Introduction to Quality Improvement in Practice

Shalani Raghavan Susan Hannah Scottish Government Leading Improvement Team

• • • •

Aims of this session

Brief introduction to the 3 Step Improvement Framework and the Model for Improvement Invite you to consider how the Model for Improvement and its methodology can help you deliver on Quality Improvement – both strategically and operationally Recognise your role in enabling and creating the conditions for Improvement Raise awareness of the support available to you to implement the Model for Improvement in your area 4

Public Finances Fall in Government expenditure

The six questions to be asked of EVERY change programme… 1 Aim Is there an agreed aim that is understood by everyone in the system?

2 Correct changes Are we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact on our aim?

3 Clear change method Does everyone know and understand the method(s) we will use to involve?

4 Measurement Can we measure and report progress on our improvement aim?

5 Capacity and capability Are people and other resources deployed and being developed in the best way to enable improvement?

6 Spread plan Have we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?

Leading Improvement Team – Our Key Objectives

• To lead project-based, organisation wide programme of improvement activity addressing key organisational and policy challenges within Scottish Goverment.

• A capability and capacity building programme to facilitate improvement across Public Services.

9

• • • • • •

LIT: Current work

• Support for Early Years Collaborative and CPP’s Education: Attainment, STEM Health: Physical Activity Justice: Building Safer Communities Corporate: FOI Awareness sessions and seminars 3 day training course 10

The Primary Drivers of Improvement

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 Will Ideas

QI

Execution Having the capacity to apply CQI theories, tools and techniques that enable the

Execution

of the ideas

By what method?

W. Edwards Deming

"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”

1941, William A. Foster

Improvement Science

“There is no substitute for knowledge ” “Stamping out fires is a lot of fun, but it is only putting things back the way they were.” “It is not necessary to change. Survival is not mandatory.” W Edwards DEMING (1900-93)

No model is perfect, some are useful.

Drug & Alcohol Game

W. Edwards Deming

Appreciation of the System Subject Matter Knowledge Understanding Variation Psychology Theory of Knowledge

What is a System?

A system is an interdependent group of people, processes or items with a common purpose .

“Every system is perfectly designed to get the results it gets.”

Senge

Deming’s Concept of the Lens of Profound Knowledge

Subject Matter Knowledge

: Specialist knowledge and skills required to be a good practitioner

Improvement Subject Matter Knowledge Profound Knowledge Profound Knowledge

: The interaction of the theories of systems, variation, knowledge and psychology.

Different Types of Systems

Public Services!

“quality improvement”

The combined and unceasing efforts of everyone –professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to better outcome, better system performance, and better professional development.

Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

So, in a chaotic world how can we get sustainable change that results in an improvement?

We need a method for testing change that ensures it is right and reliable in a given situation

Use the Model for Improvement to test and implement changes

Our change theory

• • • A clear and stretching goal – SOON is not a time, SOME is not a number A method Predictive, iterative testing – Small tests of change, less risky, but quick results HOPE is not a plan

The Model for Improvement

The Improvement Guide, API

Aim Measures Changes Execution

“Aims create systems”

Deming

The six questions to be asked of EVERY change programme… 1 Aim Is there an agreed aim that is understood by everyone in the system?

2 Correct changes Are we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact on our aim?

3 Clear change method Does everyone know and understand the method(s) we will use to involve?

4 Measurement Can we measure and report progress on our improvement aim?

5 Capacity and capability Are people and other resources deployed and being developed in the best way to enable improvement?

6 Spread plan Have we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?

Aim

• • • • • Aligned – provides a clear sense of what you are trying to accomplish Numeric and Timed – How much, by when Specific – who, where?

Unachievable by hard work alone Non-negotiable (once set)

Aim Statements

• To reduce infant mortality, i.e. deaths by 12 months of age (including stillbirths) by 15% by end 2015.

• 100% of nurseries will be participating in Childsmile by June 2013 • The EYC will be a prominent agenda item at each CPP meeting by June 2013

34

Scotland, the best small country in the world

THE BAD

Our outpatient testing and therapy patient satisfaction scores are in the bottom 10% of the national comparative database we use. As directed by senior management, we need to get the score above the 50 th percentile by the end of the 2 nd Q of 2011.

THE UGLY

By the end of 2012, hospital mortality will be reduced by 15% in Scotland

THE GOOD

Model for Improvement Q1: What are we trying to accomplish?

Take Aim

• • Take 5 minutes to think about a possible improvement aim for a project or policy that you are involved in.

Discuss it with the person next to you and give them feedback on theirs.

Exercise: Setting an Aim Aim statement: What will you do, how much and by when?

…………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………

A clear stretch aim that is:

•

Is aligned directly to what you want to achieve (what)

•

Is quantifiable (how much)

•

Identifies a time frame for achieving the aim (by when)

•

Unachievable by hard work alone (change will be necessary)

Now we have an aim, we need a Driver Diagram!

What are the things that are going to influence the aim?

A useful tool to help us understand the system and organise our ideas and measures

Here’s what it looks like…

Aim

Theories about what will drive improvement

Primary Drivers Secondary Drivers

Key factors that will Influence the aim Secondary factors which will influence delivery of the primary drivers Aim statement: general description of desired Improvement (what, how much by when)

Why a Driver Diagram?

Helps to organise theories about how to improve a system to meet the aim It displays visually our ideas on the areas we can improve to leverage the improvement we want to achieve – organises information with different levels of detail It helps a team to think critically about the issues that have the greatest impact on the desired outcome and which things will most influence those primary drivers.

Shows several strategies for achieving the aim

Driver diagram Primary Drivers

Key factors which you need to influence in order to move towards the aim. These drivers may act independently or in concert to achieve the overall goal.

Secondary Drivers

Underpinning factors affecting the associated primary driver(s). They can be used to create projects or a change package that will affect the primary drivers.

AIM PRIMARY DRIVERS By 2024, x% of adults and x% of children will meet physical activity guidelines People walk or cycle to work or school, and are active during work or school People regularly take part in sport and recreation activities in their leisure time People are aware of the physical activity guidelines, and the health benefits of physical activity Draft physical activity driver diagram SECONDARY DRIVERS Safe, attractive routes for walking and cycling are available The transport infrastructure enables people to choose to make car free journeys Workplace policies (NHS, Local Authorities, private companies, education providers) prioiritise, facilitate and reward active travel to and from work and during work hours Planning processes prioritise the creation of a built environment that encourages people to be more active Policies, services and infrastructure are planned and delivered in an integrated way, in partnership with local communities, to enable people to take part in physical activity Schools, universities and colleges prioiritise physical activity in their estates, green space and infrastructure planning People can access affordable suitable sport and recreation facilities locally Active play for children is encouraged and supported The most up to date evidence, best practice and lessons learned in increasing physical activity are shared and used to inform service improvement Local communities and individuals are supported to work to overcome barriers to people being physically active Health and Care providers establish effective person centred physical activity pathways in all relevant settings, to enable and support people to take part in physical activity Schools teach the benefits of physical activity and encourage levels of activity to meet guidelines Public messages on the health and social benefits of physical activity and the dangers of inactivity are consistent and effective

Now you drive…

• • Pick one of your aims from before.

Discuss and sketch out what would be the primary and secondary drivers for this aim

It’s ok if there are only 1 or 2 primary drivers

What Changes Can We Make?

Understanding the System for Weight Loss

Primary Drivers Secondary Drivers Outcome

AIM: A New ME!

drives drives

“Every system is perfectly designed to achieve the results that it gets”

Calories In Calories Out drives drives drives Limit daily intake Substitute low calorie foods Avoid alcohol drives Exercise drives drives Fidgiting

Ideas for Process Changes

Track Calories Plan Meals Drink H2O Not Soda Work out 5 days Bike to work Hacky Sack in office

© Richard Scoville & I.H.I.

How Will We Know We Are Improving?

Understanding the System for Weight Loss with Measures

Primary Drivers Secondary Drivers Ideas for Process Changes Outcome

drives Calories In • Daily calorie count drives drives drives • Avg cal/day Limit daily intake Substitute low calorie • % of opportunities used foods Track Calories • Running calorie total Plan Meals plan/week AIM: A New ME!

• Weight • BMI • Body Fat • Waist size drives • Exercise calorie count Calories Out drives drives Avoid alcohol • Avg drinks/ week Exercise Drink H2O Not Soda • Sodas/ week Work out 5 workouts

Measures let us • Monitor progress in improving the system • Identify effective changes

drives Fidgiting Bike to work Percent of days on bike Hacky Sack in office Etc...

Driver Diagram

Measurement for Improvement

Now back to this….

Aim Measures Changes Execution

The Improvement Guide, API

Model for Improvement Q2: How will we know that a change is an improvement?

Improvement is not just about measurement However… without measurement you will never be able to answer the question!

Why Do You Need Data and Information?

• • • • • To plan for improvement For testing change For tracking compliance For monitoring long term progress and sustainability To tell the story of your improvement journey

How Do We Know if a Change is an Improvement?

“If you can’t measure it, you can’t IMPROVE it”

Why Real Time Is Important for Measurement?

• Aggregate measures alone do not lead to predictions about future performance or insights to explain past variations • Displaying data over time (using run charts or control charts) allows us to make informed predictions, and thus make changes to create different results

Data for improvement?

Aggregated Data

Cycle time results for units 1, 2 and 3

80 70 60 50 40 30 20 10 0 70 Avg Before Change 35 Avg After Change Does this show an improvement?

Depends….

Which unit has improved?

Data over time - dynamic data 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 Change Made Change Made Change Made Unit 1 Unit 3

What measures?

Outcome measures – directly relates to the overall aim what is the result?

how is the system performing?

Process measures – are the processes that contribute to the aim performing as planned?

Balancing measures – assessing from different dimensions unanticipated consequences, other factors influencing the outcome

How do you measure up?

• • • Looking at your driver diagram, can you identify any suitable measures that would help you to understand how you were progressing?

Just take 5 minutes to discuss… Tabout possible outcome, process and hink balancing measures

Aim A NEW HEALTHIER ME!!

Weight, BMI, waist size

MEASURES 1. Rate of weight loss / week 2. Reduction in units of alcohol / week 3. Time spent exercising / week 4. Feel good factor Primary drivers

Driver diagram with measures

Secondary drivers Tests of change

Daily calorie count

CALORIES IN Limit daily intake Substitute low calorie Track calories Plan meals

Meals off plan Exercise Calorie count

CALORIES OUT Limit alcohol

Average drinks / week

Exercise Drink water not coke

Days between workouts

Gym 5 x per week

% of days On bike

Cycle to work Fidgeting Chi balls

61

EFFECT CAUSE

62