC Prioritisation
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLow Impact
Process WELL
defined
Process NOT
defined0 1 2 3 4
5
Results of OHC Prioritisation
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLow Impact
Process WELL
defined
Process NOT
defined0 1 2 3 4
5
Which cell should they focus on?
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLow Impact
Process WELL
defined
Process NOT
defined
High impact, not well defined processes are
key targets for improvement!
1
43
2
5
0 1 2 3 4
ExercisePrioritising Drivers
• Use the Prioritising Drivers Worksheet.
• Plot your secondary drivers on the grid based on your assessment of: (1) how well the process is defined, and (2) the level of impact that the driver can have.
• Discuss and select the drivers that are most important for improving your system of care.
Prioritising Drivers Worksheet
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLower Impact
Process WELL
defined
Process NOT
defined 0 1 2 3 4
5
P.50
So, it is now time to
“hang” measures on your
Driver Diagram.
The Driver Diagram
is conceptual picture
of the system you
want to improve.
We need to move the
concepts on your
Driver Diagram to
have specific
measures that define
the concepts.
Driver Diagram Tip 4Move from Concepts to Measures!
68
Concept Potential Measures
Patient Falls Percent falls
Fall rate
Number of falls
Wait Times Percent seen within 28 days
Average wait times
Number of referrals received
Percent DNAs (Did not Attend)
Employee Evaluations Percent of evaluations completed on time
Number of evaluations completed
Variance from due date
Every concept can have many measuresSource: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett, 2004.
AIM:Lose 5kg
in 3 months
Calories
in
Calories
out
Limit daily
intake
Substitute
low calorie
food
Avoid
alcohol
Exercise
Fidgeting
Track
calories
Plan meals
Drink water,
not Coke
Work out 3
times a week
Cycle to
work
Hacky sack
in office
System for Building a New Me!
AIM:Lose 5kg
in 3 months
Calories
in
Calories
out
Limit daily
intake
Substitute
low calorie
food
Avoid
alcohol
Exercise
Fidgeting
Track
calories
Plan meals
Drink water,
not Coke
Work out 3
times a week
Cycle to
work
Hacky sack
in office
System for Building a New Me!
• Weight
• BMI
• Waist size
• % body fat
Daily
calorie
count
Calorie
burnt
exercising
mg of fat
mg of sodium
mg cholesterol
# sodas each week
% of meals off
plan
Daily total
• % opportunities used
Minutes playing
game
# miles per week
Days
between
workouts
Total
minutes
spent
exercising
# drinks per week
Measures let us:
• Monitor progress in improving the system
• Identify effective changes
ExerciseHang Measures on your Driver Diagram!
Make sure that these are the most appropriate measures for the concepts you wish to
measure.
On your driver
diagram, “hang” the
outcome and
process measures
you will need to track
improvement in your
system or project.
Additional resources on Driver
Diagrams can be found on the IHI
Open School and You Tube. Just type
“ihi driver diagrams” into the You Tube
search box and you’ll find Bob &
Rebeca describing Driver Diagrams
and providing an example.
Langley, et al, The Improvement Guide, 2009
A Model for Learning and Change
Now, let’s dive
deeper into
the PDSA
cycle!
A Framework for Improvement
• Establish appropriate measures
• Set an aim and goal for each measure
• Develop theories and predictions on how you plan
on achieving the aim and an appropriate time
frame for testing
• Test your theory, implement the change concepts,
follow the measures over time and
• analyze the results
• Revise the strategy as neededPlan
Study
Act
Do
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
What will
happen if we
try something
different?
Let’s try it!Did it
work?
What’s
next?
The PDSA Cycle for Learning and Improvement
Theoretical
Concepts
(ideas & hypotheses)
Interpretation
of the Results
(asking why?)
Information
for Decision
Making
Data
Analysis and
Output
Select &
Define
Indicators
Data
Collection (plans & methods)
Deductive Phase
(general to specific)
Inductive Phase
(specific to general)
Source: R. Lloyd Quality Health Care, 2004, p. 153.
Theory
and Prediction
The scientific method provides the
foundation for the PDSA cycle
You do PDSAs throughout the
Sequence of Improvement
Sustaining improvements
and Spreading changes to
other locations
Developing
a change
Implementing a
change
Testing a
changeAct Plan
Study Do
Theory
and
Prediction
Test under a
variety of
conditions
Make part of
routine
operations
The Sequence
Testing/Implementation/Spread
• Pre-Testing: Collecting data or developing a change. At
this point you don’t have an idea (theory) to test yet. In this
stage we are learning about the system, looking for ideas to
test and understanding the variation in the system.
• Testing: Trying and adapting existing knowledge on a small
scale and under different conditions. Learning what works
in the system.
• Implementing: Making a tested change a part of the day-
to-day operation of the system in your pilot population.
• Spreading: adapting change to areas or populations other
than your pilot population(s).
Now the really hard work begins!
84
But you actually do PDSAs every day
AP D
S
A
P
D
S
AP
D S
A
P
D
S
APD
S
A
P
D
S
A P
DS
Repeated Use of the PDSA Cycle is
Essential for Improvement
Hunches
Theories
Ideas
Changes That
Result in
Improvement
Very Small
Scale Test
Follow-up
Tests
Wide-Scale Tests of Change
Implementation of Change
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 Improvement
Sequential building of
knowledge under a wide range
of conditions
Spreading
Sustaining the gains
To Be Considered a PDSA Cycle:
• The test or observation was planned(including a plan for collecting data).
• The plan was attempted (do the plan).
• Time was set aside to analyze the data
and study the results.
• Action was rationally based on what was learned.
Source: Improvement Guide pp.60-61
Why test? Why not just implement &
spread?
• Increase your degree of belief
• Give yourself an evidence base
• Learn from ‘failures’ without affecting performance
• Learn how effective this change might be
• Learn how the change works in different conditions
• Minimise resistance to implementation
• Evaluate costs and side-effects
In the following case study you will see a
number of PDSA cycles.
• How many PDSAs were performed?
• What do you think the theories and
predictions for each cycle were?
• What was learned through failure and
through success?
PDSA Example
The Case of the Sunken Vehicle(s)
Think you're having a bad
day? Check this out!
Call out the tow
truck! This will be
a no-brainer and
we’ll be at the pub
in a few minutes!
Car - upside down in
the water - see owner
standing on it?
“I could have
sworn I set the
emergency
brake!”
Coming back up …
…coming...coming…
Coming up...
almost there!
Ooops.... Slight
miscalculation!
So much for that
theory!
"I could have
sworn I set the
brakes on that
truck! Did we
block the
wheels?”
The answer…
Get a BIGGER
crane!
Ok, now that we have the
car out, let's get that other
crane out of there!
Here comes the crane
out of the water.
We’re looking good.
Just a little bit
more and we’ll
be there. Then it
will definitely be
time for the pub!
Oh no! Who's going to explain
this one to the insurance guys?
Shall we try another PDSA?
A game about theory & predictionthe key elements of PDSA
A game about theory & predictionthe key elements of PDSA
• Your aim is to identify the theory behind a sequence of numbers, so that you can predict the next numbers in the sequence
• You have three choices:
─ Develop a change
─ Test
─ Implement
A game about theory & predictionthe key elements of PDSA
• Your aim is to identify the theory behind a
sequence of numbers, so that you can predict
the next numbers in the sequence
• You have three choices:
─ Develop a change (observe and learn)
─ Test (predict the next number in the sequence)
─ Implement (predict the next 6 numbers and
write down the theory)
As in real life, there are different risks &
costs associated with each optionCost Result
Developing a change £1,000
Test a change £2,000
- if successful test Gain £2,000
- if wrong by 1 Lose £2,000
- If wrong by more than
1
Lose £4,000
Implement £5,000
- if successful Gain £40,000
- if unsuccessful Lose £40,000
• Each table starts with £50,000
• Pick a banker, to keep track of the money
• Each cycle, you will have 1 minute to discuss as a team and decide whether you will develop a change, test or implement
• One person from each table will need to share their prediction & the theory behind it
Ready to go?
The first two numbers are…
Time up!
Sequence so far: 1, 2…
Time up!
Sequence so far: 1, 2,
3…
Time up!
Sequence so far: 1, 2, 3, 6…
Time up!
Sequence so far: 1, 2, 3, 6,
7…
Time up!
Sequence so far: 1, 2, 3, 6, 7,
8…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8,
21…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21,
22…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22,
23…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23,
66…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66,
67…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66,
67, 68…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66, 67, 68,
201…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66, 67, 68,
201, 202…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66, 67, 68, 201,
202, 203…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66, 67, 68, 201, 202, 203,
606…
Time up!
Sequence so far: 1, 2, 3, 6, 7, 8, 21, 22, 23, 66, 67, 68, 201, 202, 203, 606,
607…
Time up!
So how did we do?
• How much money did each table end up
with?
So how did we do?
• How much money did each table end up
with?
• Were our predictions guided by theory for
each test?
So how did we do?
• How much money did each table end up
with?
• Were our predictions guided by theory for
each test?
• Were we learning with each test?
So how did we do?
• How much money did each table end up with?
• Were our predictions guided by theory for each test?
• Were we learning with each test?
• Could we have learnt faster?
Sustaining improvements
and Spreading changes to
other locations
Developing
a change
Implementing a
change
Testing a
changeAct Plan
Study Do
Theory
and
Prediction
Test under a
variety of
conditions
Make part of
routine
operations
The Sequence of Improvement
To Be Considered a PDSA Cycle:
• The test or observation was planned(including a plan for collecting data).
• The plan was attempted (do the plan).
• Time was set aside to analyze the data
and study the results.
• Action was rationally based on what was learned.
Source: Improvement Guide pp.60-61
Activity ≠ Change
Is a change:
• Determine if the
assessment form can be
applied
• Assess if the new protocol
can detect potential falls
• See if your checklist
generates the necessary
outcome
• See if your device reduces
noise levels
Is NOT a change:
(but may be a necessary
preliminary task)
• Planning
• Having a meeting
• Educating staff
• Creating a form
• Assigning responsibility
For each change idea, you should have an explicit
theory as to why it will work and a prediction of how it
will impact the outcome.
Why test? Why not just implement &
spread?
• Increase your degree of belief
• Give yourself an evidence base
• Learn from ‘failures’ without affecting performance
• Learn how effective this change might be
• Learn how the change works in different conditions
• Minimise resistance to implementation
• Evaluate costs and side-effects
Guidance for Testing a
Change Concept
• A test of change should answer a specific question!
• A test of change requires a theory and a prediction!
• Test on a small scale and collect data over time.
• Build knowledge sequentially with multiple PDSA
cycles for each change idea.
• Include a wide range of conditions in the sequence
of tests.
• Don’t confuse a task with a test!
More Tips for Testing
• Test with volunteers
• Use simulation (you don’t need a computer!)
• Do not worry about getting buy-in,
consensus, committee approval, etc.
• Be innovative to make test feasible
• Collect useful data during each test
• As cycles proceed, test over a wider range
of conditions
• Conduct rapid tests in short periods of time
How to accelerate the pace of testing?
Can you scale down the size of the
test?
Instead of the whole ward, maybe just
the next admission?
How to accelerate the pace of testing?
Can you shrink the timeframe?
Instead of testing over a month, can
you test on one day, or one week?
What’s the smallest time period
to allow you to learn & adapt
the intervention?
PDSA Example:Improving Reliability of Pressure Ulcer Assessment in EPCT
AP D
S
A
P
D
S
AP
D S
A
P
D
S
APD
S
A
P
D
S
A P
DS
96% Reliability
Cycle 1: Test new paper based documentation form on 1
patient in NE team. Analyse learning and modify.
Cycle 2: Test new paper based documentation pack
across entire NE team. Analyse learning.
Cycle 6: Create new
SOPs and make BAU.
Cycle 5: Spread use of
documentation pack across
entire EPCSMini-measure tracks
improvement cycles
Cycle 3: Test documentation pack on
small number of pts in NW team. Analyse
learning and modify.
Cycle 4: Test documentation pack on
all pts in NW team. Analyse learning.
57% Reliability
Waterlow risk
assessment
Clinical
management
meetings for
those with PUs
Caseload
cleansing and
management
Staffing levels
Working in Parallel on Multiple
Change Ideas or Drivers
A P
DS
A
P
D
S
APD
S
AP
DS
A P
DS
A
P
D
S
APD
S
AP
DS
A P
DS
A
P
D
S
APD
S
AP
DS
A P
DS
A
P
D
S
APD
S
AP
DS
Change Concepts, Theories, Ideas
Clinical meetings
Staffing
Waterlow
Caseload
Multiple Change Concepts for a Single Aim
Aim: To reduce pressure ulcers acquired within the ELFT extended primary
care service (EPCS).
“What we gain from
academic studies is
knowledge.
What we gain from
experience is wisdom.”Mohandas Gandhi
Failed Test…Now What?
Be sure to distinguish the reason:
• Change was not executed
• Change was executed, but not effective
If the prediction was wrong – not a failure!
• Change was executed but did not result in
improvement
• Local improvement did not impact the secondary
driver or outcome
• In either case, we’ve improved our understanding of
the system!
Learning from Failure!
The Value of “Failed” Tests
“I did not fail one
thousand times; I
found one thousand
ways how not to make
a light bulb.”
Thomas Edison
It took 40 attempts to create WD-40
The 40th time was the
charm for the blue
canister that boasts
more than 2,000 uses.
In 1953, chemist Norm
Larsen finally created
on his 40th try, a formula
to stop corrosion by
displacing moisture
(hence the name “Water
Displacement , 40th
attempt).
“I made 5,127 prototypes of my
vacuum before I got it right. There
were 5,126 failures. But I learned
from each one.
Sir James Dyson
That's how I came up with a solution. So I don't
mind failure. I've always thought that schoolchildren
should be marked by the number of failures they've
had. The child who tries strange things and
experiences lots of failures to get there is probably
more creative.”
“Not all failures lead to solutions, though.
How do you fail constructively? We're
taught to do things the right way. But if you
want to discover something that other
people haven't, you need to do things the
wrong way. Initiate a failure by doing
something that's very silly, unthinkable,
naughty, dangerous. Watching why that fails
can take you on a completely different path.
It's exciting, actually. To me, solving
problems is a bit like a drug. You're on it,
and you can't get off. I spent seven years on
our washing machine which has two drums,
instead of one.”
Fail Constructively!
October Sky PDSAs
How many PDSAs do they run?
142
Act Plan
Study Do
Act Plan
Study Do
MODEL FOR IMPROVEMENT DATE _02.10.15_ Objective for this PDSA Cycle #1:
Test the use of text messaging.
Is this cycle used to develop, test, or implement a change?
Test a change
What question(s) do we want to answer on this PDSA cycle?
Will sending text messages to service users 2 days before their appointment reduce the DNA rate
of service users across the team?
Plan:
Plan to answer questions: Who, What, When, Where
We will send text messages to all patients due to be seen in our outpatient clinic for the next 4
weeks.
Plan for collection of data: Who, What, When, Where
The following data will be collected by the relevant performance leads in the department:
•Rate of DNAs during the 4 weeks of those appointments
•Percentage of patients that were booked into assessment appointments who received a text
message reminder.
Predictions (for questions above based on plan):
Sending text messages will reduce the number of DNAs.
Let’s take a look at a PDSA
PDSA 1
Do:
Carry out the change or test; Collect data and begin analysis.
Subjective feedback from the Team
•Uncertainty about what method to use to send text messages
•Uncertainty about whose role to send text messages
Study:Complete analysis of data;
The plan for this PDSA cycle was to send text messages to all patients due to be seen in our outpatient clinic for the
next 4 weeks. There were real problems getting text messaging to be reliably implemented and we only managed to
get 55% of service users receiving text messages by week 4.
Our prediction for this PDSA cycle was that we would see a drop in the DNA rate. The data indicates we have not.
However, as we haven’t reliably implemented text messaging, it is impossible to say whether it had an impact or not.
Subjective feedback indicates there were lots of problems in the team around the method of texting & the process for
when and who did this. It was also really hard to ensure consistency owing to the size of the team.
Act:Are we ready to make a change? Plan for the next cycle
No. We need to think about being more specific about what, when and how we will test texting. It may be worth
scaling down our testing rather than working trying to initially test across the entire team.
PDSA Cycle FeedbackPurpose: To provide helpful feedback to those presenting.
PDSA cycles to develop, test or implement a change
PLAN:
• Was the objective for this PDSA cycle clear to you? If not, what would you
suggest?
• Were the questions they were trying to answer stated clearly? If not, what
would you suggest?
• Did they state their predictions? How could the predictions be improved?
• Did they address WHO, WHAT, WHERE, WHEN? If not, what would you
suggest they do to strengthen this part of their plan?
• Did they describe plan to collect the data required to answer questions? Will
they be able to evaluate the predictions using these data?
• What did you think of the scale/scope of this PDSA? (Too: large, small,
complex, simple, etc.?) What do you think would have been a more useful
size/scope for this PDSA cycle?
P.52
PDSA Cycle Feedback
DO:
• Did they attempt to carry out their plan?
• Did they document any problems or unexpected events?
• Did they collect the data they planned to collect?
• Did they capture feedback or observations from those conducting the plan?
• What are your suggestions to improve in the DO phase of their PDSA cycles?
STUDY:
• Did they complete the analysis of the data?
• Did they analyze feedback or observations?
• Did they compare the data and feedback or observations to their prediction and
summarize what they learned?
• Did they update their theories about the objective of the cycle?
• What are your suggestions?P.53
PDSA Cycle Feedback
ACT:• Did they say what will happen in the next PDSA cycle (develop change
further, test, implement?)
• What are your suggestions for them for their next PDSA cycle(s)? (What
suggestions do you have for scale, scope, sequencing of next PDSA
cycle(s)?
• Do you have an idea you’d suggest they test? (Anything you know about
this subject you could share with them?)
Series of PDSA CyclesWhat suggestions do you have on developing a series of PDSA Cycles for the
project?
P.54
Applying PDSAs to your project
• What will be your first / next PDSA?
• What can we test by next Tuesday?
• Be willing to compromise on scope, size, rigor, and sophistication, but the tests must be completed by next Tuesday!
Exercise
Plan your next / first PDSA
• Use the PDSA Worksheet, your Driver Diagram
and your Developing Ideas for Change Worksheet
as reference materials for this exercise.
• Select one idea from your Developing Ideas for
Change Worksheet as an initial test of change.
• Complete the Plan section of the PDSA Worksheet
• Get feedback on your work from others at your
table and be prepared to report your plan to the
class.
P.50
Increasing the Pace
• Smaller Scale Tests: One patient, one staff, try it once to get started
• Test Multiple Drivers: Assign individual responsibility for testing changes
• Test Multiple Change Ideas: Work in parallel to accelerate learning
• One or more Tests A Day keeps improvement in play!
150
Tower Hamlets Violence Reduction Collaborative
AIM PRIMARY DRIVERS CHANGE IDEAS
Safety Huddles
(2, 3, 5, 6, 7)
Safety discussion community
meetings (9,10,11)
Safety Cross (11,9)
Pt property bins (7)
S17 leave (7,8)
Review of blanket rules
(7,8)
Increasing prediction and
responsiveness, working as a
team
7. Minimising aggravation as a result of unmet needs
Openness, transparency and sharing of
safety as a priority for the ward community
Broset Violence Checklist (1, 5, 7)
Tower Hamlets Violence Collaborative Driver Diagram 2016, v3
SECONDARY DRIVERS
2. Effective MDT working and team communication
5. Staff skills/confidence/attitude to anticipating / predicting needs
6. Flattening of hierarchies and stronger MDT working
9. Discussion of violence with SUs and families/carers
3. Speed of decision-making and actioning decisions on ward
Daily Reviews by Drs (3,6,7,8)
11. Sharing data / information on violence and safety culture
To reduce physical
violence at THCMH by the end of
2016
1. Objective assessment of risk: mitigates against biases
8. Reducing rigidity of ward environment
Personal Support Plans (5, 7, 8)
10. Learning from feedback as a ward community
Lea’s What Works? (4, 7)4. Effective transfer of learning from
shift to shift
Safety Huddle Recording (2,4)
• 11 bedded female PICU for entire Trust
• Highest level of violence of wards participating in collaborative
• 3 PDSAs in ONE DAY!
Rosebank Ward
PDSA #1
PDSA #2
PDSA #3
UCL
LCL0
2
4
6
8
10
12
14
16
18
20
06
-Jan-1
4
20
-Jan-1
4
03
-Feb
-14
17
-Feb
-14
03
-Mar-
14
17
-Mar-
14
31
-Mar-
14
14
-Ap
r-14
28
-Ap
r-14
12
-May-1
4
26
-May-1
4
09
-Jun-1
4
23
-Jun-1
4
07
-Jul-1
4
21
-Jul-1
4
04
-Au
g-1
4
18
-Au
g-1
4
01
-Se
p-1
4
15
-Se
p-1
4
29
-Se
p-1
4
13
-Oct-
14
27
-Oct-
14
10
-No
v-1
4
24
-No
v-1
4
08
-De
c-1
4
22
-De
c-1
4
05
-Jan-1
5
19
-Jan-1
5
02
-Feb
-15
16
-Feb
-15
02
-Mar-
15
16
-Mar-
15
30
-Mar-
15
13
-Ap
r-15
27
-Ap
r-15
11
-May-1
5
25
-May-1
5
No
. o
f In
cid
en
ts
Incidents of Physical Violence (Rosebank ward) - C Chart
Testing starts
Impact across all wards
60%
reduction
Demo
160
Welcome to
the Paper
Airplane
Factory!
161
The Paper Airplane Factory Rules
• Your customer has ordered 18 planes, which are listed on the order
sheet in front of you.
• You have five (5) minutes to produce and deliver al of them.
• You must deliver/ship the planes in the order listed on the order sheet
to the customer by handing each completed plane to the customer at
your table.
• The customer (who always knows best) will accept or reject the planes
based on whether they meet the order specifications (e.g., large or
small plane, angled or straight wings, correct number of seats and
proper symbol on the wings).
• You will get credit only for planes that are delivered within the
timeframe and that meet all the customer’s specification.
162
The Paper Airplane Factory
Design Round
• You will have five (5) minutes to work together as
a team to design your system to produce the 18
paper planes requested by the customer.
• The first step is to review each plane so that you
know what the specifications are and their related
symbols on the customer order form.
• Inspect the four prototype planes on your table
and study the design for each plane.
Plane 1: This is a large, angled wing plane with 1 seat for the red circle customer.
Plane 2: This is a large, straight wing plane with 2 seats for the blue square customer.
Plane 3: This is a small, straight wing plane with 1 seat for the blue square customer.
Plane 4: This is a small, angled wing plane with 2 seats for the red circle customer.
164
• You will have five (5) minutes to work together as a team to design
your system to produce the 18 paper planes requested by the
customer.
• The first step is to review each plane so that you know what the
specifications are and their related symbols on the customer order
form.
• Inspect the four prototype planes on your table and study the design
for each plane.
• You can use the model planes at your table as a
reference and examples. They cannot be submitted
as completed planes!
The Paper Airplane Factory
Design Round (continued)
165
• You will have five (5) minutes to work together as a team to design your system to produce the 18 paper
planes requested by the customer.
• The first step is to review each plane so that you know what the specifications are and their related
symbols on the customer order form.
• Inspect the four prototype planes on your table and study the design for each plane.
• You can use the model planes at your table as a reference and examples. They cannot be submitted
as completed planes!
• Once you have designed your production system we’ll clear
the table of your Design Round planes and run your factory for
five (5) minutes and see how many planes you can construct
and ship.
• Based on your team’s ability to meet the customer’s order
you’ll have a chance to redesign your system and try again.
That is, if you need another chance.
The Paper Airplane Factory
Design Round (continued)
166
The Paper Airplane Factory
Production Round #1
Again, you are allowed to keep the 4
models at your table as a reference.
Don’t recycle them.
Now you have five (5) minutes to fill
the customer’s request for 18
planes that meet all the
specifications.
Read, set…Goooo!
167
The Paper Airplane Factory
Production Results
Team Production
Round 1
Production
Round 2
Production
Round 3
1
2
3
4
5
6
7
8
9
10
11
12
OutcomeThe number
of planes
produced that
meet ALL the
customer
specifications!
168
The Paper Airplane Factory
Production Round #2
Before we start Production Round #2 we’re going to construct a
plane together so that you can understand what the customer
expects and how to meet these expectations.
One person at each table should write down each step on a
sticky note and the rest of the team will follow along making a
plane with me. Remember to keep the sticky notes in the
correct order.
You will end up with 13 sticky notes (steps).
First we will make an angled wing plane then a straight wing
plane.
How to Construct aPaper Airplane
(in 12 easy steps)
Start
Small Plane: Tear
Fold to center
line
Small Plane: Tear
Fold to center
line
OpenSmall Plane: Tear
Defect free:
Fold to center line
Fold to center
line
Open Right Corner
Small Plane: Tear
Defect free:
Fold to center line
Fold to center
line
Open Right Corner
Left Corner
Small Plane: Tear
Defect free:
Fold to center line
Fold to center
line
Open Right Corner
Left Corner
Small Plane: Tear
Right Side
Defect free:
Fold to center line
Fold to center
line
Open Right Corner
Left Side
Left Corner
Small Plane: Tear
Right Side
Defect free:
Folds inside
plane body,
not outside.
Fold to center
line
Open Right Corner
Close
Left Side
Left Corner
Small Plane: Tear
Right Side
Defect free:
Edge of wing
meets edge of
plane
Fold to center
line
Open Right Corner
Close
Left Side
Right Wing:
ANGLED/STRAIGHT
Left Corner
Small Plane: Tear
Right Side
Angled Wings:
Fold to center
line
Open Right Corner
Close
Left Side
Left Wing:
ANGLED/STRAIGHT
Right Wing:
ANGLED/STRAIGHT
Left Corner
Small Plane: Tear
Right Side
Angled Wings:
Defect free:
Mark on top of
wing.
Fold to center
line
Open Right Corner
Close
Left Side
Left Wing:
ANGLED/STRAIGHT
Right Wing:
ANGLED/STRAIGHT
“Mark” Add
Symbols
Left Corner
Small Plane: Tear
Right Side
Defect free:
Paper clips on
bottom.
Fold to center
line
Open Right Corner
Close
Left Side
Left Wing:
ANGLED/STRAIGHT
Right Wing:
ANGLED/STRAIGHT
“Mark” Add
Symbols
Add clips/seats
Left Corner
Small Plane: Tear
Right Side
Fold to center
line
Open Right Corner
Close
Left Side
Left Wing:
ANGLED/STRAIGHT
Right Wing:
ANGLED/STRAIGHT
“Mark” Add
Symbols
Add clips/seats
Left Corner
Small Plane: Tear
Ship
Right Side
Defect free:
BACK of wing
meets BACK of plane
Fold to center
line
Open Right Corner
Close
Left Side
Left Wing:
ANGLED/STRAIGHT
Right Wing:
ANGLED/STRAIGHT
“Mark” Add
Symbols
Add clips/seats
Left Corner
Small Plane: Tear
Ship
Right Side
Straight Wings:
185
The Paper Airplane FactoryProduction Round 2
OK, what did we just do?
We determined what the customer wants, needs and expects from us.
We also broke down the work process into the relevant sequence of
steps required to meet the customer’s specifications.
We can assign responsibility for the selected tasks and start to build a
production system.
Take the 13 sticky notes and give at least 1 to each team member. Most
team members will have more than 1 sticky note.
Now, put one plane through the system to ensure it works. Everyone
has to pay attention to what the person is doing when putting the plane
through the system so everyone understands each step of the process.
Make a perfect large, angled wing plane with 1 seat for the red circle
customer.
186
The Paper Airplane Factory
Production Round 2
You have 5 minutes to
complete the customer’s
order for 18 planes as
laid out on the customer
request form.
Set the production
process in motion and
make some planes!
187
The Paper Airplane Factory
Production Round 3 Now, for Round 3, you need to come up with a simple way to never
have to talk about which plane is going through the production
system.
Use a sticky note to number each plane from the order sheet. More
specifically, have the first person in the workflow add a sticky note to
each plane with its assigned number so that the rest of the group
knows which plane they are working on when it reaches them.
Additionally, if you’d like to reassign tasks in your process, take a
minute and do that now.
TEST RUN: Run a plane through the system to confirm you don’t
have to talk to accomplish this task. Once made recycle this plane.
You now have five minutes to construct all 18 planes for the
customer. Ready, set, go!
188
The Paper Airplane Factory
Conclusions and Observations
Generally by the end of Round 3 we see each team produce 15-
18 planes that meet the customer’s specifications.
We expect no rejects at this point irrespective of how many
planes were produced.
Not every team meets the target of 18 acceptable planes. But
the planes produced are usually meeting specifications.
The production system itself is reliable enough that the team
does not need to speak. Note that speaking caused delays and
slow-downs in Round 2.
What factors kept the team from making 18 that meet
specification?
The Paper Airplane Factory
Conclusions and Observations
Discussion Questions
1. What changes did we make from Round 1 to Round 2?
• We made it very clear what the work was (aim clarification)
• We broke the process down into the relevant steps and tasks (S + P =O)
• We assigned specific tasks to each individual (process owners)
• We made sure everyone understood how their work fit into a chain of
events. No one person or task was more important than another.
2. What changes did we make from Round 2 to Round 3?
• We made it clear what you were supposed to do when each plane came to
you.
• We took steps to reduce the amount of talking (i.e., alternative or conflicting
theories) and increased the productivity of the team, not one individual.
A Challenge for you
If possible, go to a workplace (a clinic, a pharmacy, a restaurant with an open
kitchen, a hotel) and see how the processes flows. What’s the output? What’s the
flow? What are the handoffs? What are the bottle necks? Are all of these well-
defined? How would you improve the process?
190
Will
QI
Fitting all the pieces together!
The Primary Drivers of
Organizational Improvement
Will
IdeasExecution
QI
Having the Will (desire) to change the current state
to one that is better
Developing Ideas
that will contribute
to making
processes and
outcome better
Having the capacity
and capability to
apply QI theories,
tools and
techniques that
enable successful
Execution of your
ideas
Let’s revisit the Science of
Improvement Self-AssessmentInstructions:
This self-assessment is divided into six skill categories, which have been adapted from
chapter 2 of the Improvement Guide, written by our friends at Associate in Process
Improvement (API). These skills are referred to as the “Skills to Support Improvement” and
serve as the foundation for much of what we teach in our improvement science programs.
Each of the skill areas is listed below with key concepts and tools that demonstrate
knowledge of and ability to apply the concepts. For each concept or tool select the one
response that best describes your skill level. The response options are:
A. I have no knowledge of this concept/tool.
B. I have heard of this concept/tool but could not explain it or apply it.
C. I have a working knowledge of this concept/tool and could at least explain what it is.
D. I have a working knowledge of this concept/tool and could explain how to apply it if
there was someone with deeper knowledge in the room to back me up.
E. I have a solid working knowledge of this concept/tool and could demonstrate how to
apply it to daily work.
F. I am confident and comfortable in explaining, applying, and teaching this concept/tool.
©2014 Institute for Healthcare Improvement/R. Lloyd. Note: No part of this self-assessment tool may be used, reproduced
or distributed without the expressed written permission of Dr. Robert Lloyd at the IHI. Dr. Lloyd can be contacted at
©2014 Institute for Healthcare Improvement/R. Lloyd. Note: No part of this self-assessment tool may be used, reproduced
or distributed without the expressed written permission of Dr. Robert Lloyd at the IHI. Dr. Lloyd can be contacted at
Science of Improvement Self-Assessment
Science of Improvement Self-Assessment
©2014 Institute for Healthcare Improvement/R. Lloyd. Note: No part of this self-assessment tool may be used, reproduced
or distributed without the expressed written permission of Dr. Robert Lloyd at the IHI. Dr. Lloyd can be contacted at
Structure for Support and Integration
• Have you still got the right people in your project team?
• Could anyone else benefit from training?
• 3 the magic number??
It starts with your team…
• Suited for anyone interested in QI
• 2x half day modules
• Monthly
• Venue rotates around the Trust
• Access via the QI microsite
Pocket QI
QI Team
Microsite & QI Life
QI Sponsor
QI Forums
QI Coach
Service users &
structures to support you
involve people
QI Team
Microsite & QI Life
QI Sponsor
QI Forums
QI Coach
Service users &
structures to support you
involve people
Quality improvement programme-project support structures
Trust wide Strategy Group
Executive Directors:Medical Director
Director of OperationsDirector of Nursing
Service Users and Carers Central QI team
Directorate QI Forums
QI SponsorsStaff undertaking QI projects
PPLs
QI Project QI Project QI Project
Meets monthly
Meets monthly
QI Team
Microsite & QI Life
QI Sponsor
QI Forums
QI Coach
Service users &
structures to support you
involve people
Role description
Reward and recognition
http://qi.elft.nhs.uk/engaging-service-users-and-carers/
QI Resources
QI Resources
Spiral of Learning
PreworkWorkshop
9/29-10/1
Webex 1
10/14
Webex 2
11/2
Supports:
• Listserve
• Assignments
AP-1 AP-2Webex 3
11/30AP-3
Project
PlanningReliability
Sustaining
Gains
Sep/Oct
Workshop 18-20 Oct(3 days)
Webex #2
18 Jan
Webex #1
17 Nov
• Faculty consults• Webex calls• Coaching calls
Learning Set13 Dec
Webex #3 21 Feb
Learning Set 21 Mar
AP-5AP-4
The two learning sets will be focused on sharing the participants’ work on their projects and learning from each other. These sessions also will reinforce the
content from the Webex calls and the ISIA workshop.
ISIA provides a 6 month learning path(September - March)
Both 1 day learning sets @ Stratford Town
Hall
What’s coming next in the QI
programme?
AIM:To provide the highest
quality mental
health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1. Launch event & roadshows2. Microsite3. Using the power of narrative4. Celebrate successes5. Network of champions / ambassadors6. Learning events
1. Initial assessment of alignment & capability2. Recruiting central QI team3. Online training4. Face-to-face training5. Follow-up coaching on projects6. Develop in-house training for 2016 onwards
1. Align all projects with improvement aims2. Align team / service goals with improvement aims3. Align all corporate and support systems4. Patient and carer involvement in all improvement
work5. Embed improvement within management structures
Reducing Harm by 30% every year1. Reduce harm from inpatient violence2. Reduce harm from falls3. Reduce harm from pressure ulcers4. Reduce harm from medication errors5. Reduce harm from restraints
Right care, right place, right time1. Improving patient and carer experience2. Reliable delivery of evidence-based care3. Reducing delays and inefficiencies in the system4. Improving access to care at the right location
Build the will
Annual QI ConferenceFriday 31st March 2017
More bespoke learning events
QI Newsletter
Award nominations & ceremonies
Tell your story at Trust Board
International forum experience day
Future waves of ISIA
Service user half day training session
Teaching student nurses
Build improvement capability
Developing Improvement Coaches
More Publications
Available to all, all of the time Pocket QI for Luton and Beds
Alignment
QI Coaches
Data for improvement +transparency of data
Patient involvement in QI work
DMTAligning projects with prioritiesMobilising resource for project teamsRing fencing time
Developing improvement priorities at different levels
Cutting waste (lower value activity)
219 projects!
@ELFT_QIqi.elft.nhs.uk [email protected]