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Improving Improvement

A toolkit for Engineering Better Care

 

Define the Problem

The problem describes the detail of a particular challenge within a system and all the requirements for change necessary to improve the system.

Contents

 

Introduction

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

Purpose

Defining the problem has particular importance to systems improvement: describing and benchmarking the current performance of the system of interest; understanding and prioritising the needs of stakeholders and users of the system; and defining and agreeing the key requirements for improvement.

Activities

The process of defining the problem may include a wide range of activities including, but not limited to: Describe Stakeholder Experiences, Describe Patient Experiences, Measure Current Performance, Benchmark Current Performance, Capture Stakeholder Needs, Prioritise Stakeholder Needs, Agree Core Themes and Define Requirements.

Tools

The practice of defining the problem may draw on a wide range of tools including, but not limited to: Value Stream Mapping, Dependency Structure Matrix, One-to-one Interviews, Facilitated Discussion, Delphi Study, Participant Observation, Observational Study, Designing Personas, Life Café, MoSCoW, Data Analysis, Storyboarding and Fishbone Diagram.

Getting Started

Defining the problem is vital for the successful delivery of an improvement project. It is particularly important to define the problem 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 Define the Problem strand of the Understand phase, the preliminary activity is entitled Tell the Stories. For the Design, Delivery and Sustain stages, the problem should be reviewed and updated as necessary to support the ongoing improvement process.

Tell the Stories

This preliminary activity encourages people to communicate stories of patient and stakeholder experiences that bring life to the improvement challenges and deliver a description of what is known about the current challenges within the system.

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

Cards: Service Users, Service Stakeholders

Top tips:

  • Bring stories to life with images and videos of interviews
  • Use the stories to identify key elements of the system
  • Showcase areas of the system that might be improved

Following on from this preliminary activity, the remaining stage activities are: Describe Stakeholder Experiences, Describe Patient Experiences, Measure Current Performance, Benchmark Current Performance, Capture Stakeholder Needs, Prioritise Stakeholder Needs, Agree Core Themes and Define Requirements. Each of these are now described in turn, together with the tools that may be used to support them.

Activities

Describe Stakeholder Experiences

The description of stakeholder journeys, using observation and consultation approaches, to understand their experiences

Purpose: to capture stakeholder experiences of their varied and multiple journeys through the system

Inputs: Create System Maps, Create Stakeholder Map, Describe Clinical Process, Describe Patient Experiences

Tools: One-to-One Interviews, Facilitated Discussion, Delphi Study, Life Café, Storyboarding

Worksheets: Improvement Design Wall

Cards: Service Stakeholders

Outputs: a description of stakeholder experiences, highlighting the key stages and particular challenges that might be faced

Top tips:

  • Convene a representative group of service stakeholders
  • Collect stakeholder stories identifying the elements of care
  • Discuss different experiences of the service and patients

Describe Patient Experiences

The description of patient journeys, using observation and consultation approaches, to understand their experiences

Purpose: to capture patients’ experiences of their care journeys through the system

Inputs: Create System Maps, Create Stakeholder Map, Describe Clinical Process, Describe Stakeholder Experiences

Tools: One-to-One Interviews, Facilitated Discussion, Life Café, Storyboarding

Worksheets: Improvement Design Wall

Cards: Service Users

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

Top tips:

  • Convene a representative group of patients or their representatives
  • Collect patient stories identifying the elements of care
  • Discuss different experiences of the process and associated care

Measure Current Performance

The collection and analysis of recent measured performance data and targets, including both quantitative and qualitative data

Purpose: to measure current levels of performance, taking account of the prioritised stakeholder needs

Inputs: Analyse Relevant Documents, Create System Maps, Describe Clinical Processes, Describe Patient Experiences, Describe Stakeholder Experiences, Benchmark Current Performance

Tools: Observational Study, Data Analysis

Outputs: measured qualitative and quantitative performance data relating to the system of interest and its stakeholders

Top tips:

  • Monitor the current performance of the whole system
  • Estimate the levels of performance from qualitative measures
  • Derive the levels of performance from quantitative measures

Benchmark Current Performance

The collection and analysis of recent performance data and targets, benchmarked where appropriate to similar systems

Purpose: to analyse current levels of performance, taking account of the prioritised stakeholder needs

Inputs: Analyse Relevant Documents, Create System Maps, Describe Clinical Processes, Describe Patient Experiences, Describe Stakeholder Experiences, Measure Current Performance

Tools: Facilitated Discussion, Observational Study, Data Analysis

Outputs: performance data relating to the system of interest and its stakeholders, and benchmarking to similar systems

Top tips:

  • Convene a representative group of stakeholders together
  • Present recent information and benchmark the elements of care
  • Discuss different perspectives on the current performance

Capture Stakeholder Needs

The capture of stakeholder needs relating to the purpose of the system, detailing the rationale for each individual need

Purpose: to identify the full range of possible stakeholder needs relevant to the system

Inputs: Create System Maps, Create Stakeholder Map, Describe Clinical Processes, Observe Stakeholders, Consult Stakeholders, Understand Patient Diversity, Prioritise Stakeholder Needs

Tools: One-to-one Interviews, Facilitated Discussion, Delphi Study, Participant Observation, Observational Study, Designing Personas, Designing Scenarios, MoSCoW, Data Analysis, Storyboarding

Cards: Service Stakeholders

Outputs: a full list of stakeholders’ needs, including the rationale for each need

Top tips:

  • Capture and explore as many of the needs as possible
  • Describe the needs without suggesting possible solutions
  • Use a system map to assist identification of system needs

Prioritise Stakeholder Needs

The prioritisation of stakeholder needs relating to the purpose of the system, detailing the rationale for each priority

Purpose: to understand the relative priority of stakeholder needs relevant to the system

Inputs: Create System Maps, Create Stakeholder Map, Describe Clinical Processes, Observe Stakeholders, Consult Stakeholders, Understand Patient Diversity, Capture Stakeholder Needs

Tools: Value Stream Mapping, Dependency Structure Matrix, One-to-one Interviews, Facilitated Discussion, Delphi Study, Designing Personas, Designing Scenarios, MoSCoW

Outputs: a prioritized list of stakeholders’ needs, including the rationale for each need

Top tips:

  • Prioritise the stakeholders needs resolving any conflicts
  • Focus on outcomes and their values to the stakeholders
  • Develop requirements with the prioritised list in mind

Agree Core Themes

The identification and articulation of the core themes for the requirements for improvement, describing what the revised system must do

Purpose: to agree the core themes for the requirements based on the prioritised stakeholder needs

Inputs: Understand System Context, Create System Maps, Create Stakeholder Map, Generate Personas, Generate Scenarios, Prioritise Stakeholders Needs, Benchmark Current Performance, Measure Current Performance, Define Requirements, Develop Concepts, Make Models, Synthesise Evidence, Agree Aim Statement

Tools: Value Stream Mapping, Dependency Structure Matrix, Delphi Study, Life Café, MoSCoW, Fishbone Diagram

Outputs: a short list of specific, measurable, acceptable, realistic themes to act as a the focus for the improved system

Top tips:

  • Be specific, measurable, acceptable, realistic and time-bound
  • Capture the essence of what the system must do
  • Link the core themes to appropriate stakeholders

Define Requirements

The definition of requirements for improvement, describing what the revised system should be able to do and how this will be measured

Purpose: to elaborate on the core themes to develop a detailed set of system requirements

Inputs: Understand System Context, Create System Maps, Create Stakeholder Map, Generate Personas, Generate Scenarios, Prioritise Stakeholders Needs, Benchmark Current Performance, Measure Current Performance, Agree Core Themes, Develop Concepts, Make Models, Synthesise Evidence, Agree Aim Statement

Tools: Value Stream Mapping, Delphi Study, Life Café, MoSCoW, Fishbone Diagram

Outputs: a prioritised list of specific, measurable, acceptable, realistic and time-bound requirements for the improved system

Top tips:

  • Be specific, measurable, acceptable, realistic and time-bound
  • Distinguish between demands and wishes
  • Link all requirements to appropriate themes

Tools

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