Improvement Next Steps
Susan HannahPat O’Connor
Purpose of this session• Current position of the work so far… life in the fast
lane • Revisit the Science of Improvement • Consider your local work through the Lens of
Profound Knowledge • What is your data telling you… your measures
sampling and groups of work (segments) are crucial • Bringing it all together on the driver diagram • Next steps
Back at the Ranch
• Early years work is not the only game in town• Outside the SECC life goes on • Where are your bright spots and how does
everyone know about them
Discuss at your table and find out one new connection or a piece of work that is going well (5 mins)
The Improvement Guide, API
Aim
Measures
Changes
Testing & Implementation
Plan Do Study Act
“What will happen if we try something different?”
“Let’s try it!”“Did it work?”
“What’s next? ”
Cycles of Tests Build Confidence
AP D
S
AP
D S
APD
SA P
DS
Proposals, theories, hunches, intuition
Changes that will result in improvementLearning
from data
Sequence for improvement
Develop a change
Test a change
Implement a change
Sustain & spread a change to other locations
Support with data and consideration of people
Theory &prediction
Test under avariety of conditions
Make partof routineoperations
Study
Act Plan
Do
• 1 client• 1 day• 1 case• 1 worker
Move to 3,5,7…. as confidence grows
Start Small
Smaller Scale Tests: Shrink It!rapid cycles of learning
• Years• Quarters• Months• Weeks• Days• Hours• Minutes
Drop down next “two levels” to plan
test cycle!
Subject Matter Knowledge
Subject Matter Knowledge: Specialist knowledge and skills required to be a good practitioner
Profound Knowledge: The interaction of the theories of systems, variation, knowledge and psychology.
Profound Knowledge
Improvement
Viewing the System to plan for Quality Improvement
Macro – systems : e.g. Local Authority localities, Health Boards
The CPPs
Meso – system :e.g. Education Dept, Social Work Service Primary Care Service
Micro- system :e.g. Nursery School, Local Social Work Team Health Visiting Team
Appreciation of a system
Understanding Variation
Theory of Knowledge Psychology
Values
The Science of Improvement
“The aim of this chapter is to provide an outside view – a lens – that I call a System of Profound Knowledge. It provides a map of theory by which to understand the organisations that we work in.”
I’m sure glad the hole is not in our end!
People unclear on the concept of a system!
What insights might be obtained by looking through the Lens of Profound Knowledge?
Appreciation for a System• Interdependence of sub systems • Processes and interactions• System must have an aim and plan for improvement• Whole is greater than sum of the parts
Psychology• Interaction between people• Motivation• Values, beliefs, assumptions • Will to change
Understanding Variation• Knowledge of baseline• Variation is to be expected• Common or special causes• Reliability
Theory of Knowledge• Learning from theory and experience• Operational definitions • Expert prediction • MFI / PDSA for learning and improvement
Appreciation for a System• • •
Psychology• • •
Theory of Knowledge• • • •
Understanding Variation • • • •
How does the Lens of Profound Knowledge look in your system?
A System for Planning: Integrate Planning for Improvement with Other Organisation Planning Processes
Plan to Operate
FinancialPlanning
Developing OperatingBudget
DevelopingCapitalBudget
Operate and improve the Organisation
Plan to Improve
OperationsPlanning
Human Resources Planning
Product/ServiceDevelopmentPlanning
ProjectPlanning
MarketPlanning
Department and Functional Planning
TrainingPlanning
INPUTS FOR PLANING• Purpose of the Organisation• Market Analysis• Customer Research• Supplier Input• Technology Information• Economic Forecasts• Business needs• Regulations
FutureScenarios
StrategicPlanningProcess
BusinessPlanningProcess
• Key measures of the system• Customer feedback• Employee suggestions• Status of plans
Annually
Quarterly
1 to 5 years
Annually1 to 5 years
Setting Priorities: Process Condition and Strategic Impact Diagram
6
5
4
3
2
1
Strategic Impact (total rating)
Proc
ess
Con
ditio
n
0 5 10 15
7
8 4 2 5
3 19
16610 12
11
15 14 9
21
18 1
High leverage processes: develop improvement charters to address these
Thanks to Edinburgh
Use System Theory to Improve OutcomesMeasurement for Improvement
“If I had to reduce my message … to just a few words, I’d say it all had to do with reducing variation.”
Dr. W. Edwards Deming
Why Do You Need Data and Information?
• To plan for improvement• For testing change• For tracking compliance• For determining outcomes• For monitoring long term progress• To tell their story
Three Types of Measures• Outcome Measures: Voice of the customer or patient. How is
the system performing? What is the result?
• Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?
• Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome)
Fundamental Questions for Measurement
1. How can we monitor the real-time behavior of the system of care, steer it to avoid crashes, and maintain it’s operational reliability?
2. Over time, where are the gaps in practice that indicate a need for system change (i.e. improvement)?
3. In our efforts to improve, what’s working? What changes are improvements? Are we on track to meet our aims?
Look at the Relationships % high CO women referred to Smoking Cessation services
Cessation intervention delivered
Clinical attendance
Rate of pregnant women smokers
21/1
/13
24/1
/13
27/1
/13
30/1
/13
2/2/
135/
2/13
8/2/
1311
/2/1
314
/2/1
317
/2/1
320
/2/1
323
/2/1
326
/2/1
31/
3/13
4/3/
137/
3/13
10/3
/13
13/3
/13
16/3
/13
19/3
/13
22/3
/13
25/3
/13
28/3
/13
31/3
/13
3/4/
136/
4/13
9/4/
1312
/4/1
315
/4/1
318
/4/1
321
/4/1
324
/4/1
327
/4/1
330
/4/1
33/
5/13
6/5/
139/
5/13
12/5
/13
15/5
/13
18/5
/13
21/5
/13
24/5
/13
27/5
/13
0
5
10
15
20
25
nursery nurses talking to parents about reading at pick
up time
Reading Bedtime StoriesNu
mbe
r of c
hild
ren
who
had
bed
time
stor
yLittle Stars Nursery
Anytown
Speak to your neighbour
• Where are you in relation to your testing plans in each of the work stream areas?
• Where are you in relation to data and results?
• What are the prevailing challenges you are facing?
What could a family of measures for WS2 look like?
Jan-
13
Feb-
13
Mar
-13
Apr
-13
May
-13
Jun-
13
Jul-1
3
Aug
-13
Sep
-13
Oct
-13
Nov
-13
Dec
-13
0102030405060708090
100Percent of 30mth Reviews Completed
% c
ompl
ianc
e
Jan-
13
Feb-
13
Mar
-13
Apr
-13
May
-13
Jun-
13
Jul-1
3
Aug
-13
Sep
-13
0102030405060708090
100Percent of Children Meeting Developmental Milestones (27-
30mth review)
% c
ompl
ianc
e
South St HV team
Jan-
13
Mar
-13
May
-13
Jul-1
3
Sep
-13
Nov
-13
Jan-
14
01
23456789
10 Number of referrals to services post reviewSouth St HV team
Jan-
13
Feb-
13
Mar
-13
Apr
-13
May
-13
Jun-
13
Jul-1
3
Aug
-13
Sep
-13
0102030405060708090
100Percent of Children identified for support with follow up
in place
% c
ompl
ianc
eSouth St HV team
What could a family of measures look like for your area of work
Can you link your activity and potential measures to a driver diagram?
Summary • Improvement links to the big aims (driver
diagrams)• Data and measurement – dashboard of measures• Use of run charts • Annotations• Integration • Local support structure • Leadership removing barriers