An overview
Having investigated the current state and what the future state could look like it is necessary to have an understanding of the processes and issues such as flow, variation and batching so you can prepare and deliver the improvement.
The A3 reporting tool is seen as a highly effective tool to aid and guide you through this stage of quality improvement.
A rapid improvement event brings together and is based on all the stages of investigation and preparing the plan ( or project).
Tools and techniques discussed below include:
- Understanding variation including fishbone diagram template
- Understanding batching
- Root cause analysis and 5 whys.
- Spaghetti Diagrams and cellular activity
- Information hand-off charts
- Basics of Rapid Improvement Events (RIE)
- A3 planning records a high level visual action planning tool, including a template
- Milton Keynes project approach - guide to managing projects
Understanding variation
The reduction of variation is key to achieving stability.The impact of variation on customer satisfaction is important.
Self-inflicted variability – that which you control
External variability – may not be in your control to change. However, you can build in systems to mitigate the impact
Understanding the root cause of any variation enables you to start improving it.
Variation can be illustrated by
'the Smartie Game' which shows that even highly industrialised processes can have significant variation within it .
The ‘Aeroplane Simulation’ where simple basic instruction are given 'make an aeroplane using one type of material, and throw.This results in variation in distance flown. The variation can be reduced by giving explicit instructions on materials to use and how to make the paper aeroplane.
Examples of system variations include;
- Prescribing, repeat prescriptions and different approaches to patient managemen
- Quality of Information
- Complaints – receipt of and investigating
- How requests are received
- Patient demand
- Different approaches to work
Fishbone Diagram
Fishbone diagrams are used to identify the root causes of variation
Variation can be caused by
- People
- materials
- methods
- environment
- measurement
- other
Root cause analysis
Root Cause Analysis is a method that is used to address a problem or non-conformance, in order to get to the “root cause” of the problem. It is used so we can correct or eliminate the cause, and prevent the problem from recurring
When we address the symptom of a problem, rather than the cause, we will not create an improvement
We need to be.REALLY sure of what is actually causing the problem.
The 5 why’s is a tool to understand the real cause of a presenting problem.
By repeatedly asking the question ‘why?' (use five as a rule of thumb), you can peel away the layers of an issue, just like the layers of an onion, which can lead you to the root cause of a problem. The reason for a problem can often lead into another question; you may need to ask the question fewer or more than five times before you get to the origin of a problem.
The real key is to avoid assumptions and logic traps and encourage the team to keep drilling down to the real root cause
why, why why?
- I broke down
- My car ran out of petrol
- I didn’t fill up with petrol today
- I had no money
- I lost it playing poker
- I can’t read faces
Brainstorming can help with finding why the problem occurs.
The five whys can be used independently or as a part of a cause and effect diagram (Fishbone). The diagram helps you explore all potential or real causes which result in a failure or problem. Once you have established all the inputs on the cause and effect diagram, you can use the five whys technique to drill down to the root causes
You can find more information on Root Cause Analysis and the 5 Whys here on the NHS Institute for Innovation and Improvement website
Batching
Batching interrupts flow causing waste.
Queues or waiting lists are signals from a process that flow isn’t happening
Batching can be shown using the coin game which quickly illustrates the concepts of flow.
The game uses a simple simulation of 10 coins being “processed” by a number of operators. The number can vary according to how many people there are.There is a defined Customer and a set of Observers and it is run through a number of times to show the concepts. The output of the process is measured from a time & quality point of view.
Areas where batching can occur include
- Repeat prescriptions
- Project proposals
- Travel expenses
- Referral letters
- Patients waiting at reception
- Looking to triage patients
A spaghetti diagram can be used for diagnosing areas and from this a cellular layout can be identified. This will
- achieve overall flow from one end of the pathway/process to the other
- co-locates functions
- breaks up the value stream into 'pull' segments
- identifies dedicated areas, equipment, staff
Basics of rapid improvement events
A rapid improvement event involves key stakeholders, robust project plans and intense burst of implementation over consecutive days
Rapid Improvement events are based on
- Identified Compelling Need/ Metrics etc
- Value Stream Mapping event
- Identified and collected measures (demand, progress etc)
- Spaghetti Diagrams/Hand Off Charts
- Identified Improvement Projects
See NHS Institute for Innovation and Improvement : Rapid Improvement Events for more information.
A3 planning records - a useful tool which may help with managing projects
A Pragmatic approach to problem-solving, it involves thinking deeply about the problem. It accelerates rate and sustainability of problem solving and achieves quality and waste removalWhat is an A3 planning record?
A document created with a pencil and A3 piece of paper, it is simple but involves deep thought and helps solve specific problems
Its more than a tool, it forms a record. It allows you to ‘see’ the processes that complicate work rather than ‘hearing’ the complaint.
A3 Template (blank) A3 Template filled in with hints and tips.
On the left hand side is the way things happen now
Issue: state through theeyes of the patient / customer. 1-2 sentences. This allows an objective view of the problem . Remember – it is the system not the people at fault
Background:use data to describe the problem. How is it important to the organisation. e.g. it currently takes 3 hours from a decision to discharge a patient until TTO is received by Pharmacy . This is delaying patient discharge
Current condition: draw it. Highlight waste and delay. Use graphs and drawings.Use colour. Show where there is rework, interruption or where errors occur. Where is the situation not ideal. What is wrong with what happens now. Add some measurements and data.
Highlight the issues with storm clouds.
Root cause analysis: root cause analysis, keep asking why until you get to the heart of the problem. why, why, why.
It is esential to get to the bottom of the problem and thoroughly understand it. Use fishbone diagram, line drawings, stick men, arrows, colour.
Only address as many issues as you have space for on your paper. If there are more, start a new A3.
It is easy to come up with the solution if you understand the problem. Keep the A3 simple so that it is easy to get results and achieve solutions.
On the right hand side – the better way to work
Target Condition: What should it look like? Propose the improvement ?. Validate with staff.
Visualise the new process, this is the target not necessarily the ideal. The results must be achievable and realistic. It should be less complex than the current position and show continuous flow.
The question to ask is "is this moving us closer to the ideal?". Be sure to explore more than one method, focus on work methods with little or no costs.
For every storm cloud in the Current Condition there should be a fluffy cloud here
Counter measures: What are you going to do to move to the target condition. There should be at least one action for each root cause identified
Implementation Plan: What - Who - When - Outcome
Make things happen, ensure accountability. Allocate actions, the recipients should be willing and have the ability to see the actions through.
Measures & Follow Up:
Cost : How much will the solution cost? Benefit : what will be the cost benefit
Be realisitic in determining cost i.e. how much worker time will be needed to implement it, purchases etc. Hard and soft savings / people reallocation / patient safety and patient and staff satisfaction / fewer errors.
Test : Plan, Do, Check, Act. Test each idea, who, when, how. What will be the measures of success.
Follow up: who will measure the effectiveness of the solution e.g. number of incident reports over a 1 month period.
NHS MILTON KEYNES QUALITY IMPROVEMENT MODEL
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