Tools of the Trade Continuous Quality Improvement

1. Tools of the TradeContinuous Quality Improvement Anne Mason Tonia Easton Workforce Capability & Learning Consultant Area Quality Manager Organisational Capability & Learning Clinical Governance Unit Day Two 2007

2. Learning Objectives – Day 2 At the end of Day 2 participants will be able to: • Implement and evaluate the effect of potential solutions • Develop strategies to manage the change process resulting from the implementation of quality improvement solutions • Develop strategies to embed their solutions into everyday practice • Identify methods to monitor the impact of quality improvement solutions • Develop effective presentation skills

3. Review of the CQI Process

4. Project Phase

6. Mission / Aim Statement • Specific – setting boundaries • Measurable – include a numerical goal • Appropriate - related to the project title • Result orientated – focused on outcome • Time scheduled – defining a time period

7. Team membership • Ideally 5 – 9 members • Members with fundamental knowledge • Different perspectives • Quality advisor on the team • Identified team leader

8. Diagnostic Phase

10. Collecting Evidence • Flow chart • Brainstorming • Multivoting • Nominal Group Technique • Customer Focus Groups • Tag alongs

11. Prioritising Information • Cause and Effect Diagram (fishbone) • Affinity Diagram • Pareto Chart • Graphs e.g. Run chart, Statistical Process Control chart

12. Workshop 1 - Homework • Aim / mission statement • Team (Action minutes of meetings) • Determine team leader • Identify project sponsor • Identify relevant data • Flowchart • Cause and effect diagram

13. This is where we are up to

14. The improvement process

15. Intervention Phase

16. Intervention Phase • Using the causes of the problem already identified the team identifies opportunities for improvement or the changes that will lead to an improvement. • CPI / CQI model is based on a trial and learning approach to improvement.

17. PDSA (trial & learning approach) • Plan to test selected improvement or change • Who?What?When?Where? • Do the test (carry out the plan)and collect data for analysis • Study the results. Compare data to the predictions. Has the test resulted in improvement? Can the change be implemented in a larger scale? • Act on the results. Implement the improvement or changes or select another possible improvement to test. Running small cycles is often better that waiting to run large scale cycles over longer period of time

18. PDSA Cycles

19. Caution • Testing the change is not always easy. • Things may happen that were not planned for • Changes may not have an impact on the problem • There may be unwanted side effects Therefore to assist in implementation of change it is best to use the PDSA Cycle of the framework for an efficient trial and learning methodology. It begins with a plan and ends with an action based on the learning gained from the Do and Study phases of the cycle

20. Making Decisions • Identify the criteria that the decision will be based upon • Identify the relative importance of each criteria • Assign a weighted value to each criteria • Establish a decision matrix to evaluate the relative value of each potential alternative.

21. Decision Matrix

22. Selection Criteria

23. The improvement process

24. Implementation

25. Implementation Recognise that this is a change process and must be facilitated. • Recognise the complexity of the change • Planning for the change in terms of the impact upon people

26. Implementation (a change process) Consider the tools that may have already been developed and use them to facilitate the change process. • Stakeholder analysis • Force field analysis • Risk management plan • Change management action plan • Communications plan

27. Basic Steps Where do we want to be? Set Goals or objectives for change Where are we now? Assess current situation (performance levels, quality, outcomes) Maintaining the Momentum How do we get where we want to be? Cost Benefit Analysis Process Mapping Action Planning Evaluation methods New Performance targets How do we know we have arrived?

28. Strategies to support change • The purpose of the change is made clear and there is good communication during the change • Those affected by the change are involved in the planning • The appeal for change is based on professional reasons • Efforts are made to reduce the impact of excessive work pressure

29. Strategies to support change • Anxiety over job security is relieved • Issues of the ‘Vested Interest’ of the individual or a subunit of the organization is addressed • The change leader is someone who is respected or trusted • Pace of change is managed to allow staff to cope. • Past negative experience with change is addressed

30. Human response to change New World Old World Job Performance OR Staff Satisfaction Acceptance Shock Anxiety Depression Anger Staff Feelings over Time

31. Resistance to change Reasons for resistance may include: • Uncertainty • Weary of Change • A belief that the change is not in the organisation’s best interest • Concern over personal loss • Misunderstanding (communication problems; inadequate information)

32. Workshop 2 Have you met any resistance to the change you are proposing? What strategies have you used or might you use to overcome resistance to the change?

33. Strategies to reduce resistance • Manage the number of minor and uncontrolled changes which staff must cope with • Provide adequate training • Provide adequate support for staff before, during and after implementation • Involve people who resist as much as possible • Develop a plan to manage resistance

34. Strategies to reduce resistance • Reassess resistance factors throughout the change initiative • Use change sponsor to assist with high level or complex issues • Where appropriate keep staff associations and unions well informed

35. The improvement process

36. Impact Phase

38. Measure impact • To ensure intervention has resulted in an improvement • To provide evidence to justify permanent implementation of the change(s) • It is necessary to collect, analyse and display data for all to see.Two popular ways of displaying data are run charts and SPC charts.

39. Run chart

40. SPC Chart

41. Workshop 3 • How will you measure the overall impact of the change? • Have you achieved your aim or mission? • Has the magnitude of the response met your expectations?

42. The improvement process

43. Sustaining Improvement Phase

44. Standardisation of existing systems and processes for performing work activities Documentation of associated polices, procedures, protocols and guidelines Measurement & review to ensure that change becomes part of routine practice Training & education of staff

45. Maintaining the Momentum Where do we want to be? Where are we now? Maintaining the Momentum How do we get where we want to be? How do we know we have arrived?

46. Sustainability • Standardisation • Documentation • Measurement and review • Training and education

47. Sustainability • Standardisation • This ensures that the new way of doing things is consistent over time and for different staff.

48. Sustainability • Documentation • The changes need to be incorporated into policy and procedures. • The changes need to be incorporated into the standards of operation or the best practice guidelines for the unit • Changes need to be incorporated into education and training plans • Documents such as meeting minutes, reports, correspondence and worksheets form the basis for reviews.

49. Sustainability • Measurement and review • Measurement ensures that the changes are actually being implemented • Ensures that benefits continue to occur • Identifies is problems arise • Some of the testing should be considered for permanent use • Measurement supports the review of the achievements of the team • KPIs and links with Balanced Scorecard

50. Sustainability • Training and education • Staff must all know why the changes are implemented • People must know how to implement the changes • The extend of training and education required depends upon the size of the change and the number of people affected.