Quality Improvement “Moving from Good to Great”

Your guide to running an improvement project in a systematic way

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Start an Improvement Project

First of all – Don’t Panic!

When we talk about ‘improvement projects’ we don’t generally mean the sort of endeavours that need specialist project managers with high levels of governance through ‘project boards’ and ‘change control’ functions. We mean deliberate pieces of work undertaken at the point where the work happens, carried out by the people who do the work to address a specific challenge that is impacting on their delivery of ‘Great Care, Great Outcomes’.

You can perhaps think of a project as “an outcome that requires more than one step that you are committed to achieving”.

Improving is an element of all of our roles; from the top of the organisation through to the front line. Our approach to improvement seeks to use the talent, knowledge and skills of everyone in the organisation and ‘do’ the improvement work in structured, repeatable and consistent ways.

Across the pages in this guide we will lead you through using the Model for Improvement in order that you can complete your own improvement project.

We will use a template that will become your ‘project charter’ and will help you to capture the key components of your project. This template isn’t something to ‘just be filled in’ by you alone. It is a planning tool to help you think about, ‘do’ and share the work in collaboration with others. It is a tool that will help your work to be clear, focussed and organised.

It is designed to be a ‘live’ document that enables people to contribute to; put it up on your team noticeboard, talk about the work and encourage people to get involved.

If you need to, you can get some help, advice or guidance from the improvement support team by contacting them at hpft.qualityimprovement@nhs.net So, let us get started…

The Enabling Steps

To move towards making improvements there are some enabling factors that should be in place to allow your efforts to be a success:

1. A clearly identified issue to be tackled 2. A team who will do the improvement

work 3. The time to do the improvement work 4. A systematic approach to doing the

improvement work

The following pages will give further information on each of these enabling steps and how you can put them in place.

We want to know about the improvement work that is happening within HPFT so that everyone can learn from it, share and spread the successes. This guide uses a simple template that we recommend you use to direct the work, but we want everyone to use the Life QI system to control their projects. This easy to use system allows you and your project team members to capture, update and report on the work and you can find out more about the system and how to access it our website, here.

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Identify an issue to be tackled

The first part of improving is being able to see the challenge clearly - not always easy to do in our busy work lives. We can be really good at rolling our sleeves up and ‘fixing’ problems (usually in a crisis) to give a short term resolution, but what we really need to do is to make improvements that give us a sustainable solution. We advocate a simple approach to identifying issues for improvement:

Pause Curiously Reflect Take Action

The first step is to pause and take time to consider what we do and how we are doing it and where there are challenges. We already have formal and semi-formal opportunities to do this pausing – we just need to get better at using them for the purpose of thinking about improving. Some examples are:

Team meetings Supervision (group, 1:1) PDP Formal audits Team away days

It may also be that taking the time to pause and reflect is a key element of your role. If you are leading or managing this should definitely be something you are scheduling into your diary. Alternatively, it could be that we need to create specific opportunities to pause and reflect. Finally, there may be other personal or informal opportunities to pause and reflect, for example; on the journey to and from work or through a piece of study such as the Leadership Academy, perhaps. However we pause, we should try and keep it simple and part of ‘the day job’ – but make sure we do it! Pausing is the opportunity to do some curious reflection. What do we mean by that? We mean actively and purposefully thinking (critically) about what and how we do things and the impact of that. We mean stopping ourselves from rationalising our current approaches – this limits our critical thinking. We mean deliberately taking ourselves out of accepting that ‘this is the way we have to do it round here’. Ultimately, we mean asking ourselves some simple questions about things that we do:

‘Is this OK? Is this “great care, great outcomes”?’ ‘Does this deliver what the people who use our service need / want?’ ‘Are people satisfied with this?’ (us, service users, carers, commissioners, the public) ‘Can we do this better / in a better way?’

If the answer to these questions is ‘no’ (or yes to ‘can we do this better’) then we have found something to improve.

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At this point, we must stop ourselves from immediately thinking about ‘how’ this will be improved. This is to avoid two potential traps:

1. talking yourself out of starting to make an improvement because it seems difficult or you’re not sure how you will do it

2. jumping to a solution without fully understanding the problem

For the moment, we should let the fact that this is something that needs to be improved sink in and take on an importance such that we will want to do whatever we can to improve it. This is the point we are making a commitment to taking action – and that will come in the form of starting an improvement ‘project’.

But what are we asking those curious reflection questions about? Well, it depends. We all have so many things we do that could be improved, we need to focus on the important elements – the ones that contribute to delivering ‘Great Care, Great Outcomes’ the ones that impact on:

the quality of service user, carer and staff experience, on safety, on the value we deliver, on positive partnership working

Some of what we should be curiously reflecting on comes at us in a very direct but retrospective way, often following an event or situation:

an incident or near miss poor performance or targets being missed errors leading to us having to ‘fix’ something

There are other things that we should be curiously reflecting on in a prospective way - deliberately making an assessment against some framework / model, standard or expectation:

Auditing the quality of care and support plans Assessing the safety of an inpatient unit Searching for wasteful activity Declining performance trends

Curiously reflecting in the retrospective mode is often easier; simply put, the challenge has come to us. Curiously reflecting in the prospective mode is ultimately a more positive approach to identifying areas for improvement and is helped by questions, tools and techniques that give a particular focus or perspective to looking at what we do.

These tools will be many and varied and some will need specific time to be created to apply them. However, using them is a powerful and positive way of identifying improvement opportunities. Often the questions (‘is this OK? Is this “great care, great outcomes”?’, 'does this deliver what the people who use our services want / need?', ‘are people satisfied with this?’ and ‘can we do it better?’) are implied in the tool or technique, but if not then we must ask them.

In either mode – retrospective or prospective - once we have identified a challenge we need to be clear about it and the impact that it is having, and then commit to taking action. We therefore need to capture a good description of the challenge and you can find out about doing that in the following page.

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Describing the challenge

We need to be as clear as we can about the challenge / problem to help us to take improvement action and importantly we need everyone else who is going to be involved in addressing it to be clear.

We know that the work we do in one area is often highly interconnected with other parts of the service or organisation – one issue may be the cause and / or effect of others.

However, we cannot address all the problems that we have in one go, so by clearly describing the challenge we can put some boundaries around what we are trying to address, helping us with control and making improvements at pace.

A good description of the problem will include most of the following, set out succinctly and factually:

What is happening? What is the issue? Any deviation from an agreed standard How often does the issue occur? When is it observed or experienced? How is it observed / experienced? Where is it observed or experienced? Who observes / experiences it? What is the impact? Who is impacted? Can the impact be quantified – financially,

treatment outcomes, delays, volumes etc.?

We are trying to describe what the current condition is and we may not yet have enough information to do that. This is absolutely normal and our first action would be to gather the information we need. Remember, one of the key elements of Quality Improvement thinking is to be curious and understand a situation as well as we can before we start making changes.

Get your project team involved describing the problem. If you have assembled a diverse team who have a rounded view of the work then you will get a better understanding quicker. If you don’t have enough information to adequately describe it, then you will need to use some of the tools and techniques outlined later in the guide to help you gather it.

Using the template, write the description of the problem in the ‘Describe the problem / current condition’ box.

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Form a team Improvement should be a collaborative effort, ensuring the staff involved in delivering the service are engaged in some way so that the improvements are introduced consistently and remain sustainable. Having a team to do the work means that you will be able to do much more, go faster and harness the creative power of the group. However, think about the optimum size of the core team, we recommend that it should be between 5-8 people. At the start of your project, you may not have all your team members in place. You may not know some of the people who need to be involved and this may only become clear as you gain a better understanding of the challenge and the obstacles you need to overcome. You can add more people as the project progresses and should anticipate this happening as your improvement project gains momentum. A key role in your ‘team’ which needs to be filled from the start is that of the project ‘sponsor’. This will be the person who is supportive of the improvement being undertaken and who will help you to overcome any barriers you may come across as you progress your project. You will also need to think about some of the other people that you may need to help you who might not be part of the core team. Perhaps you may need a bit of advice from an HR or finance perspective or some additional data that you can't access yourself. You will need to think about who to approach and then secure their input, so it is worth giving some thought to that at the outset as well as when the project moves forward. People who use the service are invaluable The people who use the service are invaluable team members. Our improvement projects should be focused on changes that benefit the people who use our services and should be informed by an understanding of their requirements. Having them directly involved as members of the team in some shape or form is a great way to do ensure this understanding. On the project template, capture the names of the project lead (probably you!), the sponsor and the people who are your core team and additional support, so that people are clear about who is involved and to reinforce commitment to the work.

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Make time to do the work We know that finding the time to carry out an improvement project can be difficult. Our approach is geared towards ‘doing’ improvement as part of your day job’ rather than as a standalone activity. We can’t prescribe all the possible fixes to the issue of having the time, but you may want to consider using periods of time such as free slots at a team meeting or at the end of a handover. As the work is incremental and iterative, if you only get small chunks of time, then use them – the analysis and solution development etc. may take longer than you would want to (in terms of elapsed time) but at least you are still doing it and making an improvement. What is the alternative? Do nothing and stay the same? You may want to consider activities that you do that are of low or no value to the core aim of delivering 'Great Care, Great Outcomes'. Which of these can you stop doing to re-utilise the time? Obviously consider the risks and impact of stopping, but be bold and take action. Make it clear when you are going to do the work on the project template so that you are committed to creating the time or setting it aside for the work and allowing everyone to know when this will be.

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Use a systematic quality improvement approach

Using a defined approach will help to bring focus and control to your project, helping you to make a sustainable and measurable improvement based on fact and evidence rather than just implementing a change; every improvement is a change, but not every change is an improvement! We have adopted the Model for Improvement as our overarching improvement framework, an easily understood model that can be used for improvements large and small alike. Simply put, it helps us to think about our aim, measures, change ideas and how we will test them. You can read more about our approach on the Innovation and improvement website. This guide follows the model.

The important thing is for you to communicate to your project team the approach that you are taking with the work. They will need to understand about setting a clear direction to improve towards, why it is important to be able to measure progress and that you will be using a rapid experimentation process to generate and test solutions, taking small steps towards the overall goal through PDSA cycles. The PDSA cycle is the engine room of the approach, driving forward the improvements. It is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from what happens (Study), and determining what should happen next (Act).

AIM

MEASURES

IDEAS

TESTS

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Setting your direction

Through the enabling steps you have: identified a challenge that you are committed to; drawn together your core team who you will collaborate with to make improvement's; agreed when you will meet to do the work; and have briefed people on the Quality Improvement approach that you will be using. Before you can go any further, you need to know where you are going. This is the first step in the Model for Improvement - 'what are we trying to accomplish?'

What this question seeks for us to do is describe a clear aim for the work. To help us set this aim it can be useful to think about what an ideal future state would be like, or what ‘great care, great outcomes’ are for the issue you are tackling. To help you to do this, first check to see if your team or service have a vision statement that describes a broader vision that you should be moving towards. You can also ask questions such as

“What would life be like if…(current challenge was resolved)? What would people (staff / service users, carers etc.) be doing, thinking, feeling?”

“In a perfect world, what would be the best way for this service to be provided?” From this understanding you can then describe what the aim of your improvement project will be. This description should follow a few simple rules:

It should be:

Focussed on delivering value from the service user / carer / customer perspective Aspirational, stretching but achievable Timebound A measureable description of what life will be like after we have improved (e.g. 'All

calls will be answered in 12 seconds and by a trained operative')

It should not be: constrained by current ways of working A DESCRIPTION OF SOLUTIONS! – we must be clear about what we are trying to

achieve before we decide how we will achieve it

AIM

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We are describing our aim for three reasons:

1. So that everyone is clear about where we are heading towards 2. We can measure that we are going in the right direction 3. We can make sure that we are improving towards meeting service user / carer /

customer requirements Defining the aim may be a collaborative activity amongst the members of the project team. There may also be occasions where the aim is prescribed, particularly in instances where the improvement project is focused on remedial activity. However, in this latter situation, the creativity and talents of the team will still be able to be harnessed as well as the team owning the improvement work. This is because the how has not been defined by someone else – just the destination. Capture your aim on the template so that it is documented and visible to the project team and others.

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Measuring for improvement

Now we have described where we are going, we need to establish some indicators that tell us whether we are heading in the right direction and to help us make decisions. This step is all about identifying the measures or observations that will tell us how we are getting on and help us to answer the question ‘how will we know that a change is an improvement?’. The things that you measure will be directly related to your aim. They may be existing performance indicators or other metrics that you use, or something new. That means you may need to set up methods for measuring these and if you do, try and keep them as simple as possible.

Sometimes the indicators may be less tangible observations that could be captured in other ways – perhaps through pictures or brief surveys etc. so don't always think it has to be about hard data. That will be needed, but softer measures are important to. There are three categories of measure that you will want to consider keeping track of:

Outcome –measure of impacts on the ‘end user’ (service user, carers, customers, other stakeholders etc.) Examples could include; 28 day access, medication errors or recovery rates) Process –measure of how the parts of the system are performing that help deliver the outcomes. Examples could be percentage of physical health checks completed or numbers of invoices paid on date Balancing – measure of whether the changes we are implementing are having an adverse effect elsewhere in the system. An example could be length of stay reduction in inpatient units resulting in an increase in readmissions

Remember that whatever measures you set up may not need to be kept in place for ever – or they may replace other indicators that are no longer relevant.

Measurement and the various tools that can help this can sometimes be a complex topic, so try and keep things simple to start with. It may be that you have people in your project team who are have the right skills and knowledge, even if that isn't part of their 'day job' and you should draw upon those hidden talents wherever possible.

MEASURES

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It may be that you would benefit from getting support from colleagues in the Performance Improvement Team to help with this element if it is outside your teams comfort zone or current skill set. However don’t be scared of it. Get the help but in a way that you learn and can be self-sufficient going forward.

The measurement step is as important as making changes to the work you do but one that is sometimes overlooked or ignored. Don't make that mistake on your project. Identify the measures that are relevant and then take a baseline measurement of them all before you start making changes. Capture the measures and baseline on the project template. Feel free to improvise as well. You may find it helpful to set up another sheet to go with your template to show run charts, pictures and other visualisations of your measurements.

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Planning for action

We have arrived at the point whereby we have developed an understanding of the problem, set a goal for improvement and have measures that will tell us if we are achieving it You and your team are probably having ideas about the changes that will help to reach that goal. People have ideas all the time and their arrival (and departure) can be unexpected and fleeting. We cannot remember everything, so we need to write things down. The project template has a section for capturing change ideas. Use this as well as any other useful capture methods, making the ideas as clear as possible and capturing who the idea ‘author’ is, so you can check back with them if further clarity is needed.

It is tempting to rush off and start making lots of changes, but unless we do this in a controlled and structured way, we cannot be sure that we will have understood what is working / not working or helping / not helping. This is the point whereby we need to bring in some additional structure to help with controlling and directing the work. Our objective at this stage is to create a project ‘driver diagram’. This is a tool that helps us to:

understand the factors that will impact on our aim

group our change ideas around these factors

use as a catalyst for generating more ideas

prioritise the change ideas that we will test

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Before we construct the driver diagram it is helpful to identify the key factors / themes that impact on the aim. These are the ‘drivers’ that we will build our driver diagram on and are likely to have started to emerge in your thinking and discussions with the project team.

Imagine your aim is to lose weight. The main factors that impact on this would be calories in and calories out. These are the ‘primary drivers’ that will have an effect on achieving your aim.

You will find a full explanation of this technique in the following section of this guide, but for now capture your thoughts and those of the project team on the template.

A final thought at this stage is that it is helpful to check that you have a good understanding of the problem / current situation. Again, it is tempting to start making changes, but if you do this from a position of poor understanding of the current state, your solutions will not have the impact you anticipate.

Quality Improvement is a non-linear process and if you are using the curious mind-set you may have already carried out some in depth analysis. If you haven’t then your next actions are to get that understanding.

You don’t want things to slow down trying to ‘know’ everything – we would suggest that it wouldn’t be possible to do that. You just need to be confident you have understood the problem sufficiently to have a good chance of generating ideas that will improve it.

We suggest using one or many of the four techniques outlined in this guide; root cause identification, process mapping, data analysis and ‘go see’.

The reality is that understanding the problem is a highly iterative process and as you start working to make improvements, further insights into the situation will be gained which will inform your next actions.

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Driver Diagrams A driver diagram is a visual representation of a team’s thinking about what ‘drives’ or contributes to, the achievement of an improvement project’s aim. It is a picture of the teams shared view and is a helpful tool for communicating to other stakeholders. A driver diagram shows the relationship between the overall aim of the project and the primary drivers that contribute directly to achieving that aim. The diagram also shows any secondary drivers (components of a primary driver) and specific change ideas / opportunities underneath the drivers that the team can test and explore in their pursuit of achieving the aim.

Constructing a driver diagram is straightforward and you will have collected much of the required detail in the previous stages of completing the project charter. You may wonder why we are creating a driver diagram if we already have the information captured and shown in the project charter? It is so that we can quickly and clearly see our ‘theory of change’ (how we believe we will achieve our aim). This allows us to have further insights and ideas. Driver diagrams are not static documents. They should evolve and change as our understanding of the problem and potential solutions – and thus our ‘theory of change’ – evolves. You will find a blank driver diagram template on the innovation and improvement website, but you can also use a simple hand drawn one with your team. Remember, things don’t have to be neat and perfect, just helpful.

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The example driver diagram shown below is based on an improvement project centred around an individual’s weight loss.

This highlights the ‘theory of change’ that to achieve the aim, the main influencing factors are how many calories are taken on and how many are used. There have been a number of secondary drivers identified underneath these as well as some change ideas that will be tested. The measures of success are also outlined. You can quickly see how a change idea is intended to impact on the aim. For example the ‘join a weight loss group’ change idea is intended to help with a person’s motivation (a secondary driver) which in turn has been identified as a factor influencing the ‘calories out’ primary driver. Being able to ‘see’ this is important for peoples understanding. We will all have experienced a change being implemented at work where we have no real understanding of why it is happening. This can lead to people feeling confused, frustrated or concerned, which are poor conditions for an idea to succeed. In your own experience, if a ‘theory of change’ had been visible to you in a simple and quick format, do you think that would have helped with the acceptance of a change? If so, you will already understand the value of a driver diagram!

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When you start constructing your own driver diagram, start with the aim. Is it clear and timebound and do you know the measures that will tell you that you are achieving it? This is a great way of sense checking that you have captured something SMART (specific, measurable, achievable, realistic, timebound). Next, take your list of potential drivers and think about which of these are the main factors that will impact on achieving the aim. Usually you will be looking for up to 4 primary drivers, but this isn’t an hard and fast rule – you may have more, but probably not many more. Add these to your driver diagram. You may still have some other factors that you have identified and these may well be secondary drivers - components of a primary driver. If that is the case, you can add these to your driver diagram underneath the relevant primary driver. Don’t worry if you haven’t identified any secondary drivers – it isn’t a requirement that you have them. Finally, you can add your change ideas / opportunities underneath the relevant primary or secondary driver. If they seem to fit in more than one place, you can either put them in both or pick the most appropriate. Again, it is whatever makes most sense to you / your ‘theory of change’. Once you have constructed your driver diagram, you should display this alongside your project charter so that everyone can see the thinking. Now that your theory of change is visible, it can be a catalyst for generating more change ideas; people can see clearly what is trying to be achieved, what are the influencing factors and what ideas have already been generated.

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Generating and testing solutions

You will now have an initial set of ideas that you think will help to achieve the aim and these will be captured and structured in your driver diagram. Although you may have some good ideas, we encourage you to get your team (and maybe other people) to think divergently and generate as many ideas as possible. This is where you can use the creativity of the team and continue to use your open-to-anything, curious mind-set. Having lots of ideas gives you lots of options and reduces the impact of any ‘solution bias’ whereby a single idea is pursued at the expense of thinking more creatively.

There are many techniques for generating ideas, but it is likely that you will use some sort of brainstorming technique to generate many possible solutions. You should use the drivers you have identified to provide focus for peoples idea generation. Additionally, you can encourage people to build upon ideas that have been captured. This isn’t a competition, it is collaboration. Use additive thinking (that idea + this idea) rather than criticizing or dismissing ideas. Remember that some people may feel exposed putting their ideas forward and if they get bruising criticism they are unlikely to take that risk again and you have lost the creative input of that person for this project and probably others too. Of course, some ideas have more obvious potential than others and it will be those that we test first, but if these don’t have the effect we anticipate, we will need to return to the ideas pool and try something else. You will now have answered the question 'What change can we make that will result in improvement?' and are on the verge of being able to (rapidly) test your ideas. On rare occasions you may have a complete solution idea that you absolutely know will achieve the aim. If that is the case get on and implement that idea – if you are that sure it will work, don’t waste time testing, just do it! However, most of the time we don't know for sure what will work and that is why we use the PDSA technique.

IDEAS

TESTS

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Prioritising To achieve your aim you may have a set of obstacles that need to be overcome that has an obvious priority for resolution: unless 'a' is resolved, you can't address 'b' or 'c'. If that is the case, then 'a' is the obstacle you will need to start with and you will be selecting an idea to test that does that. However, you may not have an obvious priority order and if that is the case, you can start with any of your ideas. Consider picking ideas that you think will give early or obvious benefit to the people doing the improvement work as your starting point. This can give people confidence that the project will make a difference and a sense of achievement when the ideas are implemented. In either instance there may be more than one idea that you think may help. You will need to work with the team to settle on which of these is the stronger contender. Whatever your starting point, it is best not to try and work on lots of ideas at once - it can be done, but it is better to pick on a single ideas and test that rapidly using the skills and resources of your team, rather than spreading your team thinly across multiple ideas. Once you have prioritised and selected the idea that you are going to work on you are now ready to start rapid testing using the PDSA approach. Rapid Testing

Plan You now have a key part of your plan; the change idea that you think will overcome the obstacle you are working on or help move you towards achieving your aim. You may need to ‘create’ something as part of that idea – maybe you need to revise a process or work description so that people are clear on what the new way of operating is that they are testing. If you do have something to create, that all happens as part of the plan step. The other thing that happens as part of this step is deciding when, where, who and how long for you will test out the idea and what your expected results will be – which of your measures that you have identified are you hoping to affect or is there something else you need to measure to demonstrate you are getting the results your expected from the experiment? Try and keep the test periods to relatively short timescales, which is easier if you are making small changes. Remember we are trying to rapidly discover what works and what doesn’t. Do This is putting the solution into effect – finally you are experimenting with your idea, putting it into operation! You will need to keep a curious eye on how things are proceeding, making sure you are measuring appropriately and observing what happens. All of these will measures and observations will be used in the study step.

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Study You will find yourself naturally ‘studying’ whilst you are doing, but at the end of the defined testing period you need to collate your results and see what happened. Did you get the result you were expecting? Has the obstacle been overcome? Have you moved closer to achieving the aim? If not, why do you think that was? Was this the wrong solution or does it just need a few tweaks here and there? Again, this is a continuation of the curious mind-set, seeking to find out why something did or did not happen as predicted. Act The final step in the cycle. This is all about taking what you have learned in the study step and then doing something with that learning. If it was a success, do you now need to roll this solution out to a wider set of people? If it was unsuccessful do you need to go back and experiment with another of your change ideas or do you just need to make some minor adjustments to this one and test again? This iterative testing and refining of a change idea through two or more PDSA cycles is known as a PDSA ramp – literally the cycles ramping up towards a successful change:

What you can probably see is that the Act step then merges back into the Plan step as you go through another cycle of rapid experimentation. Once you have overcome your first obstacle or tested your first change idea, you just select the next one and go again. And you keep going until you achieve your aim or reach your timebound checkpoint where you will review where you are and what your next steps will be.

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Use the PDSA sheet to capture and display your work on each change idea. Capture the plan outlining what the hypothesis about the test you are going to undertake e.g. “We believe that if we [do x] then we will see [y result] which will help towards achieving our aim of [z outcome]. We will run this test for [n days / weeks / months] and study the results”. State clearly which of the measures you will be recording and studying during this test and preferably show and capture this visually in some way – e.g. a run chart that is updated with an appropriate frequency during the test period. The upper section of this sheet allows you to identify and records the tasks that are required to set up the plan. Assign the tasks as required and track their completion. You can’t start the test until all the necessary elements are in place. In the PDSA cycles section of the sheet, use the ‘Do’ box to capture the in the moment observations of the test and use the ‘Study’ box for briefly outlining the findings when your team study the results ((bullet points are always helpful). The ‘Act’ box is where you outline what will happen next – an iteration of the idea, a wider roll out of a successful test etc.

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Gaining a better understanding of the challenge Gaining a better understanding of a situation, obstacle or problem is something that you will do at various stages of an improvement project; you may need to do this to identify the obstacles that lay between where you are today and your future state, or gain a better understanding of an obstacle that you are working to overcome, or even as part of testing out a solution using PDSA. Whatever stage you are at, when you are looking to get a better understanding you will be working through a process of information gathering and analysis of that information. You will be using your curious mind-set to ask yourself “what is this information telling me? Is this enough information or do I need to find out more?” When you believe you have enough information, you can then take action from an informed position, increasing your chances of a successful outcome. The actual information that you need to take you towards this better understanding will vary from project to project and the situations and stages that you are at. The methods to gathering and analysing this information will also differ and we wouldn’t want to constrain what works for you. However, we promote some helpful techniques that are relevant to all challenges and can be used at varying levels of analysis. These techniques work well in combination and are:

Root cause identification Process mapping Data analysis ‘Go see’

Further information on each of these techniques is outlined in the following pages. You can use PDSA cycles to help with rapidly gathering the information you need:

PLAN – (hypothesis) – if we gather information on ‘x’, using ‘y’ technique, it will allow us to understand the situation / problem better DO – gather information on ‘x’ STUDY – does information on ‘x’ increase our understanding of the problem? ACT – if the answer is no, was ‘y’ the correct technique to have used? What do we need to do next to better understand…..?

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Root cause identification Getting to the root cause of a problem and resolving the issue at the most fundamental level is what we would always prefer to do, but how do you get to the root cause? And is there actually such a thing as a single ultimate root cause? There may not be an answer to the latter question, but what we do know is that there are differing levels of problem causation and getting to and resolving the deepest level possible is what will give us the greatest improvement effect. There are many different root cause identification techniques and we advocate two of the most well-known / well proven of them:

5 Why's Cause & Effect Diagrams (aka Ishikawa Diagrams)

The method for each is outlined below and you can use these techniques in many different settings. There are no right or wrong answers when you use the techniques, only more or less understanding of the problem you are considering, but any increased understanding is a positive. The more you use a technique the more comfortable and adept you will become in using it, so at the outset don't worry about 'doing it right', just use it to help you and your team with understanding and insight. 5 Why’s The 5 why’s technique simply requires you to ask ‘why?’ several times in relation to the problem you are considering. The technique is called the ‘5 why’s’ because this is often the number of times ‘why’ is asked before getting to the root cause. However, what this technique is really all about is having a questioning attitude and not accepting the first reason given. It is all about probing beyond this answer in a curious and questioning way, but never in an aggressive, demanding or accusatory way. The steps in undertaking a 5 why analysis are:

1. Determine your starting point for the analysis – perhaps the problem itself or a possible cause that you want to explore further

2. Use your / your teams curious and critical thinking to ask ‘why’ this is a problem or possible cause

3. Depict the chain of causes as you progress through asking ‘why’ to each previous answer

4. Keep going until you can no longer answer ‘why’ – this is most likely the root cause, or the deepest cause you can currently get to

This is a simple technique but not an easy one; it requires effort and for you to exert your critical thinking on the answers you come up with. Are you making assumptions in your answers? Do you understand the issue sufficiently to answer ‘why’? Do you need other people to be involved in answering it?

Cause & Effect (Ishikawa) Diagrams

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The cause and effect diagram technique does what it says on the tin – it is tool that helps understand the relationship between a problem and its causes. This is a technique that combines aspects of brainstorming together with a more systematic cause analysis and can be used to:

Generate and group problem causes Systematically evaluate cause and determine likely root causes

The technique uses a format often referred to as a ‘fishbone’ to capture the problem and potential causes – see picture below. The steps in creating a cause and effect diagram are:

1. In the right hand side of the page (the ‘head’ end of the fishbone) clearly and succinctly describe the problem that you are seeking the causes of

2. Identify the main categories of possible problem cause and write them at the top of main branches from the ‘backbone’. You can identify whichever categories make sense to your situation, but a classic set are:

People

Methods

Equipment

Environment

Materials 3. Brainstorm and write all the possible causes under the cause categories, using brief

and succinct descriptions, working through one category at a time to drive out as many possible causes as you can. If a cause goes in more than one category, put it under all that are applicable

4. After you have brainstormed the causes, you need to analyse them to determine the most likely root causes. You will want to check these with data or observations. Remember, these are the things that you will spend your time developing and testing solutions for, so you want to get to the best analysis possible. Use your critical and curious thinking to help in conducting this analysis.

Process mapping

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The features of a high quality process are that it efficiently flows high value to customers and gets it right first time, every time. Everything we do can be described in terms of a process but we don’t always perceive the work in that way and often are not able to ‘see’ what our processes are. Process mapping is a powerful technique that allows us to visually represent the work we do. To show what is actually happening with our processes, not what we think, hope or should be happening, enabling us to locate areas of problem for further investigation and resolution. Process maps can be drawn at varying levels of detail. Often a high level map will be the starting point and a section of the process is then focussed on in detail. Your improvement project may well be considering a challenge in one portion of a much larger process and it is usually helpful to understand if that is the case, particularly when considering problem areas and their solutions - perhaps these lay outside of your direct span of control? Mapping a process will help you to see that. Whatever level you are looking to map your process at, you should be clear of the start and finish points of the process you are mapping and understanding. Processes have a habit of not being that neat and tidy in real life, so you need to put some boundaries around what you are going to map. There are many mapping techniques and methodologies and it is likely that you have been involved in this activity at some point in the past. You may well be familiar with technique of using ‘post it’ notes on a large sheet of paper and this is essentially the core technique outlined below. The purpose of using post it notes as opposed to just drawing the process map is simple – you will never map it right first time! You will find different perspectives on the process, variation in the methods and all manner of sub processes and oddities that become apparent as you get into the mapping – many of these are possible causes of problems. Using post it notes allows you to easily move steps around, effectively drawing and re-drawing the process until there is a consensus on the current state. The steps in the method are:

1. Be clear about your start and end points for mapping 2. Get the people who ‘do’ the work involved - you need to be mapping based on actual

activity not perceived 3. Make the time to create the process map and gather together the materials that you

will need (post it notes in different shapes & colours (to help with differentiating items), a big enough sheet of paper / wall to work on etc.)

4. Define who the ‘customers’ of the process are. It could be an internal team or department receiving something from your process or an external organisation or individual including service users, carers, GP’s etc.

5. Be clear about the output the ‘customer’ is supposed to receive and any quality standards around it (time, specification etc.)

6. Be clear about what the required inputs are to produce the output and who supplies these inputs (this will most often be in the form of information, but could be physical / tangible items)

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7. Identify the main activities undertaken in the process to transform the inputs into the required outputs; use the post it notes to represent the key activities and add other useful information such as documents, IT systems etc. You may be wondering how much detail you need to get into and the answer is that it depends, but if you are breaking down tasks into work instruction level you’ve probably gone too far.

8. Map the process by moving the post it notes around until the people who do the work feel that it represents the most realistic picture of the current process. Don’t be tempted to start trying to ‘fix’ things at this point, just capture what is actually happening including any rework loops and related sub processes and don’t worry if it looks messy and confusing – it probably is! It is often helpful to capture who does the work and using ‘swim lanes’ is one approach to doing that (see picture below).

9. Capture this map of the current state in some way – use the least time consuming method you can, preferably a photograph if you can see the detail, but otherwise you may need to re-draw it electronically.

Analysing your process map The next steps are all about analysing the process map. You may have already started to think about that when you were mapping. You are looking to analyse at three levels:

Obvious process problems

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Where ‘value’ is added Process time analysis

Obvious process problems include:

Disconnects – steps where there are breakdowns in communications between teams, shifts, customers / suppliers etc. Bottlenecks – points in the process where volume of work outstrips capacity, slowing everything down and causing delays Redundant steps – steps in the process that duplicate activity or results elsewhere in the process Rework loops – points where activity has to be re-carried out due to errors or delayed to collect missing information etc. Decision / inspection points – steps in the process where delays or re-work are created through checking or authorisation etc.

These issues are all potential contributors to the overall challenge you are considering and critically do not add value to the people who use our services. Eliminating these issues will make for a better process which in turn will make for a better experience for the people using our services. Analysing your process for where ‘value’ is added is another way of understanding what the critical elements of the work are. Each process step should be considered as to which category it falls into and whether it can be done better (value adding & value enabling) or how it may be eliminated (non-value adding) Value adding These are the activities that are valuable from the person who uses the service’s perspective. This is crucial as any activity can be justified given the right viewpoint, but we are providing the service to deliver for our service users and carers. The criteria to judge whether a step is value adding are:

1. The person who uses the service cares about the activity and / or would be (notionally) happy to pay for it if they knew we were doing it

2. Some change is being made as a result of this activity that progresses the service – moving things around is not value adding

3. This is the first and only time we are doing the work – fixes, rework, replacements etc. are not value adding as they are correcting mistakes previously made so are not value adding All three of these criteria have to be met for the activity to be deemed value adding

Value enabling This is a class of activities that allow you to do the work for the person who uses the service more quickly or effectively, safely etc. This class of activity will include meeting legal and regulatory requirements. As an example, inputting information into an IT system may not be value adding but it may be value enabling when the alternative is making a manual record that cannot be quickly retrieved when needed. Non value adding The sorts of activities that fit into this category are, well, almost everything else! These

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include obvious items such as delays, waiting and corrections as well activities that we normally believe to be necessary such as:

Inspections & checks Setup and preparation Transportation (people, things, information) Internal reports

The final type of analysis we would suggest is that of process time and seeing where (and why) time is wasted. There are two components of process time:

Work time – the time actually spent doing something as the service flows to the person using the service Wait time – the time where someone or some thing (a referral etc.) waits for something (an action) to happen to it. Examples here are time spent in any sort of queue or batch waiting to be ‘processed’

Reducing process time (from either component) facilitates speed of receiving the services and / or productivity and this will generally be felt in a better experience by the person using the service. Current state process maps don’t need to be neat and tidy – just helpful and accurately reflect what is actually happening!

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Data analysis There are a lot of numbers floating around in the organisation and it is easy to get overwhelmed by them, so the first step of data analysis is being clear on what data you have got, what you need to have and what is going to help. Use your problem statement and future state vision to help frame the data and information that you will find helpful. You can use data in a couple of ways; you can use it to indicate where issues and problems may be and you can use it to test out hypotheses about your challenge. There are multitudes of ways in which you can analyse data so we advocate asking some simple questions to get you started and help you get curious with your data and what it is telling you. Ask questions such as:

Are there differences in performance at different times of the day / days of the week / week of the month / time of the year? What are these differences? Are there patterns?

Are there particular times when an issue is really prevalent? What is different or unusual about that time?

Are there differences between the results of different wards / teams / practitioners? Are there different practices seeking to achieve the same result or the same practice generating different results?

How much variation is there within the process? What are the causes of it? Are there particular categories of issue (e.g. certain type of datix incident or complaint type

that are more prevalent)? Which are more prevalent? Are there any corresponding things happening in other data you have? (e.g. are 28 day

breaches rising at the same point as staffing numbers fall?) Is there a genuine correlation between these two data?

There are some tools we would suggest that can help with being able to see what your data is telling you (literally, by turning numbers into charts and visualisations), including the following:

Run (trend) charts A tool used with continuous data that helps you see whether there are patterns over time Pareto charts A special type of bar chart that helps you to focus on components of a problem that are having the biggest effect. Used with discrete or attribute data. Histograms (frequency plots) Used either with continuous data or counts of attributes (discrete) data to help see variation and where the majority of measurements are occurring (distribution)

You will be able to find out more detail on these techniques on the Innovation & Improvement website.

We would advise starting off with simple run charts as these can give you some powerful information and allow you to keep track of progress as you move forward into testing solutions.. As you become more skilled at looking at and interpreting data you may look further afield for your analysis tools, but for now use those few simple tools. If you have someone in your team that is knowledgeable about other techniques then feel free to use them if they are helpful in gaining you a better understanding of the challenge. Finally, don't forget that the data will tell you something about the challenge and the problems you are facing, but it won't tell you everything! You will need to delve into the actual work, where it actually happens to get into the causes of what you are seeing in the data.

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Go see

Very often we find ourselves sitting behind out computer screen looking at reports and data discussing challenges and problems in meeting rooms and offering opinions about what is happening with the work and what should be done. But how often have we been to where the action is and if we did go, did we really look, listen and learn?

This technique is all about going to where the work happens to observe and collect the facts about what is, or is not, happening. It can be summed up simply as:

Go to the actual workplace Look at the actual process Observe what is actually happening Enquire of the people who actually do the work Collect the actual data

A lot of the time we can’t ‘see’ the process but we can learn to see it through asking the right questions (as well as using tools like process mapping). This is all about using your curious mind-set and the persistent use of Kipling’s ‘six honest serving men’:

I keep six honest serving-men (They taught me all I knew); Their names are What and Why and When And How and Where and Who

‘Going to see’ at the place where the work happens can support and / or be supported by other sources of data; they are both important, but in the same way as looking at an Ordnance Survey map won’t tell you what the terrain is actually like (it will give you a clue), data from reporting systems won’t tell you what things are like in the workplace. Who knows what cumbersome systems and processes might be in place to generate the nice neat numbers in an Excel spreadsheet?

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Scale up & spread improvements Most of the time your rapid test of change idea will be limited to a small area within a larger team or service – it is difficult to try something out rapidly if large numbers of people are involved. However, once you have tested a solution through a series of PDSA cycles and you are happy that it is stable and delivering the results that you require, it is vital that you ‘scale up’ and get this solution in place everywhere else that the same activity / process is in operation. This is probably the point in the project where you will really draw upon the project sponsor to help you, especially if you need to cross team or service boundaries and these are outside of your span of control. The thing to remember about scale up is that you can take a horse to water, but you can’t make it drink. You will need to demonstrate the problem that you overcame and the benefits that you are deriving from the improvement. One of the best ways to do this is to get the people who are operating in the new way to help you to ‘sell’ the idea to their colleagues in other teams. Enable them to show how and why the new way is better and facilitate colleagues being able to ‘go see’ for themselves so it is not just a report or vague description of why things are better, they can actually see it for themselves. Managers associated with the work have a responsibility to ensure that good ideas are spread so make sure that you are able to show them the positive benefits as well, again leveraging the positional power of your sponsor to make this happen. Every situation will be different, so it is difficult to prescribe exactly what you will need to do, but the continuous improvement team are here to give some advice on this, so please get in touch.

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Learning & Sharing

Making improvements using a systematic quality improvement method in the way that we have outlined is always a learning experience. You may have been trying out new ways of thinking about how you view the work you do and undoubtedly you will have been trying new ways of ‘doing’ the work you do. Either of those will have required you to learn and develop. You may also have learned a new set of tools to help with improvement and taken on responsibility for leading a project, which may be a new experience for you. That is all valuable learning and development as well, even if things didn’t always go as planned. In fact, when things don’t go as planned we believe you get the greater learning. We love to hear stories of how people tried something, failed and then tried something else – that is the heart of the scientific method associated with PDSA. We can imagine that at various times you will have felt excited, concerned, enlightened, overwhelmed and many other emotions. We hope now that now you are at the end of your project you will feel a sense of satisfaction and accomplishment. And we hope you feel that way even if you haven’t yet achieved everything you set out to do. We genuinely believe that the experiences you have had through the improvement project are as valuable as the improvements themselves. It is your learning and development that will allow you to take on other improvement projects and feel more confident and experienced when you do. The collaboration, empowerment and tenacity that you will have needed to work through your project are some of the hallmarks of a collective leadership culture and it is this culture, supported and enhanced by the curious mind-set that you will have developed that will be the foundations of our journey from good to great. We believe that your improvements and experiences can be a valuable aid and inspiration for other people and we want you to share your learning, which will also be an opportunity to celebrate your successes. On the Innovation & Improvement website you will find a QI project ‘story’ template that allows you to simply describe what you have done and the results that you have achieved. Completing this story template will be relatively quick and straightforward – all of the detail will have been captured in the project template and the PDSA sheets etc. When you complete the story template, be creative and engaging with how you complete it – use pictures, graphs and charts etc. to make it an easy read for people. Bullet points will also help with brevity. Remember that you are telling a brief story and if people want to know more of the detail they can come to you for that. Once you have completed your story template, send it to us at hpft.qualityimprovement@nhs.net and we will ensure it is accessible through the website and other channels. We can’t wait to hear from you and start sharing the work you are doing, taking us from good to great.

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Improvement Project Name:

Project Lead:

Project Sponsor:

Describe the aim of the improvement project (a stretching, measurable, timebound, achievable service user / carer

focussed description of how we want to be at that point in the future)

Describe the problem / current condition (what currently happens? What is the impact, how often, to whom, where,

when?)

Measures (what will we measure that will demonstrate improvement towards the

aim?)

Measure Baseline

Improvement ‘project team’ (who do we need involved? who is going to

‘do’ the work to achieve the aim?)

What are the main themes / topics / factors that impact on the aim? (what

are the areas that we will have to work on to achieve our aim? These will become our primary and secondary drivers of change)

Ideas for change (what are the ideas, opportunities etc. that might help to take us towards our aim?)

Idea / opportunity Author Idea / opportunity Author

What other support might we need? (what, who, when and how will we

secure it?)

When will we ‘do’ the work? (when will we perform analysis of the

obstacles, develop solutions, study results of PDSA cycles etc.)

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PDSA CYCLES DO

(Capture thoughts on what happened when we ‘did it’)

STUDY (What did we observe?)

ACT (What did we learn, what are we going to do

next?)

Improvement Area:

Project Lead:

Plan: (what is our working hypothesis about this change idea? How do we think it will help us to achieve our aim? What will we be measuring to to see if we are moving forward? What

are the things we need to do, by when and who will do them before we can test the idea?)

Measure(s):

Task Who is doing

it Due by date?

Complete? Date

completed

Current change idea being worked on: