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


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

  1. 1. NHSCANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement First steps towards quality improvement: A simple guide to improving services
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 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 ( 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 ( • 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: discoveryinterviews. 18/19
  11. 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 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. 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. 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