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First steps towards quality improvement: a simple guide to improving services

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  • 1. NHSCANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement First steps towards quality improvement: A simple guide to improving services
  • 2. IMPROVEMENT. PEOPLE. QUALITY. STAFF. DATA.STEPS. LEAN. PATIENTS. PRODUCTIVITY. IDEAS.REDESIGN. MAPPING. SOLUTIONS. EXPERIENCE.SHARE. PROCESSES. TOOLS. MEASURES.INVOLVEMENT. STRENGTH. SUPPORT. LEARN.CHANGE. TEST. IMPLEMENT. PREPARATION.KNOW-HOW. SCOPE. INNOVATION. FOCUS.ENGAGEMENT. DELIVERY. DIAGNOSIS. LAUNCH.RESOURCES. EVALUATION. NHS. PLANNING.TECHNIQUES. FRAMEWORK. AGREEMENT.UNDERSTAND. IMPLEMENTATION. SUSTAIN. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S CONTENTS 4 Introduction 6 Chapter 1 - Improvement models 8 Chapter 2 - Defining the change idea and developing aims 11 Chapter 3 - Managing a successful project 14 Chapter 4 - Levers and drivers – framing the work for a wider audience 16 Chapter 5 - Getting the right people involved 18 Chapter 6 - Involving patients and carers in service redesign 22 Chapter 7 - Communicating the right things to the right people 24 Chapter 8 - Improvement Tool: Process mapping 28 Chapter 9 - Improvement Tool: Plan Do Study Act Cycles 30 Chapter 10 - Measuring your efforts 34 Chapter 11 - Improvement Tool: Using statistical process control charts 37 Chapter 12 - Human dimensions of change 40 Chapter 13 - Sharing your success 44 Resources 44 Acknowledgements 2/3
  • 3. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S INTRODUCTION If you are involved at any level in improving health or Before implementing a solution and changing your service, it is social care, this resource will provide the information essential to understand your current system by mapping the you need for your first steps towards making quality process, collecting and analysing the service data, along with improvements, giving your improvement project the asking patients and staff for their views in order to determine best possible chance of success. where improvements can be made. Don’t rush into implementing whole system changes without testing and Whether you are experienced at running improvement measuring small incremental changes. Learn from experience projects or not, this blend of project management and and be prepared to be flexible as your first idea may not be the improvement tools, combined with practical know-how best or the right solution. and first hand experience gained from working with NHS teams, should prove invaluable. This resource is not intended as a complete guide but provides a short overview with the most relevant tools and other resources signposted for further exploration. If you want to deliver sustainable improvements with greater speed and confidence, this resource will help you take the first steps.“ Every system is perfectly designed to get the results it achieves” Paul Batalden 4/5
  • 4. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S Do I really need a model toCHAPTER 1 improve things? Very often, it is clear that we need to get on and improve things and youImprovement models may be tempted to leap in and do so. However, a very high proportion ofThere are many models which can support understanding what you are going to projects fail, and one way to increaseyour improvement project; however, we accomplish, identifying a core team to the chances of your own projectpromote two such models: a five step undertake the work and a team to support succeeding is to adopt a moreapproach to successfully manage the the direction of the work along with systematic, tried and tested approachchange project from initial concept to identifying patients and carers to be such as those outlined on this page.completion, and the Model for Improvement involved. Work should be aligned to both Quality improvement requires the will,to provide a framework for developing, local and national objectives together with the ideas and the execution of thosetesting and implementing changes. structured plans to measure improvements. ideas to succeed – very often, we haveFive step improvement approach The launch phase is the official start of the the will to make things happen, but byNHS Improvement has defined a five step project. The team should be formed; project using models such as these, we canimprovement approach to provide a plans, communication plans and data ensure we develop the best possiblesystematic framework from the beginning collection plans should be in place and an change ideas and approachto the end of your improvement project executive sponsor identified to support the implementation in a planned andwhich will give your project a greater project. systematic way to enhance ourchance of sustainable success. The diagnosis phase is about chances of success.• Preparation understanding the current process,• Launch dispelling assumptions, using data to define• Diagnosis the problem and to build upon the baseline• Implementation data.• Evaluation The implementation phase tests and The final phase is evaluation whereThe preparation phase incorporates measures potential solutions using a Plan Do achievements are celebrated, learning andeverything you need to do before the Study Act cycle (chapter 9), implements the principles are captured and the improvementofficial start of your project. This includes best solution and introduces standard work becomes the norm.defining your project aims and objectives, and mistake proofing for a qualitycollecting baseline data for your service, sustainable process. The sum of all of the change ideas that are • Measure regularly during testing – what is Model for Improvement tested and successfully implemented will be the impact immediately, and what is the What are we trying to accomplish? the effective redesign of processes or ways impact over a period of time? How will we know that a of working. • Continue to measure after the change is an improvement? improvement is implemented, to ensure What changes can we make that will The framework, which was developed by a that the change is sustained. result in the improvements that we seek? team at the Institute for Healthcare Improvement in the USA, includes three key What changes can we make that will questions to ask before embarking on a result in improvement? change programme, supported by a process • Many change ideas are generated at for testing change ideas using Plan, Do, process mapping events (See Chapter 8) Study, Act (PDSA) cycles. • Use techniques of creative thinking and ACT PLAN innovation to generate ideas and to sort What are we trying to accomplish? them into those to be tested • Clear and focused goals that focus on • Learn from your colleagues – we know STUDY DO problems that cause concern for patients that there are many examples of good and staff practice currently available. • Consistent with local and national outcomes, plans and frameworks The Model for Improvement is a tried and • Bold and aspirational tested approach for implementing any • With clear numerical targets. aspect of change in health services. Address the three questions before embarking on How will we know if a change is an service redesign, to keep the work focusedThe Model for Improvement improvement? and relevant and to ensure that you canThe model for improvement is incorporated • What can we measure that will change if measure the impact of changing the system.into the five step approach and was the system is improved? Use PDSA cycles (chapter 9) to test out ideasdesigned to provide a framework for • How can we obtain this data? Is it on a small scale and to win commitmentdeveloping, testing and implementing available in existing information systems, before implementing changes across wholechanges that lead to improvement. To or will we need to collect this manually? departments, processes and systems.achieve improvements we need to take the • What is the best way to display the datatime to plan change and test it out and we collect so that we can decide whether Further explanation of the Five Stepresist the temptation to rush into wholesale we are improving the system and whether Approach and Model for Improvement ischanges to systems. This way, we will know the improvement is sustainable? detailed in later chapters.what is working well, and what is not so • Measure the baseline – how is the processsuccessful. Small scale changes can be or system performing before the changeundone and replaced by alternative ideas. is made? 6/7
  • 5. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S What is the purpose of a clear aimCHAPTER 2 or objective? To ensure everyone is working towards the same goal and everyoneDefining the change idea and has the same expectations. It is important to define this clearly, sodeveloping aims that you can also identify what it is relevant to measure and to help avoidA clear and accurate project definition is one project creep as your work progresses.of the most important tasks to ensure the A good aim statement can help tosuccess of any improvement project. motivate people about your project as being something worthwhile,When starting out, begin by focusing on the measurable and achievable.problem you are trying to solve, rather thana solution you are trying to implement - noone likes change for change sake!Analyse the problem by talking and listeningto those involved, collect baseline data andrecognise the impact of not changinganything at all. Once you have a clearunderstanding of the problem, it is vital toobtain agreement and support from those Examples of poorly written project aims “ If you don’t know whereinvolved as you will find that differentpeople have different knowledge based on We will improve cancer services This aim doesn’t clearly state what the you are going, you aretheir past experiences. Agreement will alsoincrease team engagement and will provide change will actually improve and who would be responsible in improving the services. Are likely to end up somewhere else!”a stable platform to take the next step in the improvements are for every cancerdeveloping the scope of your project with patient or just patients with certain types offocused aims and objectives. cancer (e.g. breast cancer) or for all types of cancers for a specific group of patients (e.g. Yogi BerraProject scope children and young people)? The projectWhen defining your change idea, take time aim must stipulate how much the service isto consider and clearly document what is going to be improved, when it is going to bewithin the scope of your project as well as completed and what is the impact of thewhat is out of scope. improvement.The scope should include information about We will achieve a 20% reduction in Ensure your scope and aim is clear tothe project boundaries and key deliverables, emergency admissions for heart failure everyone involved. The language we use inhowever be cautious of the size of the patients by July 2013 the NHS is sometimes ambiguous and canproject scope. A large wide ranging project This example does provide a clear a be interpreted in different ways by differentscope may mean the work does not have numerical target to aim for, but what is the people, for example “Self Managementenough focus or detail, or may achieve very 20% measured against? Is it 20% reduction Plan” - Is this a piece of paper with genericlittle by trying to do too much; whereas a from the previous year? Is it realistic? Could information given to all symptomaticnarrow focused scope may lead to a project it be achieved? patients or a personalised care plan for eachthat does not make a significant difference patient? It is really important that you areand cannot be transferable or able to scale All practices need to use a care planning clear in your aim and don’t leave anything toup. approach for all patients with a long chance. term conditionA well defined project scope is critical to ‘Need to’ is not an improvement aim. Is thisprevent a project creeping out of control. all practices across the country or all‘Project Creep’ is when the scope of a practices in the consortia? Which care Why should I get consensus aboutproject grows from its original parameters planning approach should be used? When the problem before starting theinto something more or different from the should this be completed and what will it project?original intention. Implications of a achieve?changing scope could include project failure, There are numerous reasons why youunclear deliverables, confusion, increased A good aim may look like this should discuss the problem andbudgets and expanding timeframes. 100% of patients on our list with a achieve a consensus before starting confirmed diagnosis of COPD will have aProject aim comprehensive review and will have an your project. Different people willA project aim should be aspirational, individualised care plan developed with the have different ideas about themeasureable and consistent with local and lead GP or practice nurse by March 2013. problem, so it is important that younational priorities and plans. This will ensure that they are optimally cared understand their perspective (as you for and better able to manage their might learn something new) and forA good aim statement should include: condition, thereby reducing the frequency others to understand your perspective.• What we are trying to achieve and severity of exacerbations and the need See the elephant analogy in chapter 3;• For whom for possible future hospital admissions.• How much very few people will understand the• By when full story as their perspective is based• Compared to what on their own experiences. This process• And why? of gaining consensus, talking and listening to the people involved in the process will assist with engagement and support for the project. 8/9
  • 6. An adaptation of a Hindi proverb Five visually impaired people touch an elephant to learn what it is like. Each one feels a different part. "Hey, the elephant is like a tree trunk," said the first man who touched the elephant’s leg. "Oh, no! The elephant is like a snake" said the second man who felt the trunk. "Oh, no! It is like a rope," said the third man who touched the tail. "It is like a brush" said the fourth man who rubbed the elephant ear. And the fifth man said "It’s soft and mushy…" They began to argue about the elephant and they all insisted they were right. They all were right in what they were saying as they had all developed an understanding based on their own experiences and perspective. However, they did not have an understanding of the whole elephant. Imagine the elephant to be a patient. Different clinicians and health care staff see the patient in different ways, all of them correct, but by not seeing the whole patient pathway, their understanding is limited. Make sure you understand the entire process/patient pathway before starting any improvement project.FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S What makes successful projects?CHAPTER 3 • Getting the right people involved from the start of the projectManaging a successful project • Having a clear aims statement • Planning, monitoring and control • Having a real understanding ofStarting out on any improvement project is • Collecting baseline data and having a the current issue or probleman exciting time, and you are likely to be full data collection plan (Chapter 10 and 11) • Measurable improvementsof enthusiasm and optimism. However, • Understanding your customer which are achievements not justthings don’t always go entirely to plan and it requirements (Chapter 6). activitiescan be hard to maintain impetus and • Having clear links to local andprogress with enthusiasm alone. A project plan is fundamental to the national objectives i.e. a clear establishment of the project. It sets the reason to do itFor a project to be successful, it is important contract for improvement and establishes • Involving patients and carers,that an adequate amount of time is spent the mandate, priorities and resource (ideally) from the beginningon managing the project. availability. In other words, it spells out • Displaying effective clearly what, how and when is to be done, communication.Spending time getting the preparatory work so that everyone is aware of theirright first time will be beneficial later in the commitments and how they will impact onproject. Preparatory work includes: the project’s success. It can be tempting to ignore this element as “bureaucratic” or The plan is developed in the preparation• Getting the right team (Chapter 5) “administrative” but it is an essential tool phase of the project and enables decisions• Having a good relationship with your for ensuring there is clarity about the project to be made with regard to modifying or executive sponsor (Chapter 5) and that expectations are managed. This cancelling the initiative in situations where• Having a solid project plan (Chapter 3) need not be an onerous process, but the the required support for the project either• Having a robust communication plan plan does need to clearly spell out the key changes or is lacking. The plan is used (Chapter 7) areas. throughout the project for monitoring• Understanding the current service and control. (Chapter 2 and 8) 10/11
  • 7. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S Why do projects fail?A project plan should specify: • Project aims and objectives not• Aims and objectives clearly defined or articulated• Background to the project • Little or no top level support• Scope of project and leadership for the project• Expected deliverables • Lack of effective engagement• Timescale with key players and patients• Analysis of risk • Poorly planned projects• Resources • Inadequately monitored,• Budget controlled and managed• Method/process • Failure to take account of local• Accountability and national priorities e.g. QIPP• Identification of the project sponsor • Poor communication• Data and measures • Failure to divide the project into• Dependencies (i.e. links between one small manageable tasks action and another) • Unable to collect and analyse• How the work is going to be sustained data. and spread to other areas.Project plans come in many different styles, buteach should set out all the actions that have tooccur to achieve the improvement, as well asclearly stating when these will happen andwho is responsible for doing them. Does someone need to project manage for a project to be successful? Is my work a project? Yes, within the project team, someone A project is a temporary piece of work needs to be responsible for the role. with a defined start and finish, and will Without someone to undertake this not continue indefinitely. Project work role, it is unlikely that even the smallest is also designed to deliver a defined project team will deliver what it sets outcome or benefit from doing the out to achieve within the agreed work. parameters. Isn’t project management just What is the difference between a unnecessary bureaucracy and research and improvement project? administration? An improvement project is about Good project management is not just testing ways to implement evidence bureaucracy. It is about ensuring there based care and find out the best way is consistent co-ordination, drive and for a service to be organised and evaluation of the project so that it delivered. It is about testing innovation remains focused and effective. Not or new ways of working and not about having someone to manage the testing whether treatments or project usually means that no one interventions actually work. takes overall responsibility for ensuring that all the components are being delivered – and the project may then falter or fail. What is the role of a project manager? The role of a project manager is to have oversight of the entire project and take responsibility for controlling and monitoring each aspect, along with reporting the successes, learning and failures of the project. Not every project needs to a dedicated project manager, but every project requires someone to undertake the roles and responsibilities of a project manager (see chapter 5). 12/13
  • 8. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S What is QIPP?CHAPTER 4 QIPP stands for Quality, Innovation, Productivity and Prevention and originates from the White PaperLevers and drivers - framing the ‘Equity and excellence: Liberating the NHS’ which sets out the government’swork for a wider audience vision for the future of the NHS. The QIPP agenda is all about ensuring that each pound spent is used to bringChanging established systems of any kind isdifficult. It is particularly challenging within maximum benefit and quality of carehealthcare because of the complex to patients. The QIPP initiative hasrelationships between a wide range of been increasingly important inorganisations, professionals, patients and healthcare and looks set to continue What levers and drivers could becarers. relevant to my work? as the NHS needs to make savings You might need to do some research because of increasing demand from anCertain factors may help to foster an about local and national priorities. Quiteenvironment that is conducive to change ageing population and the increasing often these are obvious and you canand improvement. An organisation where need for long term condition begin to ‘frame’ your work to align tothere is strong leadership and everyone is these. For example, you might be management. The NHS needs tofocused on improving patient care is more undertaking a project in primary care to achieve value for money and the bestlikely to develop motivated staff with a reduce the number of emergency possible quality of care so that patientsdesire for continuous quality improvement. admissions to hospital where the local get the greatest benefit.However, barriers to changing established priority is to reduce bed days. Therepractice may prevent or impede progress in would be a clear link to the localall organisations, whatever the culture. initiative and the work you would then More information can be found on undertake. www.improvement.nhs.uk/qippSometimes a great idea can be presentedwith various barriers and challenges tochange. Often taking time to identify thebarriers in order to overcome these is How do I link my work to local priorities?essential to securing engagement and Talk to the local stakeholders about the work you propose and understand how it fits in. Asustainability of the work. It is also number of these stakeholders may already be part of your project steering group, so takeimportant to look at the context of work time to discuss and explore this further with them. Your local clinical network may also beyou may be undertaking in terms of able to help you link to local priorities.understanding both the local and nationaldrivers for change and levers for improvement.Drivers are those forces for change that are There are a number of local and nationaloutside the projects scope of control. initiatives looking to improve local services What is a clinical network?Drivers derive from a variety of sources, including calls for case study examples of A clinical network is a local NHSincluding policy, that will change the way in good practice. It is worth spending some organisation made up of clinicians,which the service may operate. Levers are time investigating what drivers are aligned managers and commissioners who workthose forces for change and improvement to your work, similar work within your together to improve care. They provide athat are within the projects scope of control. organisation and opportunities to gain forum to share multi professional advice, additional support where it may be influence and learning, to maximiseIn parallel, linking with what is first seen as appropriate. knowledge and deliver better outcomesprimarily a small improvement project with for patients. They do this by bringinglocal and national drivers for change can together primary care, secondary care,enable a project to be further supported, commissioners, patients, social care and How can I get wider engagement to other stakeholders with a commonsuccessful and sustainable. Quite often support my work? interest, to enable the local NHS to workteams undertaking improvement projects Raising the profile of the work, in a collaborative and co-ordinated wayfocus purely on delivering isolated outcomes for its population, to best meet local particularly if the work is aligned to localfor their work areas. Levers such as needs and priorities. priorities will increase the chances ofreducing admissions or length of stay may wider engagement and support for thebe a local priority for a number of work. Talk to the service stakeholdersorganisations in your area. It will help raise and try to secure project sponsorshipthe profile of your improvement work if the from the chief executive or board level How can a clinical network help?work is aligned to such initiatives, however director within your organisation. Also Networks focus on solving problems forsmall. discuss the work with other patients wherever they are in the system, management and clinical colleagues but stepping outside organisationalLook for similar current work already remember that these individuals may boundaries and seeking instead a wholeunderway within your organisation. span wider than your immediate project system approach to serviceConsider framing your work to the National group and include, primary care, social improvement. Networks will also shareQIPP agenda in terms of quality care, acute care, commissioners and the information, best practice, guidelines,improvement, innovation, productivity gains ambulance service where relevant. Your and clinical learning to achieve greaterand prevention work. You may be surprised local clinical network may also be able to impact than would otherwise beby how much difference your improvement assist with wider engagement and support possible. They can also influencework contributes towards reducing costs, for your work. commissioning decisions about priorities, availability and use of resources, toenhancing productivity, enhancing quality deliver optimum care to local people.and increasing patient safety. If your project demonstrates significant scope to improve care, efficiency and outcomes a network can help you spread and sustain your work. 14/15
  • 9. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S How do I keep colleaguesCHAPTER 5 engaged? Once you have built the relationship and engagement has been achieved,Getting the right people continue to work at it by:involved • Staying in regular contact • Keeping people involved and updatedSome of the biggest risks to any project can • Having meetings with acome from within the team. It is important Why do I need an executive sponsor? purpose, actions and outcomesthat the team has people with the right skills Executive sponsors should be chosen • Delivering what you haveand abilities to do the job and will be able to from the top of your organisation, ideally agreed to do.give continued support to the improvement the chief executive or someone from theinitiative. executive team. This person will champion your project, provide strategicHaving the right people involved from the support to the project, help to discussbeginning with the right expertise will give and resolve issues, celebrate achievement and provide access to HR,your project the best chance of sustainable Finance and IT teams when required.success. If the right people are not involvedfrom the start, it will be much harder toengage and involve these people at a laterdate. Why is clinical and managerial leadership important for my work?A project sponsor and involvement from Clinicians and managers providethe top of your organisation (Chief Executive different perspectives, experience andor Executive Team) is necessary to champion support to your project. They will helpyour project and provide strategic direction ensure that your project is appropriatelyto the project. This type of involvement also targeted and relevant. Also they canprovides support to discuss issues, celebrate ensure that the changes you are testingachievement and provide access to human are practically supported and promotedresources, finance, analysts, communications, across different staff groups.estates and IT teams when required.Every project should have someone with an Involve all stakeholders and grades of staffoverview of the project who is responsible (clinical staff, GPs, porters, commissioners,for the role of project manager. You reception staff, managers, pharmacists,might be fortunate to have a dedicated clinical support staff, data analyst, medicalproject manager to support your project, secretaries etc) as they will have differenthowever a project member may be required experiences, knowledge, skills, opinions,to take on the responsibilities of this role ideas and concerns.where this is not possible. It is advisable forjust one person to be accountable and have The involvement of patients, carers andownership to lead the project, ensuring charities is vital as they will be able to give adecisions are made, actions taken, and different perspective on your service andmeasurable, timely progress is made. proposed improvement plans.Within the project team it is necessary tohave a variety of individuals, some whoserole will be to make decisions and others tocarry out actions.When establishing a project team, considerindividuals or groups who are interested andenthusiastic about the work, and those whoare in a position of power and influence. Itis also worth involving people or groupswho do not have direct interest in yourproject but have a key position of power orauthority to make decisions. 16/17
  • 10. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S Why should I involve patientsCHAPTER 6 when I know what I need to do? Patients’ experience of what we say, do or mean can be very different toInvolving patients and carers that which we intend. By actively involving patients, we can find outin service redesign how what we do actually affects them, what really happens day to day and what we could do to improve patients’ experience, reduce wasteful processes and improve quality.Patients and their carers are the reasonthe health service exists and thereforethey should be at the heart of ourservices.Service improvement and redesigngenerates opportunities to involve usersand their carers who can provide a differentperspective to enable a better understandingof whether our improvements make anydifference.A patient’s experience of our service can bevery different to what we intend or assumeit to be and they can tell us what works,what doesn’t and what could be donebetter. We might ‘know’ we are doing agood job, but it needs to meet the patient’srequirements.Only when we understand a patient’s needs– by asking them, not second guessing – canwe work in a way that meets those needsand ensures they get maximum benefit from graham@ogilviedesign.co.ukour service.Why should patients and carers be Planning before involving Where can I find patients and carersinvolved in the improvement of Planning is imperative to ensure that the who may support my work?services? healthcare provider fully understands what There are many ways in which you can• Raised awareness of how the service really they want from the interaction and how interact and contact patients and carers who runs from the patient point of view, not they are going to meaningfully involve would like to be involved in service just how the service providers think it runs patients and carers. improvement work. You can approach• Different perspective on improvements people in your clinic, through hospital and priorities The following planning steps should be departments, nurse specialists and patient• Opportunity to discover what really makes undertaken before interaction with patients groups. a difference to a patient’s experience and carers:• Understanding what makes it difficult or • Be clear about what you want from Some organisations which can support the easier for the patient to manage their interaction and what you are trying to placement of volunteer patients and carers condition effectively achieve in service improvement work in the NHS• Suggestions to make things quicker, • Address any staff concerns about patient include: cheaper, easier or better to improve involvement/engagement • Local Involvement Networks (LINks) / Local services and experience for patients and • Consider what previous patient HealthWatch (www.nhs.uk) carers involvement has taken place and if this• Learning more about the patient’s actual was successful. If not, why not? experience and so providing a better • Decide on the type of patient – someone understanding of their needs and priorities who is well informed about their• Improved service user relationships with condition, newly diagnosed patient, I want to know more, where can I healthcare professionals recently discharged etc. find detailed information?• Opportunity to raise issues of importance • Decide where are you going to enlist this to patients, carers and the public type of patient? NHS Improvement has years of• Improved and increased staff morale from • Decide on the level and method of providing care to patients that they want, involvement you are going to use – i.e. experience in involving patients and in a way they want direct, indirect questioning their carers. Information can be • Ensure you have enough resources in found on our website: place, e.g. time, finances, training (www.improvement.nhs.uk/ppe) • Consider any practical arrangements that along with information about need to be made Discovery Interviews™ which is an • Test the method you propose to use, then innovative technique designed to amend where necessary • Establish plans for evaluating your improve care by gaining insight into approach. patient and carer needs and experiences: www.improvement.nhs.uk/ discoveryinterviews. 18/19
  • 11. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S• Charitable organisations such as the Stroke Association, MacMillan Cancer Support and Asthma UK (find local information on the charity websites)• Local support groups• Patient Advice and Liaison Service (PALS).You may also like to consider advertisingyour improvement work and asking forvolunteers through:• Posters in GP surgeries, outreach clinics, hospitals or other NHS settings• Posters in libraries and pharmacies• Social networking sites such as Facebook and My Space.What are the considerations forinvolving patients and carers?Sensitivity – the patients actually sufferfrom and live with their conditions / illnessesand sometimes service redesign work may graham@ogilviedesign.co.uktake a depersonalised approach. This shouldbe considered if patient representativesattend meetings or improvement events.Cost – undertaking some forms of patient Examples of techniques to involve patients and carersinvolvement may incur a cost for the patient.It is reasonable to expect that patients and Direct methods Indirect methodscarers should receive reimbursement for the Interviews Questionnairescosts they incur – travel, parking etc. Focus groups SurveysRepresentative sample – there is often a Workshops Suggestion boxeschallenge in finding patients who are Face to face meetings with individuals Analysis of complaintsrepresentative of the service you are workingto improve. For example, if meetings are Patient reps on project groups Public meetings / open daysarranged during working hours it is highly Patients attending service improvement events Social networkingunlikely that people of working age wouldbe able to attend because of other lifecommitments such as work and children. Ifyou wish your patients to be truly Top tips for involving patientsrepresentative you may have to consider a • Listennumber of methods. • Find ways to involve the seldom heard groups, those who find it difficult to access health services or people who may not routinely get involved soA range of opinions – patient engagement that you get a real understanding of different experiencesmay elicit a different or even opposing • Take time to understand the issues, don’t assume you know the answer oropinion to the work you are undertaking. It the solutionis important to know from the outset how • Use appropriate language, not jargonto manage expectation realistically but also • Be clear about why you are undertaking involvement work andto genuinely incorporate views and make how you will deal with what it revealschange. • Be clear about any areas that can not be changed or are not for discussion (e.g. national guidance), this ensures that the valuable time is spent discussing what can be changed and that patients expectations are not unduly heightened • Always provide feedback to the patient and what has happened as a result? 20/21
  • 12. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S Why should I invest time toCHAPTER 7 communicate what I know? Don’t assume that other peopleCommunicating the right things (including your staff and colleagues) know what you know. Everyoneto the right people connected to the service needs to understand what you are doing and why, and the impact it is having. Keeping the improvement at the forefront of people’s minds whenCommunication not only keeps How often are you going toeveryone up-to-date on the project communicate? things are going well will ensure theyprogress, but raises the profile of your • Daily, weekly, monthly. remain engaged and committedproject and facilitates engagement and which will make it easier for you toownership of the vision and service Who is going to be responsible for the gain support when you need it.changes. To ensure the success of a communication?project, information including the aims, • Project manager Don’t expect people to dropobjectives, expectations, deliverables, • Executive sponsor everything to help you if they havetimescales, progress, risks, challenges and • Named peopleachievements need to be communicated on • Everyone. heard nothing from you for the lasta regular basis. six months! By communicating what you are doing to others in yourThrough two way communication, youwill probably find that the staff who work “ You can have brilliant department or organisation, you might also find out informationin the area are fully aware of changes thatcan improve the service. Through ideas but if you cant get which you were not already aware of that may have a positive or negativeinvolvement, empowerment and listening,staff generated ideas and solutions are them across, your ideas impact on your work.generally most effective and sustainable.Following meetings with staff, make sure wont get you anywhere.”you take action and communicate the Lee Lacoccaprogress you have made. Smallimprovements can ignite momentum for theproject and start to get people interested.The first step to effective Communication Plancommunication is to understand who Team: Completed by: Date:you need to communicate with Who are you going What are you going How are you When are you Who is responsible• Who do you need to keep informed and to communicate to communicate to going to going to for communicating obtain information from? Staff/patients/ with? them? communicate? communicate it? the message? carers/executive board? e.g. Project teams, e.g. Improvements, e.g. Weekly e.g. Daily, weekly, Name and role• Who needs to know what is happening / exec sponsor, NHS risks and issues, meetings, fortnightly, changing? Improvement, steering measures, data, presentations, monthly, annually• Who do you require support from? group, SHA lead, project scope, news events, email, stakeholders, patients etc. letters, handouts• Who will be directly and indirectly etc. etc. affected?What do you need to tell or ask? What Communication plandoes your audience need to know? A communication plan is an easy way to• What the current service looks like actively address the interests and concerns• The vision, aim, deliverables of the key stakeholders and ensures this is• The problems, issues, risks done in a timely manner. What is the best way to• Changes to the project communicate the progress and• The benefits. In a changing environment with outcomes of my work? organisational structures being transformedHow are you going to communicate to and staff moving roles, a documented Remember that you will need toall the relevant people? communication plan will support the adopt different approaches and styles• Regular meetings progression of an improvement project. for different audiences and• Internal and external newsletters stakeholders. Try not to develop a• Memo’s Example of how a team at Hinchingbrooke• Local press Hospital communicated their work in the whole industry of reporting around• Websites local press your project but use existing channels• Emails wherever possible. Involve your local• Letters communications team as they will be• Reports able to suggest some possibilities.• Presentations Regular reports to your executive• Support from the communications sponsor, board or management department? committee are useful at the higher level, but make sure you also use local newsletters, forums and meetings to provide ongoing updates. 22/23
  • 13. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E SCHAPTER 8Improvement tool: ProcessmappingA process is made up of series of actions or People’s views about the process tend to process is an important step in movingsteps taken to achieve a specific result. change and develop following a process forward to redesign and developing a newProcess mapping is a technique used to mapping exercise as individuals have an idea process that will work better for patientsidentify all the interconnected pathway steps (a ‘mental map’) of the process, but as the and staff.and decisions in a process and coverts this process map is developed, it becomes clearinformation into a highly visual that their personal view is different from What does a process map look like?diagrammatic form. that of others in the same process. The map The map below is of a diagnostic pathway of the current process may differ from the for chronic obstructive pulmonary diseaseProcess maps can cover a short and simple mental maps that individuals in that process (COPD) and asthma.sequence of actions by one person (such as have always believed. Agreeing the currentpoint of care testing or phelbotomy) or itcould be a complex set of activities involvingmany different people over time, (such as COPD and Asthma Diagnosisthe End of Life patient pathway). If referral doesn’t meet set standards, more information is requested from GP or if does not meet the triage standards,What are the benefits of mapping letter back to GPthe process? Patient contacted• An overview of the complete process from GP referral to Referral triaged by by community team to arrange an Communication Community team Clinic referrals Secondary care manager (band 6) community nurse community specialist letter sent to book secondary care sent to secondary beginning to end, helping staff to specialist team team appointment which is close to patients patient with PIL to staff to run clinics care arranges staff to cover clinics home understand, often for the first time, how complicated the system can be for Spirometry x3 (which need to be Measure oxygen Check Check Check height Patient called Secondary care within 5%) by band sats medication demographics and weight into clinic attended for clinic patients 2 or 6 staff• Allows staff to see the pathway from the If spirometry patient’s perspective 400mg salbutamol 20 minute wait (for medication Repeat spirometry Explain results Results taken back to secondary conducted by band 2 staff results Indication and comments (via volumatic) x3 to patient documented and• A starting point for your improvement to work) care interpreted by band 6 printed project Write to GP and Decisions for Results sent to Review and patient for treatment and primary care nurse interpretation management management specialist team• The opportunity to bring together people Once the above map was completed, the team could see that the process was over- from primary, secondary, tertiary and complicated, and included many unnecessary steps, bottlenecks, wasteful activities and social care from all roles and professions avoidable delays. The process was redesigned following the mapping exercise the new• Identifies problems, delays, areas for error process below was created. As well as being simpler, the new process is much quicker for and confusion, blockages and bottlenecks the patient, takes less administrative and clinical time and costs less.• A point to create a culture of ownership, responsibility and accountability for improving the process Community Spirometry Management• An aid to help plan where to test ideas for improvements that are likely to have the If referral doesn’t meet set standards, most impact on services more information is requested from GP Interpretation in• Draws out ideas to help redesign the or if does not meet the triage standards, Band 2 staff secondary care by band 6 or above letter back to GP pathway – which particularly from members of staff who don’t normally have Patient contacted Communication Indication and Proactive approach by community team letter sent to Spirometry with comments to treatment and the opportunity to contribute to service GP referral to community nurse Referral triaged by community specialist to arrange an appointment which patient with a patient information reversablility, SpO2 by secondary care documented and sent to primary management which specialist team team may include tier 3 planning, but who really know how is convenient in proximity and time and instruction leaflet team care specialist nurse team clinic attendance, MDT discussions things work• An interactive event that gets people Band 6 staff Interpretation and or above involved, motivated and talking to each results explained to patient other• An end product – the process map – documents who does what, when, and how long it takes, is highly visual and easy How to organise an event and • Meet with managerial, clinical and service to understand. generate a process map leaders beforehand so that they feel involved in the process. Use these Preparation meetings to agree the scope that you will • Define the objectives, scope (start and end work on and the three or four basic steps points and level of detail) and the focus of that you will explore in detail at the the process mapping workshop workshop • Start is with a process that involves high • If you have the opportunity, an numbers of patients independent facilitator, not connected • Organise a half day event to draw the with the pathway, can be really useful. map and a half day to analyse and look Choose someone with service redesign for improvement opportunities. You can skills and experience. run these together as a full day event or as two half days but not more than two weeks apart 24/25
  • 14. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S I’ve already process mapped - Do I need to do this again?Who and how to invite • Write each step on an individual post-it• You need to invite people who support, note and stick them to the backing paper. Review your map. Is it valid? Have deliver and manage the entire scope of The benefit of post-it notes is that you can you checked with all those involved, the process you wish to map. This might move them around if you need to add including patients? What changes did include people from primary, secondary, some extra steps you make after you completed your tertiary and social care from all roles, • Concentrate on what happens ‘most of map? Sometimes process mapping is grades and professions the time’ rather than what occasionally• Consider how staff will be released from happens seen as an end in itself – it is not. You their job for the mapping event • If problems or issues are raised which need to use your map as a tool to• You may wish to invite patients and carers cannot be resolved in the room or in a identify where and how you can start to give their perspective and ideas defined timescale, e.g. 10 minutes, write to make changes and how you can• The invitation should come from your them on your ‘Car Park’ flipchart ready to evaluate their impact. project sponsor be addressed at a later date.• The invite include information on the background to the event, aim of the event, What level of detail? expectations, scope of the mapping etc You may map a process at ‘high level’ to obtain a clear outline of the major steps involved:• It is advisable to request that the invited participants walk through the pathway which is going to be mapped before the event. Put tea bag Put water Remove Put kettle on Get cup Add milk Drink tea in cup in cup tea bagVenue• Arrange a suitable venue, preferably off- site, as this will provide a neutral setting and people are less likely to be interrupted and it will be easier to concentrate on the Or at a more detailed level to identify the complex steps in one or more stages of the journey. task in hand. Don’t forget to organise some refreshments – process mapping can be thirsty work! Put tea bag Put water Put kettle on Get cup in cup in cupEquipment• You will need a long roll of paper (wallpaper lining or a roll of brown paper), coloured post-it notes, lots of marker Open cupboard Choose cup Select tea bag Warm cup Add tea bag to cup pens, sticky tape and two flip charts, preferably with stands.Set up Analysing your map Following completion of your map• Use a roll of brown paper or wallpaper, • From your process map you will be able to • Agree the next steps fixed firmly to the wall identify where the significant problems • Agree which parts of the process need to• Write ‘Ideas’ on one flip chart. This flip occur. This might be the most prevalent be mapped in more detail and how this chart can be used to capture all ideas that waits, delays, duplication, bottlenecks, should be arranged arise throughout the mapping exercise constraints or inefficiencies together with • Agree who should communicate with• Write ‘Car Park’ on the other flip chart. the presence of any ‘non value adding’ people who have not been able to attend This is used to capture all issues that can activities such as unnecessary hand offs the event not be resolved in a defined amount of (where the patient is passed from one • Agree when and how change ideas will be time or are not directly relevant to the person to another), transfer to queue or generated and tested map but need to be addressed. excessive administrative checks: • Tape the post-it notes to the backing • There are four main techniques to paper. The post-its will start to fall off theStart of event redesigning your process map: backing paper after a few hours in a hot• Ask one of the lead clinicians or your • Eliminate room! project sponsor to open the event, • Combine emphasising their own commitment to the • Simplify Following the event event and redesigning the process • Sequence. • Type up the process map (Microsoft Word,• If everyone doesn’t already know each Excel or specific software like Visio can be other, have a round of introductions Where possible, try to eliminate any process used, but make sure other people are able• Set some ground rules – these may include; steps. If it isn’t possible to eliminate any to view and/or amend any electronic files listening to each other, no opinion is wrong, steps, look to combine steps. After you create) no blame will be cast, it’s the process not combining, consider where the system can • Check the typed version with those who individuals that is at fault. be simplified. Once steps in the process have attended, and with others who were been have been eliminated, combined and unable to attend the eventMapping the process simplified, review the sequence of events to • Send a copy of the notes and agreed next• Review the agreed start and end of the promote efficiency: steps to each participant and to those who process didn’t attend• Agree the level of detail. It is best to start • Measure or time the process steps in order • Review the agreed actions with the at a very high level and then drill down to to set the baseline for improvement participants at regular intervals to assess the detail where necessary • Revisit those issues and ideas that were progress, capture learning and address• Start with some main headings mapped generated in the mapping event problems out on the paper – these might include: • Identify where processes that are part of • Arrange a follow up meeting. ‘presenting symptoms’, ‘referral’, ‘diagnosis’ etc. – the ‘high level’ steps in another service area have an effect upon the process. This can help to remind your service people that the purpose of the event is to • Generate action plans from the map, to map the whole of the journey, not just the test improvements using the Plan Do study elements they are familiar with Act Cycle (Chapter 9). 26/27
  • 15. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S I want to improve my wholeCHAPTER 9 service – why start small? People are more likely to trial small changes rather than a full scaleImprovement tool: Plan, Do change. People also find it easier to adopt and build on small changes inStudy Act (PDSA) Cycles behaviour so that these become the norm. Bear in mind that starting small inspires confidence and can build rapid momentum.Change on a large scale can be daunting Plan, Do Study Act (PDSA) Cyclesbut that should not deter you. Beforeimplementing a full proposal for change aPlan, Do, Study, Act (PDSA) cycle can beused to test out an idea on a small scale. PLAN DO STUDY ACTNew ideas should be introduced only after ... how to ... what you ... the ... on the explicitly test a have planned outcomes results tosufficient testing (or evidence) on a smaller small change to do expected and modify andscale has proven to have a positive effect. unexpected of improvePDSA cycles allow ideas to be introduced an the testidea in a safe, controlled way which willhave less resistance, be less disruptive anduse less resources. By building on thelearning from each PDSA cycle, newprocesses can be introduced with agreater chance of success.Plan the trial Act upon the results of the trial • Use the information that you have gained “ All improvements are• Define the objectives• State the scope of the PDSA • Do you need to modify & retest? • Do you have enough information? changes, but not all changes• What, Why, Who, How & When?• How long will the PDSA continue? • Does the trial need to be longer? • Can you implement the change are improvements.”• Are there any circumstances when you immediately? would stop the trial? • Who do you need to share your findings Eli Goldratt• Does everyone understand their role? with?• How will you communicate with these • Can other areas benefit from your people? knowledge?• How will you know if the PDSA is a • How will you performance manage the success? process in the longer term?• What data collection methods are you • Implement the new process! ADJUST PLAN using?• Who will collect the data? To develop an idea into a tested• How will you feedback to the team? improvement proposal, you may need to STUDY DO perform a number of PDSA cycles. SomeDo - carry out the trial cycles may lead to nothing, where as others• Encourage continual feedback - you may will lead to a positive improvement which is wish to set up midpoint meetings to ready to be rolled out across a whole discuss progress system.• Motivate, reassure, encourage and A P support the staff Value of PDSA S D D• Collect information. By using PDSA’s to test changes you can: P • Minimise risks and expenditures of time S AStudy the results of the trial and money A P S• Examine your findings • Make changes in a way that is less• Review and compare information from disruptive to patients and staff D before, during and after the trial • Reduce resistance to change by starting A P• Reflect on what was learned on a small scale S D• What did it feel like? Did staff and • Learn from the ideas that work, as well as patients notice an improvement? from those that do not• Was the process shorter or longer? • Generate larger improvements through• Did you achieve your objective? If not, successive quick cycles of change I want to improve my service but why not? • Increase the numbers as the idea is refined don’t have the time to trial things• What went well? • Test with people who are willing and first.• What could be improved? happy to innovate and participate • Implement the idea when you are Unfortunately, when ideas are not confident that you have considered and tested and a solution is implement, tested all the possible ways of achieving we can find we spend more time the change • Learn from the ideas that work, as well as putting things right and redoing work from those that do not. afterwards. Investing the time up front to find out what works and why can help avoid costly mistakes and wasted time in the medium term. 28/29
  • 16. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S How do I know what data I need?CHAPTER 10 Ask yourself what you trying to achieve? What would tell you that you had achieved it? What wouldMeasuring your efforts you need to have in place to know you were making progress towards that aim? These questions shouldMany people begin to feel uncomfortable Where can I find data for mywith the idea of ‘data’ and ‘measurement’ improvement project? help you identify what you need tobut they are essential if we are to There are a number of freely available data measure and therefore what data youdemonstrate that change has occurred or sources which can be used to frame your will need. You don’t need reams ofneeds to occur and whether the change is improvement project and compare your complicated data – just enough to tellan improvement. Whether the change was services to others both nationally and in the you whether you are making progressa success or didn’t demonstrate the local area. For example: or not.anticipated outcomes, it is still necessary todemonstrate its effect and learn from it. • Programme Budget Interactive Atlas - www.nchod.nhs.ukTo establish what data you need, it is • Quality Outcomes Framework (QOF) -essential first to understand what outcomes www.qof.ic.nhs.ukyou are aiming to achieve as this will help • NHS Comparators -determine your measures. You should www.nhscomparators.nhs.ukconsider which measures will best • Hospital Episodes Statistics (HES) -demonstrate whether the changes you www.hesonline.nhs.ukintroduce demonstrate a difference.Defining your aim in terms of the size of the These data sources are beneficial to set theimprovement and the timescales you are context your project, however the dataaiming for will help you to determine provided by these tools may often beappropriate measures. Try to avoid the ‘ICE’ months or even years in the past.approach: Improvement projects benefit from current,• Identify everything that is easy to measure real time data to provide a clear and count understanding of the service and the impact• Collect and report the data on everything of any small scale PDSA cycles. To get this that is easy to measure and count information, you may need to explore the• End up scratching your head thinking information available from the local “What are we going to do with all this databases or consider collecting the data?” information manually.MeasuresProject measures might include: Individual patient level data is often valuable for improvement projects as it will “ Measurement is the first• Reduction in admissions and readmissions• Reduction in outpatient appointments allow you to see the variation between patients, and can provide an insight into a step that leads to control• Reduction in prescribing• Number of patients treated/diagnosed process that are often hidden within aggregated and averaged data. For and eventually to improvement. If you cant• Patient experience example, consider looking at the variation in• Waiting days between interventions length of stay; You might identify measure something, you• Turn around times unnecessary short stays in hospital, or some• Response times particularly long stays both of which would• Staff morale. be hidden when using an average.Once you have agreed on your project Establishing a baseline cant understand it. If youmeasures, clearly articulate your operationaldefinition. An operational definition is a Establishing a true baseline of current service delivery is a major part of service cant understand it, youclear, concise, detailed definition of ameasure, so that exactly the same improvement. Without knowing what the position was, it will be difficult to know cant control it. If you cantinformation is collected before and after anintervention. Even simple measures need an whether an improvement is an improvement and has any impact on the control it, you cantoperational definition - for example, if Iasked you to measure my arm, where would process or outcomes for patient care. improve it."you measure from and to? Would it be It is essential to know your starting point i.e. H. James Harringtonfrom my shoulder, neck or armpit to my the current state and standard of currentwrist, finger or hand? performance. This is your baseline data, against which you will measure the impact of any changes that you make over the I can’t get any data – what are my course of your project. This helps determine next steps? the areas you need to focus on, what you need to measure and how much impact First try your information team to see your project is having. what is routinely available and whether you can use this information. Ask your executive sponsor for advice or help. Consider what data you can easily collect manually for the purposes of the project and look at other national sources which are freely available. 30/31
  • 17. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S I have some data – what do I do with it? Your data should provide you with an understanding of how well you areMonitoring the project Data collection plan doing at present, it may indicateTo support your improvement work, it is A data collection plan is useful to bringimportant to monitor and use data clarity to the data collection and where there may be problems in thethroughout the project and in your PDSA measurement aspects of the project. A plan system and how much impact anycycles. Using and reviewing data should be should include: changes is having. There is a numbera regular part of your project work and can of tools to help you analyse andboth motivate and focus continued • A specific question – What do you want interpret your data on ourimprovement work. Think about the to know? improvement system on our website –dashboard in your car, the “vital signs” on a • What data do you require to answer this www.improvement.nhs.uk/improvehospital life support machine, or simply the question?clock in your kitchen! Having data available • Where will you get this data from? mentsystem. Your local informationand visible is an important motivator, can • Who will collect the data? team or management team may alsoinfluence behaviour and motivate • How often will the data be collected? be able to advise you. When youimprovement activity. • Do you foresee any problems collecting have identified what the data is telling this data? you, share it with your project teamPresentation of data is a science and art in • How are you going to analyse the data? and use it to decide whether youitself; however some simple thought into • Who will be responsible? need to continue with what you havehow you present your information can • When is the raw data and analysisimprove the delivery, and usefulness of the required? done so far, change your approach orinformation. Consider your audience add to it.carefully, remember not all project membersmay be experts in data and you may needto structure the presentation of datacarefully to “tell the story” and guideproject members through what the data Don’t forget “better” is not measureable, “soon”may show. Also consider the format thatyou present the data – don’t always assume is not a timescale and “some” is not a number! “More”,data requires a complex spreadsheet,sometimes a presentation, or a simple graph “faster”, “safer” or “cheaper” can all be measured butmay be what your audience requires. only if you know how many, how fast or how expensive things were to begin with.Data analysts Data Collection PlanData analysts are a valuable resource and Team: Completed by: Date:where possible they should be an integral Specific What What source Who will How often Do you What is Lead Datepart of your project team and their skills question data do will be used collect will the forsee any you dueutilised from the very start of your project. you to get the the data? data be potential analysisBenefits of having a data analyst on your require? required collected? problems? plan?project team include: information?• Support the design of project goals, ensuring the aims are measureable and achievable• Help to understand what you need to measure, baseline and monitor• Have access to data sources (such as your local patient admissions system)• May reveal other sources of information or approaches which may be unknown to the project team.A top tip is to explain what you are trying todemonstrate rather than what you think youwant as they may be able to suggestalternative or better indicators. I don’t have access to a data analyst, who else could I ask? Try looking more widely for some support. People with access and expertise to data may not always be in analyst roles. You could contact a performance manager, clinical coder, data manager or a contract manager, who could assist you with access to data and analytical expertise. 32/33
  • 18. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S SPC charts are used:CHAPTER 11 • As simple tool for analysing data - measurement for improvement • As a tool to help make decisionsImprovement tool: Using statistical • As a tool for the ongoing monitoring and control of a processprocess control (SPC) charts • To focus attention on detecting and monitoring process variation over timeStatistical Process Control (SPC) is a simple Following root cause analysis, the next step • To help improve a process toand visual way of observing variation in your would be to reduce the variation between perform consistently andsystems and processes. Every process is the data points by small scale incremental predictably over timesubject to variation but generally speaking, improvements – (PDSA Cycles, Chapter 9) • To provide a common languagethe more variation there is in a system or for discussing processprocess, the less reliable it is, and the less performancecertainty there will be that the process orsystem will produce the outputs or resultsexpected or desired. SPC can help to identifyvariation as a first step in trying to reduce What does an SPC chart look like?and control it. 90There are some basic statistics and simple UPPER CONTROL 80maths involved, but SPC is much more thanstatistics... SPC is way of thinking. 70 60An SPC chart is essentially a run chart withstatistically calculated lines of variation with 50the main aim to understand what is 40‘different’ and what is the ‘norm’ within aprocess. By using these charts, you can then 30understand where the focus of work needs 20to be concentrated in order to make a LOWER CONTROL 10difference. 0 F M A M J J A S O N D J F M A M J J A S O N DWe can also use SPC charts to determine ifan improvement intervention is directlyimproving a process (as opposed occurringto chance) and to predict statisticallywhether a process is capable of meeting a Why focus on variation? Why not just use averages?set target. There is variation in every process. Averages can be misleading and doThe inherent strength of these charts is that However, the less variation there is in not show the full picture of what isthey provide a visual representation of the any process, the more reliable it will actually happening. The average of aperformance of a process by establishingdata comparisons against calculated limits be, in terms of safety, quality and set of numbers can be created by(known as the ‘upper and ‘lower’ control outcomes. By understanding the many different distributions, solimits). These limits, which are a function of type of variation, specific action can presenting data using averages andthe data, give an indication by means of be taken to reduce the difference. A aggregates may lose the richness andchart interpretation rules as to whether the large amount of variation shows that impact of individual data points andprocess exhibits either predictable variation the process is out of control and the variation between the data points.or there are special causes. The charts also there is a lot of uncertainty. A For example, an average waiting timevisually demonstrate the spread of thevariation being generated within any given process with a limited or no variation for an appointment could be sixprocess. is in control and will deliver standard weeks but when you look at the results. variation between individual patients,Improvement projects would first seek to some patients might be seen in tworemove anything above or below the control weeks and others in eleven weeks.lines in order to create a stable and in An improvement project would firstlycontrol process. Any data points outside strive to see a reduction in thethese lines should trigger a form of action totruly understand why it is occurring (Root variation of time that people have toCause Analysis). Finding the real cause of wait for an appointment, which inthe problem and dealing with it is imperative time would reduce the average.to improvement projects rather than simplycontinuing to deal with the symptoms / It is important to know that reducingconsequences or add another stem to solve the variation, making the processthe problem. stable and in control, could increase average waiting times and if you were just looking at averages, your project could be misinterpreted as having a negative impact. 34/35
  • 19. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S Why should I use control charts rather than any other chart? Using aggregated data and summary tabular formats are only really usefulA SPC generator is available on the NHS Improvement System. for judgment, not for improvement.www.improvement.nhs.uk/improvementsystem Control charts are the best tools to determine whether or not your improvement efforts are having the desired effect. SPC charts are more SPC chart showing step changes each month following incremental project sensitive than all other charts as other improvements charts cannot detect special causes due to point to point variation or use rules for detecting special causes. SPC Charts have the added feature of control limits which estimate natural variation and define how capable and stable a process is; therefore allow us to more accurately predict the process behavior over time. September October November December JanuaryFIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S I want to do things differently butCHAPTER 12 my colleagues are reluctant. What can I do? If your colleagues are reluctant, showHuman dimensions of change them the problem and once they understand what is wrong they may be more willing to consider change. IfDifferent people have different reactions to People respond better when they are you are trying to sell a vision to them,change. Some people are enthusiastic and presented with a problem that affects them break it down into small steps orlook forward to the challenge and new and that needs a remedy rather than being stages. Making each step manageableexperiences offered by change. Others presented with a solution that is going to be and achievable may stop some peoplehowever are much less enthusiastic and see implemented. By identifying and starting feeling discouraged and reluctant.change as threatening and destabilising – with the problem, the team will be engagedsomething to be avoided at all costs! And of in finding a solution that will make acourse there are people who are somewhere difference to the people affected.in between, and people’s response will varyaccording to the situation or the change For change to happen, it has to bebeing suggested. worthwhile. The people who are being asked to change need to understand or beUnderstanding the ‘human dimensions’ of experiencing the inconvenience or problemschange can help teams to find ways of generated by the current way of doingeffectively implementing change and things.progress the improvement work in a timelymanner. Share the vision and journey to the vision. Everyone is different; some people can seeOwnership of the problem the big picture and can work towards aOne of the first steps in change vision where as other people need to seemanagement is to start with the problem, individual achievable steps before they buynot the solution. into a vision. Develop and share the vision for the future with the team, articulating what it will look and feel like. 36/37
  • 20. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S There has been a great deal of change in my organisation already. How could I persuade colleagues that improvements are stillConsider personal styles Communication required?Different people have different personal Communication is a vital aspect in effectivelystyles that affect how they respond to managing human dimensions of change. It Identify and demonstrate the problem:information and how they communicate is important to be inclusive and to if they understand what is wrong theythoughts and ideas. Having an appreciation communicate the message in a way that will may be more willing to considerof the different personal styles can help to engage all the different types of people. change. All improvement is changeminimise conflict and ensure that everyone but not all change is improvement.gets the right message the first time. It is People can become exhausted byimportant to remember that no one style is Diffusion of Innovators change or anxious about itsright or wrong. Research suggests that for an implications for them as an individual, improvement or change to ‘take hold’ so try and build on what is in placeWhen faced with decisions, some people within a team, department or already rather than suggesting this iswill ‘ask’ and some will ‘tell’. People who organisation, approximately 20% of further change for change’s sake.ask will gather data and ask other people those individuals must be engaged with Identifying the following factors isquestions about what should be done. it. Once this group has adopted the beneficial to overcoming this: WhatPeople who tell, will tell other people what change the rest will follow. are the things that matter to them?they think should be done. How can you demonstrate that these Rogers (1995) suggests that all groups areas are not as good as they could orPeople’s preferences for facts or feelings will of people have five categories that should be?also influence their decision making make up the Diffusion of Innovatorsprocesses. People who base their decisions bell shaped curve; Innovators, Earlyon facts often prefer to control emotion and Adopters, Early Majority, Late Majoritymight be perceived by others as remote or and Laggards.detached. Those who base their decisions onemotions are happier to show their feelings The innovators and early adopters likeand are often perceived as warm or change and quickly get onboard withapproachable people. any new project and will help make up the critical 20%. The early majorityOne model from Merrill and Reid R H (1999) and the late majority subsequently(Personal Styles and Effective Performance: follow and become engaged whenMake Your Style Work for You CRC Press, they observe the project developingLondon) suggests that there are four broad and progressing. The laggards are thepersonality types: analytical, driver, amiable most sceptical group and are generallyand expressive. resistant to change.Each type has its strengths and to utilise the Diffusion of Innovators Bell Shaped Curve (Rogers 1995)team’s potential, it is important to play tothe strengths and understand thedifferences of each personality type. Early Majority Late Majority 34% 34%‘Analysts’ tend to like facts and figures andare systematic and methodical. They Earlyrespond well to being given plenty of Adoptersrelevant information and time to consider it. 13.5% Laggards 16%‘Amiables’ place value on relationships with Innovators 2.5%others and are often perceptive andsupportive. This group will want to considerthe impact of any changes on other peopleand how they might feel about it.‘Expressives’ are enthusiastic, full ofoptimism and energy, good with people andlike to talk about their ideas. They respondwell to opportunities that are new, excitingand innovative. ‘Drivers’ like getting things It is important to note that each group will require a different approach to ensuredone; they like action and results and can effective change. Consider where your project team and stakeholders are on the belloften be decisive, direct and pragmatic. This shaped curve and start by engaging the critical 20% who will in turn bring the earlygroup will want to know what is going to be majority on board. In the initial stages of your project, listen to but try not to let thedone and how soon it can be achieved. laggards drain your enthusiasm.Know yourselfFor someone who is leading change it isimportant to recognise and acknowledgeyour own attitude and approach to change,then recognise other people’s personalitytypes to ensure you use the right approachto achieve the best result. 38/39
  • 21. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E SCHAPTER 13Sharing your successAt the end of a project there can be manymixed feelings for a project team and theproject manager including: elation, pride,sadness, satisfaction and maybe even relief!There is a great temptation to take a breakfrom the intensity of the project work, oreven to move on to the next challenge,especially when resources are stretched andtime is precious.But before you do this, consider that theproject end date is not necessarily the end ofthe project. If improvements have beenmade then they should be recognised andcelebrated for the recognition and morale of The phlebotomy team at St Helens and Knowsley Teaching Hospitals NHS Trustthe people who have been involved - as well celebrate winning the Trust Award for ‘Excellence in Support Services’.as for the benefit of those out there whowould love to know about your work andwhat they can learn from it for theirpatients.Whatever your aims and objectives were,however big or small your project – successshould be celebrated and shared.Letting people know about your The next step is to consider all External publicityachievements is a major part and a duty of communication vehicles available for • Use your communications team to write aimprovement work. There are many ways in publicising your work. Here are some ideas: press release for the local and regionalwhich you can share your findings or results media e.g. newspaper, radio etc. Beand below are some suggestions as to how The project team proactive and take photos of patients/ theyou could go about it. • Get a slot on a Trust meeting agenda e.g. team (with consent) and then follow up Trust Executive Board Monthly Meeting, after the press release has been sentHowever, the first step in the process is Executive Directors meeting (often • Consider writing your results up into anactually not about sharing at all, it’s about: weekly). For more details on your own abstract or article for publication in a Trust contact the PA of the Chief Executive journal or at a conference• Reflecting on what worked, what made • Make an appointment to see the Chief • If your project or improvement has an impact and what didn’t Executive of the Trust and go in ready with demonstrated ‘QIPP’ potential, submit• Understanding the learning all the information on your project. it as a case study on NHS Evidence at• Rationalising the principles www.evidence.nhs.uk/qipp. NHS• Documenting what happened throughout Internal publicity Evidence - QIPP is a collection of real the lifetime of the project. • Get the work known throughout your examples of how health and social care own organisation through: articles in the staff are improving quality andBefore you decide to undertake any kind of staff newsletter, articles on the staff productivity across the NHS and socialpublicity or let people know what you’ve intranet, word of mouth and via your staff care.done, you need to decide what you’re going at any meetingsto tell them, what your key messages are • Hold an event within your team office,and how you are going to deliver the department or ward to celebrate the workmessage. Much of this can be taken from you have achieved and invite everyoneyour Project End Report if you have one but who has had a contribution or vestedif not it really helps as this stage to write a interest in the project I’ve finished my project, whatshort summary of where you were at the • Create an information board about your next?start, what your aims and objectives were, project and display it somewherewhat you did and then the results. It is also prominently within your building. Don’t stop there! Continue touseful to include your key milestones, how measure what you have done toyou managed risks and what worked ensure the improvements areparticularly well - as well as anything that maintained and sustained. Look fordidn’t work. We can learn as much from our other opportunities to make positivemistakes and failures as our successes. The changes that can improve quality,key is to learn from your mistakes, and safety, efficiency and staff morale.everyone else’s, preventing the same mistake Show colleagues how you improvedbeing made time and again. your service to build capability and a culture of continuous sustainable improvements. 40/41
  • 22. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E SThe clinical community Share your achievements and learning• Contact your network leads and offer with NHS Improvement to write a paper/ present your findings to the next network meeting or email Finally, make sure you record all the ways in round to the members which you have publicised your work e.g.• Contact the Strategic Health Authority press clippings, minutes of meetings so you (perhaps via their communications have an ongoing record of the ways in department) and let them know the which you shared your success. improvement work you have undertaken and the results achieved; This is great evidence in terms of: offer to be a spokesperson of best practice in order to share your model. • Making a business case for future improvement work • Personal development and adding to CVs • Enthusing new staff about your team or department as a place of success • Demonstrating to patients you really care about improving outcomes. 42/43
  • 23. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E SRESOURCESWebsiteswww.improvement.nhs.ukwww.improvement.nhs.uk/improvementsystemAcknowledgementsZoe Lord and Phil DuncanThe following people have provided a sourceof expertise and support and their help isgratefully acknowledged: Hannah Wall,Catherine Thompson, Catherine Blackaby,Alex Porter, Barbara Zutshi, Mel Varvel andJim Farrell.FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E SNOTES 44/45
  • 24. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E SNOTES
  • 25. NHSCANCER NHS ImprovementDIAGNOSTICS NHS Improvement NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improvedHEART patient experience and outcomes. Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spreadLUNG quantifiable improvements with over 250 sites across the country as well as providing an improvement tool to over 1,000 GP practices. NHS ImprovementSTROKE 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow’s improvement agenda for the NHS