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Improving Improvement

A toolkit for Engineering Better Care

 

IHI Model for Improvement

The IHI Model is a tool for accelerating improvement, based on three fundamental questions and the Plan-Do-Study-Act cycle to test changes in real work settings.

Contents

 

Introduction

The model for improvement was developed by the Associates in Process Improvement as a tool for accelerating improvement and has been adopted by the Institute of Healthcare Improvement as its primary framework for improvement in healthcare. The model has two parts: three fundamental questions, which can be addressed in any order; and the Plan-Do-Study-Act cycle to test changes in real work settings in order to determine if the change is an improvement.

Use of the model is widespread within the NHS due to its simplicity and ability to bring about rapid testing of ideas. Some criticism of its effectiveness has been raised, suggesting that it is poorly applied and often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required.

The model for improvement ensures that teams know the purpose behind what they are trying to accomplish, understand what success will look like and identify those changes that will result in improvement. It also guides them through the process of establishing appropriate measures, creating changes, evaluating changes, implementing changes and spreading changes. Following the initial questions, multiple Plan-Do-Study-Act cycles may be used to achieve the level of improvement desired.

Footnotes

See also: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Langley, Moen, Nolan, Nolan, Norman and Provost, John Wiley & Sons (2nd edition), 2009.

Getting Started

Improvement teams in health and care already have a range of theories of change and improvement approaches available: the IHI model for improvement, human factors in healthcare, lean in healthcare, experience-based co-design, root cause analysis, and six sigma to name a few.

While a number of these approaches already include tools, such as Failure Modes and Effect Analysis (FMEA) and mapping techniques that may be found in engineering methods, the systems approach presented in this toolkit has the potential to add further value to the improvement agenda in two distinct forms. The provision of new tools and ways of thinking can supplement existing approaches and the adoption of a systems approach can guide a design from a set of complex needs through to validated, effective operational systems.

There are other key areas in which new ways of thinking, derived from a systems approach, can supplement existing methods. This includes, measuring and designing system interfaces to alleviate service integration issues and using systems safety assessment to proactively design risk out of systems and avoid incidents rather than merely reactively preventing a recurrence. In such cases, existing improvement approaches may be enhanced by using techniques from a systems approach.

The Systems Approach is also a method in its own right that applies tools to answer a series of questions in an iterative and systematic way in order to guide a design from a set of complex needs through to validated, effective operational systems.

During this process, experienced improvers can use their own tools, frameworks and experiences of change to help teams understand people, deliver systems, facilitate design and manage risk. A systems approach can enhance existing approaches through additional tools and techniques, encouraging improvements to be guided by a series of critical questions or simple stage gate processes.

The following map can be used to understand the coverage of the IHI model and to suggest areas where a systems approach may assist in the provision of additional questions, activities and tools to supplement existing practice.

Comparison

The questions, activities and tools from this toolkit can be mapped to the IHI Model for Improvement to better understand the relative coverage of the two approaches. Resource material for the IHI model has been analysed in detail to ascertain how it relates to the systems approach in this toolkit, both in terms of the mention of common topics and in terms of the provision of detailed descriptions or advice relating to the same topics.

Questions, activities and tools that have particular potential to add value to the IHI model:

What are we trying to accomplish?

The focus of the first question in the IHI Model of Improvement is the agreement of a SMART aim statement that is meaningful to the users and stakeholders, and aligned with organisational goals. General project issues are also addressed at this stage, such as creation of the team, initial exploration of the problem area and needs, definition of a clear scope for the improvement, and engagement of key stakeholders.

Activities from the systems approach, not frequently mentioned in the literature on the IHI Model of Improvement relating to this question, that may add value include: Describe Clinical Processes, Describe Patient Journeys, Create Stakeholder Map, Understand Patient Diversity, Generate Personas, Generate Scenarios, Describe Stakeholder Experiences, Prioritise Stakeholder Needs, Present Case for Change and Review Project Performance.

Tools from the systems approach that may be useful include: Literature Review, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Swimlane Diagram, Value Stream Mapping, Dependency Structure Matrix, Facilitated Discussion, Delphi Study, Participant Observation, Designing Personas, Designing Scenarios, Life Café, PEST(LE) Analysis, SWOT Analysis, Stakeholder Analysis, The Five Ws and two Hs, Wardley Map, Gantt Chart, Activity Dependency Diagram and LoMo.

How will we know that a change is an improvement?

The second question relates to the identification and definition of appropriate measures to test ideas for improvement and studied. These may include outcome, process and balancing measures, proposed by the stakeholders, to ensure the agreed improvement aim is met.

Activities from the systems approach that may add value include: Analyse Relevant Documents.

Tools from the systems approach that may be useful include: Literature Review, Facilitated Discussion, Delphi Study, MoSCoW and LoMo.

What change can we make that will result in improvement?

The focus of the first question in the IHI Model of Improvement is the agreement of a SMART aim statement that is meaningful to the users and stakeholders, and aligned with organisational goals. General project issues are also addressed at this stage, such as creation of the team, initial exploration of the problem area and needs, definition of a clear scope for the improvement, and engagement of key stakeholders.

Activities from the systems approach, not frequently mentioned in the literature on the IHI Model of Improvement relating to this question, that may add value include: Describe Clinical Processes, Describe Patient Journeys, Create Stakeholder Map, Understand Patient Diversity, Generate Personas, Generate Scenarios, Describe Stakeholder Experiences, Prioritise Stakeholder Needs, Present Case for Change and Review Project Performance.

Tools from the systems approach that may be useful include: Literature Review, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Swimlane Diagram, Value Stream Mapping, Dependency Structure Matrix, Facilitated Discussion, Delphi Study, Participant Observation, Designing Personas, Designing Scenarios, Life Café, PEST(LE) Analysis, SWOT Analysis, Stakeholder Analysis, The Five Ws and two Hs, Wardley Map, Gantt Chart, Activity Dependency Diagram and LoMo.

Plan-Do-Study-Act

Plan-Do-Study-Act (PDSA) initially focuses on testing the proposed changes at limited scale to reduce risk, and then on learning from subsequent cycles to inform the scale-up of the changes. Hence, PDSA cycles also relate to second question on measures, measurement and data, and to the third regarding the current system and processes.

Activities from the systems approach that may add value include: Analyse Relevant Documents, Describe Clinical Processes, Describe Patient Journeys, Create Stakeholder Map, Generate Personas, Generate Scenarios, Describe Stakeholder Experiences, Describe Patient Experiences, Benchmark Current Performance, Review Safety, Present Case for Change and Ensure Shared Understanding.

Tools from the systems approach that may be useful include: Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Swimlane Diagram, Value Stream Mapping, Dependency Structure Matrix, Facilitated Discussion, Delphi Study, Participant Observation, Designing Personas, Designing Scenarios, Storyboarding, Fishbone Diagram, Exclusion Audit, Expert Review, User Trials, Root Cause Analysis, Failure Mode and Effects Analysis, Fault Tree Analysis, Hazard and Operability Analysis, Structured What-if Technique, Risk Matrix, PEST(LE) Analysis, SWOT Analysis, Wardley Map and LoMo.

Literature

Dixon-Woods M & Martin G (2016) Does quality improvement improve quality? Future Hospital Journal, 3(3):191-194.

Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers.

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