Project Funding – Introduction to Improvement Methodology

Julie Wild

Improvement Advisor

National Partners, Scottish Government

What I aim to cover today

• Why we use ‘improvement methodology’

• What is the model for improvement

• The three questions of the model in more detail

• The QI Toolkit

Why ‘Improvement Methodology’

Implementation of key existing policies

Reliable implementation of evidence that we know will make the biggest difference

A structured approach to change

Developing a collaborative learning system

Gaining knowledge and sharing practice to better understand the shift required to deliver better outcomes

A Collective Vision for Children & Young People

Scotland: the best place in the world to grow up

….where every child has the best start in life and is ready to succeed

Achieving Excellence & Equity – Policy Context

Early Learning

& Childcare

Family Nurse Partnership

PACE(Permanence)

Poverty related attainment gap

Scottish Attainment Challenge

National ImprovementFramework

Employability DYW / YES

Education Bill(inequalities)

Improvement in Child Protection

Realigning Children’s Services

GIRFECChildren & Young People Act

Universal HVPathway

Transferring ‘what’ we want or need to implement reliably…

... using the MFI to establish ‘how’ best to achieve this in our local context.

Implementation of improvement

Adopt, adapt or abandon?

Improvement Aim

Generating knowledge of your

system

Measures

Theories for change

Evidence drives further

improvement & improvement at

scale

(The Improvement Guide/ IHI)

Aim

Q1: What are we trying to accomplish?

Provides a clear sense of what we are trying to accomplish

Measurable – how much by when?

Specific – who, where?

Unachievable by hard work alone

An Improvement

Aim…

Examples of aims

• By end of June 2017 95% of all children in our School will be registered and active users of the school library

• By the end of Q4 2018 80% of staff in Ward D will be trained to level 1 in British Sign Language

(Operational Defintions really important)

Measures

Improvement is not

just about measurement

However….. without measures you will never know if you are improving!

Q2: How will we know if a change is an improvement?

How will we know…?

• Measurement Plan

• What does better look like?

• How will we know it when we see it?

• Did our changes help us improve?

Don’t ask “what will we measure?”

Ask “what do we need to know?” then figure out if you can measure it.

Balancing Measures

Looking at the system from different dimensions. Does improving one thing cause problems elsewhere?

ProcessMeasures

Are we doing the right things at the right time, every time?

Is the process reliable?

What we work on to get to the aim

Outcome Measures

The result!

The voice of the child / young person

Are we making things better? Are we on track to achieve our Aim?

Dave Williams, IHI

Is the young person getting the right

outcome?

Is the system working as planned?

What about the bigger picture?

Daily mile examplesBalancing measuresTotal time taken away from desk (time from “pencils down” to “pencils up”)

Number of incidents of children too cold / tired to participate in class per week

Process measures% of days it happens (of those it could have)

Number of days since any class in the school did not participate

Pupil measure: total distance completed in 15 minutes

Outcome measures% of children who can access standard PE lesson

Percentage of children classified as “healthy” weight for age/height

Targeted children: “Active” and “Healthy” rating on the 1-10 SHANARRI wheel

What does data for improvement look like?

0

1

2

3

4

5

6

Adapted from Bob Lloyd, IHI, 2012

Bar graphs and pie charts only show a snapshot

What does data for improvement look like?

Adapted from Bob Lloyd, IHI, 2012

Snapshot data is used for judgement

Showing data over time allows us to measure the impact of our

changes so that we can learn from them

Why use charts?• Data over time e.g. week by week

1. Observe process performance

2. Obtain ideas for improvement

3. Test changes

• Variation in data offers areas for improvement

• Assess progress towards an improvement aim

• Viewing changes in context of whole system

• Observations have bias: recent memory, relative, perceptions

Provost & Murray, The Healthcare Data Guide, 2011,

How can we count / measure to guide our improvement effort?

Counts – e.g. number of children

Percentages – e.g. % of children reaching goal

Values – e.g. time, distance

Rates – e.g. number of children per class

Run Chart Example -

Change Two -Staff Training completed

Project Team Established Change One – New Discharge process implemented

Aim: Reduce average length of patient stay in Ward C to 48 hours by December 2016

Aim: Raise and sustain attendance in pupils with <80% attendance

Langley et al 1996

Changes

Q3: What changes can we make that will result in improvement?‘Not all change is improvement, but all improvement

requires change’ (Berwick)

Copy: learn from the experience of others

Think creatively

Prioritise: impact on aim, feasibility

Use the evidence

Change ideas to test…

Aim(What, How Much

By When?)

Change ideas

Key factors that drive the outcome/aim

Secondary factors which will influence delivery of the primary drivers

Changes or interventions that can be tested out

Primary

driversSecondary drivers

Driver diagramsTh

eories fo

r chan

ge

Supports the team to explore all factors that will help achieve the aim

Helps identify measures

Provides an improvement route map

Communication tool

Cascading Driver Diagrams help us move up or down a level – create something meaningful for you

Why a driver diagram?

Improvement Aim

Measures

Theories for change

Generating knowledge of your system

•What’s next? •Adapt/adopt/abandon

•Did it

work?

•What will happen if we try

something different?

•Let’s try it!

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

Where to start with PDSA testing?

Plan Do Study Act

Based on slide © IHI 2009

Develop a change

Test a change

Implement a change

Sustain & spread a change to other locations

Theory &prediction

Test under avariety of conditions

Make partof routineoperations

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

Sequence for improvement

Based on slide © IHI 2008

What scale to test at?

The QI Toolkit

• The Model for Improvement gives us some structure

• We use a variety of QI Tools to support this• Capacity within the team to use the tools is

essential • Leadership sponsorship and support can make or

break the work• There are many sources of help - online

resources, Improvement Specialists within CPP, NHS, Scottish Government

Contact Details : Julie.Wild@gov.scot