improvement training Winterbourne Medicines Launch

Quality Improvement Training
Zoë Lord & Carol Marley
Improvement Managers
Improving health outcomes across England by providing improvement and change expertise

What we’re going to cover
• Improvement models & techniques
– Mapping
– Measuring
– Testing & improving…
• Understanding ourselves and others…Getting
the right people involved.

Quality Improvement
Service Improvement
Service Redesign
Process Redesign

• But there is a clear structure that we’re going to
follow, and we’re going to help you.
• Improvement work is not difficult
• It’s not necessary to start from scratch
• It’s pointless to just tell people to work harder;
it’s better to try and work differently

“Here is Edward Bear coming downstairs
now, bump, bump, bump, on the back of
his head, behind Christopher Robin. It is,
as far as he knows, the only way of
coming downstairs, but sometimes he
feels that there really is another way…
if only he could stop bumping for
a moment and think of it!”
A. A. Milne

“Every system is perfectly designed to get
the results it achieves”
Paul Batalden
Dartmouth Medical School, New Hampshire, USA.

The NHS
Change Model
8 components

Aims
Measurements
Change ideas
The Improvement Guide
Langley et al (1996)
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that will
result in improvement?
Act Plan
Study Do
Testing ideas before
implementing changes

PDSA Cycle for Learning and Development
Act Plan
Act on learning…
What is next?
Study Do
Observe the
results…
Did it work?
What will happen
if we try
something
different?
Try it!
• Ready to
implement?
• Try something
else?
• Next cycle
• Objective
• Questions and
predictions
• Plan to carry out:
Who? When?
How? Where?
• Complete data
analysis
• Compare to
predictions
• Summarise
• Carry out plan
• Document
problems
• Begin data
• analysis

We are trying to
accomplish…

Safe, appropriate and optimised use of
medication for people with learning
disabilities whose behaviour can challenge.

We all need to be talking about the
same thing…
Can you picture…
A cat on a mat!! 

“Every system is perfectly designed to
get the results it achieves”
Paul Batalden
Dartmouth Medical School, New Hampshire, USA

Process and Value Stream Mapping
• One of the most useful tools in improvement work
• Works within organisations and across organisations
• Understand current systems
• Identify areas to investigate/change/improve - particularly
‘handoffs’, duplication and “why on earth do we do that?”
• steps which do not add value for the patient
• Identify process waste
• Team-building process - helps shared understanding and
building links etc.

An elephant is
like a brush
An
elephant is
like a rope
An elephant is
An elephant is like a snake
soft and mushy An elephant
is like a tree
trunk

Lift
receiver
Simple Process Maps
Dial
Number
Let
phone
ring
Say Hello
Have
Conversation
Hang up Say Good Bye
receiver

Lift
receiver
Simple Process Maps
Dial
Number
Let
phone
ring
Say Hello
Have
Conversation
Answered?
Hang up
receiver
Say
Good
Bye
Yes
No
Key
Start Finish
Task
Decision or Choice
Direction of flow

What you think it is
What it should be
What it actually is
What it could be
Versions of a process

Value Stream Map
27 minutes hands on time = 91 days

Value Add, Non Value Add and Waste
Eliminate Minimize
Unnecessary
Value
Waste
Necessary
Waste
1st Step - Defining Value
Value Added Activity
 Any activity that changes the form, fit, or
function of a product/transaction
— OR —
 Something customers are willing to pay for
Non-Value Added Activity
• Any activity that absorbs resources but
adds no value is a Waste
Maximize

Organisational / Departmental Boundaries
B D
A C E
Acute Episode
Diagnostic process
Treatment process

Analysing a Process Map
• Are we doing the right thing? (Clinical effective)
• Are we doing them in the right order?
• Is the right/best person doing it?
• How co-ordinated is the patients journey?
• What information do we give to patients at what
stage? Is the information useful?

Non Value Add (Waste)
• Clues to Non Value Add…
– Rework
– Recheck
– Return
– Retype
– Repeat
– Recall
– Remeasure
– Redo
– Bottlenecks
– Delay
– Waits
– Movement
– Audits
– Handoffs

S.E.C.S
• Simplify
• Eliminate
• Combine
• Sequence

1 Patient has
cardiac
catheter
Example: Referral and Discharge Letters, Cardiac
4 Tape sent to
post room
CHH
5 Tape sent to
post room
HRI
6 Tape sent to
secretary at
HRI
7
Secr etary
types l etter
8 Letter to
doctor for
signature
9
Letter
signed
10 Letter
returned to
secretary
11 Letter sent
to post room
HRI
3 Tape
to war d
clerk
12 Letter sent
to post room
CHH
13 Letter
del ivered to
secretary
14a Secr etary
request
angiogram
14
Letter to
surgeon
15 Letter to
secretary
for OPD
16 Letter to
post room
CHH
17
Letter to
appointments
18
Letter sent
to patient
15a Radiographer
finds
angiogram
16a Angiograms
given to
por ter
17a Angiogram
del ivered to
secretary
2 Letter
dictated to
surgeon
19
Patient seen
in cl inic
20 Patient put
on wai ting
list
18a Angiogram
reviewed by
surgeon
19a Arteries
sui table for
surgery
20a Surgeon
considers
patient
sui table
Catheterisation Lab, Hull Royal Infirmary

…after
1
Patient has
angiogram
2 Data input
into
computer
3 Print out
data as
referral
letter
4 Letter and
angiogram
del ivered to
secretary
5 Secretary
makes OPD
appointment
6
Patient seen
in cl inic
1a
Angiogram
Tape

Hints and Tips:
¨ Define the scope
- what process are you going to map?
- what are the start and end points?
¨ Decide who is going to be involved
¨ Walk the pathway / process
¨ Start ‘high level’ - then detail where necessary
¨ Focus on the high volume work i.e. ~80% of the work. This is
called the ‘Green Stream’
¨ We’ll be helping you!!! Dates in diaries!!! 

“To change an organisation,
the more people you can involve,
and the faster you can help them
understand how the system works
and how to take responsibility for
making it work better, the faster
will be the change”
Martin Weisboard
Training and Development Journal

Measurement for Improvement
“All improvement will require change,
but not all change will result in improvement”

“It feels like…”
“I think …”
just isn’t enough!!

If you don’t measure, you won’t know…
• If the changes we make have actually made a
difference
• If it is an improvement
• How much difference the change has made
• How much variation there is in the data/process
• Whether you have achieved your aim
• If the improvement has stayed in place?

Top tips when starting to measure:
• Seek usefulness not perfection
• Measure the minimum!
• Remember the goal is improvement and not a
new measurement system.
• Aim to make measurement part of the daily
routine.

We need a baseline!
• To understand current position
• Tell a story
• Define success
• Before and after comparisons
• For evaluation and celebration!!!

Baseline examples
• How many people are on your case load:
– With challenging behaviour?
– With CB and on medication?
– With CB and on medication and had a formal
review?
• How many have had review with a clinical
pharmacist?

Developing metrics
• We’re going to help you!
• Process measures
A B
• Measure the demand on the service
• Measure your capacity
• Measure activity
• Measure backlog
• Outcome measures - reduction in inappropriate
medication

Got the data… what next?
Understanding the information
Root Cause Analysis
Problem Solving

Data Analysis
• Some people love it – but not everyone does!! But it’s
important!! And we’re going to show you how to do it!
• We want to tell a visual story!

Data Analysis
• Some people love it – but not everyone does!! But it’s
important!! And we’re going to show you how to do it!
• We want to tell a visual story!
• Easy to understand
• A way of demonstrating and thinking about variation –
good & bad!
• Statistical Process Control – SPC

What does an SPC Chart look like?
NHS Number
Days
SPC Chart to show length of time from prescription to review

NHS Number
Days

SPC
NHS Number
Days

SPC
NHS Number
Days
Upper Control
AVERAGE
Lower Control

SPC
NHS Number
Days
Time to start
asking
questions!
Variation

Root Cause Analysis
Problem Solving

90
80
70
60
50
40
30
20
10
0
F M A M J J A S O N D J F M A M J J A S O N D
Cascading Stratification
Frequency
Pareto A
Pareto B
Pareto C
Primary
Diagnosis
Ward
Doctor
Kettering General Hospital - Acute myocardial infarction admissions by
Ward - Oct 02 to Oct 03
250
200
150
100
50
0
CCU
MAU
Althorp
ITU
Surgical
admissions
Lamport
Harrowden
B
Harrowden
C
Other
Ward transfrred to
Number
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Count Cum %
Use in
combination to
validate root
causes

Root Cause Analysis
• What is it?
– Root cause analysis is the identification of the “vital few” causes
that have a material impact on the outputs of a process
• Objectives of Root Cause Analysis
– Determine with reasonable confidence what are the current
major causes of problems within a process.
• Why use it?
– Too often improvement is initiated based on anecdote and not
rigorous analysis of the facts.
– Ensures actions are taken on actual causes rather than
symptoms

Pareto – 80/20
• Named after Vilfredo Pareto in 20th century who found that
80% of the wealth in Italy was held by 20% of the population
• Helps to focus on the problems which will have the biggest
impact if addressed.
• 80% of complaints are about 20% of your services
• Shows relative importance in a simple, visual format.

Fishbone
Cause-and-Effect Analysis

How to construct a fishbone diagram
Cause 1
Equipment
Cause 2
People
Cause 3
Procedures
Cause 7
Machines
Cause 4
Measurement
Cause 5
Communications
Cause 8
Methods
Cause 6
Materials
Problem
Agree the major Statement
cause categories
and attach to the
centreline of the
diagram
Cause 9
Policies
Cause 10 Plant
Environment

How can a Fishbone help?
• To help break down a large problem into small
elements
• To reveal hidden relationships between causes &
effects
• To help identify the root of a problem
• To highlight important relationships for investigation
• To identify possible data requirements for the project
• To help individuals or groups to generate ideas
• To identify areas for quick wins

Problem Statement
- Why are 51% of
patients staying
longer than 5
days ?
Cause 3 Procedures
Cause 2 People
Cause 6 Materials
resources
Cause 5
Communications
Cause 1
Equipment
Cause 4
Measurement
No MDT’s
Delays in
patient
transfer
Transport
issues
No hospital wide
procedure
No Active
discharge
planning
Inconsistent
recording of
ward round
requirements
Inconsistent verbal
communication on
transfer
Transport not
available
T.T.O’s not
available
Duplication of
diagnostics
Limited 24/7
access to
diagnostics
Discharge lounge
not opened at
weekends
No Cath
Lab
POD not
working
weekends
Work through the
main headings
drilling down
through the
causes

We’ve made
improvements…
What next?

We’ve made improvements…
What next?
• Continuous Improvement
• Standardisation
• Mistake proofing
• Sustainability & Spread

Getting the right people
involved an supporting
the process of change

Attitudes to change differ…
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest

How do you feel if your
not told about changes?
How do you feel if you’re
the last to know?

Have you got the right people involved?
• Psychiatrists, nurses, managers, care staff,
pharmacists, patients, carers, families, speech
therapists, psychologists, commissioners, trust
service improvement / project management
office, communications team, chief executive,
schools, GPs, social services and local
authorities …

Attitudes to change
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest
Calming down
Keeping in real world
Perspective
Focussing ?
Support
Direction
Feedback
Motivating
Exploring
Evidence of benefit
“Unpacking”
Debate (argument)
Selling

Go back to your communication
plan…

We all respond differently
• Analyst
• Amiable
• Social (Expressive)
• Driver

Analyst Amiable Expressive Driver
Analytical Patient Verbal Action-orientated
Controlled Loyal Motivating Decisive
Orderly Sympathetic Enthusiastic Problem solver
Precise Team person Gregarious Direct
Disciplined Relaxed Convincing Assertive
Deliberate Mature Impulsive Demanding
Cautious Supportive Generous Risk-taker
Diplomatic Stable Influential Forceful
Accurate Considerate Charming Competitive
Conscientious Empathetic Confident Independent
Fact finder Persevering Inspiring Determined
Systematic Trusting Dramatic Results-orientated
Logical Congenial Optimistic
Conventional Animated

The Analyst: Technical Specialist
May be perceived
positively as
May be perceived
negatively as
• accurate • critical
• conscientious • picky
• serious • moralistic
• persistent • stuffy
• organised • stubborn
• deliberate • indecisive
• cautious

The Analyst
• Places an high value on, facts, figures, data and reason
• Sometimes described as analytical, systematic or
methodical
• Tend to follow an orderly approach when tackling tasks
• Well organised and thorough
• Sometimes seen as too cautious, overly structured and
does things ‘by the book’
• They view time in a linear (sequential) fashion

How do you
communicate
with an Analyst?

Communicating with an Analyst
• They want facts, figures and data in the message
• It should be presented in an orderly fashion,
with supporting documentation
• Give them time to examine reports etc.
• Written communications can be quite formal and
precise, listing key points

The Amiable: Relationship Specialist
May be perceived
positively as
May be perceived
negatively as
• patient • hesitant
• respectful • ‘wishy-washy’
• willing • pliant
• agreeable • conforming
• dependable • dependent
• concerned • unsure
• relaxed • laid back
• organised
• mature
• empathetic

The Amiable
• Interested in & places a high value on, relationships,
feelings, interactions and affiliation with others
• Often described as warm and sensitive to feelings of
others, and a loyal & supportive friend
• May be viewed as too emotional / sentimental and
too easily swayed by others
• Will often make reference to past events and their
relationships over a period of time

How do you
communicate
with an Amiable?

Communicating with an Amiable
• Make sure the human dimensions and how
people may feel are included
• Let them know who else will be involved
• Include past experiences in a similar situation
• Written communications can be quite
informal, chatty and friendly.

The Expressive: Social Specialist
May be perceived
positively as
May be perceived
negatively as
• verbal • a talker
• inspiring • overly dramatic
• ambitious • impulsive
• enthusiastic • undisciplined
• energetic • excitable
• confident • egotistical
• friendly • flaky
• influential • manipulating

The Expressive
• Interested in taking people with them,
enthusing them with optimism and energy
• Tend to be open with people and willing to
make a personal investment
• Generally very good with people
• May frighten people by being expressive!
• They tend to be poor with detail

How do you
communicate
with an
Expressive?

Communicating with an Expressive
• They will be looking for the new and the
exciting aspects of the message
• Include some kind of innovation to hook the
expressive
• Written communications can tend to be vague
and abstract.
• They are inclined to be idea orientated and
are often quite lengthy in making a point.

The Driver: Command Specialist
May be perceived
positively as
May be perceived
negatively as
• decisive • pushy
• independent • one man show
• practical • tough
• determined • demanding
• efficient • dominating
• assertive • an agitator
• risk-taker • cuts corners
• direct • insensitive
• a problem solver

The Driver
• Places great emphasis on action and results
• Often viewed as decisive, direct and pragmatic
• They view time as here and now, like to get things done
and hate spinning things out
• They translate ideas into action, and are dynamic &
resourceful
• Sometimes accused of only seeing the short term, and
neglecting long-range implications
• Can be seen as too impulsive, simplistic, and acting
before they think

How do you
communicate
with a Driver?

Communicating with a Driver
• “What are we going to do?”
• ‘When are we going to do it?”
• Written communications will be brief,
sketchy and crisp.
• They may resent having to take the
time to write and will often scribble a
reply on the senders original message
and return it to them.

Next Steps
Improving health outcomes across England by providing improvement and change expertise

Next Steps
• Dates in diaries with Zoë and Carol
• Complete and return paperwork
• Monthly reporting
• 6C’s community of practice
• Engage your team
• Define your project
• Understand your baseline and measures
• Patient engagement plans

Remember:
What people should do
What people think they do
What people say they do
May not be
What people actually do
Understand the real problem before you plan the
solution
Don't make assumptions...

@NHSIQ
enquiries@nhsiq.nhs.uk
www.nhsiq.nhs.uk
Improving health outcomes across England
by providing improvement and change expertise.

improvement training Winterbourne Medicines Launch

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