Transcript Slide 1

Promoting quality for
better health services
QI Presentation: Skills and
Examples
Dr David Gozzard
Senior Fellow, Institute for Healthcare
Improvement, Boston US
Objectives of the Session
• Understanding of relationship between
structure and process
• Introduction to process mapping
• Driver diagram development
• PDSA worked examples
System Design
Every system is perfectly
designed to achieve exactly
the results it gets
The Healthcare System
133 People to take care
of the patient
The Patient
STRUCTURE
+
PROCESS
=
OUTCOME
PROCESS MAPPING
DGCL
Why Map Processes?
A Simple Flowchart
Dealing with a nonfunctioning lamp
Another Simple Flowchart
Waking up in the
morning
Process Maps
A New Tool – Driver Diagrams
A tool to help
us understand
the messiness
of life!
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What changes can we make?
• Primary Drivers
– System components which will contribute to
moving the primary outcome
• Secondary Drivers
– Elements of the associated Primary Driver.
They can be used to create projects or a
change package that will affect the Primary
Driver.
Stroke Driver Diagram
Rapid recognition tool e.g. ROSIER
First hours bundle
Confirmation of diagnosis
Start aspirin
CT scan
First day bundle
Admission to co-located beds
Swallow screen
36h continuous monitoring
Improve the outcome for people
following stroke
First 3 days bundle
Manual handling assessment
Nutritional assessment
Physiotherapy assessment
OT assessment commenced
First 7 days bundle
MDT goal setting meeting
Information sharing with patients/carers
Reduce the number of
episodes of avoidable harm
Interventions identified by the Global
Trigger Tool analysis
Driver Diagram Exercise
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Establish stakeholder group
Objectives
Discussion regarding concerns (group)
Flipchart exercise (smaller groups)
Sticky notes exercise (individual)
Coffee!!
– Whilst this is taking place the notes are “themed”
• Stakeholders view themes (primary drivers)
• Group exercise to format driver diagram
Anaemia Management
Driver Diagram
Education
Training packages
Core Processes
Communication
Disseminating
pathway guidelines
Referral pathway
Hospital
Guidelines/Protocols
Treatment options
Better anaemia
management
Finances
Commissioning
Business cases
Involvement
Patient
Satisfaction/outcome
Service design
Primary care
Engagement
Responsibilities
How Will We Know We Are Improving?
Understanding the System for Weight Loss with Measures
Primary
Drivers
Outcome
Secondary
Drivers
Ideas for Process
Changes
• Avg cal/day
drives
Limit daily
intake
• Running
calorie total
Calories In
drives
• Daily calorie
count
drives
drives
AIM:
A New
ME!
• Weight
• BMI
• Body Fat
• Waist size
• % of
Substitute opportunities
used
low calorie
foods
Avoid
alcohol
drives
• Exercise
calorie count
• Avg drinks/
week
Plan
• Meals
Meals offplan/week
Drink H2O
Not Soda
• Sodas/
week
drives
Calories
Out
Exercise
drives
Measures let us
• Monitor progress in
improving the system
• Identify effective changes
Track
Calories
Work out 5
days
• Days between
workouts
Bike to
work
drives
Fidgiting
Percent of days
on bike
Hacky
Sack in
office
Etc...
Group Work
• Working in pairs, for an improvement aim
arising from a national audit define the
following:
• Primary drivers
• Secondary drivers
• Possible projects
• Allow 10 minutes for this exercise
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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 test sequence.
Don’t confuse a task with a test!
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The Model for Improvement
Generate new
hypothesis and
retest
Analyze and
interpret data
Define the question
Gather information
and resources
(observe)
Form hypothesis
Perform experiment
and collect data
Why Test?
Why not just implement then spread?
• Increase degree of belief
• Document expectations
• Build a common understanding
• Evaluate costs and side-effects
• Explore theories and predictions
• Test ideas under different conditions
• Learn and adapt
Repeated Use of the PDSA Cycle
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
A P
Changes That
Result in
Improvement
S D
What change can we make that
will result in improvement?
Implementation
of Change
Hunches
Theories
Ideas
A P
S D
Very Small
Scale Test
Followup Tests
Wide-Scale
Tests of
Change
The Sequence for Improvement
Make part of
routine
operations
Test under a
variety of
conditions
Theory and
Prediction
Testing a
change
Developing a
change
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Spreading a change to
other locations
Implementing a
change
Act
Plan
Study
Do
Group Work
• Working in pairs, devise a PDSA cycle to
test an idea based upon a problem arising
from a national audit.
• Note – your driver diagram exercise will
have developed some ideas for testing!
• Allow 10 minutes for the exercise
Promoting quality for
better health services
Thank You
Any Questions?