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Using Quality
Improvement ToolsMargaret Stone and James Innes
Introduction
1. Introduction to tutors
2.Project speed dating
3.Diagnosing the context for improvement work
4.Quality tools
5.Moving the project forwards
6.Questions
Learning outcomes
After the session on using Quality Improvement Tools, participants will be able to:
1. Diagnose the context for the patient safety related project.
2. Use quality tools to understand the patient safety issue.
3. Understand the next steps to move the project forwards.
Project speed dating
In your table groups:
90 secs to explain your project to the rest
of the group
Title
What is the issue you are trying to solve?
Why – do you have data to show that there is
an issue?
When bell rings, the next person has 90 secs
to explain their project
…….
Diagnosing the context for
improvement workJames Innes
Context is everything –Professor Paul Bate
The role of context in successful improvement –Professor Glenn Robert and Professor Naomi Fulop
How does context affect quality improvement? –Professor John Øvretveit
The problem of context in quality improvement –Professor Mary Dixon-Woods
What is context?
“context refers to the why and when of change, and concerns itself both with
influence from the context external to the provider (such as the prevailing economic,
social, political environment) and influences internal to the organisation under study (for example its resources, capabilities, structure,
culture and politics).”
A tool for understanding context for QI
MUSIQ(The Model for Understanding Success in Quality)
Heather Kaplan, Lloyd Provost, Craig Froehle, Peter MargolisBMJ Qual Saf 2012; 21:13-20
Model for Understanding Success in Quality (MUSIQ)
• Tool designed to help you assess aspects of your local context that may affect the success of your quality improvement project
➢ QI project team: diversity, leadership, subject matter knowledge, experience of working together.
➢ Microsystem: motivation to change, stable leadership, capability for change, culture.
➢ QI Support and capacity: data infrastructure, QI resources, access to QI knowledge.
➢ Organization: Culture focused on improvement, QI leadership, strategic importance.
➢ Environment: promoting culture of improvement, do external pressures focus attention on your project.
Model for Understanding Success in Quality (MUSIQ)
• Excel calculator
• Download from the microsite tools page
• Project lead to fill out with your QI coach at the start of your project
• Score each element of context, and it will calculate your total score
168 Highest Possible MUSIQ Score
120-168 Project has a reasonable chance of success
80-119 Project could be successful, but possible contextual barriers
50-79 Project has serious contextual issues and is not set up for success
25-49 Project should not continue as is; consider deploying resources to other improvement activities
24 Lowest Possible MUSIQ Score
• Look at areas of weakness and see if you can address at the start of the project
MUSIQ
Thinking about your own context, rate your readiness in each of the following
areas:
Not ready at all
Totally ready
Don’t knowN/A
1 2 3 4 5 6 7 0
➢QI project team
➢Microsystem
➢QI Support and capacity
➢Organization
➢Environment
Neutral
Quality ToolsMargaret Stone
What are quality tools?
Tools used to systematically and objectively investigate a
problem/issue and try to determine different areas that can be
changed to improve quality in a system.
Good lists of those used in the NHS at:
https://improvement.nhs.uk/resources/quality-service-improvement-
and-redesign-qsir-tools/
http://www.pharmacyqs.com/common-quality-improvement-tools/
We will consider
Process mapping Stakeholder analysis
Cause and effect Driver diagram
Process mapping
Map or flow chart of a journey through a process
Often from patient’s perspective
Tips:
Be honest Map what, who, how long, (where)
Involve lots of people Be prepared for problems/solutions
Don’t make assumptions Create with different coloured post-
it notes
Break down into lots of
steps
Go with most commonly used process
Include branches and side
loops
Agree start and finish points
Process maps
Stakeholder analysis
Used to identify everyone who needs to be involved in the QI project and how much time is needed for their commitment.
Use if project is bigger than just pharmacy, especially if it goes outside organisation.
Structured way to identify stakeholders, prioritise their importance to the project, then analyse their readiness for change.
Then you know who to approach, when and how to motivate them.
Prioritising importance
Cause and Effect
Form of root cause analysis, also called “fishbone”.
Systematic way to look for influencing factors.
Do with a group of people.
Be prepared for problems/solutions.
Considers different factors:
Patient Individual (staff)
Task Communication
Education and Training Equipment and Resources
Working Condition Organisational and Strategic
Patient
factors:Clinical condition
Physical factors
Social factors
Psychological/
mental factors
Interpersonal
relationships
Individual
(staff) factors:Physical issues
Psychological
Social/domestic
Personality
Cognitive factors
Task factors:Guidelines/
procedures/
protocols
Decision aids
Task design
Communicatio
n factors:Verbal
Written
Non-verbal
Management
Team factors:Role congruence
Leadership
Support + cultural
factors
Education +
Training Factors:Competence
Supervision
Availability /
Accessibility
Appropriateness
Equipment +
resources:Displays
Integrity
Positioning
Usability
Working condition
factors:Administrative
Design of physical
environment
Environment
Staffing
Workload and hours
Time
Organisational +
strategic factors:Organisational
structure
Priorities
Externally imported
risks
Safety culture
Problem
or issue
(CDP/SDP)
Driver Diagram
Used with big projects to show an overall quality improvement goal can be broken down into its underpinning drivers and sub-projects.
Useful if you will be measuring improvement – helps you work out what to measure, and the impact of a specific change.
Brainstorm with a group of people.
Agree on 1 overall, measurable project goal.
Build a driver diagram.
Agree which drivers/actions you will prioritise to achieve the overall goal.
Driver diagram
Primary driver 1
Secondary driver 1
Change idea 3
Change idea 4
Change idea 5
Secondary driver 2
Primary driver 2
Secondary driver 3
Change idea 1
Change idea 2
Aim
Over to you……………
4 activities on tables
1. Process mapping
2. Stakeholder analysis
3. Cause and effect diagram
4. Driver diagram
2 tools each
Based on 1 project from the group.
Table hosts to guide activity
Break time!!
Chat to our industry
supporters.
Chat more about your
individual project
ideas.
Find out more about
the UKCPA.
Over to you……………
4 activities on tables
1. Process mapping
2. Stakeholder analysis
3. Cause and effect diagram
4. Driver diagram
2 tools each
Based on 1 project from the group.
Table hosts to guide activity
Moving the project forwardJames Innes
The sequence of improvement
Identification of quality
issue
Understanding the problem
Developing a strategy and change ideas
Testing Implementation & sustaining the
gains
The sequence of improvement
Identification of quality
issue
Understanding the problem
Developing a strategy and change ideas
Testing Implementation & sustaining the
gains
“Tools used to systematically and objectively
investigate a problem/issue and try to
determine different areas that can be
changed to improve quality in a system.”
The sequence of improvement
Identification of quality
issue
Understanding the problem
Developing a strategy and change ideas
Testing Implementation & sustaining the
gains
The big question…
Do I:
Simply implement identified solutions/change
ideas for my project?
Test solutions/change ideas first and then scale
up?
Dr Ronald A Heifetz. LEADERSHIP WITHOUT EASY ANSWERSHarvard University Press, 1994
The Messiness of Life!
34
“Some problems are so complex that you have to be highly intelligent and well informed just to be undecided
about them.”--Laurence J. Peter
A good reference on this topic is “Wicked Problems and Social Complexity “
by Jeff Conklin, Ph.D., Chapter 1 in Dialogue Mapping: Defragmenting Projects through Shared Understanding. For more information see the CogNexus Institute website at http://cognexus.org, 2004.
A P
DS
A
P
D
S
APD
S
AP
DS
Rapid cycle
testing
Develop a strategy
Prioritise and pick
change ideas
Observe the results
Implement,
adapt or
abandon
A structured approach to tackle complex problems…
Top tips to move from strategy to action
1. Leverage your existing assets:
Can you identify a project lead, project sponsor
Use MUSIQ to improve context for your project
Can you be explicit about the aim of your project, timeline and what you will need to drive project forwards e.g. access to data, staff time etc.
Top tips to move from strategy to action
2. Build a Coalition for Change:
How can you engage and inspire people about the project?
Use stakeholder map to identify champions for this work. How can you give them a central role?
Use the power of multiple communication channels (traditional vs disruptive) to build will
Top tips to move from strategy to action
3. Build Capability:
Use QI approach that is being championed by
your organisation
3 is the magic number for building capability in a
project team around QI method you will be using
Top tips to move from strategy to action
3. Build Capability:
NHS Improvement: https://improvement.nhs.uk/resources/quality-service-
improvement-and-redesign-qsir-tools/
Pharmacy QS: http://www.pharmacyqs.com/common-quality-improvement-
tools/
Health Foundation Q Community