Continuous Quality Improvement Tools and Techniques Workbook

WORKBOOK OBJECTIVES
This workbook has pre training work to consider and a post training action plan for your service. Please agree 1 action with your line manager for consideration while on this training. Support improvement methodology awareness training sessions. Introduce Improvement tools and processes. Introduce all work streams that are used within NHS Forth Valley. Introduce how these methodologies then fit with The Quality Strategy for NHS Scotland. Develop an awareness and understanding of some improvement methodologies. Stimulate and encourage staff to utilize improvement methodology tools and processes.

By working through the tools and techniques identified in this workbook hopefully you will be able to challenge processes and identify improved methods of work to provide value to patient care and your service.

PART 1 TO BE COMPLETED PRIOR TO AWARENESS TRAINING

Are you aware of any improvement work already planned for your area? (please detail below) If so, are you involved in this? (please tick) Yes (please detail below) No

What

Why

Which Quality Strategy priority does this come under?

What do you know about the quality strategy?

Managers Signature------------------------------

What improvement work have you heard of? (please tick)

NHS Forth Valley Change and Improvement plan

http://intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/ChangeImprovement/CI_intro.asp

LEAN Releasing time to care Scottish Patient Safety Programme The Productive Community Team The Productive Leader Long term conditions collaborative (LTCC) 18 Weeks referral to treatment (18/52 RTT) Mental Health Collaborative Improving Patient Care and Experience Whole Systems Working (GP) Triple Aim
What improvement tools and techniques have you heard of? (please tick)

Process Maps PDSA ECSS Fishbone / Ishikawa 5 Whys Spaghetti Diagram 6Ss 6Ms Patient Stories Visual Management DCAQ Statistical Process Control

PART 2 TO BE COMPLETED THROUGHOUT THE TRAINING SESSION

The ultimate aim of the Quality Strategy is to deliver the highest quality healthcare services to people in Scotland and through this to ensure that NHS Scotland is recognised by the people of Scotland as amongst the best in the world. The Institute of Medicines six dimensions of quality are central to our approach to systems-based healthcare quality improvement:

Person-centred: providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions; Safe: avoiding injuries to patients from healthcare that is intended to help them; Effective: providing services based on scientific knowledge; Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy; Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status; and Timely

The Quality strategy was built around these priorities:

Caring and compassionate staff and services; Clear communication and explanation about conditions and treatment; Effective collaboration between clinicians, patients and others; A clean and safe care environment; Continuity of care; and Clinical excellence.

Continuous improvement has been described as being about:

securing commitment from all to the idea of continuous improvement involving everyone in pursuing it promoting service-user satisfaction in every interaction with the service continually seeking a better way of doing things by maintaining the best of what we have and fully using our resources implementing recognised best practice to support development and equity across NHS Scotland creating learning organisations that are able to share and sustain improvements.

It calls for: a strategy, framework and methodology to manage the technical and behavioural aspects of change integration to support organisational priorities partnerships, including with patients and the public leadership a relentless commitment to service-user focus.

And it is created by examining and reviewing: processes systems products and services deployment of resources.

Thoughts/notes

Improvement work that is currently underway in NHS Forth Valley includes:

NHS Forth Valley Change and Improvement plan

http://intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/ChangeImprovement/CI_intro.asp

LEAN Releasing time to care (RTC) Scottish Patient Safety Programme (SPSP) The Productive Community Team The Productive Leader Long term conditions collaborative (LTCC) 18 Weeks referral to treatment (18/52 RTT) Mental Health Collaborative (MHC) Improving Patient Care and Experience (IPCE) Whole Systems Working (GP) Triple Aim
There are many different improvement tools and techniques being used within NHS Forth Valley, some of these include:

Process Maps PDSA ECSS Fishbone / Ishikawa 5 Whys Spaghetti Diagram 6Ss Patient Stories Visual Management DCAQ Statistical Process Control

IMPROVEMENT TOOLS AND PROCESSES

5 Lean principles
Specify Value Identify the Value Stream Map or patient journey Make the process and value flow Let the customer Pull Pursue perfection

Value Finding out what patients really want ... This can only really be defined by the customer Value is any activity which improves the patients health, well being and experience is adding value Anything else is waste Value Stream Analysis What is Value? Something that a Patient expects to happen Why Value Stream? Eliminate stop-start-stop-start Why Value Stream Analysis? It covers the whole patient journey from start to finish and identifies which steps add value and improve quality for the patient Flow Seamlessness reduce variation, ensure everyone receives the same standard of care Doing things at the right time, in the right place Align processes to facilitate the smooth flow of patients and information Ensures balance - you have the right capacity to meet demand Pull We should deliver care on demand with the resources needed for it We need to create pull in the patient journey- every step needs to pull people, skills, materials and information towards it, one at a time when needed This means responding to demand

Pursue perfection Develop and amend processes continuously in pursuit if the ideal For the patient this means completing their care and treatment with the best outcomes- on time, with no mistakes and without delays To achieve this we need consistent and reliable processes

PROCESS MAP (OR BROWN PAPER SWIM LANE MAP) What is this a picture of?

Process Mapping and Value Stream Mapping usually documents a process and key data associated with it to help understand current problems. This enables teams to quickly see improvement opportunities in the process and begin defining changes. The first step in this entails bringing a group of involved staff together to map the process end to end and to identify how it interfaces with other processes. Having key individuals involved improves ownership and outcomes. This activity: Captures the complexity of a given process. Simplifies the process by addressing specific measurable elements i.e. timing, quantity, cost or resources utilized. Identifies and develops ownership by defining starting and finishing points Identifies the various functions of those involved in the process. Swim Lane Mapping has more of an emphasis on the who. This is useful when a process is studied across 3 or more functions to show hand-offs, transport, queues and re-work loops. This activity demonstrates how to make the process more useful by ensuring all appropriate stakeholders are involved. If procurement, catering or other departments have a part to play in the process being mapped then they should be involved in the process mapping not just the clinical areas.

What does ECSS mean?

E C S S

ECSS
Once you understand the current picture of what really happens throughout the value stream, you can begin to agree what needs to happen and then analyse the gap between the current and future states. From your current state map you will be able to identify where the significant problems occur. This might be the most prevalent waits and delays, the largest amount of work in progress between process steps or where there is considerable duplication. There are four main techniques to design your future state. ECSS!

Demand and Capacity (DCAQ) What does DCAQ stand for?

Demand, Capacity, Activity & Queue (DCAQ) is a service improvement methodology used widely within elective health care services in Scotland to: analyse waiting list management define and regulate service capacity monitor patient throughput support effective demand management.

10

The four components are described as follows. Demand is all the walk-ins, ambulance cases and referrals coming in from all sources at the point of access, such as outpatients, elective admissions or a medical assessment unit. Demand is measured by multiplying the number of patients referred by the time it takes to process a patient. Capacity is all the resources available and required to do the work, including staff and equipment. It is measured by multiplying the number of pieces of equipment by the time available to the people with the necessary skills to use it. Activity is the work done, or the throughput of the system. It is measured by multiplying the number of patients seen by the time it will take to process a patient. Queue and Backlog: queues occur where demand has not been dealt with, and result in a backlog; backlog is the previous demand that has not yet been dealt with, showing itself as a queue or waiting list. Every time your demand exceeds your capacity, you carry forward the excess demand as backlog. They are measured by multiplying the number of patients waiting by the time it will take to process a patient. Demand, capacity, activity and queue (backlog) need to be measured in the same units for the same period of time. The data and patterns that emerge can be used to start predicting demand and managing capacity, activity and queues at the bottleneck. The overall goal is to manage capacity and demand appropriately, effectively and permanently.

7 WASTES
Please completes the words below to describe things that we do that are wasteful? If possible, please give an example in the box next to it.

11

What tools could we use to identify waste?

What is this a picture of?

12

SPAGHETTI DIAGRAM
Very simple however, a very powerful technique, depicting different aspects of workflow and how staff/people/resources move around. Using a floor plan or area layout distance covered is measured in one typical operation or procedure. These diagrams measure value added (any activity that is essential to deliver the service) and non value added activities (activities that are required by the NHS which are essential but add no real value from a customers standpoint).

Fishbone/Ishikawa diagram
A visual tool for organizing information that may clarify the main causes of a given event. Used to identify and understand the potential root causes so that collective actions can be put into place to eliminate recurrence. There are three steps required to constructing a fishbone diagram. 1. Identify the problem and write a statement at the fish-head. 2. Determine the major categories of the effect 3. Explore potential root causes. Thoughts/notes

13

Can you describe what PDSA means?

PDSA CYCLE

PDSA is the recognised tool within NHS Forth Valley for supporting quick rapid cycle change. It allows staff to identify their aim, set its objective, agree who does what and when and measures its outcome. If the ultimate aim is not met, the cycle is repeated. It is best to start small, make changes then go through the cycle again and again until a full change is implemented.

14

6Ss
6S promotes a safe working environment by improving standards that produce quality to the service. This can lead to more effective and efficient operations. 6S enables teams to improve workplace safety, reduce waste, simplify processes, troubleshoot and maintain service quality.

What are the 6S? S S S S

Making it all regular, common practice by building foundations and keeping it all together through checking or auditing practices. PDSA methodology is advocated to support changes getting embedded into practice. Embedding s in all everyday activity within the area. Making things., making sure that every thing and all areas are clean and clear. How you make S., S. and S..common practice. Remove everything from the workplace that is not needed for clinical care processes. Arrange and label items so they are easily located.

S S

VISUAL MANAGEMENT
Visual management is crucial for effective communication and team inclusion. There are two types of visual management: 1. Visual control: similar to traffic light system this demonstrates current position, identifies normal/ abnormal conditions and corrective counter measures. 2. Visual display: similar to graph or chart this demonstrates historical data or information, displays original information and identifies opportunities of improvement.

15

PART 3 ACTION PLAN(Post session work)

Development of an action plan:
Developing an action plan for your team will help improve sustainability and consistency and provide team focus and ownership.

manager) This action(s) will be followed up in 30 days to review progress.

What 1 2 3 4 5 Why

Could you now make a list of improvements you would like to make and why? (Please ensure you discuss this with your line

Could you now write a PDSA template for one of the improvements you have identified? Project Title Project Lead Project Start Date Project Completion date What are we trying to accomplish?

Please describe the changes we are going to make?

16

What do we Predict will happen once we have made these changes?

What measures will be used (e.g. qualitative, quantitative, new practice)?

Who will be affected by proposed changes?

What are the tasks/actions required to test the change idea? What Who How When

Useful Websites:
17

 The Knowledge Network www.evidenceintopractice.scot.nhs.uk NHS Scotland Quality Strategy www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality Scottish Patient Safety Programme www.patientsafetyalliance.scot.nhs.uk/programme NHS Institute for Innovation and Improvement, UK www.institute.nhs.uk Lean Enterprise Academy, UK www.leanuk.org Lean Enterprise Institute, USA www.lean.org Lean Enterprise Australia www.lean.org.au Institute for Healthcare Improvement, USA www.ihi.org Leadership www.nes.scot.nhs.uk/media/4310/deliveringqualitythroughleaders hip_brochure09.pdf 18/52 RTT intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/Redesign/FVR_18 WRTP.asp Mental Health Collaborative intranet.fv.scot.nhs.uk/home/Depts/MentalHealthResources/CGMH /CGMH_intro.asp Long Term Condition Collaborative http://intranet.fv.scot.nhs.uk/home/ProjectsInitiatives/Redesign/ FVR_LTC.asp

Further Reading:
Bicheno, J. 2004 The New Lean Toolbox. Towards Fast Flexible Flow. England: Picsie Books. Jones, D and Mitchell, A. 2006 Lean thinking for the NHS Lean Enterprise Academy UK. A report commissioned by the NHS Confederation Baker, M. Taylor, I. 2009Making Hospitals Work: How to improve patient care while saving everyone's time and hospitals' resources. Lean Enterprise Academy Limited
Author: Linda McAuslan Version 3 / Date 31.01.11

18