1 “Why Improvement Matters”David Thomson; Associate Director of Nursing
2 Improvement is part of all our livesOpportunity and Innovation
3 What do you know about improvement science and methods
4 Why do we need an improvement focus?Here is Pooh Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.
5 Why is Improvement Important?‘Insanity: Doing the same thing over and over again and expecting to get different results’ ‘A person who never made a mistake never tried anything new’ Keep promoting the message of improvement They’ll get the message and advocate themselves
6 What Do You Value? Strive to deliver the best care you can?Getting through the day? The people you provide care for? People generally don’t come to work to do a bad job Improvement is about changing the system and creating the conditions for people to thrive – make the difference
7 Our environment Systems in themselves have an increasing baring on how we behave within a system. Why do we manage people and yet not the system?- Leadership?
8 What can be achieved?
9 Responding to what people want and needOur Dimensions of Quality
10 Route map to the 2020 vision
11 Political Drivers or Competing Programmes?Or at least it can feel that way! 11
12 Do we recognise when change is needed?Learning to see
13 Learning to see Creating focus in observation: When you are trying to design services, you often find that: People do not always do what they say they do People do not always do what they think they do People cannot always tell you what they need Things are not always as they seem (adapted from IDEO) NB statements drop in one by one When we think about ward process or our work environment, without good observation can we really start to redesign. Message You are experts to understand the process and the details of the very complex and motivated environment we work in, these are tools to help you redesign the process or environment or services we provide. Link this to the activity trackers as people are often surprised with their results as they can show they are not doing what they think they do! “If you want to find out about water, don’t ask a fish” Chinese proverb
14 Setting the improvement sceneImprovement principles Focussing your aim Developing theories for change Developing change ideas using diagnostic tools Profound Systems of Knowledge Productivity and Efficiency Safety Leadership Whole systems approach Person centred health & social care
15 The Primary Drivers of ImprovementHaving the Will (desire) to change the current state to one that is better Will Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas Developing Ideas that will contribute to making processes and outcome better QI Ideas Execution
16 Subject Matter KnowledgeSubject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge. Subject Matter Knowledge Improvement Profound Knowledge Profound Knowledge: The interaction of the theories of systems, variation, knowledge, and psychology. (W Edwards Deming) 16
17 Profound Systems of KnowledgeThe W. Edwards Deming Institute®
18 Profound Systems of KnowledgeAppreciation for the system Psychology Knowledge of Variation Theory of Knowledge The W. Edwards Deming Institute®
19 A Model for Learning and ChangeWhen you combine the 3 questions with the… …the Model for Improvement. PDSA cycle, you get… The Improvement Guide, API, 2009. 19
20 Reflection Think of a change that you worked to implement.If the implementation was successful, what do you think made it so? If the implementation was not successful, what may have been the challenges and barriers?
21 “People fear the uncertainties of change“People fear the uncertainties of change. The slightest suggestion that things won’t stay the same can cause panic…but the real problem isn’t the change…it’s people’s reaction to that change.” -Dr. Alan Zimmerman
22 Initial Reactions to ChangeDenial Confusion Loss Anger Transition is the psychological process that people go through in response to change 22
23 Leadership and leading changeCrixus?
24 Common vision & purpose
25 Roger’s Adopter CategoriesEverett Rogers was a communication scholar, sociologist, writer, and teacher. He is best known for originating the diffusion of innovations theory and for introducing the term early adopter He said that - Innovations can initially be perceived as uncertain and even risky. To overcome this uncertainty, most people seek out others like themselves who have already adopted the new idea. Thus the diffusion process consists of a few individuals who first adopt an innovation, then spread the word among their circle of acquaintances—a process which typically can take months or years. The process of adoption over time is typically illustrated as a classical normal distribution or "bell curve." The model indicates that the first group of people to use a new product are called "innovators," followed by "early adopters." Next come the early and late majority, and the last group to eventually adopt a product are called "laggards’ This adoption curve classifies adopters of innovations into categories, based on the knowledge that some individuals are more open to adopting change than others. Called the diffusions of innovations theory. Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
26 Roger’s Adopter Categoriesnot all people like change, and people adopt change at differing rates according to many factors including their belief that it is worthwhile or will benefit them, or will bring about an improvement. Until now most people have said that you should ignore laggards as they will come round in the end as the change spreads across the bell curve and becomes, ‘the way we do things round here’. However other commentators say that you should not try to convert laggards but you should listen to them as they may have seen a problem that no-one else has. Keep them informed, even if they are not involved in the work you are doing, this provides them with the opportunity to get involved at any point and contribute to the initiative. So, for me the message in relation to taking improvement forward is - don’t wait for the late majority and laggards to come on board, but keep them informed and aware of what’s happening – this ensures they are not left out completely…… focus your early work with the keen and enthusiastic people in the early adopters category and they will begin to influence the early majority, who in turn will influence the late majority and eventually will reach the laggards. In my experience of working in improvement – sometimes the laggards come on board earlier than you expect - word spreads that they are missing out on something really good and they want in early – depends on individuals and what motivates them as individuals. Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
27 Trying it out in real worldA clear aim Thinking Measures Ideas Trying it out in real world Doing
28 The Typical Approach… Conference Room Real World APPROVE DESIGN DESIGNTraditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business. e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable. IMPLEMENT Real World
29 The Quality Improvement ApproachConference Room DESIGN APPROVE IF NECESSARY Traditionally we have not been good at making change for improvement reliable – because we have not tested whether it will be delivered appropriately in various conditions and environments before we expect all to implement and make part of every day business. e.g. previous experience of launching new protocols/guidelines – as of Mon am….. expect all to comply fully without really knowing that it’s practical for every system – then we wonder why people don’t comply and the system is unreliable. START TO IMPLEMENT TEST & MODIFY TEST & MODIFY TEST & MODIFY Real World
30 Try to Fly! Make a plane and fly it as far as you can
31 Exercise: Operational Definitions How Big is your Banana?SIS Course December 2012 Create a step-by-step operational definition to capture the concept of “banana size” Measure your banana using the definition, and write down the result and keep it secret! Pass your definition and banana to another table. They will use your definition to measure. Compare results.
32 Setting Aims Should be impossible to achieve within the current framework of how your area functions Should embody these key elements Ambitious Measurable Time Limited Very Specific What do I mean by impossible – consider a stable predictable system where the current output or outcome is known. We will need transformative change in order to accomplish what we have set out to do
33 The aims statement measurement components:Outcome measure Process measure Balance measure Example re 1:1 Reviews NHS Borders
34 Where it all started.... Developed the theory of variance through plotting data over time; creation of data patterns Observed two situations: Patterns in the data are predictable or unpredictable By analysing the available data we can differentiate both situations and apply one of two definitions 1920’s Common causes & special causes
35 Expectations for ImprovementWhen will my data start to move? Expectations for Improvement Process measures will start to move first Outcome measures will most likely lag behind process measures Balancing measures – just monitoring – not looking for movement (pay attention if there is movement) Outcome measure - % reduction in? % Compliance with process % Compliance with process
36 UNDERSTANDING VARIATION...“There is nothing so useless as doing efficiently that which should not be done at all” Peter F. Drucker
37 Data over time!
38 Run Chart Rules Four simple rules that allow you determine if special causes or normal variation is present in your data.
39 INTERPRETING DATA...
40 Rules for Run Charts A Shift: 6 or more A Trend 5 or moreToo many or too few runs An astronomical data point Source: The Data Guide by L. Provost and S. Murray, Austin, Texas, November, 2008: p3-11
41 Sustaining ImprovementThe data needs to show a new level of improvement first (i.e.. a shift in the data – 6 or more data points on one side of the median) Following the ‘shift’ it takes at least a further 3 months/data points at the new level of performance to be considered as sustained improvement Consideration for variation is given around the new level of performance i.e. +/- 5%
42 THE PERFECT TEAM FORMULA...Every small piece of information has the potential to influence the overall improvements that meet an aim
43 THE REALITY... But! Even when we’re not working in a Formula 1 team, driving improvements can make an impact!
44 Summary It is possible to enjoy your work! Taking the opportunity to improve the care you provide is key to this The biggest challenges to quality are VARIATION and COMPLEXITY We need to utilise a rigorous proven method if we are to have any success making lasting improvement in complex living systems The Model for Improvement is a tried and tested method that can support you to do this It takes effort and careful planning to use the MfI properly – if we don’t use it properly we will struggle to make progress: Aims Measures Ideas PDSA… test… test… test… Improve Implement
45 So why does improvement Leadership matter?Image credit: William Creswell/Flickr The president of the Michigan Savings Bank advisting Henry Ford's lawyer not to invest in the Ford Motor Co., 1903.
46 You are the Champions of Improvement and Dementia careYou are the difference