Measurement for improvement
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Transcript of Measurement for improvement
© NHS Improving Quality 2014© NHS Improving Quality 2014
Measurement for Improvement
Patient Safety Team
© NHS Improving Quality 2014
• What are your expectations of the next three hours?
© NHS Improving Quality 2014
Aims and objectives
Aims• To have a greater knowledge and practical
understanding of Data Collection and Analysis
Objectives• Understand how to do ‘real’ analysis• Use data to improve decision-making and identify
real improvements
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Introduction
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Distributions – “How long do cars last?”
68.26%
95.44%
99.73%
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“Measurement is for improvement not judgement.”
D. Berwick
Measurement for improvement5
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“You can’t fatten a cow by weighing it” (Palestinian proverb)
Improvement is not about measurement, but……..
How do we know if a change is an improvement?
“If you can’t measure it, you can’t improve it”
Measurement for improvement6
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Model for improvement
A PDS
A PDS
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Measurement throughout the project cycle
Project Identification
Getting a baseline
Did project make a
difference
Will project sustain
Evaluating worth of the
project
A PDS
A PDS
A PDS
A PDS
A PDS
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7 Repeat steps 4-6
Seven steps to measurement
1 Decide Aim
2 Choose Measures
3 Define Measures
4 Collect Data
5 Analyse and Present
6 Review Measures
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Step 2 – Choose Measures
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Step 2 – What to measure?
Patient experience and outcomes
Patient satisfaction
survey
% patients complication
free in recoveryPain score Average time
patient starved
Safety and reliability Clinical incidents ReadmissionsExceptions from
time out checklist
% correct equipment to
hand
Efficiency and value Turnaround time % theatre utilisation Cancellations
Delays(Late starts &
finishes)
Leadership and high performing teams Staff survey Training and
development Staff turnover Staff absence
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Driver DiagramsSchematic view of a system on the left we depict outcomeAs we move right we drill down into the network of causes that drive the outcome, from ‘primary’ to ‘secondary’ drivers.
Aim: An improved system
PrimaryDriver
PrimaryDriver
Secondary
Driver
Secondary
Driver
Secondary
Driver
Secondary
Driver
Secondary
Driver
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Driver Diagrams
On the right we depict ideas for system changes that might ultimately impact the outcome. Diagram represents our theory about how to modify the system to change the outcome.
Aim: An improved system
PrimaryDriver
PrimaryDriver
Change
Change
Change
Secondary
Driver
Secondary
Driver
Secondary
Driver
Secondary
Driver
Secondary
Driver
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Aim: 2 stones lighter!
Energy Out
Energy In
Walk daily commute
Stairs not lift
Exercise
Reduce alcohol intake
Eat Less
Driver Diagrams – weight loss example
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Pedometer
Gym work out 3 days
Squash weekends
No pub weekdays
Take packed lunch
Low fat meals
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Aim
Defect FreeSurgery
Avoid Mistakes
AvoidComplications
AvoidDelays
Driver Intervention
Conduct team brief
Conduct team debrief
Conduct time out
Produce accurate lists
Implement SSI bundle
Implement VTE bundle
Have correct kit to hand
Ensure staff adequately trained
O1
O2
O3
O1 Overall glitch countO2 Never eventsO3 Number of surgical site infections
P1 % lists with Team BriefP2 % lists with Team DebriefP3 % compliance with SSI bundle
P2
P1
P3
Driver Diagramsclinical example
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Exercise: Create your driver diagram
Thinking about your project• Start to create a driver diagram and choose measures
• Complete the driver diagram to link Aims with Measures
You have 20 minutes
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Step 2 – Choose Measures
An important note:
As well as clinical and quality measures – you may need to consider what financial measures are required for your project? You may need initial and ongoing funding?
Your success in gaining access to funds will be helped if you have completed a project financial justification or return on project investment analysis
Covered in more detail later in the presentation …
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•Measurement Definitions
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Step 3 – Define Measures
• An operational definition is a description, in quantifiable terms, of what to measure and the steps to follow to measure it consistently
• Are we measuring the same thing?
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Exercise
• M&M Activity
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RepeatabilityCan you, who created the definition, understand it and repeat it? Also known as test-retest error, used as an estimate of short-term variation
ReproducibilityAfter repeatability, try seeing if
the definition that you have created can be reproduced by other people?
Advice on creating measurement definitions
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•The Measures Checklist
•Why important?•Who owns?•Definitions?•Goals?
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Step 4 – Collect DataPractical considerations:5 W’s and 1H
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Step 4 – Collect DataDecisions, decisions… • What - All patients or a sample?• Who – took the data? (what role?)• When – When was the data taken - real time or
retrospective?• Where is the data from?• How – was the data taken - hospital system or
audit?
• Turn the data into a different unit (hours into days)
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Step 5 – Analyse and Present
We will now focus in more detail on methods of presenting and analysing our chosen measures….
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•Understanding •and dealing with
• variation in analysis
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The Airplane GameUsing the paper provided – make a paper planeYou have 5 minutes
• When instructed – throw your planes!
• What happened?
• Why are they not flying the same distance?
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Exercise – The plane game
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Fishbone diagram
Aeroplanes fly different
distances
Problem
Equipment People Procedures
Measurement (+Diagnostic)
Communication Materials
Causes
Types of paper e.g.
card, tracing paper,
No clear instructions provided
Some tables had scissors, rulers to help
Skills / ideas
Throwing styles
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“We live in a world filled with variation –and yet there is very little recognition or understanding of variation”
William Scherkenbach
“Data should always be presented in such a way that preserves the evidence in the data…”
Walter Shewhart
Variation
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What do people understand by the word variation?
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What does this data tell us?
Patients treated in April
600
550
610
540
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570
580
590
2008 2009
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What does this data tell us?
Patients treated
650
600
550
500
450
400
350
300April 2008 April 2009
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What does this data tell us?
This Month Last Month
Given two different numbers, one will always be bigger than the other!
Som
ethi
ng I
mpo
rtan
t
What action is appropriate?
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CommonCause
Stable in time and therefore relatively predictable
Paper selection
Persons technique
Design of the plane
Special Cause
Irregular in time and therefore unpredictable
Water spill
Fire
Can we classify variation?
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It is important to distinguish between the two types of variation because they require different approaches to deal with them
Can we classify variation?
“There are different improvement strategies depending of which type of variation is present (common cause or special cause), so it is important for a team to know the difference.”
M.L. George
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Step 5 – Analyse and present
Presentation
Dot plotIndividual value Plot
Interval Plot
Bar Chart
RunChart
SPC
Pareto
Scatter Plot
Tally Chart
Pie Chart
Radar Chart
Area Chart
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SPC
Run Char
t
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Plotting the dots - example Run ChartNumber of calls to outreach team (weekly)November 2007 to June 2008
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No
of C
alls
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1st Nov 15th Nov 29th Nov 13th Dec 27th Dec 10th Jan 24th Jan 7th Feb 21st Feb 6th Mar 20th Mar 3rd Apr 17th Apr 1st May
Week
Calls per week Median
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The Myth of Trends
Upward trend ? Downward trend ?
Downturn ?Setback ?
Turnaround ?Rebound?
Static ?Flatline ?
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Time
Downward trend
Time
Upward trend
Looking for a trend
7 points all in upward direction
7 points all in downward direction
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Looking for a trend
7 points above centre line 7 points below centre line
Time
Below centre
Time
Above centre
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Exercise 7Creating your own chart
• Using graph paper, ruler and a pencil:
1. Draw and label the axis2. Plot the dots (daily or weekly data is the best)3. Work out the median and plot it4. Add a title (with dates)5. Add a legend6. Analyse it!
• You have 20 minutes
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100908070605040302010
%
% Compliance with hand hygiene (weekly) April – Sept 2008
Week1 Apr 15 298 22 6 May13 20 273 Jun10 17 241 Jul 8 15 22 295 Aug12 19 262 Sep9 16
xx
x
x
x
x
x
x
xx
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x
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xx
x
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x
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% Compliance with hand hygiene Medianx
Your chart… should look like this?
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Discussion …
• How could you apply these charts to your projects?
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•What is SPC?
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Statistical Process Control(SPC) charts…
• …use the pattern of events in the past to predict with some degree of certainty where future events should fall
• …distinguish between the natural/common cause • variation and special cause variation• …enable you to look for problems when they are there, not
when they are not• …can motivate staff to improve practice thereby reducing
adverse events and minimising variation
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Statistical Process Control(SPC) Charts:
No
of A
dmis
sion
s
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Performance Report – Number of Admissions
Week
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No Admissions Median Lower Limit (66.5) Upper Limit (222.4)
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Two ways to improve a process
If uncontrolled (special) variation
Process is unstable and unpredictable
Variation caused by factors outside process
External cause should be identified and sorted
If controlled (common) variation
Process is stable and predictable
Variation is inherent to the process
Therefore the process must be changed
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The improvement process
Pat
ient
Wai
ting
Tim
e
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Performance Report
Week
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Act Plan
DoStudy
Special causes present -
unpredictable
Process predictable
(within control limits)
Process improvement
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Three dangers to beware of …
1. Reacting to special cause variation by changing the process
2. Ignoring special cause variation by assuming “it’s part of the process”
3. Comparing more than one process
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•Interpreting •Charts
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LCL
UCL
MEAN
Point above UCL
Special causes
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X
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X
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X
X
Point below LCL
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XX
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X
Rule 1 - Any point outside one of the control limits
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LCL
UCL
MEAN
7 Points above centre line
Special causes
Rule 2 - A run of seven points all above or all below the centre line, or all increasing or all decreasing
XX
X
X
XX
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XXX X
X
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XX
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X
7 Points below centre line
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LCL
UCL
MEAN
7 Points upward direction
Special causes
Rule 2 - A run of seven points all above or all below the centre line, or all increasing or all decreasing
7 Points downward directionX
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X X
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LCL
UCL
MEAN
Cyclic pattern
Special causes
Rule 3 - Any “unusual” pattern or trends within the control limits
Trend pattern
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XXX
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© NHS Improving Quality 2014
LCL
UCL
MEAN
Less than 2/3 of all the points fall in this zone
Special causes
Rule 4
More than 2/3 of all the points fall in this zone
X
X
X XX
X
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X
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Process out of control
• These rules are important!• They tell us if the process is stable or unstable• They tell us if common or special cause • variation is present
Remember the rules!• Outside control limits• Run of 7 or more consecutive points• Patterns• Rule of thirds
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Exercise 8Interpreting SPC charts
•Apply the SPC rules to the charts in the handout
• Are there rules present?• Is the chart in control?
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Step 6 – Review Measures
“It is a waste of time collecting and analysing your data if you don't take action on the results
“
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