leading continuous improvement - nhsggc

Leading Continuous

Improvement

Why do we need continuous improvement in healthcare?

Instances of poor safety and quality,

Capacity constraints and queues,

Cash-flow crises,

Low levels of efficiency

Low levels of staff motivation

The above are not confined to the NHS

Other reasons?

Aim of the Programme

To provide training and real-life practice to

successfully implement an Improvement

Project.

To create a set of individuals who can

think about continuous improvement, ask

the right question at the right time and

then select the right tool to use in a

particular situation.

From : To :

Fire fighting symptoms Eliminating Root Causes

Ad Hoc improvement Controlled and disciplined approach

Unclear Priorities Data Driven Priorities

Function/Dept Focus Customer/Patient Focus

What side are you on ?

Lean

& Six

Sigma

PDSA

Project Management

Management of

Change

DMAIC

Focused Approach

for

Continuous

Improvement

Change Behaviour

Experience Results

Change Culture

Define, develop and

communicate the Quality

Improvement Approach.

Start using the good

behaviour this method

defines in key initiatives.

We can change our

behaviour quickly.

Communicate the results from

the Changes in Behaviour

resulting in the use of the

Quality Improvement

approach. Good results from

Quick wins can help

confidence and help the

rollout of good behaviour.

Longer term Culture

changes come from the

proliferation of good

practices and behaviours

throughout the company

building a Quality

approach into day to day

life.

How do we create a Culture focused on the Patient and Quality ?

Not Overnight but it starts here

Define Measure Analyse Improve Control

Create a

shared

need

Leading

Change

Set up for

success

Overcoming

resistance

Mobilising

Commitment

Making

Change

last

Process Change

People Change

CURRENT STATE TRANSITION STATE IMPROVED STATE

Approach

A single approach combining process and people change tools to help you through the transition required for

successful results.


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

Action Plan

Critical Customer Requirements

Process Maps

Quick Win Opportunities

Prepared Team

Activities Tools Outcomes

Team PID / Charter

Process Maps

Stakeholder Analysis

In / Out Scope Diagram

Roles & Responsibilities

Project management

Project PID

Defines (and narrows) the project’s focus

Clarify the results being sought

Confirms value to the customer & organisation

Establish boundaries & resources for the team

Communicate goals and plans

What would happen without a PID?

Project PID

1. What are we trying to accomplish? (The aims

statement)

2. How will we know a change has made an

improvement? (What does success look like? The

measures of success)

3. What steps can we take to get there? (The plan

and tests you can attempt.)

Answers the 3 Critical Questions;

In & Out of the Frame Scoping

Draw large “picture frame” on flip-chart. Use this to help team

identify what falls inside and outside the picture of their

project. This may be locations, roles, products, lines,

customers etc.

11

in in

in in

in

out

out

out

Setting up for Success

Sponsor

Team Leader/Change Agent

Team Members

Stakeholder

Role of the Sponsor

Before the project Agrees, authorises and scopes the project Helps complete the PID Identifies and releases resources needed Selects team leader/helps recruit team members

During the project Meets regularly with team leader to review progress When necessary assists with issues and links to the organisation

After the project Ensures changes made by the team are monitored, Implements changes the team is not authorised to make Recommends implementation in other areas

Being an Effective Leader of Change

Strong technical/functional knowledge

Strong change management skills

Strong interpersonal and team skills

Commitment and drive

Political awareness and influencing skills

Trust and credibility with the sponsor and stakeholders

Team Members

Accepts and works towards the goal of the team

Considers the project team to be real work and not an intrusion on their real jobs

Attends and fully participates in meetings

Fulfils responsibilities and assigned tasks outside meetings

Listens to others and be open to their ideas

Are you setup for success?

Who is a stakeholder?

A person who has

a vested interest

in the outcome of

your project

Change

Targets

Change

Leaders

Change

Advocates

The people who will need to change

The people with the authority and

position to make the change happen

The people who can influence

the change

Change

Agents

The people who will help

implement the change

Stakeholders

Who are the stakeholders?


To identify those individuals and groups who have a vested interest in the project

To anticipate forces which will act upon the project

To agree upon pro-active measures to make sure all major "forces" are supporting the project

To use the analysis during the project to keep the stakeholders in the picture

Major Stakeholders Criteria

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

Stakeholder Analysis Template

Sta

ke

ho

lde

r

Inte

res

t

Invo

lvem

en

t

Influ

en

ce

Co

nc

ern

s

Role/Name of

Stakeholder

Enter

Current

Value

Enter

Current

Value

Enter

Current

Value

Indicate if the

stakeholder scores

need to change to

assist your project

21


High interest + high involvement + low influence Do we need to increase their influence? High interest + low involvement Is it useful to increase their involvement? If yes, how? If yes, is their influence high enough? Low interest + high involvement Do we increase interest or reduce involvement? What if influence is high and involvement remains as it is?


Low interest + low involvement + high influence How do we make sure that influence is used in a proper and positive way? High negative interest + high influence Can we make interest more positive and how? Do we need to reduce the influence and how? High negative interest + low influence How can we prevent that their influence becomes higher? Low negative interest + high influence How can we prevent that interest becomes even more negative?

Identifying Problem Areas

Stakeholder Engagement


Communication Strategy

Engagement Strategy

Continuous Assessment

Communication Plan

Project Title:Status Key :

Blue = Action agreed by team as Completed

Communications Plan Amber = Action Pending - Not started yet, requires attention.

Green = Action in Progress and on Plan.

Red = Roadblock or Showstopper , requires immediate escalation.

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

1

Give the Comms a title easy to

understand and refer to that

distinguishes it from other

comms.

Who are the

primiary

recipients of the

comms

What are the key objectives

of the comms, prioritise. Too

many will mean a long

complex comms.

Define the key messages

people need to appreciate

and take from the comms.

Which medium is

to be used? Not

always email;

posters, leaflets in

canteen, face to

face, presentations

etc..

The person

responsible

for delivery.

Timing as

per your

plan.

Site,

region,

floor,

group,

event

location

etc..

Summary of the content

sourcesand structure.

As per

the RAG

status

above.

Latest updates on progress.

2

3

24

Communication Strategy


When are you motivated to participate in a project?

What does the project leader or others have to do/not

do?

When are you absolutely not motivated to participate in

a project?

What did the project leader or others do/not do?

Your examples?

Stakeholders will support the project

Commitment to

change

To be rewarded

To know what it’s all about

(be informed)

To find it meaningful

To be asked to play a role in it (participation)

To feel supported in my role

To see results and progress

1

2

3 4

5

6 • positive pressure • recognition

• information • feedback

• information • resources • coaching • learn from mistakes

• “we need your skills”

• own input • linked to goals

• information • training • knowledge

Strategies

• Information

• Presentation

• Informal

gatherings

• Challenge/

validation

sessions

• Redesign

workshop

• Interviews

• Give responsibility

to inform and

consult others

• Joint planning and

decision-making

• Involve in testing,

validation

• Roll out reviews

Key Mechanisms

Main Purpose

CONSULT COLLABORATE INFORM

Strategies & Focus

Communication

Strategies

Engagement

Strategies

Enrolling Stakeholders

Inform

Consult

Collaborate

What strategies can you use to engage

your stakeholders?

Add them to your Stakeholder Analysis.

Stakeholders Summary

You perform a stakeholder analysis to be able to

determine your communication and engagement

strategies towards your stakeholder

Commitment grows through dialogue (communication

and listening), not out of one-way communication

Enrolling stakeholders does not mean you need to

achieve consensus

You offer an opportunity to join the journey once the

direction is set

Early in the process, start building a critical mass of

people who can move the change through the

organisation

Stakeholder Summary There is something like ‘involving stakeholders too much

or too early’

Thinking about engagement is something you do

immediately when starting up the project – however this

does not mean that you involve everybody immediately

31

Understanding your Process through Mapping

Why use it

When to use it

Symbols used in it

Steps to create it

Examples

Outcomes

Why Processing Mapping

The purpose of Process Maps is to:

– Identify the complexity of the process

– Communicate the focus for problem solving

– Provide a big picture context to all those involved

– Consensus

32

Process Maps are living documents and must be

changed as the process is changed

– They represent what is currently happening, not what

you think is happening or what you would like to happen.

– They should be created with the people who are closest

to the process, the “Process Experts”.

1. When Defining the current process problem

2. When Analysing a process problem

3. When Implementing your process

improvement/change.

4. When Sustaining your new way of working.

When to use a Process Map?

33

Process Map Symbols Standard symbols for process mapping (available in Microsoft

Office™ PowerPoint & Visio™)

A RECTANGLE indicates

an activity/task.

Statements within the

rectangle should begin

with a verb A DIAMOND signifies a

decision point. Only two

paths emerge from a

decision point: No and Yes,

Pass or Fail etc..

An ELLIPSE shows the

start and end of the

process

An ARROW shows the

connection and

direction of flow

Step 1 Start Check

? Step 2 Step 3 End

Pass

Fail

Process Map

34

1. Identify

Process

needing

Mapped

Available

?

2. Identify

Process

Experts

3. Get

everyone

in a room

4. Agree

Start &

End points

first

Re-arrange

until all

available

No

Yes

Process Mapping Steps

5. Capture

all steps &

decisions.

(Warts & All)

35

Process Mapping Examples Blood Donor Flowchart example

2. Donor is

interviewe

d and fills

out form

1.

Donor

Arrives

4.

Veins

OK?

3. Donor’s

veins are

checked in

waiting

room

5.

Doctor’s

evaluation

10. Blood

drawn

from

Donor. No Yes

Donor

Rejected

6.

Health

OK?

Donor

Rejected No

7. Donor

goes to

Donor

room

Yes

8.

Phlebotomist

checks veins

9.

Veins

OK?

No

Yes

Donor

Rejected

36

Process Mapping Examples Blood Donor Flowchart example

2. Donor

interview

and fills

out form

1.

Donor

Arrives

4.

Veins

OK?

3. Donor’s

veins are

checked in

waiting

room

5.

Doctor’s

evaluation

10. Blood

drawn

from

Donor. No Yes

Donor

Rejected

6.

Health

OK?

Donor

Rejected No

7. Donor

goes to

Donor

room

Yes

8.

Phlebotomist

checks veins

9.

Veins

OK?

No

Yes

Donor

Rejected

DUPLICATION

37

Process Mapping Examples

Blood Donor “Improved” Process

1. Donor

Arrives

2. Donor is

interviewed

and fills

out form

3. Donor’s

evaluation

occurs &

phlebotomist

checks veins

5. Donor

goes to

donor

room

4. Health

& Veins ok? Yes No

6. Blood

Drawn from

the donor

38

Donor

Rejected

Patient Receives

Appointment

Patient seen at home

Is Patient Housebound ?

Patient attends

Clinic

Patient receives 1st treatment

Patient Discharged

Outcome Details

Recorded

Is Care Package

prescribed ?

Is Care Package

Long Term ?

Patient given return

appointment

Short Term Care

Patient Transferred to

Podiatry Assistant Clinic

Long Term Care

Patient given return

appointment

Long term care

process

Details sent back to referral

source

“Podiatry Patient Treatment Flowchart”

Yes

Yes

Yes

No

No

No

Podiatry Example of a Patient Flowchart:

Process Mapping Example Flowchart

Process Mapping Swimlane Process map

When multiple departments or functional groups are involved in a complex

process it is often useful to use Cross Functional Process Maps or Swim

Lane Map. This clearly shows ownership.

40

Process Mapping Examples C

linic

C

all C

en

tre

P

od

iatr

ist

Pat

ien

t G

P

2. Receive Call or

Referral

9. Treat Patient

3. Register Patient Details

on System

4. Give / Send Patient

Appointment

5. Appointment card / Letter

6. Send Details to Podiatry

Clinic

7. Receive Patient Details

8. Patient Appointment

10. Discharge Patient & Inform GP

12. GP Informed

of outcome

“Referral to Discharged” Foot care Process

1.Patient Referral

13. Update Patient Records

11. Update System Records

Swim lane Process Flowchart

41

Process Mapping

Process Mapping Outcomes

1. Whole team understanding improved

2. Whole team communication improved

3. Teamwork & Customer focus

4. Quick wins identified

5. Develop a plan for improvement

6. Use the map for Analysis using

techniques in Analyse stage.

42

1. Project Plan / Gantt chart

2. Action Tracker

Project Management basics

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

Project Title :

Project Plan updated on: 25-Aug

Tasks Start End Duration Owner

Phase 1 21-Jul-11 5-Sep-11 33

18-J

ul19

-Jul

20-J

ul21

-Jul

22-J

ul23

-Jul

24-J

ul25

-Jul

26-J

ul27

-Jul

28-J

ul29

-Jul

30-J

ul31

-Jul

01-A

ug02

-Aug

03-A

ug04

-Aug

05-A

ug06

-Aug

07-A

ug

1 Kick Off Meeting 21-Jul 22-Jul 2 Colin

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

3 Stakeholder Analysis 25-Jul 05-Aug 10 Colin

4 Data Collection Preparation 28-Jul 29-Jul 2 Colin

5 Live Data Collection 01-Aug 31-Aug 23 HR Admin

6 Process review kick off 29-Jul 29-Jul 1 Colin & Michelle

7 Priority Process Analysis & Gap id 01-Aug 31-Aug 23 Colin

8 KPI & Scorecard Development 01-Aug 31-Aug 23 Colin

9 Workload Prioritisation Session 30-Aug 30-Aug 1 Colin

12 Phase 1 Review 31-Aug 31-Aug 1 Jennifer

13 0

14 0

Today

3. Overall Project Update

Summary page

PM Tools used in the cycle:

DEFINE Stage Checklist

Task Who Status

1. Objectives 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

Pitfalls

Project charter developed by one person

Other team members don’t buy in

Scope too big! Don’t boil the ocean!

Goals not Customer focused

Compelling reason for change unclear

No tangible benefits identified

Sponsor not involved

Stakeholder missed, revealed later when too late


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 & Goals

Shared vision


Measures

Data collection

Balanced Scorecard


Plenty of data but no information!

Data = Facts

Information = Answers to questions

‘Information’ includes ‘data’

‘Data’ does not necessarily include ‘information’

Generating Information

Questions

Communication Data

Analysis

Formulate precisely the questions to ask

Collect data and facts

Analyse the data to determine the factual answer to the

question

Present the data the data in a way that clearly communicates

the answer to the question

How is data currently collected? Check sheet - Form has been

designed so that results can be readily

interpreted from the form itself

Data sheet – data is recorded in tabular format

– additional processing is required.

Checklist – Contain items which are important

or relevant to a specific issue or situation.

General purpose is for guiding operations rather

than collecting data.

Any examples?

Planning for data collection

1. What questions do we need to answer?

2. Where in the process can we get this data?

3. Who in the process will give us this data?

4. How can we collect this data from these people with minimum effort and chance of error?

Why Display Data ?

A Visual display of data is the best way

to understand what the data is telling you.

Benefits:

Graphical displays easier & quicker to interpret.

Trends and important relationships can be identified.

Reasonably quick to prepare.

Provides a single easy to understand view of performance to all.

Displaying data

Tool : What it does : When to use it :

Run Chart Show how a chosen measurable varies with respect to time.

Allows trend and pattern analysis.

When Gathering data in Stages D & M. When displaying Metrics performance after Improvement activities. When ensuring continuous improvement and sustainability in Control stage.

Pareto Enables you to identify the most significant category within your data.

Focuses your team on what’s important.

When Analysing data.

When Selecting the major problem areas from multiple areas.

Displaying clearly the 20% of causes contributing to 80% of the problem.

Bar Chart Allows you to compare several

items at the same point in time

and show the frequency

distribution across several items.

Gathering & Analysing data. When assessing the capability of a process. To answer if the process meets the customer requirements.

Issues Category Pareto

0

50

100

150

200

250

300

350

400

450

500

HES

Installatio

n

Content Sat

Func

tiona

lity

Patch

Install

Inte

rnet on

TVMed

ia

Inte

rnet Lap

top

choo

se one

Oth

ers

1.85

beta

ver

PO car

dPM

SApp

1st lev

el

Que

stion

Double Billi

ng

Wro

ng O

p

Networ

kHU

B

Demo Sys

tem

Category

Num

ber

of e

vent

s

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Cum

mul

ativ

e %

Category Qty

Cummulative %

0

20

40

60

80

100

120

1st

Qtr

2nd

Qtr

3rd

Qtr

4th

Qtr

CPU1

CPU17

Issue R eso lu tion D is tribu tion

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 6 0

1 8 0

00 - 8

8 - 1

6

16 - 2

4

24 - 3

2

32 - 4

0

40 - 4

8

48 - 5

6

56 - 6

4

64 - 7

2

72 - 8

0

80 - 8

8

88 - 9

6

96 - 1

04

104 - 1

12

112 - 1

20

120 +

H o u rs

Qty

of

Iss

ue

s r

es

olv

ed

Q ty o f Issue s

Displaying data

Hints & Tips for Stakeholder

Interviews

Non-threatening

Explain purpose of interview and project – what will be done with the information received

Explain interview structure – roles, activities, you & others

Put interviewee at ease

Open and high level questions to start

More focused as go on to get to the details

Summarise and check understanding – reflective listening

Ask about:

Issues

Possible solutions

Positive things as well as negative

Their role in the change project

Communication preferences

Potential other stakeholders

Is there anything else? (ask at end of interview)

Explain next steps

Thank you

Stakeholder Interview Example

Effective Measures

Related to customer/patient requirements

Practical to implement

Easy to understand

Able to drive desired behaviour

Developed with input & consensus from

work groups

S

U

P

P

L

I

E

R

S

C

U

S

T

O

M

E

R

S

FINANCIAL

PEOPLE

PROCESS & OPERATIONAL

PERFORMANCE

PRODUCT / SERVICE QUALITY

A Balanced set of Measures

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. Define Goals for measures

6. Gather data from stakeholders & understand themes

Pitfalls

Too much data

All measures are short term focussed

Lack of (the right) detail

Measures can drive the wrong performance

Focus on financials rather than balanced view

across the business

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


8 wastes in any process

5 whys

Cause & effect fishbone

Prioritisation VAP

Measure Analyse Improve Control

60

Identifying Process Wastes

What is Valuable or Wasteful

Categories of Waste

Exercise

Outcomes

Value Added Activity Any activity that satisfies customer/patient requirements

Unnecessary Waste Any activity that does not support customer/patient needs in any way.

Necessary Waste/Value Enabling Supports the delivery of value but is not directly value add.

It’s value if your customer/patient experiences hands on treatment/help/support/assistance improving their situation or something they will pay for. So activities that add no value can be wasteful.

Protect & Increase

What’s Valuable or Wasteful?

61

Attacking Waste !!

Waste > 90%

Value time < 10%

The Average Process :

Waste Reduction but the Value

remains.

Waste impacts all Processes

Cycle Time

Before

Step 1 Start Check

? Step 2 Step 3 End

Pass

Fail

All processes have their own proportions of Value and Wastes. All processes can benefit from Waste reduction.

After

63

1. TRANSPORT The unnecessary movement of a materials / information from one operation to the next. Moving patients to tests, patients having to attend different depts.

2. INVENTORY Build up, queue or backlog of Work-In-Process (WIP) at any particular step in the process. Sometimes an indication of a bottleneck in the process. Patients queuing for clinic, lab samples for testing, stocks on wards, dictation awaiting typing.

3. MOVEMENT / MOTION Motion that requires extra steps to accommodate an inefficient work layout. Typically hunting and searching for. Working across multiple sites, storage of consumables in disparate places

4. WAITING Periods of inactivity in a downstream process due to the late delivery of an upstream process, lack of information or instruction, etc. Inpatients waiting in ED, patients waiting for discharge, physicians waiting for test results

The 8 Wastes in any Process

64

5. OVER PROCESSING Extra work / Duplication - Rework, reprocessing, special handling & storage. Multiple bed moves, re-testing, multiple assessments.

6. OVER PRODUCTION Doing more than required. Producing ahead of demand or a process that continues after the customer requirement has been met. . Excessive reporting, unnecessary tests, Irrelevant information sent out.

7. DEFECTS Processing of any product or service that does not meet customer requirements. Needle stick injury, missing patient information, wrong information communicated

8. STAFF UNDERUTILISATION a) Using wrong staff for tasks. Mismatching skills & tasks. Medics transporting patients, not fully using skill mix of staff.

b) Untapped Human Potential (Hidden Value). Not involving staff in changes.

The 8 Wastes in any Process

65

66

Identifying Process Wastes

1. Get the process experts together

to review wastes in the process

map from Video 1.Define stage.

2. Conduct a “waste walk” through

the process with process experts

identifying waste and possible

solutions.

Layout (Distance)

Long setup time

Incapable processes

Poor maintenance

Poor/Inconsistent work

methods

Undefined roles &

responsibilities

Inadequate training

Product/Service design

Ineffective planning &

scheduling

Equipment design and

selection

Poor workplace

organization

Supplier quality / reliability

Many More . . .

Causes of Waste

Identifying Waste Outcomes

1. Team consensus on key wastes in your

process

2. Ideas & opportunities to reduce waste

3. Physical & electronic workplaces organised

to remove waste

4. Ready to identify why those wastes occur in

your process.

68

69

Discovering the Root Causes of Process Wastes

The 5 Why’s

Cause & Effect Diagram

Outcomes

What is it ?

Basically asking Why? A problem occurred at least 5 times.

A simple method of digging down to the root cause of a problem.

It cuts through the symptoms by not accepting the first explanation

of a cause.

Challenges beliefs and assumptions

How to use it :

In a team with the process experts present in order to validate the

root causes. Only factual answers accepted.

Do not accept answers such as: “It’s always been that way” or

“Because I said so” or favourite theories / urban myths.

You have reached the root cause when you have asked why

enough times that there will be no lower level explanation.

The 5 Why’s

Why?

Why?

Why?

5 WHY’s – How to

1. Gather the experts in the Process

2. Select one of your identified WASTES in your process.

3. On the top post it describe the Waste

4. Conduct 5 Why’s on “Why the Waste occurred.

5. Build up the logic chain until root cause reached.

Why?

Why?

Porters busy

transferring Blood

Tests manually

Patients waiting

for transfer

72

5 WHY’s Example

No Porters

available

Jnr Docs not

using Automated

Blood test System

Info not in their

training

Jnr Docs

never told

Why?

Why?

Why?

Why?

Why?

ROOT CAUSE

WASTE

73

5 WHY’s

Why?

Why?

Why?

Why? Why?

ROOT

CAUSE 1

WASTE

Why?

ROOT

CAUSE 2

If your Why chain splits this means multiple Root Causes and therefore multiple solutions required to eliminate the waste.

Now use the 5 Why’s tool within a Cause & Effect Diagram.

Cause & Effect The Cause & Effect Diagram helps to:

Organise the knowledge of the group

Graphically display this knowledge

A process which allows teams to identify and display all possible causes related to a problem

Allows teams to focus on one cause at a time

Main

Cause

Categories

Issue or

Problem

Cause & Effect Diagram – How to

Patients waiting on

transfer

Process

People Systems

Equipment

1. Draw a box

3. Draw an arrow pointing to the box

2. Write the problem description inside the box

4. Add the names of the main categories

5. Add sub-causes

Why?

Why?

Why?

Why?

Why?

6. Conduct 5 why’s on each sub cause.

7. Look for Common Root Causes

Porters

Nurses

Outcomes

1. Team consensus on root causes of process

wastes and issues.

2. Common Root Causes identified

3. Possible Solutions identified

4. Ready to implement those solutions to

reduce your process wastes and improve

performance.

5. Ready to use the techniques in the Improve

stage.

76

B

C

High

Low

Low High

D

Benefit (Increased Revenue,

Decreased Costs

or Cycle Times)

Effort (Resources: Time,

Money, People)

A

Zones:

A – Just Do It!

B – Plan to do?

C, D – Later…

Prioritising Opportunities Value Analysis Prioritisation Tool (VAP)

Be practical – scope what is achievable

1 2

3

4 5

6 7

8

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

Pitfalls

Assume the solutions without validation

Ignore the data

Process experts not involved

Not digging deep enough for the root causes

Treating the symptoms only

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


PDSA cycle

5S’s

Change Curve

Change Formula

Measure Improve Control Analyse

81

Making Improvements with the Plan,Do,Study,Act Model (PDSA)

1. What is it & why use it?

2. How to use it?

3. Expected Outcomes

PDSA Cycle – What & Why?

Test out change ideas on a

small scale.

Try something & assess its

impact before implementing it

widely.

Actions are clearly based on

evidence gained during small

scale tests.

It involves less Risk, less time

and less money.

Minimises resistance as people

have been involved and seen it

work on a smaller scale.

Avoids impulse actions.

Study

Act

Do

Plan

82

PDSA Cycle – What & Why?

Don’t expect to get it

perfect first time.

Try multiple small changes

Learn each cycle about

what works better

Use your learning as

evidence of the best

solution

Implement with confidence

and maximum benefit.

83

PDSA cycles form part of a framework for implementing changes leading

to improvement. The framework includes three key questions which need

to be answered before the PDSA cycle begins:

PDSA Cycle – How to.

1. What are we trying to accomplish?

(The aims statement)

2. How will we know if the change is an improvement?

(The measures of success.)

3. What changes can we make that will result in

improvement?

(The tests to try.)

Study

Act

Do

Plan

84

The PDSA Cycle - Plan

1. State objective of the cycle

2. Make predictions

3. Develop a plan to carry out

the cycle

4. Develop a plan to gather

data.

Plan

85

The PDSA Cycle - Do

1. Carry out the test as

planned

2. Document problems and

unexpected observations

3. Begin analysis of the data.

Do

86

The PDSA Cycle - Study

1. Complete analysis of the

data

2. Compare data to predictions

3. Summarize what was

learned. Study

87

The PDSA Cycle - Act

1. Did the test meet your

aims?

2. If yes then implement.

3. If no then what changes

are to be made?

4. What will be the next

cycle?

Act

Action was rationally based on what was learned 88

Outcomes

1. Tried & Tested Improvements

2. Evidence of Improvement

3. Convinced staff

4. A Successful Change.

89

What is 5S ?

A way to see and eliminate waste in your

workplace through better organisation.

Used to ensure that the workplace contains only

what is needed, when it is needed and where it

is needed.

At a glance, any abnormalities can be detected.

Minimal time is spent on non-value added

activities.

A foundation block for continuous improvement

90

What 5S does… Used to ensure that the workplace contains

only what is needed, when it is needed and

where it is needed.

Workplace organization

At a glance, any abnormalities can be

detected.

Minimal time is spent on non-value added

activities.

A critical part of continuous improvement

process

A way to see and eliminate waste.

SA

FE

TY

– IN

EV

ER

YT

HIN

G

Eliminate all unnecessary and seldom used items & equipment from the workplace. 1. Sort

Organise the way that necessary items are kept, making it easier to find, use and return to the proper location.

2. Set in Order

Maintain a Clean and Tidy work area for the already sorted and set-in-order items 3. Shine

Establish Standards to ensure sort, set-in-order, and shine are consistently followed by all users all the time.

4. Standardise

Create an environment to maintain and improve the first Four S’s and make it a natural everyday way of working.

5. Sustain

“A place for everything and everything in its place” 5S

Stop slips & trips, reduce wasted time searching, improve

efficiency and productivity, better quality, better environment to

work in, feel pride in the work place, impress your customers. 92

5S is a tool for Waste

Elimination

Before After

Office Example

What does yours look like?

After > No clutter – ease of access Only necessary items stored &

clearly labelled Items easily accessible with

minimum movement More space & time to do the job Clean and tidy area

<Before X Corridors cluttered impeding access X Unnecessary equipment stored in corridors X Undefined layout of space X Searching for equipment

5S Examples

95

After > Only necessary items stored &

clearly labelled Items easily accessible with

minimum movement More space & time to do the job Clean and tidy area Item maps visible

<Before X Storage disorganised with unnecessary

items mixed with the vital items X Unclear labelling and layout, floor being

used impeding access. X Searching for items time consuming X Lack of space because its not used

correctly

5S Examples

96

After > Space cleared for utilisation as

training/study room Only necessary equipment in

place for training & study. Access controlled Library area designated Improved staff morale

<Before X No staff training/study room available X Rooms used as dumping grounds X Space available but not utilised X Staff demoralisation

5S Examples

97

Remove anything which isn’t needed

for current work

Key: Leave only the bare essentials

Ask Yourself:

–What do we need?

–What do we not need?

–What can we remove?

–What can we throw away?

–What can I reorganize?

Distinguish the necessary

from the Unnecessary

Step 1 - Sort

Arrange items so they are:

easy to find

easy to use

easy to put away

5S Map

Visual controls

Signboards

Floor painting and taping

Outlining

Colour coding

Labelling

Methods:

A Place for Everything and Everything in its Place

Step 2 – Set in Order (Simplify)

Housekeeping

Inspection

5 minute shine

Everything is ready to use

5S Schedule

Five minute shine every day

Cleaning and inspection checklists

Checklist for Needed Maintenance

Methods

Clean and Ready to Use As Is

Step 3 – Shine

Standard Systems need to be put in place:

To readily identify abnormal conditions

To Prevent Setbacks in the First Three Stages

of 5 S

To control what happens, when it happens and

how it happens

To Focus on prevention so it won’t happen

again – SOPs , training, audits etc..

o Can I tell are there too many, too few?

o Can I easily recognize that an item is missing?

o Can I easily recognize an undesignated item?

Step 4 - Standardise

Awareness & focus

Rewards & recognition

Satisfaction & enthusiasm

5S Posters

5S Photo Exhibits

and Storyboards

5S Newsletters

Tools: 5S Pocket Manuals

5S Department Tours

5S every day

Self Discipline and Motivation

Step 5 - Sustain

Management at all levels must be committed to establishing and maintaining the 5S process.

Management must lead by example Walk the Talk !

LEADERSHIP RESPONSIBILITY

“We are what we repeatedly do: Excellence then, is not an act, but a habit”

5. Sustain

5S Guide on share drive

MS Word

Desired State

Current State

The Changing Environment

Transition State

Low stability Perceived high levels of inconsistency in the environment High emotional stress Control becomes a major issue Past patterns of behaviour become highly valued Conflict increases

Unfreezing occurs

Refreezing occurs

Leading Change

Unfreezing Techniques

Burning platform

Challenge

Evidence

Restructuring

Training & education

Visioning

Refreezing Techniques

Burning Bridges

Evidence Stream

Institutionalisation

Reward Alignment

Stages and Speed of Change

People adapt to change in 3 levels

Physical This is the time it takes for a person to

comply with the behavioral requirement of the change. This is the fastest acceptance of change.

Intellectual This is the time it takes for a person to comprehend why a change has taken place or is necessary.

Emotional This is the time it takes for a person to feel comfortable with the results of the change, the new state.

Change Curve

Stage 1

Stage 2

Stage 3

Stage 4

Recognising and Supporting

Key Reactions to Change

Shock/Denial/Anger Resistance

Exploration Acceptance

Divide categories among groups and go to exercise

Managing Change Step One : Brainstorm what behaviours you have seen

or would be demonstrated during this reaction on the

change curve

Step Two : If faced with someone demonstrating these

behaviours what would / could you do as an individual to

move the employee forward

Step Three : Go to the other completed flipcharts – do

you agree with the responses ? Add any additional input

as required.

Return to your original

flipchart.

Supporting people through the Change Curve

Reaction

Employee & Team Needs

Caution

Provide facts and continually articulate the reality of change. Create a safe place to vent anger. Recognize the feelings and help get the emotions out Help focus the individual on the priorities

Shock, Denial, Anger

Clues Expressed anger, constant complaining, withdrawing and refusing to accept changes

Avoid taking personal responsibility for the individual’s reactions


Reaction


Caution

Continue to articulate the reality of the change Listen actively Assist the person to reconcile personal frame of reference to the new reality

Resistance

Clues

Performance drops, errors, refusing assignments related to the change, negative, complaining, withdrawing

Understand that you will have questions as well Do not speculate or ‘make-up’ reality as you go along


Reaction


Caution

Provide resources, time and support to help individuals try new and realistic alternatives Give appropriate recognition, appreciation and feedback on new ideas

Exploration

Clues Ready to change, confused about what to do, loss of confidence in skills and asking others what to do

Be sure to discuss realistic options for the future Do not mistake ‘searching’ for liking the change


Reaction


Caution

Reward the team and individual for focusing on implementing the change. Encourage risk taking that supports change. Stay involved, look ahead

Acceptance

Clues Initiates problem solving on his/her own. Positive about what needs to happen, suggests ideas, supports the change

Be sure to discuss realistic options for the future

Gleicher’s Change Formula Change will occur when:-

D x V x F > R

D = dissatisfaction with status quo

V = desirable vision of future

F = first small practical steps towards the vision

R = resistance to change

Dissatisfaction

It is plain we cannot carry on as we are

The external environment makes it inevitable that we should change

It is evident from our performance in recent months that we should change

The pace of change in our environment has rather left us standing

Our systems have clearly outlasted their useful lives

D x V x F > R

Vision

All staff have bought into the vision /goal of the

change

The aspirations expressed in our change vision

are seen as achievable, if challenging

Staff can make a clear connection between our

change goals and their own jobs

D x V x F > R

First Steps

The change process is clear

The changes required in our systems and

processes have been well planned

High quality, timely communications has been a

key aspect of the change process to date

The timescale of change is demanding but

achievable

D x V x F > R

Resistance/Costs

There is a significant risk that the staff/patients will experience difficulties during this change

Major investment will be required

A number of people will have to make major changes in their approach

A number of staff will need to be retrained

D x V x F > R

Use the change equation to analyse a change

that you are;

currently dealing with or have experienced in

the past

D x V x F > R

Details/Actions What has been done?

What needs to be done

Dissatisfaction with status quo

Clarifying and communicating the future vision

Identifying and communicating the first steps/plan

What will be the impact of the change? What resistance do you anticipate?

Applying Gleicher’s Change Formula D x V x F > R

35

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

Pitfalls

Poorly communicated changes

Big bang approach instead of smaller pilots

Failed to convince others of need for change

Lack of evidence of improvement

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


Sustain/Control plan

Training Plan

Communications

Stakeholder Mgmt.

Role & Responsibility RACI matrix

Document plan

Lessons Learned

Closure Report

Measure Control Analyse Improve

Control

What steps can you take to control and ensure the sustainability of your project?

Use the Control Plan.

Control 1. Training What training is required for staff to implement new or revised processes and procedures? Think about both existing and new starts, Who will write the training material? What will the training comprise

2. Communications Review your Comms plan from the Define stage as there may be new requirements at this stage.

3. Stakeholders Revise your Stakeholder Analysis at this stage also as new Stakeholders may be involved since the changes have been implemented and their impact has spread.

4. New Roles & Responsibilities Carefully define the new Roles & Responsibilities within the new or improved process. Clarity at this stage is critical to the process being sustained. Use the RACI Chart to Identify who will be Accountable for the process tasks being carried out, who is Responsible for performing the tasks, who will need to be Consulted and when and also who will need to be informed at what point within the new process.

Control 5. Documentation Documentation is necessary to ensure that what has been learned from the project is shared and institutionalized: Used to aid implementation of solutions, Used for on-going training. Documents need to be kept current to be useful with help from the Documentation Plan.

6. Align Policies & Recognition Allowing people to change their behaviours permanently means implementing goals, measures, job descriptions, incentives etc.. Which align with the new process approach and will motivate them to sustain the changes & benefits.

7. Lessons learned Lessons Learned can be started from the beginning of the project and maintained throughout making this step at the end a summarising activity.

The main question to be addressed here is “What could we have done better and how?” using the Lessons learned matrix.

8. Capture, Document & share Success Single page overview of the improvement project to Share Learning's, Document Case Study, Communicate Success, Evidence of Improvement & Convince others to try

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

8. Complete Summary report & Lessons Learned

Pitfalls:

Teams can potentially derail when they:

Fail to engage in leadership behaviors necessary for change.

Are transferred too quickly before change has occurred.

Try to do it all alone without involving others.

Shift to other goals before completing the change. (“Flavour of the Month”)

Fail to establish and clarify the key change roles.

Allow the change process to be diluted by other priorities.

Fail to integrate the change into the “real work” of the business.


Create a

shared

need

Leading

Change

Set up for

success

Overcoming

resistance

Mobilising

Commitment

Making

Change

last

Process Change

People Change

CURRENT STATE TRANSITION STATE IMPROVED STATE

1. Stakeholder

Analysis & Q’s

2. SIPOC

3. Flowcharts

4. Gantt Chart

5. Actions tracker

TEM

PLA

TES

6. Comms Plan

7. Run chart

8. Pareto chart

9. Bar chart

10. 8 Wastes

11. Fishbone

12. PDSA

13. 5S Audit

14. Progress

Update

15. Gleicher

formula

16. Control Plan

17. Training Plan

18. Docs Plan

19. RACI Chart

20. Lessons

Learned

21. Closure Report

33