First steps towards quality improvement: a simple guide to improving services

NHS
CANCER DIAGNOSTICS HEART LUNG STROKE
NHS Improvement

First steps towards quality improvement:

A simple guide to improving services

IMPROVEMENT. PEOPLE. QUALITY. STAFF. DATA.
STEPS. LEAN. PATIENTS. PRODUCTIVITY. IDEAS.
REDESIGN. MAPPING. SOLUTIONS. EXPERIENCE.
SHARE. PROCESSES. TOOLS. MEASURES.
INVOLVEMENT. STRENGTH. SUPPORT. LEARN.
CHANGE. TEST. IMPLEMENT. PREPARATION.
KNOW-HOW. SCOPE. INNOVATION. FOCUS.
ENGAGEMENT. DELIVERY. DIAGNOSIS. LAUNCH.
RESOURCES. EVALUATION. NHS. PLANNING.
TECHNIQUES. FRAMEWORK. AGREEMENT.
UNDERSTAND. IMPLEMENTATION. SUSTAIN.

FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S

CONTENTS
4 Introduction
6 Chapter 1 - Improvement models
8 Chapter 2 - Defining the change idea and developing aims
11 Chapter 3 - Managing a successful project
14 Chapter 4 - Levers and drivers – framing the work for a wider audience
16 Chapter 5 - Getting the right people involved
18 Chapter 6 - Involving patients and carers in service redesign
22 Chapter 7 - Communicating the right things to the right people
24 Chapter 8 - Improvement Tool: Process mapping
28 Chapter 9 - Improvement Tool: Plan Do Study Act Cycles
30 Chapter 10 - Measuring your efforts
34 Chapter 11 - Improvement Tool: Using statistical process control charts
37 Chapter 12 - Human dimensions of change
40 Chapter 13 - Sharing your success
44 Resources
44 Acknowledgements

2/3


INTRODUCTION
If you are involved at any level in improving health or Before implementing a solution and changing your service, it is
social care, this resource will provide the information essential to understand your current system by mapping the
you need for your first steps towards making quality process, collecting and analysing the service data, along with
improvements, giving your improvement project the asking patients and staff for their views in order to determine
best possible chance of success. where improvements can be made. Don’t rush into
implementing whole system changes without testing and
Whether you are experienced at running improvement measuring small incremental changes. Learn from experience
projects or not, this blend of project management and and be prepared to be flexible as your first idea may not be the
improvement tools, combined with practical know-how best or the right solution.
and first hand experience gained from working with NHS
teams, should prove invaluable. This resource is not intended as a complete guide but provides a
short overview with the most relevant tools and other resources
signposted for further exploration.

If you want to deliver sustainable improvements with greater
speed and confidence, this resource will help you take the first
steps.

“ Every system is
perfectly designed
to get the results it
achieves”
Paul Batalden

4/5


Do I really need a model to

CHAPTER 1 improve things?

Very often, it is clear that we need to
get on and improve things and you
Improvement models may be tempted to leap in and do so.
However, a very high proportion of
There are many models which can support understanding what you are going to projects fail, and one way to increase
your improvement project; however, we accomplish, identifying a core team to the chances of your own project
promote two such models: a five step undertake the work and a team to support succeeding is to adopt a more
approach to successfully manage the the direction of the work along with systematic, tried and tested approach
change project from initial concept to identifying patients and carers to be such as those outlined on this page.
completion, and the Model for Improvement involved. Work should be aligned to both Quality improvement requires the will,
to provide a framework for developing, local and national objectives together with
the ideas and the execution of those
testing and implementing changes. structured plans to measure improvements.
ideas to succeed – very often, we have
Five step improvement approach The launch phase is the official start of the the will to make things happen, but by
NHS Improvement has defined a five step project. The team should be formed; project using models such as these, we can
improvement approach to provide a plans, communication plans and data ensure we develop the best possible
systematic framework from the beginning collection plans should be in place and an change ideas and approach
to the end of your improvement project executive sponsor identified to support the implementation in a planned and
which will give your project a greater project.
systematic way to enhance our
chance of sustainable success.
The diagnosis phase is about chances of success.
• Preparation understanding the current process,
• Launch dispelling assumptions, using data to define
• Diagnosis the problem and to build upon the baseline
• Implementation data.
• Evaluation
The implementation phase tests and The final phase is evaluation where
The preparation phase incorporates measures potential solutions using a Plan Do achievements are celebrated, learning and
everything you need to do before the Study Act cycle (chapter 9), implements the principles are captured and the improvement
official start of your project. This includes best solution and introduces standard work becomes the norm.
defining your project aims and objectives, and mistake proofing for a quality
collecting baseline data for your service, sustainable process.

The sum of all of the change ideas that are • Measure regularly during testing – what is
Model for Improvement
tested and successfully implemented will be the impact immediately, and what is the
What are we trying to accomplish? the effective redesign of processes or ways impact over a period of time?
How will we know that a of working. • Continue to measure after the
change is an improvement? improvement is implemented, to ensure
What changes can we make that will
The framework, which was developed by a that the change is sustained.
result in the improvements that we seek? team at the Institute for Healthcare
Improvement in the USA, includes three key What changes can we make that will
questions to ask before embarking on a result in improvement?
change programme, supported by a process • Many change ideas are generated at
for testing change ideas using Plan, Do, process mapping events (See Chapter 8)
Study, Act (PDSA) cycles. • Use techniques of creative thinking and
ACT PLAN innovation to generate ideas and to sort
What are we trying to accomplish? them into those to be tested
• Clear and focused goals that focus on • Learn from your colleagues – we know
STUDY DO problems that cause concern for patients that there are many examples of good
and staff practice currently available.
• Consistent with local and national
outcomes, plans and frameworks The Model for Improvement is a tried and
• Bold and aspirational tested approach for implementing any
• With clear numerical targets. aspect of change in health services. Address
the three questions before embarking on
How will we know if a change is an service redesign, to keep the work focused
The Model for Improvement improvement? and relevant and to ensure that you can
The model for improvement is incorporated • What can we measure that will change if measure the impact of changing the system.
into the five step approach and was the system is improved? Use PDSA cycles (chapter 9) to test out ideas
designed to provide a framework for • How can we obtain this data? Is it on a small scale and to win commitment
developing, testing and implementing available in existing information systems, before implementing changes across whole
changes that lead to improvement. To or will we need to collect this manually? departments, processes and systems.
achieve improvements we need to take the • What is the best way to display the data
time to plan change and test it out and we collect so that we can decide whether Further explanation of the Five Step
resist the temptation to rush into wholesale we are improving the system and whether Approach and Model for Improvement is
changes to systems. This way, we will know the improvement is sustainable? detailed in later chapters.
what is working well, and what is not so • Measure the baseline – how is the process
successful. Small scale changes can be or system performing before the change
undone and replaced by alternative ideas. is made?

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What is the purpose of a clear aim

CHAPTER 2 or objective?

To ensure everyone is working
towards the same goal and everyone
Defining the change idea and has the same expectations. It is
important to define this clearly, so
developing aims that you can also identify what it is
relevant to measure and to help avoid
A clear and accurate project definition is one project creep as your work progresses.
of the most important tasks to ensure the A good aim statement can help to
success of any improvement project. motivate people about your project as
being something worthwhile,
When starting out, begin by focusing on the measurable and achievable.
problem you are trying to solve, rather than
a solution you are trying to implement - no
one likes change for change sake!

Analyse the problem by talking and listening
to those involved, collect baseline data and
recognise the impact of not changing
anything at all. Once you have a clear
understanding of the problem, it is vital to
obtain agreement and support from those
Examples of poorly written project aims
“ If you don’t know where
involved as you will find that different
people have different knowledge based on
We will improve cancer services
This aim doesn’t clearly state what the you are going, you are
their past experiences. Agreement will also
increase team engagement and will provide
change will actually improve and who would
be responsible in improving the services. Are likely to end up
somewhere else!”
a stable platform to take the next step in the improvements are for every cancer
developing the scope of your project with patient or just patients with certain types of
focused aims and objectives. cancer (e.g. breast cancer) or for all types of
cancers for a specific group of patients (e.g. Yogi Berra

Project scope children and young people)? The project
When defining your change idea, take time aim must stipulate how much the service is
to consider and clearly document what is going to be improved, when it is going to be
within the scope of your project as well as completed and what is the impact of the
what is out of scope. improvement.

The scope should include information about We will achieve a 20% reduction in Ensure your scope and aim is clear to
the project boundaries and key deliverables, emergency admissions for heart failure everyone involved. The language we use in
however be cautious of the size of the patients by July 2013 the NHS is sometimes ambiguous and can
project scope. A large wide ranging project This example does provide a clear a be interpreted in different ways by different
scope may mean the work does not have numerical target to aim for, but what is the people, for example “Self Management
enough focus or detail, or may achieve very 20% measured against? Is it 20% reduction Plan” - Is this a piece of paper with generic
little by trying to do too much; whereas a from the previous year? Is it realistic? Could information given to all symptomatic
narrow focused scope may lead to a project it be achieved? patients or a personalised care plan for each
that does not make a significant difference patient? It is really important that you are
and cannot be transferable or able to scale All practices need to use a care planning clear in your aim and don’t leave anything to
up. approach for all patients with a long chance.
term condition
A well defined project scope is critical to ‘Need to’ is not an improvement aim. Is this
prevent a project creeping out of control. all practices across the country or all
‘Project Creep’ is when the scope of a practices in the consortia? Which care Why should I get consensus about
project grows from its original parameters planning approach should be used? When the problem before starting the
into something more or different from the should this be completed and what will it project?
original intention. Implications of a achieve?
changing scope could include project failure, There are numerous reasons why you
unclear deliverables, confusion, increased A good aim may look like this should discuss the problem and
budgets and expanding timeframes. 100% of patients on our list with a
achieve a consensus before starting
confirmed diagnosis of COPD will have a
Project aim comprehensive review and will have an your project. Different people will
A project aim should be aspirational, individualised care plan developed with the have different ideas about the
measureable and consistent with local and lead GP or practice nurse by March 2013. problem, so it is important that you
national priorities and plans. This will ensure that they are optimally cared understand their perspective (as you
for and better able to manage their might learn something new) and for
A good aim statement should include: condition, thereby reducing the frequency others to understand your perspective.
• What we are trying to achieve and severity of exacerbations and the need
See the elephant analogy in chapter 3;
• For whom for possible future hospital admissions.
• How much very few people will understand the
• By when full story as their perspective is based
• Compared to what on their own experiences. This process
• And why? of gaining consensus, talking and
listening to the people involved in the
process will assist with engagement
and support for the project.

8/9

An adaptation of a Hindi proverb
Five visually impaired people touch an elephant to learn
what it is like. Each one feels a different part.

"Hey, the elephant is like a tree trunk," said the
first man who touched the elephant’s leg.
"Oh, no! The elephant is like a snake" said the
second man who felt the trunk.
"Oh, no! It is like a rope," said the third man who
touched the tail.
"It is like a brush" said the fourth man who
rubbed the elephant ear.
And the fifth man said "It’s soft and mushy…"

They began to argue about the elephant and they all
insisted they were right. They all were right in what they
were saying as they had all developed an understanding
based on their own experiences and perspective. However,
they did not have an understanding of the whole elephant.

Imagine the elephant to be a patient. Different
clinicians and health care staff see the patient in
different ways, all of them correct, but by not seeing
the whole patient pathway, their understanding is
limited. Make sure you understand the entire
process/patient pathway before starting any
improvement project.


What makes successful projects?

CHAPTER 3 • Getting the right people
involved from the start of the
project
Managing a successful project • Having a clear aims statement
• Planning, monitoring and control
• Having a real understanding of
Starting out on any improvement project is • Collecting baseline data and having a the current issue or problem
an exciting time, and you are likely to be full data collection plan (Chapter 10 and 11) • Measurable improvements
of enthusiasm and optimism. However, • Understanding your customer which are achievements not just
things don’t always go entirely to plan and it requirements (Chapter 6). activities
can be hard to maintain impetus and • Having clear links to local and
progress with enthusiasm alone. A project plan is fundamental to the national objectives i.e. a clear
establishment of the project. It sets the reason to do it
For a project to be successful, it is important contract for improvement and establishes • Involving patients and carers,
that an adequate amount of time is spent the mandate, priorities and resource (ideally) from the beginning
on managing the project. availability. In other words, it spells out • Displaying effective
clearly what, how and when is to be done, communication.
Spending time getting the preparatory work so that everyone is aware of their
right first time will be beneficial later in the commitments and how they will impact on
project. Preparatory work includes: the project’s success. It can be tempting to
ignore this element as “bureaucratic” or The plan is developed in the preparation
• Getting the right team (Chapter 5) “administrative” but it is an essential tool phase of the project and enables decisions
• Having a good relationship with your for ensuring there is clarity about the project to be made with regard to modifying or
executive sponsor (Chapter 5) and that expectations are managed. This cancelling the initiative in situations where
• Having a solid project plan (Chapter 3) need not be an onerous process, but the the required support for the project either
• Having a robust communication plan plan does need to clearly spell out the key changes or is lacking. The plan is used
(Chapter 7) areas. throughout the project for monitoring
• Understanding the current service and control.
(Chapter 2 and 8)

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Why do projects fail?

A project plan should specify: • Project aims and objectives not
• Aims and objectives clearly defined or articulated
• Background to the project • Little or no top level support
• Scope of project and leadership for the project
• Expected deliverables • Lack of effective engagement
• Timescale with key players and patients
• Analysis of risk • Poorly planned projects
• Resources • Inadequately monitored,
• Budget controlled and managed
• Method/process • Failure to take account of local
• Accountability and national priorities e.g. QIPP
• Identification of the project sponsor • Poor communication
• Data and measures • Failure to divide the project into
• Dependencies (i.e. links between one small manageable tasks
action and another) • Unable to collect and analyse
• How the work is going to be sustained data.
and spread to other areas.

Project plans come in many different styles, but
each should set out all the actions that have to
occur to achieve the improvement, as well as
clearly stating when these will happen and
who is responsible for doing them.

Does someone need to project
manage for a project to be
successful?
Is my work a project? Yes, within the project team, someone
A project is a temporary piece of work needs to be responsible for the role.
with a defined start and finish, and will Without someone to undertake this
not continue indefinitely. Project work role, it is unlikely that even the smallest
is also designed to deliver a defined project team will deliver what it sets
outcome or benefit from doing the out to achieve within the agreed
work. parameters.

Isn’t project management just What is the difference between a
unnecessary bureaucracy and research and improvement project?
administration? An improvement project is about
Good project management is not just testing ways to implement evidence
bureaucracy. It is about ensuring there based care and find out the best way
is consistent co-ordination, drive and for a service to be organised and
evaluation of the project so that it delivered. It is about testing innovation
remains focused and effective. Not or new ways of working and not about
having someone to manage the testing whether treatments or
project usually means that no one interventions actually work.
takes overall responsibility for ensuring
that all the components are being
delivered – and the project may then
falter or fail.

What is the role of a project
manager?
The role of a project manager is to
have oversight of the entire project
and take responsibility for controlling
and monitoring each aspect, along
with reporting the successes, learning
and failures of the project. Not every
project needs to a dedicated project
manager, but every project requires
someone to undertake the roles and
responsibilities of a project manager
(see chapter 5).

12/13


What is QIPP?

CHAPTER 4 QIPP stands for Quality, Innovation,
Productivity and Prevention and
originates from the White Paper
Levers and drivers - framing the ‘Equity and excellence: Liberating the
NHS’ which sets out the government’s
work for a wider audience vision for the future of the NHS. The
QIPP agenda is all about ensuring that
each pound spent is used to bring
Changing established systems of any kind is
difficult. It is particularly challenging within maximum benefit and quality of care
healthcare because of the complex to patients. The QIPP initiative has
relationships between a wide range of been increasingly important in
organisations, professionals, patients and healthcare and looks set to continue
What levers and drivers could be
carers. relevant to my work? as the NHS needs to make savings
You might need to do some research because of increasing demand from an
Certain factors may help to foster an about local and national priorities. Quite
environment that is conducive to change ageing population and the increasing
often these are obvious and you can
and improvement. An organisation where need for long term condition
begin to ‘frame’ your work to align to
there is strong leadership and everyone is these. For example, you might be management. The NHS needs to
focused on improving patient care is more undertaking a project in primary care to achieve value for money and the best
likely to develop motivated staff with a reduce the number of emergency possible quality of care so that patients
desire for continuous quality improvement. admissions to hospital where the local get the greatest benefit.
However, barriers to changing established priority is to reduce bed days. There
practice may prevent or impede progress in would be a clear link to the local
all organisations, whatever the culture. initiative and the work you would then More information can be found on
undertake. www.improvement.nhs.uk/qipp
Sometimes a great idea can be presented
with various barriers and challenges to
change. Often taking time to identify the
barriers in order to overcome these is How do I link my work to local priorities?
essential to securing engagement and Talk to the local stakeholders about the work you propose and understand how it fits in. A
sustainability of the work. It is also number of these stakeholders may already be part of your project steering group, so take
important to look at the context of work time to discuss and explore this further with them. Your local clinical network may also be
you may be undertaking in terms of able to help you link to local priorities.
understanding both the local and national
drivers for change and levers for improvement.

Drivers are those forces for change that are There are a number of local and national
outside the projects scope of control. initiatives looking to improve local services What is a clinical network?
Drivers derive from a variety of sources, including calls for case study examples of A clinical network is a local NHS
including policy, that will change the way in good practice. It is worth spending some organisation made up of clinicians,
which the service may operate. Levers are time investigating what drivers are aligned managers and commissioners who work
those forces for change and improvement to your work, similar work within your together to improve care. They provide a
that are within the projects scope of control. organisation and opportunities to gain forum to share multi professional advice,
additional support where it may be influence and learning, to maximise
In parallel, linking with what is first seen as appropriate. knowledge and deliver better outcomes
primarily a small improvement project with for patients. They do this by bringing
local and national drivers for change can together primary care, secondary care,
enable a project to be further supported, commissioners, patients, social care and
How can I get wider engagement to other stakeholders with a common
successful and sustainable. Quite often
support my work? interest, to enable the local NHS to work
teams undertaking improvement projects
Raising the profile of the work, in a collaborative and co-ordinated way
focus purely on delivering isolated outcomes for its population, to best meet local
particularly if the work is aligned to local
for their work areas. Levers such as needs and priorities.
priorities will increase the chances of
reducing admissions or length of stay may wider engagement and support for the
be a local priority for a number of work. Talk to the service stakeholders
organisations in your area. It will help raise and try to secure project sponsorship
the profile of your improvement work if the from the chief executive or board level How can a clinical network help?
work is aligned to such initiatives, however director within your organisation. Also Networks focus on solving problems for
small. discuss the work with other patients wherever they are in the system,
management and clinical colleagues but stepping outside organisational
Look for similar current work already remember that these individuals may boundaries and seeking instead a whole
underway within your organisation. span wider than your immediate project system approach to service
Consider framing your work to the National group and include, primary care, social improvement. Networks will also share
QIPP agenda in terms of quality care, acute care, commissioners and the information, best practice, guidelines,
improvement, innovation, productivity gains ambulance service where relevant. Your and clinical learning to achieve greater
and prevention work. You may be surprised local clinical network may also be able to impact than would otherwise be
by how much difference your improvement assist with wider engagement and support possible. They can also influence
work contributes towards reducing costs, for your work. commissioning decisions about priorities,
availability and use of resources, to
enhancing productivity, enhancing quality
deliver optimum care to local people.
and increasing patient safety.
If your project demonstrates significant
scope to improve care, efficiency and
outcomes a network can help you
spread and sustain your work.

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How do I keep colleagues

CHAPTER 5 engaged?

Once you have built the relationship
and engagement has been achieved,
Getting the right people continue to work at it by:

involved • Staying in regular contact
• Keeping people involved and
updated
Some of the biggest risks to any project can • Having meetings with a
come from within the team. It is important Why do I need an executive sponsor? purpose, actions and outcomes
that the team has people with the right skills Executive sponsors should be chosen • Delivering what you have
and abilities to do the job and will be able to from the top of your organisation, ideally agreed to do.
give continued support to the improvement the chief executive or someone from the
initiative. executive team. This person will
champion your project, provide strategic
Having the right people involved from the support to the project, help to discuss
beginning with the right expertise will give and resolve issues, celebrate
achievement and provide access to HR,
your project the best chance of sustainable
Finance and IT teams when required.
success. If the right people are not involved
from the start, it will be much harder to
engage and involve these people at a later
date. Why is clinical and managerial
leadership important for my work?
A project sponsor and involvement from Clinicians and managers provide
the top of your organisation (Chief Executive different perspectives, experience and
or Executive Team) is necessary to champion support to your project. They will help
your project and provide strategic direction ensure that your project is appropriately
to the project. This type of involvement also targeted and relevant. Also they can
provides support to discuss issues, celebrate ensure that the changes you are testing
achievement and provide access to human are practically supported and promoted
resources, finance, analysts, communications, across different staff groups.
estates and IT teams when required.

Every project should have someone with an Involve all stakeholders and grades of staff
overview of the project who is responsible (clinical staff, GPs, porters, commissioners,
for the role of project manager. You reception staff, managers, pharmacists,
might be fortunate to have a dedicated clinical support staff, data analyst, medical
project manager to support your project, secretaries etc) as they will have different
however a project member may be required experiences, knowledge, skills, opinions,
to take on the responsibilities of this role ideas and concerns.
where this is not possible. It is advisable for
just one person to be accountable and have The involvement of patients, carers and
ownership to lead the project, ensuring charities is vital as they will be able to give a
decisions are made, actions taken, and different perspective on your service and
measurable, timely progress is made. proposed improvement plans.

Within the project team it is necessary to
have a variety of individuals, some whose
role will be to make decisions and others to
carry out actions.

When establishing a project team, consider
individuals or groups who are interested and
enthusiastic about the work, and those who
are in a position of power and influence. It
is also worth involving people or groups
who do not have direct interest in your
project but have a key position of power or
authority to make decisions.

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Why should I involve patients

CHAPTER 6 when I know what I need to do?

Patients’ experience of what we say,
do or mean can be very different to
Involving patients and carers that which we intend. By actively
involving patients, we can find out
in service redesign how what we do actually affects
them, what really happens day to day
and what we could do to improve
patients’ experience, reduce wasteful
processes and improve quality.
Patients and their carers are the reason
the health service exists and therefore
they should be at the heart of our
services.

Service improvement and redesign
generates opportunities to involve users
and their carers who can provide a different
perspective to enable a better understanding
of whether our improvements make any
difference.

A patient’s experience of our service can be
very different to what we intend or assume
it to be and they can tell us what works,
what doesn’t and what could be done
better. We might ‘know’ we are doing a
good job, but it needs to meet the patient’s
requirements.

Only when we understand a patient’s needs
– by asking them, not second guessing – can
we work in a way that meets those needs
and ensures they get maximum benefit from graham@ogilviedesign.co.uk
our service.

Why should patients and carers be Planning before involving Where can I find patients and carers
involved in the improvement of Planning is imperative to ensure that the who may support my work?
services? healthcare provider fully understands what There are many ways in which you can
• Raised awareness of how the service really they want from the interaction and how interact and contact patients and carers who
runs from the patient point of view, not they are going to meaningfully involve would like to be involved in service
just how the service providers think it runs patients and carers. improvement work. You can approach
• Different perspective on improvements people in your clinic, through hospital
and priorities The following planning steps should be departments, nurse specialists and patient
• Opportunity to discover what really makes undertaken before interaction with patients groups.
a difference to a patient’s experience and carers:
• Understanding what makes it difficult or • Be clear about what you want from Some organisations which can support the
easier for the patient to manage their interaction and what you are trying to placement of volunteer patients and carers
condition effectively achieve in service improvement work in the NHS
• Suggestions to make things quicker, • Address any staff concerns about patient include:
cheaper, easier or better to improve involvement/engagement • Local Involvement Networks (LINks) / Local
services and experience for patients and • Consider what previous patient HealthWatch (www.nhs.uk)
carers involvement has taken place and if this
• Learning more about the patient’s actual was successful. If not, why not?
experience and so providing a better • Decide on the type of patient – someone
understanding of their needs and priorities who is well informed about their
• Improved service user relationships with condition, newly diagnosed patient, I want to know more, where can I
healthcare professionals recently discharged etc. find detailed information?
• Opportunity to raise issues of importance • Decide where are you going to enlist this
to patients, carers and the public type of patient?
NHS Improvement has years of
• Improved and increased staff morale from • Decide on the level and method of
providing care to patients that they want, involvement you are going to use – i.e. experience in involving patients and
in a way they want direct, indirect questioning their carers. Information can be
• Ensure you have enough resources in found on our website:
place, e.g. time, finances, training (www.improvement.nhs.uk/ppe)
• Consider any practical arrangements that along with information about
need to be made Discovery Interviews™ which is an
• Test the method you propose to use, then
innovative technique designed to
amend where necessary
• Establish plans for evaluating your improve care by gaining insight into
approach. patient and carer needs and
experiences:
www.improvement.nhs.uk/
discoveryinterviews.

18/19


• Charitable organisations such as the
Stroke Association, MacMillan Cancer
Support and Asthma UK (find local
information on the charity websites)
• Local support groups
• Patient Advice and Liaison Service (PALS).

You may also like to consider advertising
your improvement work and asking for
volunteers through:
• Posters in GP surgeries, outreach clinics,
hospitals or other NHS settings
• Posters in libraries and pharmacies
• Social networking sites such as Facebook
and My Space.

What are the considerations for
involving patients and carers?
Sensitivity – the patients actually suffer
from and live with their conditions / illnesses
and sometimes service redesign work may graham@ogilviedesign.co.uk
take a depersonalised approach. This should
be considered if patient representatives
attend meetings or improvement events.

Cost – undertaking some forms of patient Examples of techniques to involve patients and carers
involvement may incur a cost for the patient.
It is reasonable to expect that patients and Direct methods Indirect methods
carers should receive reimbursement for the Interviews Questionnaires
costs they incur – travel, parking etc.
Focus groups Surveys
Representative sample – there is often a Workshops Suggestion boxes
challenge in finding patients who are
Face to face meetings with individuals Analysis of complaints
representative of the service you are working
to improve. For example, if meetings are Patient reps on project groups Public meetings / open days
arranged during working hours it is highly Patients attending service improvement events Social networking
unlikely that people of working age would
be able to attend because of other life
commitments such as work and children. If
you wish your patients to be truly Top tips for involving patients
representative you may have to consider a • Listen
number of methods. • Find ways to involve the seldom heard groups, those who find it difficult
to access health services or people who may not routinely get involved so
A range of opinions – patient engagement that you get a real understanding of different experiences
may elicit a different or even opposing • Take time to understand the issues, don’t assume you know the answer or
opinion to the work you are undertaking. It the solution
is important to know from the outset how • Use appropriate language, not jargon
to manage expectation realistically but also • Be clear about why you are undertaking involvement work and
to genuinely incorporate views and make how you will deal with what it reveals
change. • Be clear about any areas that can not be changed or are not for discussion
(e.g. national guidance), this ensures that the valuable time is spent
discussing what can be changed and that patients expectations are not
unduly heightened
• Always provide feedback to the patient and what has happened as a
result?

20/21


Why should I invest time to

CHAPTER 7 communicate what I know?

Don’t assume that other people

Communicating the right things (including your staff and colleagues)
know what you know. Everyone

to the right people connected to the service needs to
understand what you are doing and
why, and the impact it is having.

Keeping the improvement at the
forefront of people’s minds when
Communication not only keeps How often are you going to
everyone up-to-date on the project communicate? things are going well will ensure they
progress, but raises the profile of your • Daily, weekly, monthly. remain engaged and committed
project and facilitates engagement and which will make it easier for you to
ownership of the vision and service Who is going to be responsible for the gain support when you need it.
changes. To ensure the success of a communication?
project, information including the aims, • Project manager
Don’t expect people to drop
objectives, expectations, deliverables, • Executive sponsor
everything to help you if they have
timescales, progress, risks, challenges and • Named people
achievements need to be communicated on • Everyone. heard nothing from you for the last
a regular basis. six months! By communicating what
you are doing to others in your
Through two way communication, you
will probably find that the staff who work “ You can have brilliant department or organisation, you
might also find out information
in the area are fully aware of changes that
can improve the service. Through ideas but if you can't get which you were not already aware of
that may have a positive or negative
involvement, empowerment and listening,
staff generated ideas and solutions are them across, your ideas impact on your work.
generally most effective and sustainable.
Following meetings with staff, make sure won't get you anywhere.”
you take action and communicate the
Lee Lacocca
progress you have made. Small
improvements can ignite momentum for the
project and start to get people interested.

The first step to effective Communication Plan
communication is to understand who Team: Completed by: Date:
you need to communicate with
Who are you going What are you going How are you When are you Who is responsible
• Who do you need to keep informed and
to communicate to communicate to going to going to for communicating
obtain information from? Staff/patients/ with? them? communicate? communicate it? the message?
carers/executive board? e.g. Project teams, e.g. Improvements, e.g. Weekly e.g. Daily, weekly, Name and role
• Who needs to know what is happening / exec sponsor, NHS risks and issues, meetings, fortnightly,
changing? Improvement, steering measures, data, presentations, monthly, annually
• Who do you require support from? group, SHA lead, project scope, news events, email,
stakeholders, patients etc. letters, handouts
• Who will be directly and indirectly etc. etc.
affected?

What do you need to tell or ask? What Communication plan
does your audience need to know? A communication plan is an easy way to
• What the current service looks like actively address the interests and concerns
• The vision, aim, deliverables of the key stakeholders and ensures this is
• The problems, issues, risks done in a timely manner. What is the best way to
• Changes to the project communicate the progress and
• The benefits. In a changing environment with outcomes of my work?
organisational structures being transformed
How are you going to communicate to and staff moving roles, a documented Remember that you will need to
all the relevant people? communication plan will support the adopt different approaches and styles
• Regular meetings progression of an improvement project. for different audiences and
• Internal and external newsletters
stakeholders. Try not to develop a
• Memo’s Example of how a team at Hinchingbrooke
• Local press Hospital communicated their work in the
whole industry of reporting around
• Websites local press your project but use existing channels
• Emails wherever possible. Involve your local
• Letters communications team as they will be
• Reports able to suggest some possibilities.
• Presentations Regular reports to your executive
• Support from the communications
sponsor, board or management
department?
committee are useful at the higher
level, but make sure you also use
local newsletters, forums and
meetings to provide ongoing
updates.

22/23


CHAPTER 8
Improvement tool: Process
mapping
A process is made up of series of actions or People’s views about the process tend to process is an important step in moving
steps taken to achieve a specific result. change and develop following a process forward to redesign and developing a new
Process mapping is a technique used to mapping exercise as individuals have an idea process that will work better for patients
identify all the interconnected pathway steps (a ‘mental map’) of the process, but as the and staff.
and decisions in a process and coverts this process map is developed, it becomes clear
information into a highly visual that their personal view is different from What does a process map look like?
diagrammatic form. that of others in the same process. The map The map below is of a diagnostic pathway
of the current process may differ from the for chronic obstructive pulmonary disease
Process maps can cover a short and simple mental maps that individuals in that process (COPD) and asthma.
sequence of actions by one person (such as have always believed. Agreeing the current
point of care testing or phelbotomy) or it
could be a complex set of activities involving
many different people over time, (such as COPD and Asthma Diagnosis
the End of Life patient pathway).
If referral doesn’t meet set standards,
more information is requested from GP
or if does not meet the triage standards,
What are the benefits of mapping letter back to GP

the process?
Patient contacted
• An overview of the complete process from GP referral to Referral triaged by
by community team
to arrange an
Communication Community team Clinic referrals
Secondary care
manager (band 6)
community nurse community specialist letter sent to book secondary care sent to secondary
beginning to end, helping staff to specialist team team
appointment which
is close to patients
patient with PIL to staff to run clinics care
arranges staff to
cover clinics
home
understand, often for the first time, how
complicated the system can be for Spirometry x3
(which need to be Measure oxygen Check Check Check height Patient called Secondary care
within 5%) by band sats medication demographics and weight into clinic attended for clinic
patients 2 or 6 staff

• Allows staff to see the pathway from the
If spirometry
patient’s perspective 400mg salbutamol
20 minute wait
(for medication Repeat spirometry Explain results
Results taken
back to secondary
conducted by band
2 staff results
Indication and
comments
(via volumatic) x3 to patient documented and
• A starting point for your improvement to work) care interpreted by
band 6
printed

project
Write to GP and Decisions for Results sent to
Review and
patient for treatment and primary care nurse
interpretation
management management specialist team

• The opportunity to bring together people Once the above map was completed, the team could see that the process was over-
from primary, secondary, tertiary and complicated, and included many unnecessary steps, bottlenecks, wasteful activities and
social care from all roles and professions avoidable delays. The process was redesigned following the mapping exercise the new
• Identifies problems, delays, areas for error process below was created. As well as being simpler, the new process is much quicker for
and confusion, blockages and bottlenecks the patient, takes less administrative and clinical time and costs less.
• A point to create a culture of ownership,
responsibility and accountability for
improving the process
Community Spirometry Management
• An aid to help plan where to test ideas for
improvements that are likely to have the If referral doesn’t
meet set standards,
most impact on services more information
is requested from GP Interpretation in

• Draws out ideas to help redesign the or if does not meet
the triage standards,
Band 2 staff secondary care by
band 6 or above
letter back to GP
pathway – which particularly from
members of staff who don’t normally have Patient contacted Communication Indication and Proactive approach
by community team letter sent to Spirometry with comments to treatment and
the opportunity to contribute to service GP referral to
community nurse
Referral triaged by
community specialist
to arrange an
appointment which
patient with a
patient information
reversablility, SpO2
by secondary care
documented and
sent to primary
management which
specialist team team may include tier 3
planning, but who really know how is convenient in
proximity and time
and instruction
leaflet
team care specialist
nurse team
clinic attendance,
MDT discussions

things work
• An interactive event that gets people Band 6 staff Interpretation and
or above
involved, motivated and talking to each results explained
to patient

other
• An end product – the process map –
documents who does what, when, and
how long it takes, is highly visual and easy How to organise an event and • Meet with managerial, clinical and service
to understand. generate a process map leaders beforehand so that they feel
involved in the process. Use these
Preparation meetings to agree the scope that you will
• Define the objectives, scope (start and end work on and the three or four basic steps
points and level of detail) and the focus of that you will explore in detail at the
the process mapping workshop workshop
• Start is with a process that involves high • If you have the opportunity, an
numbers of patients independent facilitator, not connected
• Organise a half day event to draw the with the pathway, can be really useful.
map and a half day to analyse and look Choose someone with service redesign
for improvement opportunities. You can skills and experience.
run these together as a full day event or as
two half days but not more than two
weeks apart

24/25


I’ve already process mapped -
Do I need to do this again?
Who and how to invite • Write each step on an individual post-it
• You need to invite people who support, note and stick them to the backing paper. Review your map. Is it valid? Have
deliver and manage the entire scope of The benefit of post-it notes is that you can you checked with all those involved,
the process you wish to map. This might move them around if you need to add including patients? What changes did
include people from primary, secondary, some extra steps you make after you completed your
tertiary and social care from all roles, • Concentrate on what happens ‘most of
map? Sometimes process mapping is
grades and professions the time’ rather than what occasionally
• Consider how staff will be released from happens seen as an end in itself – it is not. You
their job for the mapping event • If problems or issues are raised which need to use your map as a tool to
• You may wish to invite patients and carers cannot be resolved in the room or in a identify where and how you can start
to give their perspective and ideas defined timescale, e.g. 10 minutes, write to make changes and how you can
• The invitation should come from your them on your ‘Car Park’ flipchart ready to evaluate their impact.
project sponsor be addressed at a later date.
• The invite include information on the
background to the event, aim of the event, What level of detail?
expectations, scope of the mapping etc You may map a process at ‘high level’ to obtain a clear outline of the major steps involved:
• It is advisable to request that the invited
participants walk through the pathway
which is going to be mapped before the
event.
Put tea bag Put water Remove
Put kettle on Get cup Add milk Drink tea
in cup in cup tea bag
Venue
• Arrange a suitable venue, preferably off-
site, as this will provide a neutral setting
and people are less likely to be interrupted
and it will be easier to concentrate on the Or at a more detailed level to identify the complex steps in one or more stages of the journey.
task in hand. Don’t forget to organise
some refreshments – process mapping can
be thirsty work!
Put tea bag Put water
Put kettle on Get cup
in cup in cup
Equipment
• You will need a long roll of paper
(wallpaper lining or a roll of brown paper),
coloured post-it notes, lots of marker Open
cupboard
Choose cup
Select
tea bag
Warm cup
Add tea bag
to cup
pens, sticky tape and two flip charts,
preferably with stands.

Set up Analysing your map Following completion of your map
• Use a roll of brown paper or wallpaper, • From your process map you will be able to • Agree the next steps
fixed firmly to the wall identify where the significant problems • Agree which parts of the process need to
• Write ‘Ideas’ on one flip chart. This flip occur. This might be the most prevalent be mapped in more detail and how this
chart can be used to capture all ideas that waits, delays, duplication, bottlenecks, should be arranged
arise throughout the mapping exercise constraints or inefficiencies together with • Agree who should communicate with
• Write ‘Car Park’ on the other flip chart. the presence of any ‘non value adding’ people who have not been able to attend
This is used to capture all issues that can activities such as unnecessary hand offs the event
not be resolved in a defined amount of (where the patient is passed from one • Agree when and how change ideas will be
time or are not directly relevant to the person to another), transfer to queue or generated and tested
map but need to be addressed. excessive administrative checks: • Tape the post-it notes to the backing
• There are four main techniques to paper. The post-its will start to fall off the
Start of event redesigning your process map: backing paper after a few hours in a hot
• Ask one of the lead clinicians or your • Eliminate room!
project sponsor to open the event, • Combine
emphasising their own commitment to the • Simplify Following the event
event and redesigning the process • Sequence. • Type up the process map (Microsoft Word,
• If everyone doesn’t already know each Excel or specific software like Visio can be
other, have a round of introductions Where possible, try to eliminate any process used, but make sure other people are able
• Set some ground rules – these may include; steps. If it isn’t possible to eliminate any to view and/or amend any electronic files
listening to each other, no opinion is wrong, steps, look to combine steps. After you create)
no blame will be cast, it’s the process not combining, consider where the system can • Check the typed version with those who
individuals that is at fault. be simplified. Once steps in the process have attended, and with others who were
been have been eliminated, combined and unable to attend the event
Mapping the process
simplified, review the sequence of events to • Send a copy of the notes and agreed next
• Review the agreed start and end of the
promote efficiency: steps to each participant and to those who
process
didn’t attend
• Agree the level of detail. It is best to start
• Measure or time the process steps in order • Review the agreed actions with the
at a very high level and then drill down to
to set the baseline for improvement participants at regular intervals to assess
the detail where necessary
• Revisit those issues and ideas that were progress, capture learning and address
• Start with some main headings mapped
generated in the mapping event problems
out on the paper – these might include:
• Identify where processes that are part of • Arrange a follow up meeting.
‘presenting symptoms’, ‘referral’,
‘diagnosis’ etc. – the ‘high level’ steps in another service area have an effect upon
the process. This can help to remind your service
people that the purpose of the event is to • Generate action plans from the map, to
map the whole of the journey, not just the test improvements using the Plan Do study
elements they are familiar with Act Cycle (Chapter 9).

26/27


I want to improve my whole

CHAPTER 9
service – why start small?

People are more likely to trial small
changes rather than a full scale
Improvement tool: Plan, Do change. People also find it easier to
adopt and build on small changes in
Study Act (PDSA) Cycles behaviour so that these become the
norm. Bear in mind that starting
small inspires confidence and can
build rapid momentum.
Change on a large scale can be daunting
Plan, Do Study Act (PDSA) Cycles
but that should not deter you. Before
implementing a full proposal for change a
Plan, Do, Study, Act (PDSA) cycle can be
used to test out an idea on a small scale. PLAN DO STUDY ACT

New ideas should be introduced only after ... how to ... what you ... the ... on the
explicitly test a have planned outcomes results to
sufficient testing (or evidence) on a smaller
small change to do expected and modify and
scale has proven to have a positive effect. unexpected of improve
PDSA cycles allow ideas to be introduced an the test
idea in a safe, controlled way which will
have less resistance, be less disruptive and
use less resources. By building on the
learning from each PDSA cycle, new
processes can be introduced with a
greater chance of success.

Plan the trial
Act upon the results of the trial
• Use the information that you have gained “ All improvements are
• Define the objectives
• State the scope of the PDSA
• Do you need to modify & retest?
• Do you have enough information? changes, but not all changes
• What, Why, Who, How & When?
• How long will the PDSA continue?
• Does the trial need to be longer?
• Can you implement the change are improvements.”
• Are there any circumstances when you immediately?
would stop the trial? • Who do you need to share your findings Eli Goldratt
• Does everyone understand their role? with?

• How will you communicate with these • Can other areas benefit from your
people? knowledge?
• How will you know if the PDSA is a • How will you performance manage the
success? process in the longer term?
• What data collection methods are you • Implement the new process!
ADJUST PLAN
using?
• Who will collect the data? To develop an idea into a tested
• How will you feedback to the team? improvement proposal, you may need to
STUDY DO
perform a number of PDSA cycles. Some
Do - carry out the trial cycles may lead to nothing, where as others
• Encourage continual feedback - you may will lead to a positive improvement which is
wish to set up midpoint meetings to ready to be rolled out across a whole
discuss progress system.
• Motivate, reassure, encourage and
A P
support the staff Value of PDSA S D
D

• Collect information. By using PDSA’s to test changes you can:
P

• Minimise risks and expenditures of time
S
A

Study the results of the trial and money
A P
S

• Examine your findings • Make changes in a way that is less
• Review and compare information from disruptive to patients and staff
D

before, during and after the trial • Reduce resistance to change by starting A P
• Reflect on what was learned on a small scale S D
• What did it feel like? Did staff and • Learn from the ideas that work, as well as
patients notice an improvement? from those that do not
• Was the process shorter or longer? • Generate larger improvements through
• Did you achieve your objective? If not, successive quick cycles of change I want to improve my service but
why not? • Increase the numbers as the idea is refined don’t have the time to trial things
• What went well? • Test with people who are willing and first.
• What could be improved? happy to innovate and participate
• Implement the idea when you are Unfortunately, when ideas are not
confident that you have considered and tested and a solution is implement,
tested all the possible ways of achieving
we can find we spend more time
the change
• Learn from the ideas that work, as well as putting things right and redoing work
from those that do not. afterwards. Investing the time up
front to find out what works and why
can help avoid costly mistakes and
wasted time in the medium term.

28/29


How do I know what data I need?

CHAPTER 10 Ask yourself what you trying to
achieve? What would tell you that
you had achieved it? What would
Measuring your efforts you need to have in place to know
you were making progress towards
that aim? These questions should
Many people begin to feel uncomfortable Where can I find data for my
with the idea of ‘data’ and ‘measurement’ improvement project? help you identify what you need to
but they are essential if we are to There are a number of freely available data measure and therefore what data you
demonstrate that change has occurred or sources which can be used to frame your will need. You don’t need reams of
needs to occur and whether the change is improvement project and compare your complicated data – just enough to tell
an improvement. Whether the change was services to others both nationally and in the you whether you are making progress
a success or didn’t demonstrate the local area. For example: or not.
anticipated outcomes, it is still necessary to
demonstrate its effect and learn from it. • Programme Budget Interactive Atlas -
www.nchod.nhs.uk
To establish what data you need, it is • Quality Outcomes Framework (QOF) -
essential first to understand what outcomes www.qof.ic.nhs.uk
you are aiming to achieve as this will help • NHS Comparators -
determine your measures. You should www.nhscomparators.nhs.uk
consider which measures will best • Hospital Episodes Statistics (HES) -
demonstrate whether the changes you www.hesonline.nhs.uk
introduce demonstrate a difference.
Defining your aim in terms of the size of the These data sources are beneficial to set the
improvement and the timescales you are context your project, however the data
aiming for will help you to determine provided by these tools may often be
appropriate measures. Try to avoid the ‘ICE’ months or even years in the past.
approach:
Improvement projects benefit from current,
• Identify everything that is easy to measure real time data to provide a clear
and count understanding of the service and the impact
• Collect and report the data on everything of any small scale PDSA cycles. To get this
that is easy to measure and count information, you may need to explore the
• End up scratching your head thinking information available from the local
“What are we going to do with all this databases or consider collecting the
data?” information manually.

Measures
Project measures might include:
Individual patient level data is often
valuable for improvement projects as it will “ Measurement is the first
• Reduction in admissions and readmissions
• Reduction in outpatient appointments
allow you to see the variation between
patients, and can provide an insight into a step that leads to control
• Reduction in prescribing
• Number of patients treated/diagnosed
process that are often hidden within
aggregated and averaged data. For and eventually to
improvement. If you can't
• Patient experience example, consider looking at the variation in
• Waiting days between interventions length of stay; You might identify

measure something, you
• Turn around times unnecessary short stays in hospital, or some
• Response times particularly long stays both of which would
• Staff morale. be hidden when using an average.

Once you have agreed on your project Establishing a baseline
can't understand it. If you
measures, clearly articulate your operational
definition. An operational definition is a
Establishing a true baseline of current service
delivery is a major part of service
can't understand it, you
clear, concise, detailed definition of a
measure, so that exactly the same
improvement. Without knowing what the
position was, it will be difficult to know
can't control it. If you can't
information is collected before and after an
intervention. Even simple measures need an
whether an 'improvement' is an
improvement and has any impact on the
control it, you can't
operational definition - for example, if I
asked you to measure my arm, where would
process or outcomes for patient care.
improve it."
you measure from and to? Would it be It is essential to know your starting point i.e.
H. James Harrington
from my shoulder, neck or armpit to my the current state and standard of current
wrist, finger or hand? performance. This is your baseline data,
against which you will measure the impact
of any changes that you make over the I can’t get any data – what are my
course of your project. This helps determine next steps?
the areas you need to focus on, what you
need to measure and how much impact First try your information team to see
your project is having. what is routinely available and
whether you can use this information.
Ask your executive sponsor for advice
or help. Consider what data you can
easily collect manually for the
purposes of the project and look at
other national sources which are
freely available.

30/31


I have some data – what do I do
with it?

Your data should provide you with an
understanding of how well you are
Monitoring the project Data collection plan
doing at present, it may indicate
To support your improvement work, it is A data collection plan is useful to bring
important to monitor and use data clarity to the data collection and where there may be problems in the
throughout the project and in your PDSA measurement aspects of the project. A plan system and how much impact any
cycles. Using and reviewing data should be should include: changes is having. There is a number
a regular part of your project work and can of tools to help you analyse and
both motivate and focus continued • A specific question – What do you want interpret your data on our
improvement work. Think about the to know? improvement system on our website –
dashboard in your car, the “vital signs” on a • What data do you require to answer this
www.improvement.nhs.uk/improve
hospital life support machine, or simply the question?
clock in your kitchen! Having data available • Where will you get this data from? mentsystem. Your local information
and visible is an important motivator, can • Who will collect the data? team or management team may also
influence behaviour and motivate • How often will the data be collected? be able to advise you. When you
improvement activity. • Do you foresee any problems collecting have identified what the data is telling
this data? you, share it with your project team
Presentation of data is a science and art in • How are you going to analyse the data? and use it to decide whether you
itself; however some simple thought into • Who will be responsible?
need to continue with what you have
how you present your information can • When is the raw data and analysis
improve the delivery, and usefulness of the required? done so far, change your approach or
information. Consider your audience add to it.
carefully, remember not all project members
may be experts in data and you may need
to structure the presentation of data
carefully to “tell the story” and guide
project members through what the data
Don’t forget “better” is not measureable, “soon”
may show. Also consider the format that
you present the data – don’t always assume
is not a timescale and “some” is not a number! “More”,
data requires a complex spreadsheet,
sometimes a presentation, or a simple graph “faster”, “safer” or “cheaper” can all be measured but
may be what your audience requires.
only if you know how many, how fast or how expensive
things were to begin with.

Data analysts Data Collection Plan
Data analysts are a valuable resource and Team: Completed by: Date:
where possible they should be an integral
Specific What What source Who will How often Do you What is Lead Date
part of your project team and their skills
question data do will be used collect will the forsee any you due
utilised from the very start of your project. you to get the the data? data be potential analysis
Benefits of having a data analyst on your require? required collected? problems? plan?
project team include: information?

• Support the design of project goals,
ensuring the aims are measureable and
achievable
• Help to understand what you need to
measure, baseline and monitor
• Have access to data sources (such as your
local patient admissions system)
• May reveal other sources of information or
approaches which may be unknown to
the project team.

A top tip is to explain what you are trying to
demonstrate rather than what you think you
want as they may be able to suggest
alternative or better indicators.

I don’t have access to a data
analyst, who else could I ask?

Try looking more widely for some
support. People with access and
expertise to data may not always be
in analyst roles. You could contact a
performance manager, clinical coder,
data manager or a contract manager,
who could assist you with access to
data and analytical expertise.

32/33


SPC charts are used:

CHAPTER 11 • As simple tool for analysing data
- measurement for improvement
• As a tool to help make decisions
Improvement tool: Using statistical • As a tool for the ongoing
monitoring and control of a
process
process control (SPC) charts • To focus attention on detecting
and monitoring process variation
over time
Statistical Process Control (SPC) is a simple Following root cause analysis, the next step • To help improve a process to
and visual way of observing variation in your would be to reduce the variation between perform consistently and
systems and processes. Every process is the data points by small scale incremental predictably over time
subject to variation but generally speaking, improvements – (PDSA Cycles, Chapter 9) • To provide a common language
the more variation there is in a system or for discussing process
process, the less reliable it is, and the less performance
certainty there will be that the process or
system will produce the outputs or results
expected or desired. SPC can help to identify
variation as a first step in trying to reduce What does an SPC chart look like?
and control it.
90
There are some basic statistics and simple UPPER CONTROL
80
maths involved, but SPC is much more than
statistics... SPC is way of thinking. 70

60
An SPC chart is essentially a run chart with
statistically calculated lines of variation with 50

the main aim to understand what is 40
‘different’ and what is the ‘norm’ within a
process. By using these charts, you can then 30

understand where the focus of work needs 20
to be concentrated in order to make a LOWER CONTROL
10
difference.
0
F M A M J J A S O N D J F M A M J J A S O N D

We can also use SPC charts to determine if
an improvement intervention is directly
improving a process (as opposed occurring
to chance) and to predict statistically
whether a process is capable of meeting a Why focus on variation? Why not just use averages?
set target.
There is variation in every process. Averages can be misleading and do
The inherent strength of these charts is that However, the less variation there is in not show the full picture of what is
they provide a visual representation of the
any process, the more reliable it will actually happening. The average of a
performance of a process by establishing
data comparisons against calculated limits be, in terms of safety, quality and set of numbers can be created by
(known as the ‘upper and ‘lower’ control outcomes. By understanding the many different distributions, so
limits). These limits, which are a function of type of variation, specific action can presenting data using averages and
the data, give an indication by means of be taken to reduce the difference. A aggregates may lose the richness and
chart interpretation rules as to whether the large amount of variation shows that impact of individual data points and
process exhibits either predictable variation the process is out of control and the variation between the data points.
or there are special causes. The charts also
there is a lot of uncertainty. A For example, an average waiting time
visually demonstrate the spread of the
variation being generated within any given process with a limited or no variation for an appointment could be six
process. is in control and will deliver standard weeks but when you look at the
results. variation between individual patients,
Improvement projects would first seek to some patients might be seen in two
remove anything above or below the control weeks and others in eleven weeks.
lines in order to create a stable and in An improvement project would firstly
control process. Any data points outside
strive to see a reduction in the
these lines should trigger a form of action to
truly understand why it is occurring (Root variation of time that people have to
Cause Analysis). Finding the real cause of wait for an appointment, which in
the problem and dealing with it is imperative time would reduce the average.
to improvement projects rather than simply
continuing to deal with the symptoms / It is important to know that reducing
consequences or add another stem to solve the variation, making the process
the problem.
stable and in control, could increase
average waiting times and if you were
just looking at averages, your project
could be misinterpreted as having a
negative impact.

34/35


Why should I use control charts
rather than any other chart?

Using aggregated data and summary
tabular formats are only really useful
A SPC generator is available on the NHS Improvement System. for judgment, not for improvement.
www.improvement.nhs.uk/improvementsystem Control charts are the best tools to
determine whether or not your
improvement efforts are having the
desired effect. SPC charts are more
SPC chart showing step changes each month following incremental project
sensitive than all other charts as other
improvements
charts cannot detect special causes
due to point to point variation or use
rules for detecting special causes. SPC
Charts have the added feature of
control limits which estimate natural
variation and define how capable and
stable a process is; therefore allow us
to more accurately predict the process
behavior over time.

September October November December January


I want to do things differently but

CHAPTER 12 my colleagues are reluctant. What
can I do?

If your colleagues are reluctant, show
Human dimensions of change them the problem and once they
understand what is wrong they may
be more willing to consider change. If
Different people have different reactions to People respond better when they are you are trying to sell a vision to them,
change. Some people are enthusiastic and presented with a problem that affects them break it down into small steps or
look forward to the challenge and new and that needs a remedy rather than being stages. Making each step manageable
experiences offered by change. Others presented with a solution that is going to be and achievable may stop some people
however are much less enthusiastic and see implemented. By identifying and starting feeling discouraged and reluctant.
change as threatening and destabilising – with the problem, the team will be engaged
something to be avoided at all costs! And of in finding a solution that will make a
course there are people who are somewhere difference to the people affected.
in between, and people’s response will vary
according to the situation or the change For change to happen, it has to be
being suggested. worthwhile. The people who are being
asked to change need to understand or be
Understanding the ‘human dimensions’ of experiencing the inconvenience or problems
change can help teams to find ways of generated by the current way of doing
effectively implementing change and things.
progress the improvement work in a timely
manner. Share the vision and journey to the vision.
Everyone is different; some people can see
Ownership of the problem the big picture and can work towards a
One of the first steps in change vision where as other people need to see
management is to start with the problem, individual achievable steps before they buy
not the solution. into a vision. Develop and share the vision
for the future with the team, articulating
what it will look and feel like.

36/37


There has been a great deal of
change in my organisation already.
How could I persuade colleagues
that improvements are still
Consider personal styles Communication required?
Different people have different personal Communication is a vital aspect in effectively
styles that affect how they respond to managing human dimensions of change. It Identify and demonstrate the problem:
information and how they communicate is important to be inclusive and to if they understand what is wrong they
thoughts and ideas. Having an appreciation communicate the message in a way that will may be more willing to consider
of the different personal styles can help to engage all the different types of people. change. All improvement is change
minimise conflict and ensure that everyone but not all change is improvement.
gets the right message the first time. It is People can become exhausted by
important to remember that no one style is Diffusion of Innovators change or anxious about its
right or wrong. Research suggests that for an implications for them as an individual,
improvement or change to ‘take hold’ so try and build on what is in place
When faced with decisions, some people within a team, department or already rather than suggesting this is
will ‘ask’ and some will ‘tell’. People who organisation, approximately 20% of further change for change’s sake.
ask will gather data and ask other people those individuals must be engaged with Identifying the following factors is
questions about what should be done. it. Once this group has adopted the beneficial to overcoming this: What
People who tell, will tell other people what change the rest will follow. are the things that matter to them?
they think should be done. How can you demonstrate that these
Rogers (1995) suggests that all groups areas are not as good as they could or
People’s preferences for facts or feelings will of people have five categories that should be?
also influence their decision making make up the Diffusion of Innovators
processes. People who base their decisions bell shaped curve; Innovators, Early
on facts often prefer to control emotion and Adopters, Early Majority, Late Majority
might be perceived by others as remote or and Laggards.
detached. Those who base their decisions on
emotions are happier to show their feelings The innovators and early adopters like
and are often perceived as warm or change and quickly get onboard with
approachable people. any new project and will help make up
the critical 20%. The early majority
One model from Merrill and Reid R H (1999) and the late majority subsequently
(Personal Styles and Effective Performance: follow and become engaged when
Make Your Style Work for You' CRC Press, they observe the project developing
London) suggests that there are four broad and progressing. The laggards are the
personality types: analytical, driver, amiable most sceptical group and are generally
and expressive. resistant to change.

Each type has its strengths and to utilise the Diffusion of Innovators Bell Shaped Curve (Rogers 1995)
team’s potential, it is important to play to
the strengths and understand the
differences of each personality type. Early Majority Late Majority
34% 34%

‘Analysts’ tend to like facts and figures and
are systematic and methodical. They
Early
respond well to being given plenty of Adopters
relevant information and time to consider it. 13.5%
Laggards
16%
‘Amiables’ place value on relationships with Innovators
2.5%
others and are often perceptive and
supportive. This group will want to consider
the impact of any changes on other people
and how they might feel about it.
‘Expressives’ are enthusiastic, full of
optimism and energy, good with people and
like to talk about their ideas. They respond
well to opportunities that are new, exciting
and innovative. ‘Drivers’ like getting things It is important to note that each group will require a different approach to ensure
done; they like action and results and can effective change. Consider where your project team and stakeholders are on the bell
often be decisive, direct and pragmatic. This shaped curve and start by engaging the critical 20% who will in turn bring the early
group will want to know what is going to be majority on board. In the initial stages of your project, listen to but try not to let the
done and how soon it can be achieved. laggards drain your enthusiasm.

Know yourself
For someone who is leading change it is
important to recognise and acknowledge
your own attitude and approach to change,
then recognise other people’s personality
types to ensure you use the right approach
to achieve the best result.

38/39


CHAPTER 13
Sharing your success

At the end of a project there can be many
mixed feelings for a project team and the
project manager including: elation, pride,
sadness, satisfaction and maybe even relief!

There is a great temptation to take a break
from the intensity of the project work, or
even to move on to the next challenge,
especially when resources are stretched and
time is precious.

But before you do this, consider that the
project end date is not necessarily the end of
the project. If improvements have been
made then they should be recognised and
celebrated for the recognition and morale of The phlebotomy team at St Helens and Knowsley Teaching Hospitals NHS Trust
the people who have been involved - as well celebrate winning the Trust Award for ‘Excellence in Support Services’.
as for the benefit of those out there who
would love to know about your work and
what they can learn from it for their
patients.

Whatever your aims and objectives were,
however big or small your project – success
should be celebrated and shared.

Letting people know about your The next step is to consider all External publicity
achievements is a major part and a duty of communication vehicles available for • Use your communications team to write a
improvement work. There are many ways in publicising your work. Here are some ideas: press release for the local and regional
which you can share your findings or results media e.g. newspaper, radio etc. Be
and below are some suggestions as to how The project team proactive and take photos of patients/ the
you could go about it. • Get a slot on a Trust meeting agenda e.g. team (with consent) and then follow up
Trust Executive Board Monthly Meeting, after the press release has been sent
However, the first step in the process is Executive Directors meeting (often • Consider writing your results up into an
actually not about sharing at all, it’s about: weekly). For more details on your own abstract or article for publication in a
Trust contact the PA of the Chief Executive journal or at a conference
• Reflecting on what worked, what made • Make an appointment to see the Chief • If your project or improvement has
an impact and what didn’t Executive of the Trust and go in ready with demonstrated ‘QIPP’ potential, submit
• Understanding the learning all the information on your project. it as a case study on NHS Evidence at
• Rationalising the principles www.evidence.nhs.uk/qipp. NHS
• Documenting what happened throughout Internal publicity Evidence - QIPP is a collection of real
the lifetime of the project. • Get the work known throughout your examples of how health and social care
own organisation through: articles in the staff are improving quality and
Before you decide to undertake any kind of staff newsletter, articles on the staff productivity across the NHS and social
publicity or let people know what you’ve intranet, word of mouth and via your staff care.
done, you need to decide what you’re going at any meetings
to tell them, what your key messages are • Hold an event within your team office,
and how you are going to deliver the department or ward to celebrate the work
message. Much of this can be taken from you have achieved and invite everyone
your Project End Report if you have one but who has had a contribution or vested
if not it really helps as this stage to write a interest in the project I’ve finished my project, what
short summary of where you were at the • Create an information board about your next?
start, what your aims and objectives were, project and display it somewhere
what you did and then the results. It is also prominently within your building. Don’t stop there! Continue to
useful to include your key milestones, how measure what you have done to
you managed risks and what worked ensure the improvements are
particularly well - as well as anything that maintained and sustained. Look for
didn’t work. We can learn as much from our other opportunities to make positive
mistakes and failures as our successes. The changes that can improve quality,
key is to learn from your mistakes, and safety, efficiency and staff morale.
everyone else’s, preventing the same mistake Show colleagues how you improved
being made time and again. your service to build capability and a
culture of continuous sustainable
improvements.

40/41


The clinical community Share your achievements and learning
• Contact your network leads and offer with NHS Improvement
to write a paper/ present your findings
to the next network meeting or email Finally, make sure you record all the ways in
round to the members which you have publicised your work e.g.
• Contact the Strategic Health Authority press clippings, minutes of meetings so you
(perhaps via their communications have an ongoing record of the ways in
department) and let them know the which you shared your success.
improvement work you have
undertaken and the results achieved; This is great evidence in terms of:
offer to be a spokesperson of best
practice in order to share your model. • Making a business case for future
improvement work
• Personal development and adding to CVs
• Enthusing new staff about your team or
department as a place of success
• Demonstrating to patients you really care
about improving outcomes.

42/43


RESOURCES
Websites
www.improvement.nhs.uk
www.improvement.nhs.uk/improvementsystem

Acknowledgements

Zoe Lord and Phil Duncan

The following people have provided a source
of expertise and support and their help is
gratefully acknowledged: Hannah Wall,
Catherine Thompson, Catherine Blackaby,
Alex Porter, Barbara Zutshi, Mel Varvel and
Jim Farrell.


NOTES

44/45


NOTES

NHS
CANCER
NHS Improvement

DIAGNOSTICS

NHS Improvement
NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of
experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and
demonstrates some of the most leading edge improvement work in England which supports improved
HEART
patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector partners,
professional bodies and charities, over the past year it has tested, implemented, sustained and spread
LUNG quantifiable improvements with over 250 sites across the country as well as providing an improvement
tool to over 1,000 GP practices.

NHS Improvement
STROKE 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

Delivering tomorrow’s
improvement agenda
for the NHS

First steps towards quality improvement: a simple guide to improving services

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