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Improving Improvement

A toolkit for Engineering Better Care

 

Understand the Context

The context describes the circumstances or setting that surround a system and all the factors that could influence the system and its improvement.

Contents

 

Introduction

The need to Understand the Context is the first of the seven strands in the improvement model. It underlines the importance of understanding the context of the system to be improved, as a precursor to defining the problem, developing the solution and collecting the evidence. As a result, it is expected that such understanding will be developed in the early stages of the improvement process and revised, as appropriate, as the process develops.

Purpose

Understanding the context has particular relevance to systems: reflecting the position of the system of interest among other related, adjacent systems; capturing the intended purpose of the system; describing the people and things that make up the system; and analysing the current performance of the system.

Activities

The process of understanding the context may include a wide range of activities including, but not limited to: Understand Political Context, Analyse Relevant Documents, Observe Stakeholders, Consult Stakeholders, Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys, Create System Maps, Create Stakeholder Map, Understand Patient Diversity, Generate Personas and Generate Scenarios.

Tools

The practice of understanding the context may draw on a wide range of tools including, but not limited to: Literature Review, Soft Systems Method, Causal Loop Diagram, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Flow Chart, Swimlane Diagram, Spaghetti Diagram, Value Stream Mapping, Dependency Structure Matrix, One-to-one Interviews, Facilitated Discussion, Delphi Study, Participant Observation, Observational Study, Designing Personas, Designing Scenarios, Life Café and Storyboarding.

Getting Started

Understanding the context is critical to the successful delivery of an improvement project. It is particularly important to understand the context at the beginning of the improvement process and to update the description as necessary throughout the process.

The Understand, Design, Deliver and Sustain stages of an improvement process were previously described within the Introduction section, where each stage will likely comprise a preliminary activity, followed by a number of stage activities.

For the Understand the Context strand of the Understand phase, the preliminary activity is entitled Sketch the System. For the Design, Delivery and Sustain stages, the context should be reviewed and updated as necessary to support the ongoing improvement process.

Sketch the System

This preliminary activity encourages people to show the relationships between all the elements, people, locations, conditions, tasks and information and deliver a sketch or rich picture describing what is known about the system and its context.

Tools: Soft Systems Method, Entity Relationship Diagram

Worksheets: Improvement Questions, Improvement Stakeholders, Improvement Stands Canvas, Improvement Plan

Top tips:

  • Use shapes to describe system elements and people
  • Use labelled arrows to describe the relationships between them
  • Use multiple diagrams to show different perspectives

Following on from this preliminary activity, the remaining stage activities are: Understand Political Context, Analyse Relevant Documents, Observe Stakeholders, Consult Stakeholders, Describe Clinical Processes, Create System Maps, Create Stakeholder Map, Understand Patient Diversity, Generate Personas and Generate Scenarios. Each of these are now described in turn, together with the tools that may be used to support them.

Activities

Understand Political Context

The location of the system in its wider geographical, political, management and cultural context.

Purpose: to understand the management, policy and political landscape within which the system exists

Inputs: Analyse Relevant Documents, Create System Maps, Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys

Tools: Entity Relationship Diagram

Outputs: a comprehensive description of the wider geographical, political, management and cultural context of the system

Top tips:

  • Describe the geographical and political context of the system
  • Describe the management and leadership context of the system
  • Understand local practice and policy on improvement and innovation

Analyse Relevant Documents

The analysis of documents relating to the system of interest, to reveal the current extent, behaviour and performance of the system

Purpose: to understand the system of interest, its context, stakeholders, elements and performance

Inputs: Understand System Context, Create System Maps, Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys

Tools: Literature Review

Outputs: a compendium of relevant documents and commentary on their content and likely influence on the improvement

Top tips:

  • Collect documents relevant to the system of interest
  • Identify other literature of relevance to the system
  • Analyse the documents and literature

Observe Stakeholders

The observation of individual stakeholders, i.e. service providers and users, to better understand their experiences of care

Purpose: to observe stakeholders within the system and document their actual behaviour

Inputs: Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys, Consult Stakeholders

Tools: Participant Observation, Observational Study, Spaghetti Diagram

Outputs: a description of the actual behaviour and journeys undertaken by individual stakeholders

Top tips:

  • Use a variety of observation and ethnographic tools
  • Select a representative sample of stakeholders
  • Observe links with other stakeholders

Consult Stakeholders

The consultation of individual stakeholders, i.e. service providers or users, to better understand their needs and experiences of care

Purpose: to consult stakeholders within the system and understand their expected behaviour

Inputs: Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys, Observe Stakeholders

Tools: One-to-one Interviews, Facilitated Discussion, Delphi Study

Outputs: a description of the expected behaviour and journeys undertaken by individual stakeholders

Top tips:

  • Use a variety of interview, discussion and survey tools
  • Select a representative sample of stakeholders
  • Consult on links with other stakeholders

Describe Clinical Processes

The mapping of the clinical processes that make up and support the patient journey through the system of interest

Purpose: to describe the clinical processes, key decisions and expected outcomes associated with the system

Inputs: Understand System Context, Analyse Relevant Documents, Create System Maps, Create Stakeholder Map, Describe Patient Journeys, Observe Stakeholders, Consult Stakeholders, Describe Patient Experiences, Describe Stakeholder Experiences

Tools: Literature Review, Soft Systems Method, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Flow Chart, Swimlane Diagram, Spaghetti Diagram, Storyboarding

Outputs: a description of clinical processes, highlighting the key stages and any particular challenges that might be faced

Top tips:

  • Convene a representative group of service stakeholders
  • Think broadly to identify where the stakeholder journeys begin
  • Consider all stages of the subsequent stakeholder journeys

Describe Patient Journeys

The mapping of the patient journeys associated with particular clinical processes within the system of interest

Purpose: to describe the patient journeys through the system associated with particular clinical processes

Inputs: Understand System Context, Analyse Relevant Documents, Create System Maps, Create Stakeholder Map, Describe Clinical Processes, Observe Stakeholders, Consult Stakeholders, Describe Patient Experiences, Describe Stakeholder Experiences

Tools: Soft Systems Method, Entity Relationship Diagram, State Transition Diagram, Flow Chart, Swimlane Diagram, Spaghetti Diagram, Life Café, Storyboarding

Outputs: a description of patient journeys, highlighting the key stages and any particular challenges that might be faced

Top tips:

  • Convene a representative group of patients or their representatives
  • Think broadly to identify where the patient journey begins
  • Consider all stages of the subsequent patient journey

Create System Maps

The mapping of the system of interest, to identify key elements and their interfaces to each other and neighbouring systems

Purpose: to create a common view of the system, its elements, architecture and interfaces to other systems

Inputs: Understand System Context, Analyse Relevant Documents, Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys, Describe Patient Experiences, Describe Stakeholder Experiences

Tools: Literature Review, Soft Systems Method, Causal Loop Diagram, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Flow Chart, Swimlane Diagram, Dependency Structure Matrix

Outputs: a set of maps of the system, its elements and their interfaces to each other and other systems

Top tips:

  • Include anything that can impact on the desired outcomes
  • Link to stakeholder map, clinical pathway and patient journeys
  • Reflect on what is noteworthy about the location of the system

Create Stakeholder Map

The mapping of the links between stakeholders, i.e. service providers or users, who have a direct or indirect interest in the system to be improved

Purpose: to create a common view of the range of stakeholders, their interests, and the links between them

Inputs: Understand System Context, Analyse Relevant Documents, Create System Maps, Describe Clinical Processes, Describe Patient Journeys, Describe Patient Experiences, Describe Stakeholder Experiences

Tools: Literature Review, Soft Systems Method, Causal Loop Diagram, Entity Relationship Diagram, Swimlane Diagram, Dependency Structure Matrix

Worksheets: Improvement Stakeholders

Cards: Service Users, Service Stakeholders

Outputs: a map of the system stakeholders, their interests and the links between them

Top tips:

  • List stakeholders starting with those at the heart of the system
  • Describe the likely interests of the stakeholders in the system
  • Identify links through formal and informal networks and pathways

Understand Patient Diversity

The acknowledgement of the diversity of patients and their corresponding journeys and experiences of care

Purpose: to understand the diversity of patients within the system and their particular needs and capabilities

Inputs: Create System Maps, Describe Clinical Processes, Describe Patient Journeys, Observe Stakeholders, Consult Stakeholders, Describe Patient Experiences, Describe Stakeholder Experiences

Tools: One-to-One Interviews, Facilitated Discussion, Participant Observation, Observational Study

Cards: Service Users

Outputs: a description of the diversity of patients and their experiences of care

Top tips:

  • Consider the range of patients navigating the user journey
  • Expect to see diversity in sensory, cognitive and motion capability
  • Expect to see diversity in gender, culture and socioeconomic status

Generate Personas

The drafting of short, narrative descriptions of people, as providers or recipients of care, to inspire and test ideas for improvement

Purpose: to describe stereotypical patients or care providers, with a range of medical conditions and capabilities

Inputs: Create System Maps, Create Stakeholder Map, Understand Patient Diversity, Describe Patient Journeys, Generate Scenarios, Describe Stakeholder Experiences, Describe Patient Experiences

Tools: Designing Personas

Cards: Service Users, Service Stakeholders

Outputs: a set of personas that are representative of the range or possible users of the system

Top tips:

  • Ensure personas emphasise notable user characteristics
  • Generate a set of personas to caricature the diversity of users
  • Use personas as a means to test ideas for improvement

Generate Scenarios

The drafting of short, narrative descriptions of a range of scenarios of care to inspire and test ideas for improvement

Purpose: to describe stereotypical scenarios of care involving a range of typical patients and care providers

Inputs: Create System Maps, Create Stakeholder Map, Describe Clinical Processes, Describe Patient Journeys, Understand Patient Diversity, Generate Personas, Describe Stakeholder Experiences, Describe Patient Experiences

Tools: Designing Scenarios

Cards: Service Users, Service Stakeholders

Outputs: a set of scenarios that are representative of the range of possible journeys through the system

Top tips:

  • Ensure scenarios emphasise notable pathway characteristics
  • Generate a set of scenarios to caricature the diversity of care
  • Use scenarios as a means to test ideas for improvement

Tools

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