“Why Improvement Matters”
David Thomson; Associate Director of Nursing
[email protected]
Improvement is part of all our lives
Opportunity and Innovation
What do you know about
improvement science and methods
Why do we need an improvement focus?
Here is Pooh Bear, coming
downstairs now, bump,
bump, bump, on the back of
his head, behind Christopher
Robin.
It is, as far as he knows, the
only way of coming
downstairs, but sometimes
he feels that there really is
another way, if only he could
stop bumping for a moment
and think of it.
Why is Improvement Important?
• ‘Insanity: Doing the same thing over and over
again and expecting to get different results’
• ‘A person who never made a mistake never
tried anything new’
Keep promoting the message
of improvement
They’ll get the message
and advocate themselves
What Do You Value?
• Strive to deliver the best care you can?
• Getting through the day?
• The people you provide care for?
• People generally don’t come to work to do a
bad job
• Improvement is about changing the system
and creating the conditions for people to
thrive – make the difference
Our environment
• Systems in themselves have an increasing
baring on how we behave within a system.
• Why do we manage people and yet not the
system?- Leadership?
What can be achieved?
Responding to what people want and need
Our Dimensions of Quality
Route map to the 2020 vision
Political Drivers or Competing Programmes?
Or at least it can feel that way!
Do we recognise when change is needed?
Learning to see
Learning to see
Creating focus in observation:
When you are trying to design services, you often find that:
•
•
•
•
People do not always do what they say they do
People do not always do what they think they do
People cannot always tell you what they need
Things are not always as they seem
(adapted from IDEO)
“If you want to find out about water, don’t ask a fish”
Chinese proverb
Setting the improvement scene
•Improvement principles
•Focussing your aim
•Developing theories for change
•Developing change ideas using diagnostic tools
Profound Systems of Knowledge
Productivity and Efficiency
Safety
Leadership
Whole systems approach
Person centred health & social care
The Primary Drivers of
Improvement
Having the Will (desire) to change the current state to one that is better
Will
Developing
Ideas that will
contribute to
making
processes and
outcome better
QI
Ideas
Execution
Having the
capacity to apply
CQI theories,
tools and
techniques that
enable the
Execution of the
ideas
Subject Matter Knowledge: Knowledge basic to the things
we do in life. Professional knowledge.
Improvement
Subject Matter
Knowledge
Profound
Knowledge
Profound Knowledge: The interaction of the theories of
systems, variation, knowledge, and psychology.
(W Edwards Deming)
Profound Systems of Knowledge
The W. Edwards Deming Institute®
Profound Systems of Knowledge
Appreciation for the system
Psychology
Knowledge of Variation
Theory of Knowledge
The W. Edwards Deming Institute®
A Model for Learning and Change
When you
combine
the 3
questions
with the…
…the Model
for
Improvement.
PDSA cycle,
you get…
The Improvement Guide, API, 2009.
Reflection
• Think of a change that you worked to
implement.
• If the implementation was successful, what do
you think made it so?
• If the implementation was not successful,
what may have been the challenges and
barriers?
“People fear the uncertainties of
change. The slightest suggestion
that things won’t stay the same can
cause panic…but the real problem
isn’t the change…it’s people’s
reaction to that change.”
-Dr. Alan Zimmerman
21
Initial Reactions to Change
•
•
•
•
Denial
Confusion
Loss
Anger
• Transition is the psychological process that people
go through in response to change
22
22
Leadership and leading change
Crixus?
Common vision & purpose
Roger’s Adopter Categories
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
Roger’s Adopter Categories
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
A clear aim
Thinking
Measures
Ideas
Doing
Trying it out
in real
world
The Typical Approach…
Conference Room
DESIGN
Real World
DESIGN
DESIGN
DESIGN
APPROVE
IMPLEMENT
The Quality Improvement Approach
Conference Room
APPROVE
DESIGN
Real World
IF NECESSARY
TEST &
MODIFY
TEST &
MODIFY
TEST &
MODIFY
START TO
IMPLEMENT
Try to Fly!
Make a plane and fly it as far as you can
Exercise: Operational Definitions
How Big is your Banana?
• Create a step-by-step operational definition to
capture the concept of “banana size”
• Measure your banana using the definition, and write
down the result and keep it secret!
• Pass your definition and banana to another table.
They will use your definition to measure.
• Compare results.
Setting Aims
• Should be impossible to achieve within the
current framework of how your area functions
• Should embody these key elements
– Ambitious
– Measurable
– Time Limited
– Very Specific
The aims statement measurement components:
• Outcome measure
• Process measure
• Balance measure
• Example re 1:1 Reviews NHS Borders
Where it all started....
Developed the theory of variance
through plotting data over time; creation
of data patterns
Observed two situations:
Patterns in the data are predictable or
unpredictable
By analysing the available data we can
differentiate both situations and apply
one of two definitions
1920’s
Common causes & special causes
Expectations for Improvement
When will my data start to move?
• Process measures will start to move first
•
Outcome measures will most likely lag behind process measures
•
Balancing measures – just monitoring – not looking for movement (pay
attention if there is movement)
% Compliance with process
% Compliance with process
Outcome measure - % reduction in?
UNDERSTANDING VARIATION...
“There is nothing so useless as doing efficiently
that which should not be done at all”
Peter F. Drucker
Data over time!
Run Chart Rules
Four simple rules that allow you determine if
special causes or normal variation is present in
your data.
INTERPRETING DATA...
Rules for Run Charts
A Shift:
6 or more
Too many or
too few runs
A Trend
5 or more
An astronomical
data point
Source: The Data Guide by L. Provost and S. Murray, Austin, Texas, November, 2008: p3-11
Sustaining Improvement
• The data needs to show a new level of
improvement first (i.e.. a shift in the data – 6
or more data points on one side of the
median)
• Following the ‘shift’ it takes at least a further 3
months/data points at the new level of
performance to be considered as sustained
improvement
41
THE PERFECT TEAM FORMULA...
Every small piece of information has the
potential to influence the overall
improvements that meet an aim
THE REALITY... But!
Even when we’re not
working in a Formula
1 team, driving
improvements can
make an impact!
•
•
•
•
•
Summary
It is possible to enjoy your work! Taking the opportunity to improve
the care you provide is key to this
The biggest challenges to quality are VARIATION and COMPLEXITY
We need to utilise a rigorous proven method if we are to have any
success making lasting improvement in complex living systems
The Model for Improvement is a tried and tested method that can
support you to do this
It takes effort and careful planning to use the MfI properly – if we
don’t use it properly we will struggle to make progress:
1. Aims
Improve
2. Measures
3. Ideas
4. PDSA… test… test… test…
Implement
So why does improvement
Leadership matter?
•
Image credit: William Creswell/Flickr
The president of the Michigan Savings
Bank advisting Henry Ford's lawyer not
to invest in the Ford Motor Co., 1903.
• You are the Champions of Improvement and
Dementia care
You are the difference