insert name of presentation on master slide a consistent approach to the methodology 27 october 2011...

Insert name of presentation on Master Slide

A consistent approach to the methodology

27 October 2011

Presenters: Mike Davidge & Joy Whitlock

Model for Improvement & PDSA Cycles

Model for Improvement

Part One:Where does it come from?

Part Two:What is it and

How does it work?

Improvement methodology


QI

In an article in the Journal of Quality Improvement, 92 QI projects were compared. What was the timeframe from problemIdentification to completionof first pilot?

1. 23 days

2. 60 days

3. 397 days

4. 504 days


Journal of Quality Improvement

504 days from problem identification to completion of first pilot

397 days from first team meeting to the end of first cycle

75 days to describe current situation in flowchart

62 days for data collection if change was improvement

Alemi, Safaie, Neuhauser “A Survey of 92 Quality Improvement Projects.”

Journal of Quality Improvement 2001, 27(11): 619-632

There’s a lot of material out there


So what now?


We’ll conduct a 3 month pilot then we’ll roll out We’ll just tell staff that this is the new way of working We’ll do an audit to get a baseline and then repeat it

after 6 months We want all our departments to be 100% efficient, it’s

taxpayers money we’re spending after all

What mindset?


Results in LAME thinking not LEAN thinking

Lean As Misguidedly Executed

Science of Improvement

Appreciation of a system

Understanding Variation

Theory of Knowledge

Psychology

The Lens of Profound Knowledge

QI

Two Types of Knowledge

Profound Knowledge

Subject Matter Knowledge

Profound Knowledge: The interplay of the theories of systems, variation, knowledge, and psychology.

Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.

Knowledge for Improvement

Profound Knowledge

Subject Matter Knowledge

Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement.

Improvement

Appreciation for a System• Interdependence, dynamism• World is not deterministic• Optimisation, interactions• System must have an aim• Whole is greater than sum of the parts Understanding Variation

• Variation is to be expected• Common or special causes• Ranking, tampering• Potential mistakes

Theory of Knowledge• Prediction• Learning from theory, experience• Operational definitions • PDSA for learning and

improvement

Psychology• Interaction between

people• Intrinsic motivation,

movement• Beliefs, assumptions • Will to change

What insights might be obtained by looking through the Lens of Profound Knowledge at your

project?

Profound Knowledge: Systems Thinking

Appreciation of a

System


Theory of Knowledge Psycholog

y

Deming’s original diagram


“A system is a network of interdependent components thatwork together to try to accomplish the aim of the system”

I’m sure glad the hole is not in our

end! People unclear on

the concept of a system!

Two Fundamental System Principles

The System is perfectly designed to achieve the

results it gets.

If each part of a system, considered separately, is

made to operate as efficiently as possible, then the

system as a whole will not operate as effectively as

possible.

- Ackoff (1981)

Profound Knowledge: Psychology

Appreciation of a

System



y

Psychology• Interaction between people• Intrinsic motivation• Beliefs & assumptions • Will to change

We understand that we have bad systems, not bad people

How many of us come to work to do a bad job?

Communications“NHS staff save lives every day – 1000 Lives Plus will help

save more”

Leadership– Approach to motivation

The impact?


Profound Knowledge: Variation

Appreciation of a

System

Understanding

Variation

Theory of Knowledge Psychology

Understanding Variation• Variation is to be expected• Common or special causes• Ranking, tampering• Potential mistakes

“If I had to reduce my message for management to just a few words, I’d say it all had to do with reducing variation.” W E Deming


The MBFC Index

You will need a coin

And two free hands!

Just how competitive can you get?

It’s easy to react in the wrong way Natural variation is really quite large It’s the system not the individual

Lessons?


But when will we know that there really is something there?


Walter A. Shewhart(early 1920’s, Bell Laboratories)

While every process displays variation: some processes display controlled

variation (common cause)– stable,consistent pattern of variation– constant causes/ “chance”

while others display uncontrolled variation– pattern changes over time– special cause variation/“assignable” cause


Shewhart’s purpose

Data contains both signal and noise. To be able to extract information, one must separate the signal from the noise within the data.


01020304050607080

F M A M J J A S O N D J F M A M J J A S O N D

Upper process

limit

Mean

Lower process

limit

A typical process control chart

Part One:Where does it come from?

Part Two:What is it and

How does it work?


Profound Knowledge: Theory of Knowledge

Appreciation of a

System



y

Theory of Knowledge• Prediction• Learning from theory,

experience• Operational definitions • PDSA for learning and

improvement


A change is a prediction Comparing the predictions to the results of a test of

change is a key source for learning A “good” theory makes clear predictions that can be

used…– to confirm or modify the theory,– to generate new exploration, and– to suggest practical application

Prediction Based on Theory


What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?


AIM


Aim Exercise




What change can we make that will result in improvement?


AIM

Goals &

Measurement


You can’t fatten a cow by weighing it….


Measurement

Tracking a few key

measures over time is

the single most

powerful tool a team

can use.




What change(s) can we make that will result in improvement?

AIM

Goals &

Measurement

Change(s)


What changes can we make that lead to an improvement?



Test ….

Most improvement usually requires change…..

however not all change is an Improvement!

ActAdapt?

Adopt ? Abandon?

Next cycle?

PlanObjectiveQuestions and predictions (why)Plan to carry out the cycle (who, what, where, when)

Study Complete the

analysis of the dataCompare data to

predictionsSummarize

what was learned

DoCarry out the plan(on a small scale) Document problemsand unexpectedobservationsBegin analysis

The PDSA Cycle:



Test of change have been going on for years

“Negative results on the fish…Let’s try rubbing two sticks together.”

BreakthroughResults

Theories, hunches,& best practices

Learning and improvement

A P

S D

Evidence & Data

A P

S D

A P

S D

A PS D

Develop a change

Test a change

Test new conditions

Implement a change

Building Knowledge with Multiple PDSA Cycles

Sequential building of knowledge

Include a wide range of conditions in the sequence of tests



PDSA Cycle Example

Change: Communication process to Physicians

AIM: Improve Communication and obtain appropriate intervention DATA

A PS D

APS

D

A PS D

D SP A

D SP A

Cycle 1A: One nurse to use SBAR form to report on one patient to one physician.

Cycle 1D: SBAR use on Unit A for a week

Cycle 1?: Implement…. Wide Scale Cycles : when might it fail ?

Cycle 1B:Same nurse to use revised form for two physicians for two nights.

Cycle 1C: Three nurses requested to use SBAR form for their shift.


Why test?

Learning

Confidence

Resistance


How small is small ?

Data collection, feedback

and testing

Many PDSAs on different

elements of the bundle

continued to achieve process

reliability

Implementation and spread

throughout unit

SKIN Bundle Compliance

Days between pressure damage events

Learning by doing

This is a practical approach


“Improvement happens project by project and in no

other way”Joseph Juran

Bottom up so perfect for students

The Ohno circle test

Stand in circle Watch and note down

what you see Go and make

improvements

insert name of presentation on master slide a consistent approach to the methodology 27 october 2011...

Documents

improvement methodology

days slide

science of improvement

improvement methodology

improvement alemi

knowledge basic

professional knowledge

quality improvement