Improve

Embedding a culture of continuous learning through a common methodology.

Our Methodology

We advocate the Institute of Healthcare Improvement’s Model for Improvement with an emphasis on teamworking and stakeholder engagement as well as establishing and identifying the problem to be addressed.  This methodology provides a simple, easy to follow 7-step process which is easily scaled to the size of your improvement project.

 

The Model for Improvement is a simple yet powerful framework for accelerating improvement and has two parts:

 

  • Three fundamental questions to answer:
    • What are we trying to accomplish?
    • How will we know that change is an improvement?
    • What change can we make that will result in improvement?

 

  • The Plan-Do-Study-Act (PDSA) cycle to test and adapt changes to ensure they result in the desired improvement.

 

The Model for Improvement has been used successfully in many industries, including thousands of health care organizations in numerous countries to improve countless different processes and outcomes.

 

The 7-step methodology sets out each key element of running an improvement project in order to minimise resistance to change and deliver sustainable, measurable improvement.

FORM YOUR TEAM

Form your team

Improvement work thrives with a team. People involved in parts of the process or system that you are trying to improve bring diverse perspectives and expertise that can fuel more effective ideas for change that are more likely to be sustained while building will to make improvements. 

Key steps:

  1. Consider the purpose of your improvement
  2. Go to where the improvement effort is needed
  3. Ensure the people who are familiar with this area/problem are involved.
  4. ALWAYS think of your customer.
  5. Think about the role people play.
  6. Consider how you will communicate with everyone to maximise success.

SET YOUR AIM

An aim statement answers the first question of the Model for Improvement: What are we trying to accomplish?  To understand this, you first need to identify the problem you want to solve. What is the reason for change?

Key Steps:

  1. Data gathering
  2. Understand and map the process
  3. Observe the process in action

Once the reason for change is clear you can establish your aim. A good aim statement will:

  • Tell us what is being improved.
  • Be time-bound and measurable (how much? by when?) 
  • Define the specific population whose lives will be affected by the improvement effort
  • Identify where the improvement is taking place

It is important to engage the individuals who will most benefit from the improvement in defining the aim.

Key Steps:

  1. Keep it SMART (specific, measurable, achievable, realistic and time-bound)
  2. Codesign the aim with your stakeholders, including your Experts by Experience

Establish measures

Measures help teams answer the second question of the Model for Improvement: How will we know that a change is an improvement? 

Teams use feedback in the form of quantitative and qualitative data to learn if a specific change leads to an improvement. The individuals who will most benefit from the improvement must contribute to identifying measures that reflect improvement from their perspective.

Key steps:

  1. Agree your measures
  2. Think about the different types of measures – outcome, process, structure, balancing
  3. Think about using qualitative and quantitative data
  4. Think about how you will present the data

Select changes

To answer the third question of the Model for Improvement — What change can we make that will result in improvement? — teams identify potential ideas for change. 

Ideas for change may come from those who provide input into, work in, or are recipients or customers of the system, or from the experience of others who have successfully improved. Engage the individuals who will most benefit from the improvement in identifying and co-designing potential changes.

Key steps:

    1. Select ideas for change – what can be tested
    2. What did your examination of the existing system tell you? What are the wastes? Where are the opportunities for improvement?
    3. Bring together different groups of people to generate ideas
    4. Honourable creative theft! Find out what others have done.  Use our Knowledge and Library services to help investigate best practice and understand what is possible.

Test changes

The Plan-Do-Study-Act (PDSA) cycle is a method for learning how the change will work in practice – by planning, trying it, observing what happens and acting on what is learned.  It is a fundamental part of the Model for Improvement.

Testing on a small scale before widespread implementation costs less time and money and reduces risks.  It also helps to increase the belief that the change will result in an improvement and acts to minimise resistance as people feel part of the change.  It is a powerful learning tool.

Key steps:

  1. Plan – What are you testing? Predict what might happen. Develop the plan to test.
  2. Do – Carry out the test.  Document what happened. Collect relevant data.
  3. Study – Analyse the data. Compare the data to your predictions. Reflect on what you learned.
  4. Act – Act on what you learned. Decide to adapt and test again, abandon or adopt.

Implement changes

After testing and finding a change you are confident will result in an improvement, you will need to make the changes permanent and sustainable.  The change will need to be hardwired into current work practices so the necessary infrastructure will need to be in place to ensure the change is supported and sustained over time.

Key steps:

  1. Be clear that a process is in place to support the change.
  2. Make things fool-proof.
  3. Provide sufficient training and support.
  4. Keep measuring to show impact.

Example:

  • Testing – a new medication order form is tested on a ward by different nurses on different shifts
  • Implementing – the new form is made standard practice. All staff are notified of the change and offered training and support, and the old form is removed from the ward. The new form is saved and a plan made for who will ensure there are sufficient copies of the new form available.

spread improvement

Spread is the process of taking a change that has been successful in one place and using it in another.  We will know that we have succeeded when knowledge for improvement developed anywhere in the system rapidly becomes common knowledge and is acted upon by all parts of the organisation. Successful spread requires the same elements as the original improvement change.

Key steps:

  1. Leadership
  2. Adoption plan
  3. Good communication
  4. Clear measurement
  5. Feedback

Example:

  • Implementation – A new form is made standard practice in one hospital. The form is embedded into their electronica patient record (EPR) and all new staff are trained on it.
  • Spread – another hospital using they same EPR meets with the team involved in implementing the new form to understand their learning during testing and implementation. This will then accelerate the pace of testing and implementation in their own hospital.

 

It is important throughout the seven steps, but in particular at the end to recognise the team’s efforts and celebrate the success of the improvement.  Share the learning, both what worked well and what didn’t, with others as part of the organisational lessons learned plan.

Our project documentation supports you through each element of this pathway and will enable you to maximise the delivery of successful and sustainable change. You will find more support under the resource and template section.

Toolkit

There are a number of tools that will help you at the different stages of your improvement journey. Some tools can be used at more than one stage.

The matrix below will help identify what activity and tools can help you.

Forming the Team

What needs to be done?

  • Who needs to be involved?
  • What role will they play?
  • How will you communicate?
  • Who will be part of the core team?
  • When/how will you meet?
  • How will you involve those with lived experience?

Key Activites

  • Stakeholder Analysis
  • Kick-start meeting
  • Co-design workshops

Consider

  • Think about engagement and communications
  • Think about Human dimensions of change

Optional support tools and templates

  • Stakeholder analysis grid

Set your aim

What needs to be done?

  • What is the problem you are addressing?
  • Is there a consensus
  • What does the data, patient, staff tell us?

Key Activites

  • Mapping
  • Observations
  • Data Gathering
  • Co-design workshops

Consider

  • Think about Human factors
  • Mapping current state
  • Observations of the process
  • Think about storytelling – How will you create a narrative to engage everyone
  • Think about value, waste and variability
  • Think about how clinical audit identifies areas for improvement
  • Think about what is in your control to change

Optional support tools and templates

  • Brainstorming – wall of opportunity
  • Process mapping
  • Fishbone
  • Five Whys
  • Problem statement template
  • Aim statement template
  • Driver diagram

Establish Measures

What needs to be done?

  • How will you know your change is an improvement?
  • What measures will you agree?
  • How will you collect the data?
  • Who will collect the data?
  • How often will you collect the data?
  • Ensure you collect your baseline measures before making any changes.

Key Activites

  • Data Gathering
  • List of measures
  • Collect baseline measures
  • Set up regular project huddles
  • Identify benefits from the project
  • Think about risks and issues to delivery
  • Open up your lessons learnt log
  • QEIA process

Consider

  • Think about collecting qualitative and quantitative data
  • Select different types of measures
  • Think how to display the data – run charts are best for showing improvement over time
  • How to use visual management tools to support your improvement (e.g. quality boards)

Optional support tools and templates

  • Driver diagram
  • Measures template
  • Benefits realisation template
  • QEIA full template

Selecting changes

What needs to be done?

  • Select ideas for change? What will you test?
  • Understand what has been done elsewhere – what is the best practice?

Key Activites

  • Co-design workshops
  • Literature Review – seek out best practice elsewhere

Consider

  • Think about involving different people and going to different places to generate ideas and challenge thinking

Optional support tools and templates

  • Brainstorming – wall of opportunity
  • Prioritisation tools – MSC, TPN

Testing changes

What needs to be done?

  • Carry out Plan, Do, Study, Act cycles
  • Plan what you will do and predict the outcome, carry out the plan and review what happened, compare to your prediction, plan the next step.
  • Keep testing until you are sure you have found the best way of doing things

Key Activites

  • PDSA Cycles

Optional support tools and templates

  • PDSA Template

Implementing Changes

What needs to be done?

  • Embed the chosen change
  • Ensure processes are in place to support the change
  • Ensure people are trained and supported
  • Keep measuring

Key Activites

  • Measuring
  • Establish processes
  • Establish training packages

Consider

  • Think about making new processes fool-proof so the change is sustained and embedded
  • Think about how you move this into business as usual
  • Think about the training and support that staff and patients may need
  • Think about your resilience – this is often the most difficult part of the project

Optional support tools and templates

  • Celebration poster/video

Spread

What needs to be done?

  • Share the learning and see if it can be adapted/adopted in other areas
  • Share the lessons learned log
  • Thank the team and celebrate the improvement

Key Activites

  • Sharing the celebration event
  • Spread process

Consider

  • Think about how the improvement change can be shared elsewhere
  • Does it need to be adapted to better fit a different team/area
  • Consider the project methodology and how it will re-start to support the adoption of this change in a new area

Optional support tools and templates

  • Celebration poster/video
  • Consider earlier documentation to ‘start’ the project in other areas

Improvement Tools and templates

[List of tools and templates as on I&I ICON page – but need to review and order according to each step and also be able to search alphabetically.]

Improvement coaching

Our ambition is for all our staff to continually improve, and we have built our improvement curriculum to support that.  However, the reality is that the process of embodying continuous improvement principles is challenging. So how do we ensure that everyone receives the support they need to improve their services?  

 

We do this by providing access to improvement coaching.

People doing improvement work

  • Numerous in size: NHS ambition is that everyone does improvement, every day.
  • Often only basic QI knowledge
  • Training up everyone in advanced improvement methods and skills isn’t the answer.

Central Improvement Team

  • Improvement experts
  • Often small in number (WTE)
  • Large and broad remit
  • Support organisational priorities (e.g. waiting times, flow, etc).
  • Support ‘bottom-up’ improvement by providing training in improvement methods and facilitation of project work

Quality Coach

  • Frontline staff who have been trained in how to coach and support teams through QI work
  • Championing the importance of improvement at a local level

Coaching improvement involves working with teams and individuals to coach and support them through improvement work.  It is based on conventional coaching (focused on self-development and growth), with improvement skills in order to help others to success in their improvement work.

Improvement coaching - how can it help me?

Improvement coaching can help you at any stage of your improvement project from diagnosing the problem right through to sustaining and closing the work.

An improvement coach will bring their knowledge of our improvement methodology and associated tools and challenge and encourage you to make the most of your improvement project.

 

Our improvement coaches are either from our core  improvement and innovation team or are individuals with a passion for and experience in improvement who have attend our coaching development programme.

 

As well as providing practical coaching advice and tools along your journey, our coaches can also offer facilitation support for process mapping or stakeholder engagement sessions.

 

To ask for support with your improvement project please contact tsdft.improvementandinnovation@nhs.net

Improvement coaching - how can I become one?

Improvement coaches play a crucial role in our organisation, supporting the development of a culture of continuous improvement. Improvement coaches help to bridge the gap between the bottom of the triangle where all staff should have an understanding of improvement and the top where the improvement and innovation sit.  

 

Our Coaching development programme provides an opportunity to capitalise your passion and enthusiasm and knowledge already gained and to further develop your coaching skills and improvement techniques so that you can then support others to successfully test and implement improvement change.

 

The only pre-requisite is that you have already attended our 4-day practitioner programme (or equivalent) and are able to attend the top-up programme.  You will then become the ‘go-to’ improvement support within your area whilst knowing you have the support of the Improvement and Innovation team and are part of a wider improvement coach network.

 

We run one coaching development programme a year, to find out more contact tsdft.improvementandinnovation@nhs.net or click on the HIVE to find the next dates.

Improvement stories

[Link to our case studies and posters]

Knowledge & Library Services

[Link to Library pages]

Other learning sites

Below you can find some links to a variety of other useful learning sites & resources