2. By the end of this session, participants will be able to:
Discuss the utility of Driver Diagrams as QI tools to systematically identify
change ideas to address quality challenges
Define primary and secondary drivers as they relate to quality challenges
Apply Driver Diagrams to quality challenges
Learning Objectives
3. Outline
What is a Driver Diagram?
Components and Development of Driver Diagrams
Techniques for generating change ideas
Group Work
4. Recap: QI Tool: Root Cause Analysis
Makes issues less
ambiguous
Minimizes bias
Incorporates the
perspective of
multiple team
members
Allows for a full
understanding of
all processes
Provides baseline
data
5
5. 1. Establish a QI team
2. Define the problem
3. Determine overall improvement aim
4. Develop system for measuring improvement
5. Identify & test change ideas
6. Collect data & analyze change
REMINDER: COMMON QI PROJECT STEPS
6. The Model for Improvement
AIM
What are we trying
to accomplish?
MEASUREMENT
How will we know if
a change is an
improvement?
CHANGE
What changes can
we make to result in
improvement?
Act Plan
Do
Study
- Langley G, Nolan T, Norman C, Provost L (1996) The Improvement Guide
Driver diagrams are a
QI tool that can help
teams answer this
question
7. Help to answer the question,
What change can we make that will lead to improvement?
• Conceptualize a quality issue and generate change ideas linked to root
causes
• Explore systems and process mechanisms through primary and secondary
drivers
• Generate theories and hypotheses about change initiatives that can
lead to improvement
Driver Diagrams
8. • Strategic planning and analysis tool that is updated
systematically throughout an entire project
• Breaks down an aim into the drivers that contribute to and
the detailed actions that could be done to achieve the aim
• Helps to focus on the cause-and-effect relationships
that exist in complicated systems
• Provides a pathway for change which identifies the types of
interventions that can bring about the desired outcome
Driver Diagrams: Purpose
9. Driver Diagrams
Logically links change ideas to drivers
Often used with Fishbone Diagrams and Process Maps as part of the
participatory improvement process to utilize the list of identified causes
and organize them into action steps that will lead to improvement aim
10. Driver Diagrams
Where possible, driver
diagrams should be
measurable and SMART
Can serve as both a
change and measurement
framework for tracking
progress towards aim
There is no right or wrong
driver diagram, diagrams
represent the team’s
shared mental model
Diagrams are living
documents and will adapt
as change ideas are tested
and results measured
through PDSA cycles.
11. • Aim Statement
• Primary Drivers: System factors, processes,
structures and influences that directly link to
aim
• Secondary Drivers: Situation-specific factors
that can form the basis for specific
interventions
• Change Ideas
• Measurement Indicators
Driver Diagrams: Main Components
12. Improvement
Aim
Primary Driver
Secondary Driver Change Idea
Secondary Driver Change Idea
Primary Driver
Secondary Driver Change Idea
Secondary Driver Change Idea
OUTCOME MEASURES PROCESS
MEASURES
Driver Diagrams: Outline
13. Key Components of a Driver Diagram
Improvement
Aim
Primary Driver
Secondary Driver Change Idea
Secondary Driver Change Idea
Primary Driver
Secondary Driver Change Idea
Secondary Driver Change Idea
Primary Drivers
System factors,
processes,
structures and/or
influences that are
directly linked to
the aim
Secondary Drivers
Situation-specific
factors that can
form the basis for
individual
interventions
Aim Statement
Improvement
goal
Change Ideas
Interventions
14. • Team approach: Gather key stakeholders
• Start with the improvement aim
• Brainstorm: What main factors influence the aim?
» Where? What? When? Who? Why?
• Group drivers into primary or secondary
• Generate change ideas related to the drivers
• Link the drivers and change ideas with arrows
• Include indicators and measurements
Developing a Driver Diagram
15. High-level factors that directly influence the aim
Can form the basis for outcome indicators
Examples can include the major categories in a fishbone diagram:
Primary Drivers
6 M’s
8 P’s
6 Performance
Factors
Manpower, Machines, Management, Measurement, Methods & Materials
Price, Promotion, People, Process, Place, Policy, Procedure & Product
Surroundings, Suppliers, Systems & Skills
4 S’s
Job expectations, Performance feedback, Environment &
tools, Skills & Knowledge, Organisational Support, Motivation
16. • Lower-level, more actionable drivers
• Drivers that can form the basis for specific interventions
• Situation-specific causes or factors that are related to the primary driver
• Measurable components are usually process indicators
Secondary Drivers
17. Is My Set of Primary and Secondary Drivers Complete?
To determine if the driver lists are complete, ask:
If I could influence or improve all these drivers, is there anything else that could
go wrong and prevent me from achieving my aim?
Completing Driver Lists
18. • Is This a Primary or Secondary Driver?
• To differentiate between drivers, ask:
If I made an improvement in this driver what would it achieve?
• If the answer closely describes the improvement aim, it is most likely a
primary driver
• If the driver is very closely linked with a specific intervention, it is
likely a secondary driver
Determining Driver Category
19. • Literature reviews and evidence base
• Professional networks and associations
• Stealing, borrowing and collaborations
• Review of failed ideas
• Creative brainstorming methods
• Other suggestions?
Generating Change Ideas
20. • Eliminate redundant steps
• Minimize handoffs
• Use multiple reminders, job aids, checklists
• Move steps in the process closer together
• Create closed-loop communication
• Remove bottlenecks
• Do tasks in parallel, use “coordinators”
• Increase access to information
• Use cross-training and optimize supportive supervision and mentoring
Change Ideas: Project Level
21. • Redesign processes
• Update and standardized treatment guidelines
• Reorganize staff and supervision
• New technology
• Bundle a package of changes
• Engage clients and communities
• Benchmark sites and teams
Change Ideas: Program Level
22. • System redesign
• Task-shifting and sharing, introduction of new cadres
• Integration of services
• Regulatory changes
• Benchmarking of programs and regions
• Linking payments and performance, for example performance-based
financing
Change Ideas: System Level
23. Aim for quantity (The more ideas the better)
Encourage participation (Welcome & note all ideas)
Do not rush to criticize
Once list is complete
o Categorize/group ideas
o Analyze & reduce list of ideas
Brainstorming change ideas: Dos & Don’ts
24. PRIMARY SECONDARY INTERVENTIONS
Human
Resources
Knowledge of
Handwashing
Staff Shortage
Poor
Deployment of
Trained Nurses
Advocate to
Employ More
Nurses
Effective
Deployment of
Trained Nurses
Training &
Mentorship on
Handwashing
- Kenya Global Nurse Capacity-Building Program
Common Errors
#9:Driver Diagrams are a tool designed to answer that question.
The driver diagram is a useful tool for Gaining knowledge about improvement. Aids in establishing consensus in change initiatives.
Serves an excellent communication tool for the team approach, leadership commitment. Helps teams focus and communicate thoughts
Another example of a QI tool that can be applied in almost any environment for any level of the health system
Action Oriented tool!
#14:Driver diagrams are a tool designed to answer this question. In addition, they:
Are useful tool for gaining knowledge about improvement, and aid in establishing consensus around change initiatives
Serve as an excellent communication tool that help teams build rapport while focusing ideas
Can be applied in almost any environment, for any level of health system
Are action oriented (i.e. living documents that evolve over time)
#15:Before we dive more deeply into driver diagrams, I want to introduce this example from a district-level QI project in South Africa.
Without having any other information about this project, what can you tell me about this particular project?
Driver diagrams help generate theories about what change ideas will lead to improvement, based on the drivers of the problem at hand. They help predict what types of system changes will affect improvement towards achieving the aim.
As my colleagues have been emphasizing greatly, the team approach is a core component of any QI initiative, but that’s much easier said than done! Tools, including driver diagrams, can help facilitate the discussion process while allowing all team members a chance to voice their perspective. This also helps build trust and buy-in among team members for implementing change ideas. Driver diagrams are helpful in communicating and demonstrating that interventions are based on a sound theory of change (practical) and accountable for results (measurable).
#16:Here are a few core concepts of driver diagrams, however it’s important to remember that QI teams may construct their driver diagrams differently, which is completely fine as they are shaped by the language and thought processes used in creating them. (They are the result of a team’s shared mental model.)
#18:Relationship arrows show the connection between drivers and the aim and change ideas.
Relationship arrows also Demonstrate the causal relationship
#19:Driver diagrams have a somewhat backwards approach to developing a shared theory of change. You start with the aim statement and unpack factors that contribute to achieving it (i.e. drivers). Broadly speaking, there are six steps to developing a driver diagram:
Start with the aim statement
Brainstorm drivers (factors that will contribute to achieving the aim)
Group drivers into ‘primary’ and ‘secondary’ categories
Link primary and secondary drivers with relationship arrows/lines
Generate change ideas linked to secondary drivers
Develop a measurement plan
#20:In addition to what’s illustrated here, relationship arrows/lines demonstrate the connection or causal relationship between the aim, drivers and change ideas.
#22:Other examples can include:
Often primary drivers are easier to identify especially in a system that is well known.
#24:When you are finished with the steps In constructing a driver diagram.
Review with the team to determine if its complete.
#25:It is very common to wonder and debate: is this a primary or secondary driver?
Use this guiding question to help teams feel more confident with their categorizations.
When identifying drivers or testing them for completeness do not get too hung up on finding every driver or determining if it is a primary or secondary driver. T
he purpose here is to help you identify improvement opportunities and be able to show a clear, defensible logic for how your improvement projects contribute to achieving your main aim or goal.
#31:Let’s revisit the first example I shared from a district-level QI project in South Africa. They prioritized the three change ideas highlighted in orange.
#32:Having asked questions, generated and prioritized change ideas, this QI team is now ready to begin taking action to test whether their change ideas affect improvement.
#33:Here is part of a driver diagram taken from the Kenya Global Nursing project. Can I have a volunteer to critique it?
What I want to illustrate is that interventions or change ideas need to be an actual activity rather than simply restating the secondary driver. In addition, ‘training and mentorship’ is a bit vague, but then so it advocacy…
#36:Okay. I think you’re all ready now to work with your teams to develop a driver diagram for your QI for DSD projects. You’ll have one hour and I encourage you to refer to the fishbone diagram you developed yesterday.
