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Lauren de Kock
Technical Director:
Quality Improvement and Training
The Aurum Institute
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Red Bead Game
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Mass Production and Standardisation
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Statistical Process Control
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Responding to Variation
TIME
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Responding to Variation
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Time
Mea
sure
of
Inte
rest
Median of baseline performance
Target
Started testing
Module 6 page 6
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The Basis for the Science of Improvement
Human
Side
of Change (Psychology)
Appreciation
of a system
Building
Knowledge (Theory of
Knowledge)
Understanding
Variation
Based on Deming’s System of Profound Knowledge
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QI LENS (SYSTEM OF PROFOUND KNOWLEDGE)
Appreciation of a system
Building Knowledge (Theory of Knowledge)
Understanding
Variation
Human Side
of Change
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Quality Improvement
Subject Matter
Knowledge
Improvement Knowledge:
Variation
Systems
Theory of Knowledge
Psychology
Increased
Capability To
Make
Improvements in
MY SYSTEM
Edward Demming
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Complex Systems View
12
Step 1
• Instruction
Step 2
• Instruction
Step 3
• Instruction
Step 4
• Instruction etc
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Systems
13
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Investigate for TB if symptomatic, retest for HIV in 6 weeks
Adult ART Process Map Provider initiated counselling & testing, TB screening
HIV+
Start TB treatment prior to ART, manage as per TB/HIV co-infection guidelines
yes
yes
Counselling, investigations for creatinine clearance
12 month assessment : CD4, VL, safety bloods
VL supp’d
Patient returns within 7 days for results
Assess after 2 weeks on ART
Patient returns within 7 days for results
Initiate on TDF/FTC/EFV
CD4 count <
350 cells/mm3
or stage 3 or 4
no
Review after 1 month on ART & then monthly – side effects, adherence, counselling, safety bloods, TB screening, IPT if eligible
yes
no
no
yes no
bloods for CD4 count, haemoglobin WHO staging
Initiate alternative regimen
6 month visit; viral load (VL) & safety bloods
Stage 2
yes
no
Continue regimen
Continue regimen
Assess 3 monthly if stable, VL every 12 months, safety bloods as per protocol
Creatinine clearance
>50ml/min
no
yes
Start bactrim
VL suppressed
Reassess 6 monthly - CD4 count, staging
yes
no
If eligible and not on bactrim, initiate after 1 week on ART
TB symptoms
Investigate for TB & manage according to
guidelines
no
yes
Assess for & prescribe IPT if eligible
0
Assess adherence, monitor closely, repeat VL as per guidelines, consider change to 2nd line if VL >1000 on 2 occasions
TB symptoms
Assess 3 monthly if stable
Assess adherence, monitor closely, repeat VL as per guidelines, consider change to 2nd line if VL >1000 on 2 occasions
CD4 count<100 and Crag positive
no
yes
Manage as per prevention of cryptococcal meningitis guidelines
Investigate for TB
TB diagnosed
no
yes
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Theory of Knowldege
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What are we trying to accomplish?
Model for Improvement
Act Plan
Study Do
What change can we make that
will result in improvement?
How will we know that a
change is an improvement?
HOW TO Guide – Module 1 www.auruminstitute.org
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PLAN
STUDY
Do Act
PLAN
STUDY
Do Act
PLAN
STUDY
Do Act
PLAN
STUDY
Do Act
Scale of learning not just testing for improvement
Testing and developing a Theory NOT just testing a change idea
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Psychology
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Interaction of Variables of Profound Knowledge
• A system of work that is not mindful of or interpreting variation correctly that is not mindful of systems and their causality that is not mindful of the beauty of continuous learning and failure as instructive, produces a dynamic that chills and kills the underlying motivation of human being
– Don Berwick (2016)
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Douglas McGregor - The Human Side of Enterprise
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Science of Improvement
Subject Matter
Knowledge
Improvement Knowledge
Variation
Systems
Theory of Knowledge
Psychology
A Place where
thriving and
learning can
and does take
place
Edward Demming