improvement methodology work book

8/13/2019 Improvement Methodology Work Book

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Continuous QualityImprovement

Tools and

TechniquesWorkbook


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WORKBOOK OBJECTIVES

This workbook has pre training work to consider and a post training action

plan for your service. Please agree 1 action with your line manager for

consideration while on this training.

Support improvement methodology awareness training sessions.

Introduce Improvement tools and processes.

Introduce all work streams that are used within NHS Forth Valley.

Introduce how these methodologies then fit with The Quality Strategy for

NHS Scotland.

Develop an awareness and understanding of some improvement

methodologies.

Stimulate and encourage staff to utilize improvement methodology tools

and processes.

By working through the tools and techniques identified in this workbookhopefully you will be able to challenge processes and identify improvedmethods of work to provide value to patient care and your service.


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PART 1 TO BE COMPLETED PRIOR TO

AWARENESS TRAINING

Are you aware of any improvement work already planned for yourarea? (please detail below)

If so, are you involved in this? (please tick)

Yes (please detail below)

No

What Why Which Quality

Strategy prioritydoes this come

under?

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2

3

4

What do you know about the quality strategy?

Managers Signature------------------------------


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What improvement work have you heard of?(please tick)

NHS Forth Valley Change and Improvement planhttp://intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/ChangeImprovement/CI_intro.asp

LEAN

Releasing time to care

Scottish Patient Safety Programme

The Productive Community Team

The Productive Leader

Long term conditions collaborative (LTCC)

18 Weeks referral to treatment (18/52 RTT)

Mental Health Collaborative

Improving Patient Care and Experience

Whole Systems Working (GP)

Triple Aim

What improvement tools and techniques have you heard of?(please tick)

Process Maps

PDSA

ECSS

Fishbone / Ishikawa

5 Whys

Spaghetti Diagram

6Ss

6Ms

Patient Stories

Visual Management

DCAQ

Statistical Process Control


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PART 2 TO BE COMPLETED THROUGHOUT THETRAINING SESSION

The ultimate aim of the Quality Strategy is to deliver the highestquality healthcare services to people in Scotland and through this toensure that NHS Scotland is recognised by the people of Scotlandas amongst the best in the world.

The Institute of Medicines six dimensions of quality are central to ourapproach to systems-based healthcare quality improvement:

Person-centred:providing care that is responsive to individualpersonal preferences, needs and values and assuring that patientvalues guide all clinical decisions;

Safe:avoiding injuries to patients from healthcare that is intended tohelp them;

Effective:providing services based on scientific knowledge; Efficient:avoiding waste, including waste of equipment, supplies,

ideas, and energy;

Equitable:providing care that does not vary in quality because ofpersonal characteristics such as gender, ethnicity, geographic locationor socio-economic status; and

Timely

The Quality strategy was built around these priorities:

Caringand compassionatestaff and services; Clear communicationand explanation about conditions and

treatment;

Effective collaborationbetween clinicians, patients and others; A cleanand safe care environment; Continuityof care; and Clinicalexcellence.


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Continuous improvement has been described as being about:

securing commitment from all to the idea of continuous improvement involving everyone in pursuing it promoting service-user satisfaction in every interaction with the service continually seeking a better way of doing things by maintaining the

best of what we have and fully using our resources

implementing recognised best practice to support development andequity across NHS Scotland

creating learning organisations that are able to share and sustainimprovements.

It calls for:

a strategy, framework and methodology to manage the technical andbehavioural aspects of change

integration to support organisational priorities partnerships, including with patients and the public leadership a relentless commitment to service-user focus.

And it is created by examining and reviewing:

processes systems products and services deployment of resources.

Thoughts/notes


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Improvement work that is currently underway in NHS Forth Valley includes:

NHS Forth Valley Change and Improvement planhttp://intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/ChangeImprovement/CI_intro.asp

LEANReleasing time to care (RTC)

Scottish Patient Safety Programme (SPSP)

The Productive Community Team

The Productive Leader

Long term conditions collaborative (LTCC)

18 Weeks referral to treatment (18/52 RTT)

Mental Health Collaborative (MHC)

Improving Patient Care and Experience (IPCE)

Whole Systems Working (GP)

Triple Aim

There are many different improvement tools and techniques being usedwithin NHS Forth Valley, some of these include:

Process MapsPDSA

ECSS

Fishbone / Ishikawa

5 Whys

Spaghetti Diagram

6Ss

Patient Stories

Visual Management

DCAQ

Statistical Process Control


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IMPROVEMENT TOOLS AND PROCESSES

5 Lean principles Specify Value Identify the Value Stream Map or patient journey

Make the process and value flow Let the customer Pull Pursue perfection

Value Finding out what patients really want ... This can only really be defined by the customer Value is any activity which improves the patients health, well being

and experience is adding value Anything else is waste

Value Stream AnalysisWhat is Value? Something that a Patient expects to happen

Why Value Stream? Eliminate stop-start-stop-start

Why Value Stream Analysis? It covers the whole patient journey from start to finish and identifies whichsteps add value and improve quality for the patient

Flow

Seamlessness reduce variation, ensure everyone receives the samestandard of care

Doing things at the right time, in the right place Align processes to facilitate the smooth flow of patients and

information Ensures balance - you have the right capacity to meet demand

Pull We should deliver care on demand with the resources needed for it We need to create pull in the patient journey- every step needs to pull

people, skills, materials and information towards it, one at a time whenneeded

This means responding to demandPursue perfection

Develop and amend processes continuously in pursuit if the ideal For the patient this means completing their care and treatment with

the best outcomes- on time, with no mistakes and without delays To achieve this we need consistent and reliable processes


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PROCESS MAP(OR BROWN PAPER SWIM LANE MAP)

What is this a picture of?

Process Mapping and Value Stream Mapping usually documents a process andkey data associated with it to help understand current problems. This enablesteams to quickly see improvement opportunities in the process and begindefining changes. The first step in this entails bringing a group of involved

staff together to map the process end to end and to identify how it interfaceswith other processes. Having key individuals involved improves ownership andoutcomes.

This activity: Captures the complexity of a given process. Simplifies the process by addressing specific measurable elements i.e.

timing, quantity, cost or resources utilized. Identifies and develops ownership by defining starting and finishing

points Identifies the various functions of those involved in the process.

Swim Lane Mapping has more of an emphasis on the who. This is usefulwhen a process is studied across 3 or more functions to show hand-offs,transport, queues and re-work loops.

This activity demonstrates how to make the process more useful by ensuringall appropriate stakeholders are involved. If procurement, catering or otherdepartments have a part to play in the process being mapped then they

should be involved in the process mapping not just the clinical areas.


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What does ECSS mean?

E

C

S

S

ECSS

Once you understand the current picture of what really happens throughoutthe value stream, you can begin to agree what needsto happen and thenanalyse the gap between the current and future states.From your current state map you will be able to identify where the significantproblems occur. This might be the most prevalent waits and delays, thelargest amount of work in progress between process steps or where there isconsiderable duplication.

There are four main techniques to design your future state. ECSS!

Demand and Capacity (DCAQ)

What does DCAQ stand for?

Demand, Capacity, Activity & Queue (DCAQ) is a service improvementmethodology used widely within elective health care services in Scotlandto:

analyse waiting list management define and regulate service capacity monitor patient throughput support effective demand management.


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The four components are described as follows.

Demand is all the walk-ins, ambulance cases and referrals coming in fromall sources at the point of access, such as outpatients, elective admissions

or a medical assessment unit. Demand is measured by multiplying thenumber of patients referred by the time it takes to process a patient.

Capacity is all the resources available and required to do the work,including staff and equipment. It is measured by multiplying the numberof pieces of equipment by the time available to the people with thenecessary skills to use it.

Activity is the work done, or the throughput of the system. It is measuredby multiplying the number of patients seen by the time it will take toprocess a patient.

Queue and Backlog: queues occur where demand has not been dealtwith, and result in a backlog; backlog is the previous demand that hasnot yet been dealt with, showing itself as a queue or waiting list. Everytime your demand exceeds your capacity, you carry forward the excessdemand as backlog. They are measured by multiplying the number ofpatients waiting by the time it will take to process a patient.

Demand, capacity, activity and queue (backlog) need to be measured inthe same units for the same period of time. The data and patterns thatemerge can be used to start predicting demand and managing capacity,activity and queues at the bottleneck. The overall goal is to managecapacity and demand appropriately, effectively and permanently.

7 WASTES

Please completes the words below to describe things that we dothat are wasteful? If possible, please give an example in the boxnext to it.

W

O

R


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M

P

I

T

What tools could we use to identify waste?

What is this a picture of?


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SPAGHETTI DIAGRAM

Very simple however, a very powerful technique, depicting different aspectsof workflow and how staff/people/resources move around.Using a floor plan or area layout distance covered is measured in one typicaloperation or procedure. These diagrams measure value added (any activitythat is essential to deliver the service) and non value added activities(activities that are required by the NHS which are essential but add no realvalue from a customers standpoint).

Fishbone/Ishikawa diagram

A visual tool for organizing information that may clarify the main causes of agiven event. Used to identify and understand the potential root causes so thatcollective actions can be put into place to eliminate recurrence.

There are three steps required to constructing a fishbone diagram.

1. Identify the problem and write a statement at the fish-head.2. Determine the major categories of the effect3. Explore potential root causes.

Thoughts/notes


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Can you describe what PDSA means?

PDSA CYCLE

PDSA is the recognised tool within NHS Forth Valley for supporting quick rapidcycle change. It allows staff to identify their aim, set its objective, agree whodoes what and when and measures its outcome. If the ultimate aim is notmet, the cycle is repeated. It is best to start small, make changes then gothrough the cycle again and again until a full change is implemented.


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6Ss

6S promotes a safe working environment by improving standards thatproduce quality to the service. This can lead to more effective and efficientoperations. 6S enables teams to improve workplace safety, reduce waste,simplify processes, troubleshoot and maintain service quality.

What are the 6S?

S

Remove everything from the workplace that is notneeded for clinical care processes.

S

Arrange and label items so they are easily located.

S

Making things., making sure that every thing andall areas are clean and clear.

S

How you make S., S. and S..common practice.

S

Making it all regular, common practice by buildingfoundations and keeping it all together through checkingor auditing practices. PDSA methodology is advocated tosupport changes getting embedded into practice.

S

Embedding s in all everyday activity within the area.

VISUAL MANAGEMENT

Visual management is crucial for effective communication and team inclusion.There are two types of visual management:

1.Visual control:similar to traffic light system this demonstratescurrent position, identifies normal/ abnormal conditions and correctivecounter measures.

2.Visual display: similar to graph or chart this demonstrates historicaldataor information, displays original information and identifiesopportunities of improvement.


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PART 3 ACTION PLAN(Post session work)

Development of an action plan:

Developing an action plan for your team will help improve sustainability andconsistency and provide team focus and ownership.

Could you now make a list of improvements you would liketo make and why? (Please ensure you discuss this with your linemanager) This action(s) will be followed up in 30 days to reviewprogress.

What Why

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2

3

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5

Could you now write a PDSA template for one of theimprovements you have identified?

Project Title

Project LeadProject Start Date

Project Completion date

What are we trying to accomplish?

Please describe the changes we are going to make?


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What do we Predict will happen once we have made these changes?

What measures will be used (e.g. qualitative, quantitative, newpractice)?

Who will be affected by proposed changes?

What are the tasks/actions required to test the change idea?

What Who How When

Useful Websites:


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The Knowledge Network www.evidenceintopractice.scot.nhs.uk NHS Scotland Quality Strategy

www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality

Scottish Patient Safety Programmewww.patientsafetyalliance.scot.nhs.uk/programme NHS Institute for Innovation and Improvement, UK www.institute.nhs.uk Lean Enterprise Academy, UK www.leanuk.org Lean Enterprise Institute, USA www.lean.org Lean Enterprise Australia www.lean.org.au

Institute for Healthcare Improvement, USA www.ihi.org

Leadershipwww.nes.scot.nhs.uk/media/4310/deliveringqualitythroughleadership_brochure09.pdf

18/52 RTTintranet.fv.scot.nhs.uk/home/ProjectsInitiatives/Redesign/FVR_18WRTP.asp

Mental Health Collaborativeintranet.fv.scot.nhs.uk/home/Depts/MentalHealthResources/CGMH/CGMH_intro.asp

Long Term Condition Collaborativehttp://intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/Redesign/FVR_LTC.asp

Further Reading:

Bicheno, J. 2004The New Lean Toolbox. Towards Fast Flexible Flow.England: Picsie Books.

Jones, D and Mitchell, A. 2006 Lean thinking for the NHS Lean EnterpriseAcademy UK. A report commissioned by the NHS Confederation

Baker, M. Taylor, I. 2009Making Hospitals Work: How to improve patient carewhile saving everyone's time and hospitals' resources. Lean EnterpriseAcademy Limited

Author:Linda McAuslan

Version 3 / Date 31.01.11

improvement methodology work book

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