learning session 2 · 2018-07-10 · workbook p28 . last session global aim 1 2 3 5 p assessment...
TRANSCRIPT
Learning Session 2
MCA Ward Collaborative
Steve
9.00 – 9.15
Welcome Back & Agenda
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Workbook p28
Last Session Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
P
a
r
t
i
c
i
p
a
n
t
P
a
r
t
i
c
i
p
a
n
t
P
a
r
t
i
c
i
p
a
n
t
L
e
a
d
e
r
F
a
c
i
l
i
t
a
t
o
r
R
e
c
o
r
d
e
r
T
i
m
e
-
k
e
e
p
e
r
P
a
r
t
i
c
i
p
a
n
t
Rol
es
Rot
ate
Participant Participant
Participant
Leader
Facilitator
Recorder
Time -
keeper
Participant
Roles
Rotate
5P Assessment
Last Session Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Purpose
5 Ps
Purpose
5 Ps
P
a
r
t
i
c
i
p
a
n
t
P
a
r
t
i
c
i
p
a
n
t
P
a
r
t
i
c
i
p
a
n
t
L
e
a
d
e
r
F
a
c
i
l
i
t
a
t
o
r
R
e
c
o
r
d
e
r
T
i
m
e
-
k
e
e
p
e
r
P
a
r
t
i
c
i
p
a
n
t
Rol
es
Rot
ate
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Progress Reports from
Wards – Throughout
the day
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Osborn
3
Brearley
5&6
Hadfield
3&4
E1&2
F1
Cardiology
Osborn
2
Time Topic Where Who
9.00 Welcome back & Agenda Lecture Theatre Steve
9.15 Progress Report from E1 & E2 Lecture Theatre
9.25 Themes and Global Aims Lecture Theatre Claire
9.45 Progress Report from Cardiology Lecture Theatre
9.55 Break Post Grad Room
10.10 Progress Report from Osborn 3 Lecture Theatre
10.20 Specific Aims & Fishbone Lecture Theatre Jo, Maria
11.00 Progress Report from Brearley 5 & 6 Lecture Theatre
11.10 Change ideas – Brainstorming and Multi-voting Lecture Theatre Nicola
11.50 Progress Report from Hadfield 3 & 4 Lecture Theatre
12.00 Progress Report from Osborn 2 Lecture Theatre
12.10 Lunch Post Grad Room
13.00 Story from the field – Hadfield 6 Lecture Theatre Steve
13.50 Measurement Basics Lecture Theatre Maria, Tim
14.30 Progress Report from F1 Lecture Theatre
14.40 PDSA & Activity Post Grad Room Steve
15.25 Break Post Grad Room
15.40 Planning Time – Next steps Post Grad Room Maria
16.20 Final Reflections, next steps and close Post Grad Room All
Template
INFECTIOUS DISEASES
E1 & E2
9.15 – 9.25
Progress Report
INFECTIOUS DISEASES E1 & E2 What progress have you made since the last
session?
· Staff survey analysed
· Commenced/distributed patient surveys
· Agreed purpose/process map/patterns
· Meetings - weekly & set time
· Board-round
What’s going well?
What are your challenges? What are your plans and next steps?
· Receiving responses from patient surveys
· Staffing levels
· Impact from Trust (new innovations with
strict time-frames)
· Daily pressures/variable
· Representative from medical team
· Feedback from meetings to rest of team
· Holding regular weekly meetings
· Ownership
· Board-round (positive feedback in a short
time-frame)
· New shift times commencing 3rd August
· Raised profile on the microsystems work
· To display feedback on progress plans in E3
training room
· Agree themes for improvement
Claire
9.25 – 9.45
Themes & Global Aims
Learning Outcomes
By the end of this session you will be able to…
- Describe to other members of staff on the ward, what
happens after you have completed your 5Ps poster
- Explain what it will be used for
- Write your own aims
Workbook p60
Example:
We aim to improve patient flow in the midwifery booking
clinic. The process begins when the woman books in at
reception and ends when she books out at reception.
By working on this we expect to improve patient
experience, reduce waiting times, organise our
resources effectively and make the department look
less chaotic. It is important to work on this now because
women are dissatisfied with the time they spend here,
they become lost in the department and we are
frustrated and embarrassed about this”
Your turn to have a go…
This family of 4 are struggling to leave the house in the morning on time
(Mondays to Fridays). They monitored their leaving time and realised they
leave their house late 50% of the time.
What could their Global Aim be?
6 years old, goes to school
goes to work
goes to work
2 years old, goes to nursery
Workbook p60
Learning Outcomes
By the end of this session you will be able to…
- Describe to other members of staff on the ward, what
happens after you have completed your 5Ps poster
- Explain what it will be used for
- Write your own global aim
CARDIOLOGY
9.45 – 9.55
Progress Report
OSBORN 3
10.10 – 10.20
Progress Report
OSBORN 3 What progress have you made since the last
session?
• Staff Survey
• Patient Survey
• Significant amount of data
collected
• Started work on emerging
themes
What’s going well?
What are your challenges? What are your plans and next steps?
• Variable ward participation
• Staff time outside meetings to
carry out actions
• Maintaining staff motivation in the
light of ward vacancies
• Some ideas link with other wards
and pathways
• Weekly meetings
• Improved recording of meetings
and actions
• Growing list of car park ideas
• Using effective meeting skills and
timekeeping
• Evaluating sessions
• Complete work on picking themes—to
discuss at the next meeting and decide
on key themes for wider discussion
• Continue to look at some patterns data
• Whole ward to vote on prioritising
themes
• Start testing some ideas—likely to be
based around communication
Jo & Maria
10.20 – 11.00
Specific Aim
Fishbone
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
What is a specific aim?
• At its simplest its what you want to achieve & by
when
• Allows you to make a start on comparing now
with a future improved state
• Gives you a detailed & clear focus for planning
changes
• Its measurable
Why do we use them?
Specific Aim
Global Aim
Theme Data
Specific aim
Increase
Reduce
Numbers
or %
Numbers
or %
Specific aim
By when? By August
2014 The next 10 clinics
Some principles
Clear & precise
Use numerical goals
Stretch goals
Avoid drift but be adaptable
You don’t need permission to
do
You can work on now
Set a specific target date
Examples
“We aim to reduce to the number of central line
infections in the intensive care ward from 12 per
year to zero by 1st July 2013.”
Measure: The number of central line infections
recorded on the intensive care ward
IHI Collaborative Specific Aims re:
Reducing Adverse Drug Events.
34
Examples
“We aim to decrease the amount of nursing
overtime worked within the Anticoagulation Clinic
from an average of 22.5 hours per week by 50%
by 31 May 2015
&
to 0 hours by 31 October 2015”
Measure: The total number of hours overtime
worked by nursing staff in the clinic per week
.
Examples
“We aim to decrease the length of waiting time
from referral to first appointment
from a current maximum of 17 weeks wait
to a wait of 9 weeks or less
by December 2015”
Measure: The number of weeks wait from patient
referral to attending first appointment
.
From “Global” to “Specific” Aim
- Antenatal Clinic
“We aim to improve patient flow in the midwifery booking clinic.
The process begins when the woman books in at reception.
The process ends when the woman books out at reception.
By working on this we expect to improve patient experience,
reduce clinic waiting times, organise our resources effectively
and make the department look less chaotic.
It is important to work on this now because women are
dissatisfied with the time they spend here, they become lost in
the department and we are frustrated and embarrassed about
this”
37
From “Global” to “Specific” Aim
- Antenatal Clinic
“We aim to improve patient flow in the midwifery booking clinic.
The process begins when the woman books in at reception.
The process ends when the woman books out at reception.
By working on this we expect to improve patient experience,
reduce clinic waiting times, organise our resources effectively
and make the department look less chaotic.
It is important to work on this now because women are
dissatisfied with the time they spend here, they become lost in
the department and we are frustrated and embarrassed about
this”
38
Antenatal Clinic
“We aim to decrease patient waiting in the
midwifery booking clinic by 50% by 1st August 2015”
Measure: The time in minutes that patients wait in
the waiting room
39
Global/Specific Aim Worksheet
Write a Theme for Improvement: _________________________________________
Global Aim Statement Create an aim statement that will help keep your focus clear and your work productive:
We aim to improve: ____________________________________________________ _____________ (Name the process)
In: _______________________________________________________________________________ (Clinical location in which process is embedded)
The process begins with: _____________________________________________________________ (Name where the process begins)
The process ends with: _______________________________________________________________ (Name the ending point of the process)
By working on the process, we expect: __________________________________________________ (List benefits)
It is important to work on this now because: ______________________________________________ (List imperatives)
Create Flowchart
Specific Aim Statement We will: _ improve _ increase _ decrease
The: _ quality of _ number/amount of _ percentage of ________________________ (describe what will b e measurably different)
By: ___________________________________________________________________ (percentage)
OR
From: _________________________________________________________________ (baseline state/number/amount/percentage)
To/By: ____ _____________________________________________________________ (describe the change in quality or state the number/amount/percentage)
By: ____________________________________________________________ (date)
Example: We will decrease the amount that my dog weighs from 55 pounds to 50 pounds by August 31, 2007.
Or simply
How much?
By When? Workbook p70
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Workbook p16
• Optimised nutrition
• Optimised weekly training programmes
• Improved the ergonomics of the bike seats
• Optimised the weight of the tires
• Discovered the pillow that offer the best sleep
• Tested for the most effective type of massage gel
• Trained the riders the best way to wash their hands to avoid infection
Improving by just 1% isn’t notable, but can be
just as meaningful, especially in the long run
Team
performance
ergonomics
of the seat
nutrition
the weight of
the tires
infection
massage gel
pillows
Fishbone or Cause and Effect Diagrams
Why do we use them? • Health care is complex
• Outcomes are due to multiple causes
• Improvement requires management of the most important causes of undesirable outcomes
What is it? • An organised picture of the factors thought to produce a
result.
How do we construct one? • Put our problem or aim at end of arrow and brainstorm
major categories of contributing factors and subcategories
Fishbone Diagram
Result
/effect
Driver
Driver Driver
Driver
45 Workbook p72
Major
driver
Sub-category
driver
Fishbone Diagram
Result
/effect
People
Materials Process
Equipment
Workbook p72
This family of 4 are struggling to leave the house in the morning on time
(Mondays to Fridays). They monitored their leaving time and realised they
leave their house late 50% of the time.
Global Aim: To improve the process of getting out of the house in
the morning on time
6 years old, goes to school
goes to work
goes to work
2 years old, goes to nursery
Your 10 min challenge:
• To write a SPECIFIC AIM for this family
• To create a CAUSE AND EFFECT DIAGRAM for this specific aim
‘the problem’
primary cause
secondary
causes
What?
How much?
By when?
GSM - BREARLEY 5 & 6
11.00 – 11.10
Progress Report
Progress Since the Last Session
• ‘Give it a go week’ – board rounds PDSA
• Work on noise monitoring
• Finished 5Ps
• Posters inviting people to get involved
• Changed meeting time & date to improve
attendance
• Going to view V4 and B2 board rounds
Purpose
We provide truly holistic patient-centred care; we
treat and support our patients to achieve the best
outcome they can with dignity and without delay.
We promote a collaborative learning environment
where we can support each other and develop new
skills, work as a team and have good job
satisfaction. We strive to continuously improve our
service, make a difference and work together to
provide care for patients and carers that looks after
our patients in the way we would wish for members
of our own family.
‘Give it a go’
What’s going well
• Positive meeting evaluations
• Already tested using PDSA
• Working together positively
• We have themes to work on
‘It’s encouraging
and inspiring to
find that this work
is going on’
GSM SHO
Themes
Ward Processes
Falls
Communication (Board Rounds,
Handovers, referrals)
Noise
What are your challenges
• Attendance, Busy-ness and Staffing issues
• Encouraging regular attendance from
representation from all the MDT
• Communication – getting information and
awareness out (Info doesn’t ‘cascade’)
What are your plans and next steps
• Collect data on ‘noise’
• Continue to work and test board-rounds
–develop an ‘ideal’ structure
• Work on the themes – progress up the ramp
Change Ideas
Brainstorming & Multivoting
Nicola
11.10 – 11.50
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Workbook p16
How do we generate change ideas to test?
Map out the process and look at the gap between
current and ideal.
Workbook p68
How do we generate change ideas to test?
Use other investigative tools eg Fishbone
Lengthy
Appointments
People Equipment
Materials Process
Clinical staff inconsistent Support staff not
trained
No one responsible for patient flow Patients arrive with more
needs than originally
stated
Providers are lateSupport staff unprepared
for patient visits
Equipment
broken
Not enough computers
Equipment missing
Inventory low
Missing exam
room supplies
Charts are missing
Information, e.g. test
results missing
No standard
registration processMA does paper flow and patient flow
Variation in rooming process
Check out
process delays
Poor communication between all
staff on patient status
Fishbone (Cause and Effect) of Lengthy Appointments
How do we generate change ideas to test?
Tap into local knowledge
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Osb
orn 3
Brearl
ey
5&6
Hadfi
eld
3&4
E1&
2
Cardiol
ogy
Osb
orn 2
F1
How do we generate ideas to test? Using benchmarking - searching for best practice in
other organisations.
63
Average Length of Stay for HRG xyz
0
2
4
6
8
10
12
14
How do we generate change ideas to test?
Langley and Nolans Change Concepts
• Change concepts are stimulants to develop and design
detailed and specific tests of change
• A change concept combined with your knowledge of the
process will help lead to new thinking about the process
• Use change concepts to “jump start” your thinking
65
Creativity: The connecting and rearranging of
knowledge — in the minds of
people who will allow themselves
to think flexibly — to generate
new, often surprising ideas that
others judge to be useful.
How do we generate change ideas to test?
Brainstorming
66
Edward De Bono’s Mental Valleys Model of Thinking
“Creative thinking involves breaking out of
established patterns (valleys) in order to look at
things in a different way.” de Bono
67
Attention…..Escape……Movement
Movement Play imaginatively with this suggestion and generate ideas from
it without judgement or critiscism. Encouraging mental
movement.
“Let’s try to generate at least 10 ideas for ways to manage
patients arrivals in outpatients without a receptionist or a desk”
Attention Looking closely, observing with fresh perspective and really
noticing current rules and assumptions.
“patients who come to outpatients must first come to reception”
Escape Challenge or block an existing rule is encouraging escape from
the current mental valley.
“the Trust has made it illegal to have a receptionist and a desk in
outpatients”
68
Brainstorming
Successful
brainstorming:
•Encourage creativity
• Involve everyone
•Generate excitement
and energy
•Levels out hierarchy
Workbook p76
69
Brainstorming Steps
1. Review the topic, clarify as needed
2. Take a minute or two of SILENT thinking
3. Go around the table for each person to give
an idea.
4. After the first round, members can pass.
5. Once one member passes, let all members of
the group shout out ideas.
When ideas start to flow…let them come!
Workbook p77
70
Brainstorming cont.
-Go for Quantity….NO DISCUSSION at this
stage.
-NO CRITICISM of ideas…not even a groan or a
grimace….or even ‘that’s a great idea’!
-Build on each others ideas
-Encourage wild ideas.
-One conversation at a time.
-Write ALL ideas on flipchart for all to see
Workbook p78
This family of 4 are struggling to leave the house on time in the morning (Monday
to Friday) resulting in Mum and Dad frequently being late for work, the children
being late for school/nursery and the environment being pressured and stressful.
Their specific aim is to increase the proportion of days (Monday to Friday)
when they leave the house on time from 50% to 100% by 31 October 2015
6 years old, goes to school
goes to work
goes to work
2 years old, goes to nursery
72
EXERCISE.
- Get into groups of at least 8?
- Brainstorm for 5 minutes.
‘Generate at least 20 ideas that could help
the family get to work/nursery/school on time
and be happy!’
Get
clothes
ready
Have a
sock
strategy
Make
lunch night
before
Play
speedy
music
Army
routine
Clock in
the
shower
Kids
checklist
Bags
ready at
door
Get a
nanny
Socks in
basket
by door
Ring a 5
min bell
Check
traffic
reports
Dress
rehearse
schedule
Make a
robot Do stuff in
the car
Do
routine
stuff first
Hire a
helicopte
r
Have
loads of
alarm
clocks
Allocate
jobs
Have an
emergency
pack
74
Affinity Grouping and Multivoting
• Affinity grouping is a brainstorming method in
which participants organise their ideas and identify
common themes. In the brainstorming all ideas
need to be recorded on Post ITs and posted up
onto the flip chart.
• Multi-voting is a structured series of votes by a
team, in order to narrow down a broad set of
options to a few.
Workbook p79
75
1. Clarify and remove duplicates.
2. Start by choosing two ideas.
3. Agree with the group whether they are related.
If they are related put them together.
4. At the end of the exercise there should be less
than 10 groups of post it notes.
5. Give a short descriptive header to each group.
Affinity Grouping
Get
clothes
ready
Have a
sock
strategy
Make
lunch night
before
Play
speedy
music
Army
routine
Clock in
the
shower
Kids
checklist Bags
ready at
door
Get a
nanny
Socks in
basket
by door
Ring a 5
min bell
Check
traffic
reports
Dress
rehearse
schedule
Make a
robot
Do stuff in
the car
Do
routine
stuff first
Hire a
helicopt
er
Have
loads of
alarm
clocks
Allocate
jobs
Have an
emergency
pack
Night
before
plan
Morning
strategy
Schedulin
g process
Time
reminders Others do
the jobs
Travel
method
Increase
pace
77
Multi-voting Steps
-Number each idea.
-Each person can have 1/3rd of the ideas to vote on.
eg if 21 ideas were generated, each person gets 7 votes. They can not
vote on one idea more than once.
-Tally votes.
-Eliminate ideas with few votes.
- If this identifies 3 -4 ideas to work with stop here.
Otherwise repeat with the remaining items.
Selection Criteria
Add some criteria to help the voters
Suggestions might be depending on the change -
Ideas that can be started fast
The change is reasonably low cost
The effort is small compared to the impact
The idea can be tested without getting ‘permission’
from others
78
Workbook p80
79
Multi-voting Steps
Voting methods:
-Colored sticky dots
- Individually write choices on piece of paper
-Go to the list and indicate your choice w/marker
-A show of hands as each number is called out.
-Remember selection criteria
Get
clothes
ready
Have a
sock
strategy
Make
lunch night
before
Play
speedy
music
Army
routine
Clock in
the
shower
Kids
checklist Bags
ready at
door
Get a
nanny
Socks in
basket
by door
Ring a 5
min bell
Check
traffic
reports
Dress
rehearse
schedule
Make a
robot
Do stuff in
the car
Do
routine
stuff first
Hire a
helicopt
er
Have
loads of
alarm
clocks
Allocate
jobs
Have an
emergency
pack
Night
before
plan
Morning
strategy
Schedulin
g process
Time
reminders Others do
the jobs
Travel
method
Increase
pace
Have a
sock
strategy
Play
speedy
music
Kids
checklist Bags
ready at
door
Get a
nanny
Ring a 5
min bell
Hire a
helicopt
er
Have an
emergency
pack
Night
before
plan
Morning
strategy
Schedulin
g process
Time
reminders Others do
the jobs
Travel
method
Increase
pace
GASTROENTEROLOGY –
HADFIELD 3 & 4
11.50 – 12.00
Progress Report
Progress Since the Last Session
• Completed 5P poster and reviewed data
• Identified 3 themes.
• Strong patient voice through Patient Governor help.
• Doing PDSA for Board Rounds looking at attendance,
timings etc. Data collected by Occupational Therapist.
• Collected data on TTO’s by Pharmacist.
• Patient Governor doing surveys about food.
5Ps to Themes
Patient Flow Patient
Nutrition Patient
Entertainment
Global Aims written for all themes. We aim to improve patient flow on
Robert Hadfield 3 and 4.
The process begins with admission to the ward.
The process ends with the patient discharge home.
By working on the process we expect to; provide patients with a timely
safe discharge without delay, reduce patient readmissions, reduce patient
length of stay on the ward and improve the patient and staff experience of
the ward.
It is important to work on this now because; staff feel this would have
the biggest impact for patients and staff, patient feedback found that
patients experienced delays getting on the ward, it builds on the work we
have started already by introducing Board Rounds and it is a priority for the
Gastroenterology and Hepatology directorate
What’s going well
• Having regular weekly meetings.
• Good wide core representation
• Improved communication
• Progressing through the Microsystem improvement ramp.
• Using effective meeting skills
What are your plans and next steps
• Attend a directorate consultant meeting to share what
we have been doing and seek engagement in mapping
patient discharge processes.
• Review information from food related surveys
• Process map - organising patient meals
• Brainstorm about patient entertainment
OSBORN 2
12.00 – 12.10
Progress Report
What progress have you made since the last session?
More people attending meetings
Since last time completed 5Ps including:
Typical patients
Patient and staff feedback
Process mapping
Discussed patterns
Identified common themes
OSBORN 2 PROCESS MAPS FOR TYPICAL PATIENTS
What is going well? (1/2)
Identified THEMES
Time management
and organisation
Communication
Staffing level
Keeping patients occupied
What is going well? (2/2)
Improved staff representation
Improved on all points from 15/05/2015:
People talking about it
New members each meeting
Commitment
Effective meeting skills
Supporting each other
Transparency
Good posters – eye catching and more powerful
Level of enthusiasm is high
What are your challenges?
Staff off ward to meetings
Consistency of MDT staff to meetings
Due to building work- difficulties to meet / view posters
Getting action started from last meeting
What are your plans and next steps?
Plan occasional odd days for meetings (ward clerk,
domestic staff etc)
Collecting data
Work on handover (outside representation)
Look on themes split into sections
All to get email to meetings
SharePoint site – add our info to it
Looking at global aims and themes
Story From the Field
GSM Ward - Hadfield 6
13.00 – 13.50
Maria & Tim
13.50 – 14.30
Measurement Basics
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Workbook p16
Why do we need to measure?
If you wanted to reduce your calorie intake,
which food should you give up?
If we don’t measure, how will we know that
the change is an improvement?
all food here is 200 kcal
If we don’t measure, how will we know if
what we are observing is not due to chance?
103
2020? 2014 2015
Welcome to Royal
Hallamshire Hospital
What can we measure?
Time
• Length of stay
• Length of ward rounds
• Length of drug rounds
• Time of discharge
Proportion / percentage / rate
• x% of staff would recommend this ward
as a place to work
• X% of patients would recommend this
hospital to friends and family
• Infection rate
• X% of our admissions fall on a Monday
Number / frequency
• Number of admissions
• Number of accidents
• Number of falls
• Number of time you are
interrupted during the drug
round
Value / cost
• Cost of delayed discharge
(extra bed nights)
• Cost of extra staff
• Cost of re-work
• Cost of extra kit
• Value of saved staff time
SOME EXAMPLES:
When do we need to measure?
Global AimThe ‘big picture’
Specific Aim The ‘component
parts’
Change Idea
Conceptual Definition
‘The Measure’
Operational Definition ‘Specify & Quantify’
Measurement Plan
‘The How’
Workbook p88
Global Aim
Specific Aim
Change Idea
Conceptual Definition
Measurement
Plan
‘The How’
Operational
Definition
“The Big Picture”
“The Component
Parts”
“How you will do it”
The Measure (Abstract Idea)
The Measure
(“Specify and Quantify”)
The “How, What, Where, When and
Who”
Workbook Page 90
We aim to improve the
discharge process and make
it more efficient and patient-
centred
We will improve patient
waiting time for ambulance
by 30% by August 2015
We will book an ambulance
as soon as the decision to
discharge is made
We will improve patient waiting time for
ambulance by 30% by August 2015
Global AimThe ‘big picture’
Specific Aim The ‘component
parts’
Change Idea
Conceptual Definition
‘The Measure’
Operational Definition ‘Specify & Quantify’
Measurement Plan
‘The How’
Conceptual Definition Tells WHAT will be measured
Patient Waiting for an ambulance
Operational Definition Tells HOW it will be measured
Time elapsed from the time the ambulance was
booked by the ward clerk until the ambulance
crew arrives to collect the patient in hrs (or min)
or
How many times in a week do our patients wait
for an ambulance for over 2 hours?
or What proportion of patients (%) wait over 2 hours
every week?
Exercise: What is a clean room?
• Conceptual Definition (what) = Clean
• What is the operational definition (how) in the following contexts?
-A teenager’s bedroom
-The presidential suite at a five star hotel
-An operating room at a hospital
110
Collecting your data
Global Aim
Specific Aim
Change Idea
Conceptual Definition
Measurement
Plan
‘The How’
Operational
Definition
“The Big Picture”
“The Component Parts”
“How you will do it”
The Measure (Abstract Idea)
The Measure
(“Specify and Quantify”)
The “How, What, Where, When and
Who”
Data Collection Plan
“If you fail to plan, you are planning to fail”
Benjamin Franklin, 1706-1790
• What data will be collected?
• How will the data be collected?
• Who will collect this data and how will they be trained?
• Where will the data be collected
• When will data collection start and stop?
Data Collection Plan
“What, How, Who, Where, and When”
• We will measure the time between when the ambulance is
booked until the time when the ambulance crew arrives to
collect the patient in hours
• We will gather data from database X (time of request) and
medical records (time of crew arrival)
• We will collect the data on ward Y for all patients requiring 2-
men ambulance
• We will collect data for all days and shifts in July 2015
What is missing?
Data Collection Plan Example
• We will measure the time between when the ambulance is
booked until the time when the ambulance crew arrives to
collect the patient in hours
• We will gather data from database X (time of request) and
medical records (time of crew arrival)
• We will collect the data on ward Y for all patients requiring 2-
men ambulance
• We will collect data for all days and shifts in July 2015
Who is going to collect the data?
Data Collection Plan Example
What will help us make sense of the data?
• Frequently used
• Compare categories of data
• Useful for: visual display of data at
any one point in time (e.g. results of
staff and patient surveys)
• Less useful for: tracking the changes
over time
Bar Charts
What was the Best Thing About your visiti to the Clinic?
0 2 4 6 8 10 12 14 16 18 20
Clean environment
Familiar Expert Doctor
Friendly and Caring Staff
Going Home
Information and Advice
Meeting fellow patients
Ongoing monitoring of
condition
Reassurance
Well Organised
Responses
I would recommend this clinic as a great place to
work
0
2
4
6
8
10
12
Strongly Agree Agree Disagree Strongly Disagree
Nu
mb
er
of
resp
on
ders
• Simple to construct
• Show changes over time
• Useful for: Measuring
changes over time, or for
consecutive patients. Helps
to identify whether the
change led to improvement.
• Less useful for: when
poorly annotated (e.g. no
title or axis labels)
Run Charts
• Show proportions of data
within a group
• Useful for: visual display of
data at any one point in time
(e.g. results of staff and
patient surveys)
• Less useful for: tracking
the changes over time, data
can be skewed by the
number of survey responses
Pie Charts
9
2
11
Which staff group best describes you?
Administration, Clerical & Secretarial Staff Medical Staff Nursing/Therapy Staff
• Show differences between
elements of categories as well
as categories
• Actual numbers lost
• Useful for: visual display of
data and focusing the team on
areas to improve
• Less useful for: tracking the
changes over time, data can be
skewed by the number of
survey responses
Proportional Bar Charts
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Duration of vis it
Staff working patterns/opening hours
Waiting time for patients
Appointment scheduling
Transport
Hospital environment
Information available for patients/carers
What would you change about your service
0 - No change required 1 2 3 4 - Large change required
• Shows relationship between
two sets of data
• Can add trend line
• Useful for: showing the
relationship between two
parameters (e.g. height and
weight), shows
abnormalities in data
prompting question
• Less useful for: tracking
changes over time and
putting data into categories
Scatter graphs
0
20
40
60
80
0 5 10 15 20
He
igh
tAge
Height vs Age
• Shows patient journey
through a clinic
• Quickly shows wait
• Useful for: visually showing
delays in patient journey
• Less useful for:
understanding the reasons
for delays or total wait time
at a glance
Patient Flow Charts
Patient 1
Obs &Swabs Patient 2
Assessment Patient 3
ECG Patient 4
Bloods Patient 5
Xray Patient 6
Additional Obs Patient 7
Examination Patient 8
Wait Patient 9
Unknown Patient 10
Review Notes Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
Patient 16
Patient 17
Patient 18
Patient 19
Patient 20
Patient 21
Patient 22
Patient 23
Patient 24
Patient 25
Patient 26
Patient 27
Patient 28
Patient 29
Patient 30
Patient 31
Patient 32
Patient 33
Patient 34
Patient 35
Patient 36
Patient 37
Patient 38
RHH Pre-Op Clinic
10/05/12 13:4008:2008:0007:40 12:0011:4011:20 14:00 14:4014:2013:2013:0012:4012:2011:0009:2009:0008:40 10:4010:2010:0009:40
• Shows themes from
free text responses
• Useful for: visual
display of qualitative
data (free text surveys)
and its thematic
analysis
• Less useful for:
numerical data
Wordle
What would improve your working day?
• Shows different types of
data
• Useful for: understanding
precise data
• Less useful for: tracking
changes over time, showing
co-relation between data or
data trends
Tables
Day of Clinic Number of
Patients
Number of
DNAs
Cost of
Clinic
Monday 15 3 £1504
Tuesday 13 1 £1367
Wednesday 10 0 £1243
Friday 16 4 £1794
• It doesn’t have to be technical
• Use tally charts and hand
drawn graphs
Measurement Top Tips
Patterns Patterns can be found through tracking the volumes and types of telephone calls. Review the categories on the telephone
tracking list to ensure they reflect the general categories of calls your practice receives. Ask clerical staff to track the telephone calls over the course of a week to find the patterns of each type of call and the volume peaks and valleys.
Put a tally mark each time one of the phone calls is for one of the listed categories. Total the calls for each day and then total the calls in each category for the week. Note the changes in volume by the day of the week and am/pm.
Primary Care Practice Telephone Tracking Log
Week of Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Week Total
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
Appointment for Today
\ \\ \ \ \\ \\ \\\ 12
Total
Appointment for Tomorrow
Total
Appointment for Future
Total
Test Results
Total
Nurse Care \\\ \\\\\
\\\\ \\\\ \\\\\
\\ \\\\\ \\\\ \\\\\
\\\\ \\ \\\\\
\\ \\\ 52
Total
Prescription Refill
\\\ \\\\\\\\\\\
\\\\ \\\\\\\
\\\\\ \\\\ \\\\\\\\\\\\
\\ \\\\\\\
\\\ 55
Total
Referral Information
Total
Need Information
Total Message for
Provider
Total
Talk with Provider
Total
DAY TOTAL
• Make sure the graphs help
• If it doesn’t, try something
else
Measurement Top Tips
02468
101214161820
What was the best thing about your visit to the clinic?
• Make sure the graphs help
• If it doesn’t, try something
else
Measurement Top Tips
3
15
6
5 6 4
19
12 3
What was the best thing about your visit to the clinic?
Well organsied
Reassurance
Ongoing montoring of condition
Meeting fellow patients
Information and advice
Going Home
Friendly and Caring staff
Familiar expert Doctor
Clean Environment
• Make sure the graphs help
• If it doesn’t, try something
else
Measurement Top Tips
0 2 4 6 8 10 12 14 16 18 20
Well organsied
Reassurance
Ongoing montoring of condition
Meeting fellow patients
Information and advice
Going Home
Friendly and Caring staff
Familiar expert Doctor
Clean Environment
What was the best thing about your visit to the clinic?
• Make it easy, is the data already being collected
somewhere?
• Make sure everyone knows what they’re collecting. It’ll
only be useful if everyone collects the same thing.
Remember your operational definition.
Measurement Top Tips
Operational Definition Tells HOW it will be measured
Time elapsed from the time the ambulance was
booked by the ward clerk until the ambulance crew
arrives to collect the patient in hrs (or min)
or
How many times in a week do our patients wait for
an ambulance for over 2 hours?
or What proportion of patients (%) wait over 2 hours every
week?
Definition of a clean… (3 min)
Teenager’s
bedroom
Presidential suite
at a five star hotel
Operating room
at a hospital
Cardiology E1 & 2 F1
Osborn 3 Gastro Osborn 2
Brearley 5 & 6
Report back – 1 min for each team
ORTHOPAEDICS – F1
14.30 – 14.40
Progress Report
Orthopaedics F1 What progress have you made since the last
session?
• Patient demographic survey (joint school)
• Staff survey
• Process map
• Meetings - weekly & set time
• Patient property PDSA
• Drug card audit
What’s going well?
What are your challenges? What are your plans and next steps?
• Not enough patients!
• Difficult to work on our microsystem when
we’re being pulled off the ward and not in
our usual pattern of work
• Keeping momentum when we have
different people at each meeting
• Moving on/ closing down conversations
• Representative from social work
• Holding regular weekly meetings
• Getting more of the MDT to the meetings
• Making and measuring improvements
• Finish our 5Ps
• Discharge planning theme
Steve
14.40 – 15.25
PDSA & Activity
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Workbook p28
Plan
Do Study
Act
Specific Aim
Measurement Plan
Change Ideas
Workbook p120
Plan
•Objective
•Questions and
predictions (Why)
•The plan – who what
where when
Do
•Do the Plan
•Document problems,
observations
•Begin analysis
of the data
Study
•Complete analysis of
data
•Compare data to
predictions
•Summarise the
learning
Act
•What changes
are to made now?
•What is the next
cycle
PDSA
PDSA - experimentation • Always start with a specific aim - What are we trying to accomplish?
• How will know if this is an improvement? – Data.
• Small tests of change over a short time
• Debrief frequently
• Communicate results
• Repeated Cycles
• When we meet our aim? –
SDSA = Standardise
SDSA
1
3
2
P
DS
A
P
DS
A
P
DS
A
P
DS
A
P
DS
A
P
DS
A
4
5
6
PDSA Cycle: Deciding on Scale of Test
Current Situation Resistant
(No commitment)
Indifferent
(some
commitment)
Ready
(strong
commitment)
Low Degree of Belief that
change idea will lead to
Improvement
Cost of
failure large
Very Small Scale
Test
Very Small Scale
Test
Very Small Scale
Test
Cost of
failure small
Very Small Scale
Test
Very Small Scale
Test Small Scale Test
High Degree of Belief that
change idea will lead to
Improvement
Cost of
failure large
Very Small Scale
Test Small Scale Test Large Scale Test
Cost of
failure small Small Scale Test Large Scale Test Implement
Engagement, Readiness to Change
Source - The Improvement Guide
Co
nfi
den
ce
Workbook p82
Workbook p84
Workbook p84
PDSA Exercise
14.55 – 15.25
Maria
15.40 – 16.20
Planning Time
Template
Steve
16.20 – 16.30
Final Reflections
Next Steps
Close
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart or Process Map
Cause & Effect
The Microsystem
Improvement Ramp
Effective Meeting Skills
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Ward Collaborative Overview
Workbook p15
Learning Session Overview
Session 1 Session 2 Session 3 Session 4
Introduction to the
collaborative.
QI and
microsystem
fundamentals,
Effective meeting
skills,
understanding
your system using
the 5Ps
Process mapping,
Patient
involvement.
Story from the
field. (CHANGE
room).
Progress reports
from all teams,
Feedback and
sharing on the
5Ps,
Themes and Aim
statements,
Change Ideas and
PDSA,
Measurement
basics.,
Story from the
field. (Hadfield 6)
Planning Time
Progress Reports
from all teams,
Psychology for
improvement
Run charts and
Variation,
5s,
SDSA and
sustaining
improvement.
Planning Time
Progress Reports
from all teams as
posters and
presented case
studies.
Capacity and
demand basics.
Planning multiple
improvements
using driver
diagrams
Ward Collaborative Overview
Workbook p15
MCA Connect
• 11 September 2015, 9am - 4pm
• R Floor, Royal Hallamshire Hospital
• Ward Collaborative Session is planned– come
and share your work!
• If you are interested speak to your coach & email
Jess