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Leading an improvement project
1. Action on Frailty Learning Event – 28
September 2016
Leading an Improvement Project
Stephen Ramsden
2. Leading a patient safety improvement
project
Some service improvement tools and techniques,
this will include:
• Introduction to improvement science
• The model for improvement, PDSA and small
tests of change
• Measurement for improvement
• Key elements of project management
• Spread and sustainability
3. Research Clinical audit Quality
Improvement
Performance
management
Purpose Generates new
knowledge
Tests hypotheses
Tells us if we are
following good
practice
Examines our
processes and guides
improvement
Judges whether we
are meeting required
standards
Scope May be generalisable Sample size not
necessarily
scientifically valid –
valid within the
organisation
Usually focuses within
one institution or
process
Institution or part of
or system
Measurement Detailed statistical
Analysis
Basic statistical
analysis
Statistical process
control
Bench-marking
Design Scientific framework
well controlled
No allocation of
patients to different
treatment groups
Focuses on three key
questions see PDSA
Often determined
centrally
Patient
involvement
Ethics approval
required
No ethics approval
usually required
No ethics approval
usually required
No ethics approval
required
Results used to Generate new
knowledge, influence
practice
Encourage best clinical
practice
Bring about
improvement in safety
and quality
Ensure compliance
with standards
4. How Can We Foster the Adoption of Successful
Change Ideas?
The Traditional Approaches
5. The model for improvement
The model for
improvement is a
systematic approach,
using specific techniques
to improve the quality of
healthcare, and patient
and staff experience.
6. The PDSA Cycle for Learning and Improvement
What’s
next?
Did it
work?
What will
happen if we
try something
different?
Let’s try it!
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
8. The Sequence of Improvement
Sustaining improvements
and Spreading changes to
other locations
Developing
a change
Implementing a
change
Testing a
change
Act Plan
Study Do
Theory
and
Prediction
Test under a
variety of
conditions
Make part of
routine
operations
9. Which one is SMART ?
I. We will help teams who look after patients to
understand when they should refer patients for a
nutritional assessment
II. We will improve nutrition
III. We will aim to increase the number of patients who
get a nutrition screen within 4 hours from 60% to 90%
IV. We will increase the number of patients (admitted to
Ward G4) who get a nutritional management plan
within 6 hours from 60% to 90% by june 2012
12. Measurement for improvement
Measurement framework: some principles
• Use sampling – make it sufficient
• Measures must relate back to your aim(s)
• Keep it simple, relevant and able to be incorporated into
daily work
• Consider process and outcome measures
• Plot data over time
• Different measures will be appropriate for different
audiences – e.g. ward or Board
• Good enough – not perfect!
13. Three types of Measures
• Outcome measures ie what is the end result that the
process/system is achieving
• Process measures ie a measure of the reliability of the
process/system
• Balancing measures ie are there any unintended
consequences of changes to the outcome and/or process
measures . Could be in productivity or mortality or experience
etc
14. Run charts and SPC
• Run charts and control charts turn data into
information
• They enable us to understand variation and
whether it is special cause or common cause
17. Types of variation
Common cause
• Is inherent in the design of the process
• Is due to regular natural or ordinary causes
• Affects all the outcomes of a process
• Results in a “stable” process that is predictable
• Also known as random variation
18. Types of variation (cont.)
Special cause variation
• Is due to irregular or unnatural causes, not inherent
in the design of the process
• Affects some but not necessarily all of the process
• Results in an unstable process that is not predictable
• Also known as non-random variation
19. What to look for
• Upward trend?
• Downward trend?
• Static line?
• Intervention point?
• Sustained improvement?
• Special cause?
• Normal variation?
20. Statistical Process Control
• Run charts at their simplest
• Use upper and lower control limits either side of median (centre)
line
• Need 15-20 data points
• 7 successive points below/above the median or constantly going
up/down is a trend
• Points either side of the control limits = look for a special cause
• Aim to reduce variation
Every system is perfectly designed to produce the results it achieves !
22. A self-assessment exercise -
measurement
How do we know care is safe? 22
Some questions to ask of your teams:
1. What information do you currently collect?
2. Does it help you to answer the question: how safe is our care?
3. Is your data accurate, comparable and meaningful?
4. Do you need to stop collecting some data?
5. Do you need to start collecting other data?
23. Small tests of change - tips
• Keep tests small
• Pick willing volunteers
• Choose tests that do not need lots of approval (ask
for forgiveness not permission)
• Steal shamelessly/Pinch with pride
• Pick easy changes to try
• Avoid technical slowdowns
• Reflect on every change
• Be prepared to change tack or stop your test
27. Meet their needs Key player
Least important Show consideration
Power/influenceofstakeholders
Interest of stakeholders
Stakeholder quadrant
28. Meet their needs
•engage & consult on interest area
•try to increase level of interest
•aim to move into right hand box
Key player
•key players focus efforts on this group
•involve in governance/decision making bodies
•engage & consult regularly
Show consideration
•make use of interest through involvement in low risk areas
•keep informed & consult on interest area
•potential supporter/ goodwill ambassador
Least important
•minimum effort
•inform via general communications – newsletters, website, mail shots
•aim to move into right hand box]
www.stakeholdermap.com
32. Spreading a change
• Spread is the degree to which learning, best practice
or improvement is adopted across an organisation or
region by those who would benefit from the change
• Follows implementation on pilot unit
• Can occur passively through diffusion or actively
through planned design
• Key is to actively move the improvement across the
organisation without causing resistance to change
• 1 – 3 - 5
32
33. The Seven Spreadly Sins
(If you do these things, spread efforts will fail!)
Step #1 Start with large pilots
Step #2 Find one person willing to do it all
Step #3 Expect vigilance and hard work to solve the problem
Step #4 If a pilot works then spread the pilot unchanged
Step #5 Require the person and team who drove the pilot to be
responsible for system-wide spread
Step #6 Look at process and outcome measures on a quarterly basis
Step #7 Early on expect marked improvement in outcomes without
attention to process reliability
34.
35. Sustainability model
Transforming Health Ltd
0
2
4
6
8
10
12
14
16
Benefits beyond
helping patients
Credibility of the
evidence
Adaptability of
improved process
Effectiveness of the
system to monitor
progress
Staff involvement
and training to
sustain the process
Staff behaviours
toward sustaining
the change
Senior leadership
engagement
Clinical leadership
engagement
Fit with
organisational
strategic aims and
culture
Infrastructure for
sustainability
Sustainability Review Survey
Adminstration Excellence Project
TARGET SCORES
TEAM SCORES
N=10
Sustainability model and guide www.institute.nhs.uk
The gap between the
blue shading and the
red shading shows the
improvement potential
for each of the ten
factors. Staff
involvement, clinical
involvement and
senior leadership
engagement provide
the areas for greatest
potential
improvement.
36. Some questions to reflect on
1. Am I adopting a service improvement approach?
2. Have I adequately understood the problem?
3. Have I involved the right people?
4. Do I have the right leadership involvement?
5. Have I understood other perceptions? – emotional, hearts and minds?
6. Is my aim clear?
7. Is my measurement system clear?
8. Am I running tests of change?
9. Am I measuring results using SPC on a regular basis and displaying my
results?
