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Improving quality by changing the service. Most people would like to ‘do something about quality ’ but don't have the time. They are too busy dealing with complaints, correcting mistakes, doing the wrong things right and doing what they do twice. paraphrased from Øvretveit (1992).

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improving quality by changing the service
Improving quality by changing the service

Insert name of presentation on Master Slide


Most people would like to ‘do something about quality’ but don't have the time.

They are too busy dealing with complaints, correcting mistakes, doing the wrong things right and doing what they do twice.

paraphrased from Øvretveit(1992)

listen to the story
Listen to the Story
  • How does listening to the story make you feel from a personal point of view?
  • If you had this situation presented to you, what would you do about it?

other stories that are easy to find and use ……,,


In pairs …

In 5 minutes, one of you should describe a situation when you felt optimal care was not provided – this should not be an issue of clinical negligence – but a something that you were left feeling uncomfortable about.

The listener should ‘draw’ the patient/situation.

After 5 minutes swap roles.

Stick the pictures around the room.


There are 2,231 words meaning drunk …

but only one word for quality


What is quality?

Tell the students to imagine they are going shopping (for anything – food, clothes, a bit of IT kit) then ask them in groups (3 to 6 depending on numbers) to discuss how they will know they have bought quality.

Take feed back – discuss their ideas and if possible towards the end of the discussion lead them towards the next slide...


Quality does not necessarily mean excellence …

Quality means:

fit for the purpose.

the model for providing care
The Model for Providing Care

Functional Health Status

Access System




Satisfaction against need

Clinical Outcomes


Patient with needs

Total Costs

Balanced measure of care

To provide quality care we need to understand what we can do …

most of the theory of quality improvement comes from engineering – and most private services can

select their customers (e.g. M&S Simply Food is in competition with Waitrose, not Aldi or Lidl). We however cannot pick our customers. We have patients with needs. They arrive with all their baggage plus their health conditions.

We also need a BALANCED MEASURE OF CARE. We tend to only measure clinical outcomes and

total costs but if we don’t measure functional health status or satisfaction against need we miss some of

the fundamentals.

However, to have an impact on the balanced measure of care we can only change on the bit

we actually do – the cycle in the middle.

6 components of quality
6 components of Quality

There are many definitions of quality – and the only reason this one is highlighted is that this is what government health documents usually use. They do not identify the ‘Maxwell’s 6 components of quality’ but they tend to use these headings.

I’ve added Sue Lister’s 7th component, which is Humanity (not published anywhere other than on this slide and I don’t care if you want to take ownership and put your name there)

      • Access
      • Relevance to need
      • Effectiveness
      • Equity
      • Acceptability
      • Efficiency
  • (Maxwell 1984)
  • 7. Humanity
  • (Lister’s 7th component of Quality)
it is the system
It is the system …

Every system is perfectly designed to produce the outcome it achieves!

paraphrased from Berwick (1996)


These are the same – what turns your input (the ingredients) into your outcome (the cake) is what you do to them – the process … the system.

If there is something wrong with

your outcome shouting at your

ingredients won’t make it better!

This can just as easily be done with a cup of tea!

process mapping

Select a process

Map the process

Analyse the current situation

Identify opportunities to improve

Process mapping …
map the process
Map the process

A useful tip – never do a flowchart directly onto a white board or flip chart … use ‘post-it’ notes. You will always forget a stage in the process and ‘post-it’ notes can be moved about until you get it right. If you have written it on a board/paper – you’ll have crossings out or bits you try and squeeze in.

This isn’t rocket science ... it is the application of the bleeding obvious. The map of the process is simply a flow chart of what actually happens.

analyse the current situation
Analyse the current situation

Reworked loops


Lots of steps


Reworked loops

swiss cheese management model
Swiss Cheese management model

Swiss cheese is full of holes but doesn’t collapse because the holes don’t join up – our systems are full of holes but we don’t have constant disasters because the holes don’t line up … mainly due to lots of little miracles. When disasters or near-misses are analysed you normally find the holes lined up (because one of the miracles didn’t happen)

identify opportunities to improve
Identify opportunities to improve

With as few steps as possible

Each step must add value to the process.

This is the fundamental rule of lean


The health service has many heroes. The staff who work harder, predict problems and compensate for short comings.

Heroic thoroughness may make patients lives a little safer, but a real improvement in the quality of care provided to patients is not created by heroes who compensate for the flawed processes.

The real heroes are those who change the system to remove the flaws!

End of lecture 1!

workshop activity
Workshop activity

In groups of about 6 and to go back to the original people that are stuck on the post-it notes around the room and as a group pick 1 to work on.

Attempt to process map the system that the person was in.

If you don’t have enough information on the actual system you can process map what you think should happen (as opposed to what went wrong).

between lecture activity
Between lecture activity

If they get the opportunity between the 1st lecture and the 2nd ask them, at a hospital to ‘find the way from the bus stop to a specific ward or department only using the signs that are available’

– and/or –

Spend 30 minutes in a waiting room & observe behaviour. How do patients respond, how do staff behave, what do the notices on the notice board – are they useful? They should not be in the waiting room of their ‘own’ department e.g. Send nurses to X-ray etc...


The tribal wisdom of the Dakota Indians, passed from generation to generation, states that when you discover that you are riding a dead horse the best strategy is to dismount.

However modern management best practice within government and large organisations has developed other strategies, including the following:

  • Change Riders.
  • Say things like “this the way we always ride horses”
  • Appoint a committee to study the horse.
  • Arrange to visit other sites to see how they ride dead horses.
  • Hold training sessions to improve dead horse riding ability.
  • Compare the state of dead horses in today’s environment.

Lecture 2


Re-classify the dead horse as “living, impaired”.

  • Pass legislation declaring that “this horse is not dead”
  • Harness several dead horses together for increased the speed
  • Do a cost analysis study to see if contractors can ride it cheaper
  • Offer the horse career counselling and the option of a transfer to a less stressful position of equivalent status
  • Check with IT Support to see if the whole network is down, or if it is just the horse
  • Promote the dead horse to a Senior Management position
a model for improvement

What are you trying toaccomplish?


Three fundamental questions for improvement

How will you know that achange is an improvement?


What changes can you make that will

result in the improvements you seek ?

Ideas, hunches,other people etc.



How to make change happen



A model for improvement

It’s too complicated in one go, so over the next few slides we build it up a bit as a time …

Langley et al (1996) – cited 1000 Lives plus (2012)



What are you trying toaccomplish?

How will you know that achange is an improvement?


What changes can you make that will result in the improvements you seek ?

Ideas, hunches,etc.



Three fundamental questions for improvement


1] Small and specific … not big or all encompassing

2] All improvement needs change but not all change is an improvement. Therefore … what will I see that is different if I come back next month/6 months/next year?

3] Move onto next slide and PDSA cycle

the pdsa cycle



How to make change happen …



Walton (1989)

The PDSA Cycle
  • What changes
  • are to be made?
  • Next cycle?
  • Objective
  • What do we want to do?
  • Plan to carry out the cycle
  • (who, what, where, when)
  • Plan for data collection

It does was it says on the can!

I emphasise that Deming originally had PDCA - the C was Check but people think of Check as something that is done to you – people ‘check-up’ on you. So he changed it to Study – you study it yourself/selves

  • Analyse the data
  • What did or didn’t
  • work?
  • Summarise what
  • was learnt
  • Just do it!
  • Carry out the plan
  • Document problems
  • and unexpected
  • observations
repeated pdsa cycles
Repeated PDSA Cycles


that result in


It has been shown that making small continuous changes, adapting as the team assesses what needs to be done through repeating PDSA cycles that the resulting change is greater – embedded and much more appropriate.




















a model for improvement1

What are you trying toaccomplish?


Three fundamental questions for improvement

How will you know that achange is an improvement?


What changes can you make that will

result in the improvements you seek ?

Ideas, hunches,other people etc.



How to make change happen



A model for improvement

Then put it back together

Langley et al (1996) – cited 1000 Lives plus (2012)

examples of student i mprovement projects sips
Examples of Student Improvement Projects (SIPs)
  • OT equipment arriving on time
  • Face wipes to improve the quality of life
  • Repeated taking of bloods
  • Advice about vital signs in young children
  • When the artificial feed pump goes wrong
  • No clock in an operating theatre scrub area
  • Overrunning clinic

The important thing is to keep SIPs small and manageable – you need to stop students trying to solve world poverty. Giving examples often helps them to focus on something that they can do. You will obviously develop your own examples over time.

workshop activity1
Workshop activity
  • Report back on the activity (waiting room or following signs) and discuss how patient focused they are.
  • Go back to the process map you have undertaken and consider the PDSA cycle …
  • Plan a change (the P of PDSA)
  • Consider all the changes you can.


Batalden PB & Stoltz PK (1993) A Framework for the Continual Improvement of Healthcare: Building and Applying Professional and Improvement Knowledge to Test Changes in Daily Work. Journal on Quality Improvement, October. 19 (10) 424-452

Berwick DM (1996)A primer on leading the improvement of systems. BMJ 312 619-622

Cox S, Wilcock P & Young J (1999) Improving the Repeat Prescribing Process in a Busy General Practice - A study using continuous quality improvement methodology, Quality in Health Care, 8 119-125

Maxwell RJ (1984) Quality assessment in health. BMJ; 288: 1470-2

Nelson G, Batalden P, Plume S, Mohr J (1996) Improving Health Care Part 2 - A Clinical Improvement Worksheet and Users’ Manual. The Joint Commission Journal on Quality Improvement. 22 (8) 531-548

1000 Lives Plus (2012) The Quality Improvement Guide for Educators and Students. Available on line at;

Øvretveit J. (1992) Health Services Quality: An introduction to quality methods for health services. Blackwell Scientific. London

Scholtes PR, Joiner BL, Streibel JL (2003) The Team Handbook – 3rd Edition. Pub: Oriel Inc.

useful links
Useful Links Lives Plus , NHS Wales

www.ihi.orgInstitute for Health Care Improvement (USA)

www.teamhandbook.comWebsite for the Scholteset al (2003)

referenced above of patient experiences.