national leading health and wellbeing programme 14 march 2014 leadership for improvement jean penny
TRANSCRIPT
National Leading Health and Wellbeing Programme
14 march 2014
Leadership for improvement Jean Penny
All working life in NHSDiagnostic Radiographer and teacherImprovement roles since 1994
BPR Leicester Royal Infirmary 1994 - 1999National Patients ‘Access Team 1999 - 2002NHS Modernisation Agency 2002 – 2005NHS Institute for Innovation and Improvement 2005 -2008
Awarded OBE for services to NHS 2003Visiting professor University of Derby 2008
[email protected] Improvement: 19 years and still
learning
Linking strategic goals and frontline improvements
Measuring for improvement not judgement
Developing and testing change ideas
“All models are wrong but some are useful”
W Deming
“A promise to learnA commitment to act”
D Berwick
Find two other people who you have not worked with before
Watch the slideshow Remember as many images as possible
◦ The countdown slide is not one of the images!
No writing down or conferring!
Any improvement is a change◦not every change is an improvement◦but we cannot improve something unless
we change it
Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River
Press, Massachusetts
Any improvement is a change any change is a perceived threat to security◦there will always be someone who will
look at the suggested change as a threat
Eliyahu Goldratt
Any improvement is a change any change is a perceived threat to security
any threat to security gives rise to emotional resistance◦ you can rarely overcome emotional resistance
with logic alone
Eliyahu Goldratt
“Anyone who thinks you can
overcome emotional
resistance with logic was probably
never married”
Any improvement is a change any change is a perceived threat to
security any threat to security gives rise to
emotional resistance emotional resistance can only be
overcome by a stronger emotion
Eliyahu Goldratt
What to change?◦ Pin point the core problems
What to change to?◦ Construct (simple) practical solutions
How to cause the change?◦ Induce the appropriate people to invent such solutions ◦ they must own the problem
Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River
Press, Massachusetts
Have a goal Be honest and understand where you are
today Have a plan Never underestimate the power of small
positive changes. Tiny incremental changes add up and make a large impact
Commitment to continuously improve
August 2012
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
The interventions / change ideas that contribute directly to secondary drivers
Secondary Drivers:Contribute directly to
primary drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
?
Primary Drivers:Contribute
directly to the strategic aim
The strategic aim (and
big problem)
Linking strategic goals and frontline improvements
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
The interventions / change ideas that contribute directly to secondary drivers
Secondary Drivers:Contribute directly to
primary drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
?
Primary Drivers:Contribute
directly to the strategic aim
The strategic aim (and
big problem)
Linking strategic goals and frontline improvements
If I had one hour to save the world, I would spend 59 minutes defining the problem and one minute finding a solution
A Einstein
Ishikawa (Fishbone) Diagrams
PPPP
People Place
Procedures Policies
What are you trying to accomplish?
How will you know that a change is an
improvement What changes can you make that will result in an
improvement?
Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done? What hunches do we have? What can we learn as we go along?Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco
Aspect Improvement Accountability Research
Aim Improvement of care Comparison, choice, reassurance, spur for
change
New knowledge
Methods:
• Test Observability
Tests are observable No test; merely evaluate current performance
Test blinded or controlled tests
• Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small sequential samples
Obtain 100% of available, relevant data
“Just in case” data
• Flexibility of
Hypothesis
Hypothesis flexible, changes as learning takes
place
No hypothesis Fixed hypothesis
• Testing Strategy Sequential tests No tests One large test
• Determining if a Change is an Improvement
Run charts or control charts
No change focus Hypothesis, statistical tests (t-test, F-test, chi
square), p-vlaues
• Confidentiality of the Data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
Robert Lloyd Executive Director IHI adapted from Solberg L, Mosser G, Mcdonald S (1997) Three faces of performance
measurement: Improvement, accountability and research Journal of Quality Improvement Vol. 3 No 3
http://www.institute.nhs.uk/productive_general_practice/general/knowing_how_we_are_doing.html
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0102030405060708090
Day
1 4 7 10 13 16 19
Seco
nds
to
answ
er p
hon
e
Seven one side
Seven down (or up)
Change
Just like a TPR chart
Average length of pre-ward stayStroke Ward
from 01/2007 to 07/2007
0
0.5
1
1.5
2
2.5
3
3.5
1 2 3 4 5 6 7Months
Mike Davidge NHS Institute for Innovation and
Improvement
Average length of pre-ward stayStroke Ward
from 01/2007 to 07/2007
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Weeks
Patient length of pre-ward stay Stroke Ward
from 01/2007 to 07/2007
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Patients
What are you trying to accomplish?
How will you know that a change is an
improvement What changes can you make that will result in an
improvement?
Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done? What hunches do we have? What can we learn as we go along?Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco
How is a paradigmformed?
Streams of thinking Valleys
Creativity: The connecting and rearranging of knowledge to generate new, often surprising ideas that others judge to be useful.
Innovation occurs when a creative idea is put into practice.
Vast majority of creative thoughts are never acted upon: Creativity without innovation
Breaking the rules
Identify the underlying assumptions, mental models, unwritten rules and thinking that maintain the status quo.
Then deliberately think around them to create new ideas for service delivery
Ask ◦ Why is that step there? What are the unwritten rules
behind what is going on here? ◦ What aspects of the rule can we break? And what
aspects of the rule would we want to keep and why?
You are creative?
Lets be creative!
Pick up your pen and turn each box into a different object
Coffee
Some Idea’s
Pyramid from above
Mouse hole
Stepping stones Off beat ideas and wild scenarios can serve
as catalysts or mental stepping stones to help us make an intuitive leap to a really good idea
Scenario: A mysterious virus has affected all who work in the Ambulance Service. So they are unable to work. Everyone else is completely unaffected.
How are you going to do to link users to the care they need? Be Creative !!!
http://www.institute.nhs.uk/building_capability/new_model_for_transforming_the_nhs/thinking_differently_guide
Attention Escape Movement
White hat
Data, facts and information
Yellow hat
Positives, benefits, good things
Black hat
Negatives, warnings, pitfalls
Green hat
Creative possibilities, new ideas
Red hat
Feelings, intuitions
Blue hat
Control or direction in thinking
Attention Escape Movement De Bono (2000) Six thinking hats Penguin London
Use on one idea
ImaginationCreativity
Doing and changingInnovation
400ideas
generated
75ideas
harvested
20ideas
developed
8ideastested
4ideas
implemented
Practicality, Impact, Cost, Outcome
Attention Escape Movement
What are you trying to accomplish?
How will you know that a change is an
improvement What changes can you make that will result in an
improvement?
Model for ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done? What hunches do we have? What can we learn as we go along?Langley G, Moen R, Nolan K, Nolan
T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco
Solution / change in
organisation A
Change principle Change principle
Solution / change in
organisation B
PDSA cycle for learning and improvement
Act
• what changes are to be made?
• next cycle?
Plan•objective• questions and predictions (why)• plan to carry out the cycle (who, what, where, when)
Study
•complete the analysis of the data
•compare data to predictions
•summarise what was learned
Do
• carry out the plan• document problems and unexpected observations• begin analysis of the data
We planned to….. ( state the basic plan) In order to ….. (tie it back to the Aim)
What we did was….. (brief description of actions)
Looking at what happened, what we learned from this was….. ( lessons learned)
What we plan to do next is …. (state next plan)
© Paul Plsek
P
D
S
A
PDSA
PDSA
PDSA
PDSA
PDSA
Data Driven Change
Change in Team Culture
Hunches
Theories
Ideas
Aim•What am I trying to achieve?•How will I know a change is an improvement?•What changes can I make that will result in the improvement
Need to start small!!
The Model for Improvement breaks things down into small steps and works of the ‘little dots’ – at the frontline
These small steps should be part of the answer to the question of how to move the big dots
Align all improvement projects to strategy
Macro
Meso
Micro
©Profound Knowledge Products, Inc. 2008 All Rights Reserved
Ask yourself
•What are the problems that cause the bigger problem?
•What are you trying to achieve? (aim for each driver)
•How will you know a change is an improvement ? (outcome measures for each driver )
Drivers
Which in turn contribute directly to the ‘bigger’ aim
AimThe ‘big’ dots
Ask yourself
•What is the big (possibly strategic) problem you are addressing?
•What are you trying to achieve? (aim)
•How will you know a change is an improvement ? (outcome measures)
Ask yourself
What changes can you make that will result in the improvement you seek?
•What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing?
•How will you know a change is an improvement? (process measures for each intervention)
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Interventions The ‘small’ frontline dots
Contribute directly to the driversActivity: Process and outcome measures?
1. Set Direction: Mission, Vision and Strategy
Make the status quo uncomfortable
Make the future attractive
3. Build Will•Plan for improvement•Set aims/allocate resources•Measure system
performance•Provide encouragement•Make financial linkages•Learn subject matter
5. Execute Change•Use Model for Improvement for
design and redesign•Review and guide key initiatives•Spread ideas•Communicate results•Sustain improved levels of performance
4. Generate Ideas•Understand organisation as a
system•Read and scan widely, learning
from other industries and disciplines
•Benchmark to find ideas•Listen to patients• Invest in research and
development•Manage knowledge
2. Establish the Foundation• Prepare personally• Choose and align the senior
team
• Build relationships• Develop future leaders
• Reframe operating values• Build improvement capability
Source: Robert LloydExecutive Director Performance Improvement
Institute for Healthcare Improvement January 16, 2007
Affection Trust
Distrust Respect
Extent to which I believe
you care about me
Extent to which I believe you are competent and capable
LOW
HIGH
HIGH
Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill
Think quietly by your self for a few minutes Then find two others and share
Work with your team /colleagues: value differences Really understand the problem Develop aims and measures: What are you trying to
achieve? Measure for improvement: How will you know a change
is an improvement? Gather change ideas: What changes can you make that
will result in the improvement you want? Test change ideas (PDSA cycles) before implementing
and learn from things that do not work Link frontline changes to strategic objectives Share achievements and learning with others
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make that
will result in improvement?
Model for Improvement