quality improvement methodology – next steps
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Quality Improvement Methodology – Next Steps. Purpose of this Session. Consider the components of a learning system in your own improvement activity : 4. Sequential testing of new theories 6. Planning for spread at scale - PowerPoint PPT PresentationTRANSCRIPT
Quality Improvement Methodology – Next Steps
Purpose of this Session
Consider the components of a learning system in your own improvement activity :
4. Sequential testing of new theories
6. Planning for spread at scale
What stage are you at in relation to these aspects of the improvement journey?
What do you need to do next to ensure that your tests are scaled up and spread correctly?
The Improvement Guide, API
Aim
Measures
Changes
Testing & Implementation
Cycles of Tests Build Confidence
AP D
S
AP
D S
APD
SA P
DS
Proposals, theories, hunches, intuition
Changes that will result in improvement
Learning from data
• 1 child• 1 day• 1 family• 1 setting
Move to 3,5,7…. as confidence grows
Start small
Years
Quarters
Months
Weeks
Days
Hours
Minutes
Drop down next “two levels” to plan test cycle!
You can only learn as quickly as you test!
Components of a Learning System
1. System level measures
2. Explicit theory or rationale for system changes
3. Segmentation of the population
4. Learn by testing changes sequentially
5. Use informative cases: “Act for the individual learn for the population”
6. Learning during scale-up and spread with a production plan to go to scale
7. Periodic review
8. People to manage and oversee the learning system
From Tom Nolan PhD, IHI
Sequential Testing & Scale Up
Hunch/TheoryA structured handover
will ensure accurate information sharing between prof teams
Data/learning/adapting
Cycle 1: Test developed handover form 1 HV/1 SW 1 family (Mon)
Cycle 2: Test with 3 family handovers/ same HV (Wed)
Cycle 3: Test with 5 more families/ same HV (Mon/Tu)
Cycle 4:Test with all handovers-1 HV/1week
AimAchieve improved communication
process for HV and SW handovers using standardised format
Cycle 5: other team HVs/SWs- 1 day
AP D
S
AP
D S
APD
SA P
DS
Cycle 6: Test all handovers-1 week
Implement
Learning Through Sequential Testingat your tables discussion time
Where are you currently?
Can you describe an example of the following?
Multiple tests with different people/under different conditions?
Learning/data captured to describe your testing journey?
Testing v Implementation
Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system. Multiple tests in a variety of conditions…………………
Implementation – Making the change a part of the day-to-day operation of the system. Permanent change
Would the change persist even if its champion were to leave the organisation?
Avoid implementation until confident that processes are robust
How Many Tests?
Components of a Learning System
1. System level measures
2. Explicit theory or rationale for system changes
3. Segmentation of the population
4. Learn by testing changes sequentially
5. Use informative cases: “Act for the individual learn for the population”
6. Learning during scale-up and spread with a production plan to go to scale
7. Periodic review
8. People to manage and oversee the learning system
From Tom Nolan PhD, IHI
Better Ideas•Develop the case•Describe the ideas
Set-up•Target population•Adopter audiences•Successful sites•Key partners•Initial spread plan
Knowledge Management
Measurement and Feedback
Communication (awareness & technical)
Social System•Key messages•Communities•Technical support•Transition issues
Leadership•Topic is a key strategic initiative•Goals and incentives aligned•Executive sponsor assigned•Day-to-day managers identified
A Framework for Spread
Institute for Healthcare Improvement
Things to ConsiderChecklists For Spread
•Leadership, Better Ideas & Set Up
•General Communication & knowledge transfereveloping Measurement, Feedback and Knowledge Management Systems
Take a strategic approach to scaling up
Level of testing
Strategy
1
5
25
125
250
Increasing uptake of Healthy Start Vitamins
Level of testing
Strategy
1 1 EY practitioner gives vits to 1 mum
5
25
125
250 Free vitamins in Asda with every pregnancy kit
Are You Ready for Scale up & Spread?Table discussion time
In the context of your current improvement activity:
Have you been testing a theory so that it could be considered ready for implementation in the area you are working? and/or…
Do you have a strategy for moving to scale up and spread to other sites/teams?
The Seven Spreadly SinsStep 1 Start with large pilots
Step 2 Find one person willing to do it all
Step 3 Expect vigilance and hard work to solve the problem
Step 4 If a pilot works then spread the pilot unchanged
Step 5 Require the person and team who drove the pilot to be responsible for system-wide spread
Step 6 Look at process and outcome measures on a quarterly basis
Step 7 Early on expect marked improvement in outcomes without attention to process reliability
Institute for Healthcare Improvement
To be clear
DO NOT DO
THIS AT
HOME!!!
Sustaining Improvement
Having the correct measures to provide assurance that new processes are reliable
Measuring compliance or satisfaction through regular and random sampling of the population
Understanding the variation that exists in your data
What measures?
Outcome measures – directly relates to the overall aim what is the result? how is the system performing?
Process measures – are the processes that contribute to the aim performing as planned?
Balancing measures – assessing from different dimensions unanticipated consequences, other factors influencing the outcome
If we don’t understand the variation that lives in our data, we will be tempted to…
• Deny the data as it doesn’t fit with our view of reality• See trends where there are none• Try to explain natural variation as special events• Blame and give credit to people for things over which
they have no control• Distort the process that produced the data• Kill the messenger!
V RA I A
T
IO
N
Common Cause Variation
Define measures that will measure the impact of the
Improvement work over time
They will guide your progress through and beyond testing to implementation and monitoring for continuous improvement.
Different ways of measuring e.g.,
• Percent compliance with process
• A count of correct attempts/number of attendances
• Verbal feedback /surveys
Measurement of Improvement
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
Measure 83 80 81 84 83 85 68 87 89 92 91
HC Data Guide
Why a run chart and not just a graph or table?
Month
Median = 84%
Run Chart
Testing with all
Families
Prompt sticker
tested in case referral
Testing screening tool with 1 family
Testing screening tool with 5
families
Prompt sticker used on all referrals Testing screening
tool with 3 Families
Source: The Data Guide by L. Provost and S. Murray, Austin, Texas, February, 2007:
Non-Random Rules For Run Charts
A Shift: 6 or more
A Trend:5 or more
An astronomical
data point
Too many or too few
runs
0
5
10
15
20
25
9/1
/08
10/1
/08
11/1
/08
12/1
/08
1/1
/09
2/1
/09
3/1
/09
4/1
/09
5/1
/09
6/1
/09
7/1
/09
8/1
/09
9/1
/09
10/1
/09
11/1
/09
12/1
/09
1/1
/10
2/1
/10
3/1
/10
4/1
/10
5/1
/10
Nu
mb
er
Month
What is this data telling you?
Data 11 1 3 4 5 9 10 4 11 7 10 10 7 6 22 4 2 2 1 3 4
0
5
10
15
20
259/1
/08
10/1
/08
11/1
/08
12/1
/08
1/1
/09
2/1
/09
3/1
/09
4/1
/09
5/1
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6/1
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7/1
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8/1
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9/1
/09
10/1
/09
11/1
/09
12/1
/09
1/1
/10
2/1
/10
3/1
/10
4/1
/10
5/1
/10
Nu
mb
er
Month
What is this data telling you?
Median 1 1 2 2 3 3 4 4 4 4 5 6 7 7 9 10 10 10 11 11 22
Median = 5
Shift
Shift
Trend
AstronomicalPoint
Measurement Principles• Develop aims before measuring
• Design measures around aims ‘How Good By When’
• Be clear on your operational definitions
• Establish a reliable baseline
• Track progress over time using annotated run charts• Teams need measures to give them feedback that the changes
they are making are resulting in improvement• Need to understand common cause and special cause variation to
ensure we don’t over/under react to situations
Appreciation of a System• Complex system of interaction between people, procedures and equipment• Success depends on integration, not performance of individual parts
Understanding Variation• Variation is to be expected – everything we measure varies We make decisions based on interpretation• Data over time – data story of what has been happening
Theory of Knowledge•Change is prediction of improvement based on knowledge of the system•Learning from theory, experience Operational definitions are the basis for improvement with PDSA cycles for learning
Psychology•Interaction of people with systems•Motivation & will of individuals & teams•Situation awareness/decision making•Managing stress and fatigue•Helps planning for change management
Improvement
Spread to Total System
(Additional units, sites, organisations)
Single-unit prototype: segments
System Targeted for Implementation(Defined by Aim)
What’s the Scope of Change?
As you move from pilot testing to
implementation to spread, your population of
interest will need to be adjusted.
Thank You