“Mind the Gap”
The Journey
24/11/2016
Theory of Improvement
- PDSA cycles. (we all do…)
- Clear objectives.
- Test of change.
- Continuous audits and data gathering.
Reasons to Test Changes
- To decide which of several proposed changes will lead to
the desired improvement and whether they will work in the
environment of interest.
- To evaluate how much improvement can be expected from
the change.
- To decide which combinations of changes will have the
desired effects on the important measures of quality.
- To minimize resistance upon implementation.
Run Charts
-Complex statistical tools
-Study time to understand statistical analysis
-Help you test the changes made
-Help to quantify improvement / worsening
-Easy to understand graphics
-Sigma limits (Random & Non-random)
-To improve a process we must reduce variation
Safety cross help to
visualize performance at
a glance
Account time of
administration
missed
Highlight previous data to
keep track of progress
NR
Occurrences
NR
Occurrences
Segregated
data (21.5)
Trans. resp
Mind the gap &
safety cross
Name
and
shame
Handover
checks
Transfer of
responsibility
Handover
checks(3.8%)
Back to
old shifts
(4.15%)
Staff meeting
(12.97%)
Transfer of
responsibility
Reduced
Variation
OP!!
People
dependent
process!!
Name and
shame
stopped!
Safety cross
stopped! (19.44%)
Safety
cross back
(5.16%)
New poster
(10.5%)
Error reporting
(14.3%)
Implementation Advice
- Nursing team must take lead and accountability.
- Pharmacy in supporting role (data analysis)
- It is a cultural change so will take time
- Little changes may go a long way…
- Use small but significant sample to start with
- The more data the better!! (3+ years of weekly audits)
- Praise / challenge appropriately
- Avoid spreading too early!
Results so Far…
Reduction of blank boxes 40% (80% AIB)
- Time consuming but can be rewarding (sometimes!!!)
- Scared of my green pen and pink highlighter 
- Currently transferred to nursing team (still counting though)