Leading Continuous Improvement - NHSGGC

Leading Continuous Improvement

Define Measure Analyse Improve Control

What are we trying to achieve? What’s important? What does success look like? What steps can we take? Who needs to be involved & when?

Define the goals of the improvement activity, include deliverables & benefits.

Identify the Customer (patients directly or other internal customers) and their goals.

Agree & clearly state scope of activities.

Understand the current processes and performance.

Define team involved and timelines.

Setting up for Success

Approved PID / Charter

Action Plan

Critical Customer Requirements

Process Maps

Quick Win Opportunities

Prepared Team

Activities Tools Outcomes

Goal Setting

Team PID / Charter

SIPOC Diagram

Process Maps

Stakeholder Analysis

In / Out Scope Diagram

Roles & Responsibilities

1

Suppliers

WHO provides the inputs to the process

Input

WHAT is it they provide to our process; Material, equipment, appointments, hardware, software, training, resources, information, data, products

Process

The sequence of activities that convert the Inputs from individual

entities to a valuable

outcome/output.

Output

WHAT does the process provide as an output from its activities. Completed treatment, an appointment schedule, a diagnosis, data, information, referral.

Customers

WHO receives the outputs; Patient, GP, Onward referral departments. Who else has an interest; management teams, committees, agencies.

Process Mapping But before we get flowcharting, let’s understand

the whole picture first using SIPOC

2

How to construct a Flow Chart ?

1. Clearly identify where the process starts (inputs) and ends (output).

2. Brainstorm a list of the suppliers, major steps, decisions and customers involved in

the process from start to end.

3. Arrange the steps in the order they occur, use post its until you are certain of the

order then add in the connecting arrows showing the flow of activity.

PROCESS

Outputs

(Customers)

Inputs

(Suppliers)

Resources

Controls Process step or activity

Decision required, Yes or No, Pass / Fail.

Start or end terminator

Arrow showing Direction of flow.

Process Mapping

3

Stakeholder Analysis

Sta

ke

ho

lde

r

Inte

res

t

Invo

lve

me

nt

Influ

en

ce

Co

nc

ern

s

4

Major Stakeholders Criteria

1. Interest in the project (indicate also + or - )? 5. All

4. A lot

3. Medium

2. Little

1. No

2. How much are they involved?

5. Extremely involved

4. Highly involved

3. Regularly involved

2. Little involved

1. No involvement 3. Influence on the project?

5. Very high influence

4. A lot of influence

3. Something to say

2. Can speak up for themselves

1. No influence

5

DEFINE Stage Checklist

Task Who Status

1. SMART Goals defined

2. Stakeholders enrolled

3. Team Selection

4. Complete Project PID, all sections

5. Review existing Process documentation

6. Define Timings & Plan

7. Define & Map current “as is” process

8. Review and redefine project scope if necessary

9. Gain approval of Sponsor before next stage

6

Define Measure Analyse Improve Control

How do we measures our problem? Where does the data come from? What is the performance now? How will we demonstrate before & after ?

Collect data on the current process.

Establish a baseline of current performance.

Establish the metrics to help monitor progress towards the goals stated in the “Define” stage.

Answer how we measure project success.

Creating a shared need

Measures/KPI Definitions

Data Collection Plans

Baseline Performance Metrics

Shared vision

Activities Tools Outcomes

Measures

Data collection

Balanced Scorecard

Stakeholder Engagement

7

Communications Plan

Comms Title Audience Objectives Message How By Who When Where Content Status Comments

1

2

3

4

5

8

Stakeholders Interview

Background

What is your official job title?

Can you please outline your key responsibilities and accountabilities?

How does performance affect you and your team?

Current Issues

What in your opinion are the key issues impacting efficiency?

What is the root cause of these issues?

How do they manifest themselves – lost time / cancelled patients / more work What is currently being done to address these issues?

Who is leading / responsible for driving home these changes?

What impact are the changes having?

What 3 changes to current working practices would you like?

Have the biggest impact

Make your job easier

Influencers / power base

Who do we need to win over to ensure maximum chances of success in this project

9

MEASURE Stage Checklist

Task Who Status

1. Identify critical Customer/Patient related measures

2. Define Data Collection process

3. Display the data clearly & simply

4. Identify trends & patterns

5. Develop a balanced set of measures

6. Gather data from stakeholders & understand themes

10

Define

How does the process really work? What does our knowledge about the process say? What does the data tells us about the process? What are the root causes of our process problem?

Analyse the process to identify ways of eliminating the gap between current and desired performance.

Isolate root causes not just symptoms.

Prioritise the areas of focus and id resources required to help.

Identify any obstacles or risks to success.

Identify resistance to change

Process & Data Analysis

Validated Root Causes

Potential Solutions

Prioritised focus areas

Identifying and overcoming barriers to change

Activities Tools Outcomes

Value Stream mapping

8 wastes

Cause & effect fishbone

5 whys

Prioritisation VAP

Gleicher Change Formula

Measure Analyse Improve Control

11

1. Waiting Inpatients waiting in ED, patients waiting for discharge, physicians waiting for test results

2. Inventories Patients queuing for clinic, lab samples for testing, stocks on wards, dictation waiting for typing

3. Defects Needle stick injury, missing patient information, wrong information communicated

4. Excessive Processing Re-sticks, multiple bed moves, re-testing, multiple assessments 5. Overproduction Excessive reporting, unnecessary tests, Irrelevant information sent out

6. Movement working across multiple sites, storage of consumables in disparate places

7. Transportation Moving patients to tests, patients having to attend different depts.

8. Under-utilisation Physicians transporting patients, not fully using skill mix of staff

The 8 Wastes in Healthcare

12

Cause and Effect

13

ANALYSE Stage Checklist

Task Who Status

1. Analyse your data for patterns & trends

2. Analyse your process for wastes

3. Identify opportunities to remove the wastes

4. Prioritise the opportunities

5. Perform root cause analysis on the process issues

6. Analyse people’s behaviours in the process too

14

Define

What are all the possible solutions? Which ones are best? How can we try it out? Has it worked as we expected? Which ones will we keep?

Improve the process.

Be creative in finding new ways to do things, quicker, cheaper & better.

Use structured methods to implement changes.

Collect data on measures to validate improvement/

Manage & communicate changes.

Mobilising Commitment to change.

Tried & tested Solutions

Process Maps and Documentation

Cost/Benefit Analyses

Improvement Impacts and Benefits

Pilot and Solution Results

Storyboard

Staff engagement

Activities Tools Outcomes

PDSA cycle

Project management

5S’s

Change Curve

Measure Improve Control Analyse

15

PDSA Template

16

PDSA Template

Plan-the change, predictions and data collection

What are we testing and who is carrying out the test?

Who are we testing the change on?

When are we testing?

Where are we testing?

Do – test (carry out the change)collect data and begin analysis

What was actually tested?

What happened?

Observations

Problems

Study

Complete analysis of data, summarize what was learned, compare data to predictions

Act

What changes should we make before the next test cycle?

What will the next test cycle be?

Are we ready the implement the change?

Which actions need to be conducted in the 30 day sustain period?

17

5S Scorecard

Level O

f Im

provem

ent

Steps of Implementation

20

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

Area owners

identified and

responsibilities

documented.

Level

Anything not

required for

immediate

utilization is

removed from

the area

Immediate actions

taken against

abnormalities. Area

kept orderly on a

continuous basis.

Non-utilized cabinets,

benches, tables,

Equipment & stock

etc.identified and

removed from

area.

Unneeded equipment

& stock removed

from area not

stored away.

Needed and unneeded

equipment & stock

have been identified

and separated.

Needed and unneeded

equipment & stock

are mixed throughout

the work area.

Daily cleanliness

inspection of

equipment and stock.

Repeated between

cases.

Visual controls

established and well

marked for work area.

Work areas unkempt.

No visual controls in

place. Information is

difficult to

access

Level 4

Level 3

Level 2

Level 1

Immediate actions

taken

against

abnormalities.

Team take

ownership; standards

are followed.

Daily checks performed

by Team Leaders;

standards are regularly

reviewed and

updated.

Periodic checks are

performed by Team

Leaders.

No area checks are

performed; standards

are not established.

Sustain Sort Shine 5S’s

Establish & follow

standard procedures.

They are clear,

up-to-date,

and displayed

in work areas.

Area layout,

equipment, stock &

communications are

documented,

standardized &

followed rigorously.

Labeling of items

with required

quantities are

standardized.

Procedures are

documented, but not

consistently followed.

No procedures in

place.

Standardize All items can be

easily

retrieved by

anyone;

they are clearly

marked.

Standardized item

quantities are

established;

Correct locations are

outlined.

Needed items have

dedicated locations

which are clearly

labeled.

Needed items have

been safely stored

and organized.

Items are placed

randomly throughout

the work place.

Set in Order

5

Area: Date:

Auditor:

5 S Scorecard

18

Sample Project Plan

Project Plan updated on: 25-Aug

Tasks Start End Duration Owner

Project Name:

01-O

ct02

-Oct

03-O

ct04

-Oct

05-O

ct06

-Oct

07-O

ct08

-Oct

09-O

ct10

-Oct

11-O

ct12

-Oct

13-O

ct14

-Oct

15-O

ct16

-Oct

17-O

ct

DEFINE STAGE

1 Kick Off Meeting 21-Jul 22-Jul 2

2 Charter, Plan & Actions Development 22-Jul 23-Jul 1

3 Stakeholder Analysis 25-Jul 05-Aug 10

4 Data Collection Preparation 28-Jul 29-Jul 2

MEASURES STAGE

5 Live Data Collection 01-Aug 31-Aug 23

6

7

8

9

12

Today

19

Progress Summary Project Title:

PROGRESS TO PLAN:

Status : Progress Summary:

KEY ISSUES Owner Due

ACHIEVEMENTS:

PLANS Owner Due

Project Leader :

Project Manager :

Green = On plan.

Amber = Requires attention to meet plan

Red = Progress stopped, requires immediate escalation

Date :

20

Action Tracker

Open Actions Tracker Status Key :

Blue = Action agreed by team as Completed

Last Updated : 15/08/08 by : CA Amber = Action Pending - Not started yet, requires attention.

Green = Action in Progress and on Plan.

Red = Roadblock or Showstopper , requires immediate escalation.

# ACTION / ISSUE CATEGORY RAISED BY RAISED ON OWNER

PLANNED

COMPLETION

DATE

NEW

COMPLETION

DATE

DEPENDENCY COMMENTS / UPDATES STATUS

G

A

R

Complete

Project Title :

21

Project Management basics

Project Governance cycle:

Mon Tues Wed Thurs Fri

Sponsor

Team Lead

/ PM

Team

Members

Prepare Updates

for Weekly Review

Collate & issue

Team Update

Report

Weekly

Progress

Review

Meeting /

Con Call

Monthly Board

Progress

Updates

Progress Tasks

22

IMPROVE Stage Checklist

Task Who Status

1. Plan your changes – start with PDSA

2. Perform pilot change small scale first

3. Assess pilot results

4. Re run pilot if necessary

5. Develop implementation plan

23

Define

How do we makes our changes normal operation? How can we sustain our improvements & benefits? How will we measure in future? Have we met the goals we set and can we close the project?

Control the new processes.

Embed the changes into everyday routines and systems.

Maintain monitoring reports.

Demonstrate and Sustain the benefits.

Making Change Last

Sustaining Benefits

Standards and Procedures

Standardization

Trained staff & training Plans

Project & Team Review

Success Stories

Replication opportunities

Activities Tools Outcomes

Sustain/Control plan

Measure Control Analyse Improve

24

Control Plan Steps you can take to ensure the sustainability of your project

Improvement How go wrong?

How stop it?

How know when gone wrong?

How correct?

Action & owner

25

Making Change

Last

Integration

Resources

Excitement

Commitment

Early Successes

Learn from Experience

Components of Sustained Success

26

Components of sustained success Early Successes

– Were they communicated to other functions and locations? – Were early successes built into the project plan? – Were they linked to longer term outcomes?

Commitment Did there continue to be visible, impactful sponsorship? Was there a continuing sense of energy and excitement? Did sufficient funds continue to be committed? Were appropriate deadlines achieved (or was the project completion date

advanced, or were people diverted to other work?)

Excitement Has the sponsor maintained a high level of personal enthusiasm? Does the project team show excitement and enthusiasm? Is the excitement communicated through words and actions?

Resources Are adequate resources available throughout the project? Have new resource needs been identified in a timely fashion? Has timing of resource allocation been linked with life cycle of project team?

27

CONTROL Stage Checklist

Task Who Status

1. Complete Control Plan for changes made

2. Define Control measures/metrics

3. Rollout improved processes/changes

4. Monitor Progress using measures

5. Conduct training on new processes

6. Document new processes

7. Define ownership of new processes

28