In this second IGNITE presentation from Liz Twelves of AQuA we are introduced to Quality Improvement methods.

1. Introduction to QI
methods

2. Mobile Phones
Fire Alarms
Toilets
Fire Exits
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3. Your facilitator today is:-
Liz Twelves
Academy Programme Lead
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4. What is AQuA?
Advancing Quality Alliance
• North West quality improvement organisation
• Established 2010
• Membership: 70 organisations - Acute, Primary care,
Community, Mental health and Ambulance trusts
across North West England
• Core team of around 30 staff plus Associates and
Affiliates
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5. Expectations?

6. Learning Objectives for the Session
By the end of the session you should be able
to:
Understand aspects of the philosophy of QI
Be able to apply a model for improvement
Improve your ability to frame your project
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7. Getting to Know You

8. Activity
- In groups, discuss some of the following to find
out what you may have in common:
- Where you were born
- Where you work
- What you do
- Where you studied
- What can people do to help you to learn
something new?

9. The aim of this chapter is to provide an outside view – a lens – that I
call a system of profound Knowledge. It provides a map of theory by
which to understand the organizations that we work in.”
(Deming 1993 p. 92)
Appreciation
of a System
Understanding
Variation
Theory of
Knowledge
Psychology
Subject Matter
Knowledge
Knowledge
for
Improvement
9
Deming’s System of Profound
Knowledge

10. Activity
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11. © 2010 AQuA
11
The Model for Improvement
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if a
change is an improvement?
CHANGE: What changes can we make
that will result in improvement?
© Associates for Process Improvement

12. PDSA Testing - simulation exercise
The Skittle Challenge

13. The Skittle Challenge
• Aim – to be left with one Skittle
• Execution
– Put a Skittle on each circle
– Remove one to start
– Jump over one at a time and remove it
– Keep going until you can’t jump over any more
– How many are left?

14. The Skittle Challenge
• Aim – to be left with one Skittle
• Measure – number of Skittles left
• Changes – which one to remove first?
– what order to remove them in?
– how you work as a team?
• Execution
– Put a Skittle on each circle
– Remove one to start
– Jump over one at a time and remove it
– Keep going until you can’t jump over any more
– How many are left? (Plot your data and annotations)
– Think about how it went and what you could improve next round.
(Theory and prediction based on learning)
–DO NOT EAT the Skittles – yet…

15. PDSA
#
Theory Prediction
1 Start with No.
5 empty
Will have 3
skittles left
2
3
4
5
6
Number of Skittles
Left
7
Numberleft
6
5
4
3
2
1
1 2 3 4 5 6
PDSA

16. Why Test Changes?
• To increase the belief that the change will result in
improvements in your setting
• To learn how to adapt the change to conditions in your
setting
• To evaluate the costs and “side-effects” of changes
Overall to minimise the resistance when spreading the
change throughout the organisation.

17. “What will
happen if we try
something
different?”
“Let’s try it!”“Did it work?”
“What’s next? ”

18. Cycles of Tests Build Confidence
AP
DS
A
P
D
S
AP
D S
A
P
D
S
AP
DSA
P
D
S
A P
DS
Proposals,
theories,
hunches,
intuition
Changes that
will result in
improvement
Learning
from data

19. Run Chart to Measure Performance
Test 1
ABCXYZ
Test 2 -
XYZABC
Test 2 123456
Tests 3-6
987654
0
1
2
3
4
5
6
7
8
9
10
1 2 3 4 5 6 7 8 9 10 11 12 13
skittles left
skittles left

20. A solution….
6-1, 4-6, 1-4, 7-2, 13-4, 2-7, 11-4, 14-5, 10-3, 3-8, 4-13,
12-14, 15-13.

21. The Skittle Challenge
• Consistency of purpose
• Prediction
• Planning
• Documentation
• Sharing and stealing!
• Learning from failure

22. Measurement and Data Collection during PDSA Cycles
• Collect useful data, not perfect data –
data for learning, not evaluation
• Use a pencil and paper until the information system is
ready
• Record what went well and what didn’t work so well
during the test of change

23. All improvement comes from
designing, testing and
implementing changes
Seven Propositions of the Science of Improvement. Perla et al , 2013

24. The aim of this chapter is to provide an outside view – a lens – that I
call a system of profound Knowledge. It provides a map of theory by
which to understand the organizations that we work in.”
(Deming 1993 p. 92)
Appreciation
of a System
Understanding
Variation
Theory of
Knowledge
Psychology
Subject Matter
Knowledge
Knowledge
for
Improvement
24
Deming’s System of Profound
Knowledge

25. Getting to the root of the
problem

26. My trip to work
Mean
Upper process limit
Lower process limit
0
20
40
60
80
100
120
Consecutive trips
Min.

27. Monthly data shows improvement
Average length of pre-ward stay on Barnsley
Stroke Ward
from 01/2007 to 07/2007
0
0.5
1
1.5
2
2.5
3
3.5
1 2 3 4 5 6 7
Months
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The chart shows
the average
monthly length of
time before
patients got to the
Stroke ward
6/17/2016 © AQuA Academy 2013

28. Weekly data tells a slightly different story
Average length of pre-ward stay on Barnsley
Stroke Ward
from 01/2007 to 07/2007
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
Weeks
286/17/2016 © AQuA Academy 2013

29. Patient level data adds another level of
understanding
296/17/2016 © AQuA Academy 2013

30. Types of Variation
Common Cause Variation
• Inherent in the design of
the process
• Is due to regular, natural or
ordinary causes
• Affects all outcomes of the
process
• Results in a ‘stable’ process
that is predictable
• Also known as random or
unassignable variation
Special Cause Variation
• Is due to irregular or
unnatural causes that are not
inherent in the design of the
process
• Affect some, but not
necessarily all aspects of the
process
• Results in an ‘unstable’
process that is not predictable
• Also known as non-random or
assignable data

32. © 2014 AQuA

33. Group
Work
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34. Issues with lunch
Patient complaints
• My lunch was late
• I have nowhere to eat except my bed
• I got the wrong food
• My food was cold/lukewarm
• I didn’t like the quality of the food
• I didn’t like the selection
• I couldn’t eat the lunch I was given because it was the wrong kind of food for me
• I wasn’t on the ward when lunch arrived and the food had gone when I got back
Complaints from the catering department
• No one was available on the ward to give out the lunches when they arrived
• Kitchen – didn’t get the order early enough
• The patient was away for tests when the food arrived and I ended up taking it
back
• There was nowhere to put food that couldn’t be distributed at the time
• No one let me on to the ward for ages when I arrived
• Staff didn’t know who was meant to be helping distribute the lunch
• Some of the orders were wrong when we arrived

35. Fishbone diagram
A systematic and structured method for identifying
potential root causes of failures
– Classifies potential causes for a failure into
five basic separate categories (but you can also adapt
these to suit your areas)
– Very logical and analytical method of
determining potential causes for failures

36. © AQuA Academy 36

37. Understanding the root cause
5 Whys
• To get to the solution you need to understand the root cause
for the most significant direct causes
• This could take any number of “whys”
• Do not stop until you reach what you believe is a ‘cause’ and
not a ‘symptom’
• If you reach a cause that cannot be controlled, such as
weather, go back one level and see if eliminating that cause
will help
© AQuA Academy 37

39. Complaints about
lunches
MethodsEnvironment
PeopleEquipment
Choices not collected
accurately
Menu cards not used
Dietary requirements
not fully understood
Patients not available
to receive not lunch
Not correctly positioned
Patients off-ward for
treatment / appointment
Staff not available
to dispense
lunches
Not all staff trained
Not lunch duty rota
Busy ward
Insufficient staff
Lunch not arriving
on time
Orders not sent early enough
Issues accessing
the ward
Delivery time not
agreed
No social space to
eat lunch
Miscommunication
between ward and
catering
Food not a correct
temperature
No where to store
hot/cold food on ward
Food quality and
selection not good
Fixed supplier
Small ward – limited
facilities

40. © 2010 AQuA
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The Model for Improvement
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if a
change is an improvement?
CHANGE: What changes can we make
that will result in improvement?
© Associates for Process Improvement

41. Aim Statement
Good Bad Ugly
We aim to reduce harm and improve patient safety for all of our
internal and external customers.
By June of 2012 we will reduce the incidence of pressure ulcers in the
critical care unit by 50%.
Our outpatient testing and therapy patient satisfaction scores are in the
bottom 10% of the national comparative database we use. As directed
by senior management, we need to get the score above the 50th
percentile by the end of the 1st Quarter of 2012.
We will reduce all types of hospital acquired infections.
According to the consultant we hired to evaluate our home health
services, we need to improve the effectiveness and reliability of home
visit assessments and reduce rehospitalisation rates. The board agrees,
so we will work on these issues this year.
Our most recent data reveal that on the average we only reconcile the
medications of 35% of our discharged inpatients.We intend to increase
this average to 50% by 1/4/12 and to 75% by 31/8/12.
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42. Aim Statement
Team name: ……………………….
• What are you trying to achieve? – ………………………..
• By how much? – ………………………
• By when? – …………………………..
• For whom? – …………………………………….
Aim statement
…………………………………………………………………………….
Adapted from
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43. Aim Statement
• Team name: Lunch time – on time
• What are you trying to achieve? – Get the patients
their lunch of choice on time everyday
• By how much? – 95% of lunches
• By when? – December 2015
• For whom? – Patient in Bay 1
• Aim statement
95% of patients in Bay 1 receive their lunch of choice
every day by December 2015
Adapted from
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44. What changes can we make that
will lead to an improvement?
• Knowledge
• Ideas
• Creativity

45. De Bono’s 6 Thinking Hats
Managing the thinking process: Could you summarise finding so far?
Information / data needs: What are the facts
Ideas: Is there a different way of looking at this?
Benefits / positives: Can we list them?
Negatives / risk: What can go wrong?
Emotion / gut feeling: What is your gut feeling?

46. Repeated use of the PDSA cycle
Testing and
refining ideas
Implementing new
procedures & systems
- sustaining change
Bright
idea!

47. Scottish Primary Care Collaborative
Borders GP Practice
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%ofPeoplewithDiabetes
% of Diabetes Patients with a BP<140/80
Diabetes (blood pressure)
Improvements with PDSAs
PDSAs to improve
shared diabetes
information with
Secondary Care
PDSA to contact all
Patients who have not
had a BP check in the
last year
PDSAs
PDSAs PDSAs
PDSAs to improve
current patient
recall system
PDSAs to
Validate
Diabetes
Register

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Analysis:
• 8 runs – can apply rules
• Shift aligned to new menu card process
New menu card
process
Staff briefing

49. Create Multiple PDSA Ramps
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receptionist porters Nurses

50. Summary & Close

52. Contact AQuA Via
• liz.twelves@srft.nhs.uk
• The website at:
www.advancingqualityalliance.nhs.uk
• Email at: AQuA@srft.nhs.uk
• Phone AQuA on: 0161 206 8938
• @AQuA_NHS
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53. Thank you and ….

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