IGNITE! Introduction to QI Methods

Introduction to QI methods

Mobile Phones

Fire Alarms

Toilets

Fire Exits

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Your facilitator today is:-

Liz Twelves

Academy Programme Lead

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What is AQuA?

Advancing Quality Alliance • North West quality improvement organisation

• Established 2010

• Membership: 70 organisations - Acute, Primary care, Community, Mental health and Ambulance trusts across North West England

• Core team of around 30 staff plus Associates and Affiliates

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Expectations?

Learning Objectives for the Session

By the end of the session you should be able to:

Understand aspects of the philosophy of QI

Be able to apply a model for improvement

Improve your ability to frame your project

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Getting to Know You

Activity - In groups, discuss some of the following to find

out what you may have in common:

- Where you were born

- Where you work

- What you do

- Where you studied

- What can people do to help you to learn

something new?

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 organizations that we work in.” (Deming 1993 p. 92)

Appreciation

of a System

Understanding Variation

Theory of Knowledge

Psychology

Subject Matter Knowledge

Knowledge

for

Improvement

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Deming’s System of Profound Knowledge

Activity

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© 2010 AQuA

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The Model for Improvement

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if a

change is an improvement?

CHANGE: What changes can we make

that will result in improvement?

© Associates for Process Improvement

PDSA Testing - simulation exercise

The Skittle Challenge

The Skittle Challenge

• Aim – to be left with one Skittle

• Execution

– Put a Skittle on each circle

– Remove one to start

– Jump over one at a time and remove it

– Keep going until you can’t jump over any more

– How many are left?

The Skittle Challenge

• Aim – to be left with one Skittle • Measure – number of Skittles left • Changes – which one to remove first? – what order to remove them in? – how you work as a team? • Execution

– Put a Skittle on each circle – Remove one to start – Jump over one at a time and remove it – Keep going until you can’t jump over any more – How many are left? (Plot your data and annotations) – Think about how it went and what you could improve next round.

(Theory and prediction based on learning)

– DO NOT EAT the Skittles – yet…

PDSA #

Theory Prediction

1 Start with No. 5 empty

Will have 3 skittles left

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3

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Number of Skittles Left

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PDSA

Why Test Changes?

• To increase the belief that the change will result in

improvements in your setting

• To learn how to adapt the change to conditions in your

setting

• To evaluate the costs and “side-effects” of changes

Overall to minimise the resistance when spreading the

change throughout the organisation.

“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

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APD

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A P

DSProposals,

theories,

hunches,

intuition

Changes that

will result in

improvement

Learning

from data

Run Chart to Measure Performance

Test 1

ABCXYZ

Test 2 -

XYZABC

Test 2 123456

Tests 3-6

987654

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skittles left

skittles left

A solution….

6-1, 4-6, 1-4, 7-2, 13-4, 2-7, 11-4, 14-5, 10-3, 3-8, 4-13, 12-14, 15-13.

The Skittle Challenge

• Consistency of purpose

• Prediction

• Planning

• Documentation

• Sharing and stealing!

• Learning from failure

Measurement and Data Collection during PDSA Cycles

• Collect useful data, not perfect data –

data for learning, not evaluation

• Use a pencil and paper until the information system is ready

• Record what went well and what didn’t work so well during the test of change

All improvement comes from designing, testing and implementing changes

Seven Propositions of the Science of Improvement. Perla et al , 2013

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 organizations that we work in.” (Deming 1993 p. 92)

Appreciation

of a System

Understanding Variation

Theory of Knowledge

Psychology

Subject Matter Knowledge

Knowledge

for

Improvement

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Deming’s System of Profound Knowledge

Getting to the root of the problem

My trip to work

Mean

Upper process limit

Lower process limit

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120

Consecutive trips

Min.

Monthly data shows improvement Average length of pre-ward stay on Barnsley

Stroke Ward

from 01/2007 to 07/2007

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0.5

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1.5

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3.5

1 2 3 4 5 6 7

Months

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The chart shows

the average

monthly length of

time before

patients got to the

Stroke ward

6/17/2016 © AQuA Academy 2013

Weekly data tells a slightly different story

Average length of pre-ward stay on Barnsley

Stroke Ward

from 01/2007 to 07/2007

0.0

1.0

2.0

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Weeks

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Patient level data adds another level of understanding

29 6/17/2016 © AQuA Academy 2013

Types of Variation Common Cause Variation

• Inherent in the design of the process

• Is due to regular, natural or ordinary causes

• Affects all outcomes of the process

• Results in a ‘stable’ process that is predictable

• Also known as random or unassignable variation

Special Cause Variation

• Is due to irregular or unnatural causes that are not inherent in the design of the process

• Affect some, but not necessarily all aspects of the process

• Results in an ‘unstable’ process that is not predictable

• Also known as non-random or assignable data

© 2014 AQuA

Group

Work

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Issues with lunch

Patient complaints

• My lunch was late

• I have nowhere to eat except my bed

• I got the wrong food

• My food was cold/lukewarm

• I didn’t like the quality of the food

• I didn’t like the selection

• I couldn’t eat the lunch I was given because it was the wrong kind of food for me

• I wasn’t on the ward when lunch arrived and the food had gone when I got back

Complaints from the catering department

• No one was available on the ward to give out the lunches when they arrived

• Kitchen – didn’t get the order early enough

• The patient was away for tests when the food arrived and I ended up taking it

back

• There was nowhere to put food that couldn’t be distributed at the time

• No one let me on to the ward for ages when I arrived

• Staff didn’t know who was meant to be helping distribute the lunch

• Some of the orders were wrong when we arrived

Fishbone diagram

A systematic and structured method for identifying potential root causes of failures

– Classifies potential causes for a failure into

five basic separate categories (but you can also adapt these to suit your areas)

– Very logical and analytical method of

determining potential causes for failures

© AQuA Academy 36

Understanding the root cause 5 Whys

• To get to the solution you need to understand the root cause for the most significant direct causes

• This could take any number of “whys”

• Do not stop until you reach what you believe is a ‘cause’ and not a ‘symptom’

• If you reach a cause that cannot be controlled, such as weather, go back one level and see if eliminating that cause will help

© AQuA Academy 37

Complaints about

lunches

Methods Environment

People Equipment

Choices not collected

accurately

Menu cards not used

Dietary requirements

not fully understood

Patients not available

to receive not lunch

Not correctly positioned

Patients off-ward for

treatment / appointment

Staff not available

to dispense

lunches

Not all staff trained

Not lunch duty rota

Busy ward

Insufficient staff

Lunch not arriving

on time

Orders not sent early enough

Issues accessing

the ward Delivery time not

agreed

No social space to

eat lunch

Miscommunication

between ward and

catering

Food not a correct

temperature

No where to store

hot/cold food on ward

Food quality and

selection not good

Fixed supplier

Small ward – limited

facilities

© 2010 AQuA

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The Model for Improvement

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if a

change is an improvement?

CHANGE: What changes can we make

that will result in improvement?

© Associates for Process Improvement

Aim Statement

Good

Bad

Ugly

We aim to reduce harm and improve patient safety for all of our

internal and external customers.

By June of 2012 we will reduce the incidence of pressure ulcers in the

critical care unit by 50%.

Our outpatient testing and therapy patient satisfaction scores are in the

bottom 10% of the national comparative database we use. As directed

by senior management, we need to get the score above the 50th

percentile by the end of the 1st Quarter of 2012.

We will reduce all types of hospital acquired infections.

According to the consultant we hired to evaluate our home health

services, we need to improve the effectiveness and reliability of home

visit assessments and reduce rehospitalisation rates. The board agrees,

so we will work on these issues this year.

Our most recent data reveal that on the average we only reconcile the

medications of 35% of our discharged inpatients. We intend to increase

this average to 50% by 1/4/12 and to 75% by 31/8/12.

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Aim Statement Team name: ……………………….

• What are you trying to achieve? – ………………………..

• By how much? – ………………………

• By when? – …………………………..

• For whom? – …………………………………….

Aim statement

…………………………………………………………………………….

Adapted from

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Aim Statement • Team name: Lunch time – on time

• What are you trying to achieve? – Get the patients their lunch of choice on time everyday

• By how much? – 95% of lunches

• By when? – December 2015

• For whom? – Patient in Bay 1

• Aim statement

95% of patients in Bay 1 receive their lunch of choice every day by December 2015

Adapted from

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What changes can we make that will lead to an improvement?

• Knowledge

• Ideas

• Creativity

De Bono’s 6 Thinking Hats

Managing the thinking process: Could you summarise finding so far?

Information / data needs: What are the facts

Ideas: Is there a different way of looking at this?

Benefits / positives: Can we list them?

Negatives / risk: What can go wrong?

Emotion / gut feeling: What is your gut feeling?

Repeated use of the PDSA cycle

Testing and

refining ideas

Implementing new procedures & systems - sustaining change

Bright

idea!

Scottish Primary Care Collaborative

Borders GP Practice

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% of Diabetes Patients with a BP<140/80

Diabetes (blood pressure) Improvements with PDSAs

PDSAs to improve

shared diabetes

information with

Secondary Care

PDSA to contact all

Patients who have not

had a BP check in the

last year

PDSAs

PDSAs PDSAs

PDSAs to improve

current patient

recall system

PDSAs to

Validate

Diabetes

Register

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Analysis:

• 8 runs – can apply rules

• Shift aligned to new menu card process

New menu card process

Staff briefing

Create Multiple PDSA Ramps

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receptionist porters Nurses

Summary & Close

Contact AQuA Via

• liz.twelves@srft.nhs.uk

• The website at: www.advancingqualityalliance.nhs.uk

• Email at: AQuA@srft.nhs.uk

• Phone AQuA on: 0161 206 8938

• @AQuA_NHS

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Thank you and ….

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