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Improving Improvement

A toolkit for Engineering Better Care

 

Improvement Tools

A selection of tools are used to enable activities to be executed in a planned order to ensure the efficient and effective execution of a programme of improvement.

Contents

 

Introduction

The tools in this toolkit are largely off-the-shelf, established and well used. Simple guidance is provided for their use and reference given to resources that describe them in more detail. The intention is not to provide full instructions for their use here, rather to point to their existence and indicate where they might be used. They are catalogued according to their most likely contribution to the key strands of the improvement process, but may be used at any stage.

Useful toolkit resources: Cards for each of these tools are included in the Resources part of this toolkit. A number of blank cards are included to allow additional tools to be created.

Tools may be mapped to activities to assist in their selection. More than one tool may be used for any particular purpose and this is often encouraged. The mapping provides clear indication as to how tools might be used to support activities, but is not expected to exhaustively show where tools have actually been used in practice.

 

Context

Literature Review

A systematic review of the literature describing the system being improved and its behaviour.

Top tips:

  • Define relevant search terms and likely sources of literature
  • Filter the literature retrieved to maximise its utility
  • Search the grey literature for additional practical insights

https://www2.open.ac.uk/students/skillsforstudy/conducting-a-literature-review.php


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Soft Systems Method

A means to foster learning and appreciation of the problem situation within a complex system

Top tips:

  • Look at the real-world situation rather than the problem
  • Develop conceptual models to aid understanding of the system
  • Define actions to improve that are shared by stakeholders

https://www.wiley.com/en-gb/Soft+Systems+Methodology+in+Action-p-9780471986058


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Causal Loop Diagram

A means to capture the variables of interest in a complex system and understand their effect on outcomes

Top tips:

  • Identify the variables of interest and link them together
  • Label and characterise the causal loops within the system
  • Use the causal loops to tell the story of the system

https://thesystemsthinker.com/fine-tuning-your-causal-loop-diagrams-part-i/


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Entity Relationship Diagram

A means to identify and map the entities in a complex system and the relationships between them

Top tips:

  • Look at the real-world situation rather than the problem
  • Identify the entities and the nature of the relationships between them
  • Use the relational loops to tell the story of the system

https://www.open.edu/openlearn/science-maths-technology/computing-and-ict/models-and-modelling/content-section-8.1


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Data Flow Diagram

A means to identify and map the functions in a complex system and the things flowing between them

Top tips:

  • Look at the real-world situation rather than the problem
  • Identify the functions and the data/things flowing between them
  • Use the function/data loops to tell the story of the system

https://www.open.edu/openlearn/science-maths-technology/computing-and-ict/models-and-modelling/content-section-4.1


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State Transition Diagram

A means to identify and map the states in a complex system and the transitions between them

Top tips:

  • Look at the real-world situation rather than the problem
  • Identify the states and nature of the transitions between them
  • Use the transition loops to tell the story of the system

https://www.open.edu/openlearn/science-maths-technology/computing-and-ict/models-and-modelling/content-section-9.1


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Flow Chart

A means to map the key activities and decisions in a system and understand their impact on performance

Top tips:

  • Identify key activities in the system and the decisions that link them
  • Look for unexpected feedback loops that may affect performance
  • Identify the resources required to deliver the activities and decisions

https://www.open.edu/openlearn/science-maths-technology/computing-and-ict/models-and-modelling/content-section-7.1


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Swimlane Diagram

A means to map the key activities and decisions in a system and understand their impact on performance

Top tips:

  • Identify key activities in the system and the decisions that link them
  • Identify the resources required to deliver the activities and decisions
  • Look for unexpected feedback loops that may effect performance

https://www.open.edu/openlearn/science-maths-technology/computing-and-ict/models-and-modelling/content-section-7.1


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Spaghetti Diagram

A tool to establish the optimum layout for a department based on observations of movement

Top tips:

  • Obtain a detailed floor plan of the department of interest
  • Capture the movements of people or products within the department
  • Analyse the lines of flow to identify unnecessary movement

https://improvement.nhs.uk/documents/2168/spaghetti-diagram.pdf


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Value Stream Mapping

A tool to help understand and improve the material and information flow within organisations

Top tips:

  • Present the whole process from end to end
  • Use a simple graphical format to map current and future states
  • Encourage a team approach to constructively critique activity

https://improvement.nhs.uk/documents/2133/value-stream-mapping.pdf


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Dependency Structure Matrix

A structured representation of the dependencies between individual elements of a system

Top tips:

  • Identify the relevant elements of the system and their dependencies
  • Present the rows and columns of the matrix in the same order
  • Apply clustering and sequencing algorithms to analyse the system

http://www.dsmweb.org/en/dsm/websitestructure.html


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One-to-one Interviews

A means to elicit information about a particular topic or area of interest in a one-to-one conversation

Top tips:

  • Select participants with a range of views on the chosen topic
  • Prepare some key questions as the basis of the conversation
  • Determine the degree of structure required before the interview

https://www.methods.manchester.ac.uk/themes/qualitative-methods/


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Facilitated Discussion

A means to elicit perceptions about a particular topic or area of interest in a non-threatening environment

Top tips:

  • Select participants with a range of views on the chosen topic
  • Encourage all participants to contribute to the discussion
  • Use visualisation tools to summarise and communicate the results

https://www.methods.manchester.ac.uk/themes/data-collection/


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Delphi Study

An iterative approach to develop a consensus view regarding the current performance of the system

Top tips:

  • Select experts with a range of views on the chosen topic
  • Design the questionnaires to inform and elicit a consensus view
  • Ensure a quick turnaround of views between the study cycles

https://www.rand.org/topics/delphi-method.html


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Participant Observation

A means to understand how things are really done in a particular situation or area of interest

Top tips:

  • Design the study carefully to define its scope and appropriate duration
  • Use ethnographic methods early in a programme of change
  • Identify key activities, actions and detailed behaviours

https://www.methods.manchester.ac.uk/themes/ethnographic- methods/


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Observational Study

A means to observe how things are done in a particular situation or area of interest

Top tips:

  • Design the study carefully to define its scope and appropriate duration
  • Use observational methods early in a programme of change
  • Identify key activities, actions and detailed behaviours

https://www.methods.manchester.ac.uk/themes/qualitative- methods/


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Designing Personas

A means to create representations of stereotypical users and their conditions, capabilities and responsibilities

Top tips:

  • Conduct user research to identify key users and their behaviours
  • Focus on the expectations, needs and motivations of key users
  • Describe realistic people with backgrounds, goals and values

https://www.usabilitybok.org/persona


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Designing Scenarios

A means to create the stories of stereotypical users reflecting their conditions, capabilities and responsibilities

Top tips:

  • Conduct user research to identify key stories and their context
  • Focus on the expectations, needs and motivations of key users
  • Describe realistic scenarios involving stereotypical users

https://www.usabilitybok.org/scenario-of-use


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Problem

Life Café

A means to elicit an understanding of the needs for a system, taking account of the full range of stakeholders

Top tips:

  • Enable community members to express what matters to them
  • Generate conversations within a safe and familiar environment
  • Tailor the experience for different people, situations or environments

https://www.lifecafe.org.uk/


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MoSCoW

A means to capture a prioritised list of must, should, could and won’t have requirements for improvement

Top tips:

  • Capture the requirements that must be met
  • Identify those requirements that should or could be met
  • List those requirements that would be required later

https://www.toolshero.com/project-management/moscow-method/


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Data Analysis

A means to analyse available data to understand the current levels of performance of the system

Top tips:

  • Collect relevant performance data across the systems of interest
  • Select the analytical tools most appropriate to explore the data
  • Use visualisation tools to summarise and communicate the results

https://www.methods.manchester.ac.uk/themes/survey-and-statistical-methods/


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Storyboarding

A means to clearly articulate a view of a better system based on an understanding of the current system

Top tips:

  • Identify all the key steps in the end-to-end patient journey
  • Make each step small enough to elicit subtle but significant issues
  • Look at each step from different stakeholder perspectives

https://www.toolshero.com/problem-solving/storyboarding/


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Fishbone Diagram

A method to think through the causes of a problem before starting to identify its root causes

Top tips:

  • Define the main problem to be resolved
  • Identify the main categories of potential causes
  • Allow progressive identification of the most likely causes

https://improvement.nhs.uk/documents/2093/cause-effect-fishbone.pdf


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Solution

Brainstorming

A means to encourage the generation of ideas and concepts to facilitate system improvement

Top tips:

  • Encourage free thinking in the generation of ideas and concepts
  • Focus initially on the quantity of ideas and concepts created
  • Filter the ideas and concepts to identify potential winners

https://www.ifm.eng.cam.ac.uk/research/dmg/tools-and-techniques/brainstorming/


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Disney

A means to encourage the dreamer, the realist and the critic to develop ideas for system improvement

Top tips:

  • Allow the sharing of dreams without restriction or criticism
  • Filter ideas to turn imaginary ideas into a manageable action plan
  • Provide constructive critique for the ideas and action plan

https://www.toolshero.com/creativity/walt-disney-method/


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Six Thinking Hats

A means to encourage different ways of thinking to reach innovative concepts for system improvement

Top tips:

  • Establish the facts and encourage intuitive thinking
  • Allow a structured mix of creative, constructive and cautious thinking
  • Facilitate and manage the critical thinking discussions

https://improvement.nhs.uk/documents/2167/six-thinking-hats.pdf


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Morphological Chart

A means to help organise the presentation of ideas and concepts to facilitate system improvement

Top tips:

  • Encourage free thinking in the generation of ideas and concepts
  • Arrange the ideas and concepts in organisational or functional groups
  • Create potential solutions as combinations of ideas and concepts

https://www.ifm.eng.cam.ac.uk/research/dmg/tools-and-techniques/morphological-charts/


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Evidence

Exclusion Audit

A systematic approach to estimating potential levels of exclusion when using a system

Top tips:

  • Identify the location and cause of potential exclusion
  • Estimate the likelihood and impact of potential exclusion
  • Assess the risk of exclusion and determine its criticality

http://www.inclusivedesigntoolkit.com/GS_evaluate/evaluate.html#exclusion


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Expert Review

A systematic approach to identifying potential causes of difficulty when using a system

Top tips:

  • Identify the location and cause of potential challenges
  • Estimate the likelihood and impact of potential challenges
  • Assess the risk of challenges and determine their criticality

http://www.inclusivedesigntoolkit.com/GS_evaluate/evaluate.html #experts


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User Trials

An experimental approach to identifying potential causes of difficulty when using a system

Top tips:

  • Observe the location and cause of actual challenges
  • Estimate the likelihood and impact of actual challenges
  • Assess the risk of challenges and determine their criticality

http://www.inclusivedesigntoolkit.com/GS_evaluate/evaluate.html#testuser


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Root Cause Analysis

A systematic approach for identifying the root cause of a problem within a system

Top tips:

  • Define the problem and its impact on different stakeholders
  • Identify possible causal factors and the real reason for the problem
  • Recommend solutions to prevent the problem from happening again

https://improvement.nhs.uk/documents/2156/root-cause-analysis-five-whys.pdf


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Failure Mode and Effects Analysis

A systematic approach for identifying the causes of all possible failures in a system and their consequent risk

Top tips:

  • Identify the location and cause of potential failure modes
  • Estimate the likelihood and impact of potential failure modes
  • Assess the risk of potential failure modes and determine their criticality

https://www.iso.org/standard/51073.html


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Fault Tree Analysis

An approach to identifying desirable or undesirable events and the combinations of actions that lead to them

Top tips:

  • Identify key events representing success or failure
  • Map the combinations of actions that may lead to these events
  • Estimate the likelihood of the actions and consequent events

https://www.iso.org/standard/51073.html


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Hazard and Operability Analysis

A systematic approach for identifying deviations from normal operation and their undesirable consequences

Top tips:

  • Identify and quantify key flows within the system
  • Investigate a range of possible deviations from normal operation
  • Estimate the impact of deviations on system operation

https://www.iso.org/standard/51073.html


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Structured What-If Technique

A systematic approach for identifying risks within a system using structured brainstorming and guidewords

Top tips:

  • Identify and quantify key flows within the system
  • Use a suitable list of prompts to initiate discussion of potential risks
  • Involve a multidisciplinary team of experts in the review

https://www.iso.org/standard/51073.html


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Risk Matrix

A structured representation of the likelihood and impact of threats and opportunities in the system

Top tips:

  • Quantify possible threats and opportunities
  • Map the likelihood and impact of the threats and opportunities
  • Identify unacceptable threats to the system performance

https://www.iso.org/standard/51073.html


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Case

PEST(LE) Analysis

A broad approach to identify the external factors most likely to impact a proposed change

Top tips:

  • Consider the external factors associated with a proposed change
  • Add environmental and legal factors to conduct a PESTLE
  • Use the results of the analysis as input to a SWOT analysis

https://www.professionalacademy.com/blogs-and-advice/marketing-theories---pestel-analysis


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SWOT Analysis

A means to identify the strengths, weaknesses, opportunities and threats associated with a change

Top tips:

  • Consider the external factors involved with a proposed change
  • Use the results of a PEST analysis as input to the SWOT analysis
  • Set the final change objective following the SWOT analysis

https://www.professionalacademy.com/blogs-and-advice/marketing-theories---swot-analysis


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Stakeholder Analysis

An analysis of the potential for stakeholders to drive or block the outcome of a proposed change

Top tips:

  • Identify drivers and blockers likely to influence a proposed change
  • Develop a strategy to engage with the key influencers
  • Ensure good communication with all stakeholders

https://www2.mmu.ac.uk/media/mmuacuk/content/documents/research/Impact-Tool---Stakeholder-Analysis.pdf


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The Five Ws and Two Hs

A means to summarise the rational for and initial description of a proposed change

Top tips:

  • Answer the who, what, where, when and why simply and clearly
  • Describe how the change will be delivered and how much it will cost
  • Use this approach to support other problem solving challenges

https://www.inloox.com/company/blog/articles/back-to-basics-part-3-kick-start-your-projects-with-the-5ws-and-2hs/


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Wardley Map

A linked map of stakeholder values set against the maturity of the elements that create them

Top tips:

  • Identify the key components of stakeholder value
  • Map value against the maturity of the elements that produce it
  • Connect components on the map that are linked in any way

https://blog.gardeviance.org/2015/02/an-introduction-to-wardley-value-chain.html


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Plan

Driver Diagram

A theory-of-change that can be used to collaboratively plan improvement project activities

Top tips:

  • Capture a clearly defined and measurable aim
  • Identify the drivers which will contribute to the aim
  • Formulate the ideas for change designed to meet the aim

https://improvement.nhs.uk/documents/2109/driver-diagrams.pdf


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Gantt Chart

A bar chart to illustrate the schedule required to deliver a programme of improvement

Top tips:

  • Identify the key activities and deliverables
  • Show dependencies if appropriate to illustrate task precedencies
  • Cluster the activities by function or in order of start time

https://www.ifm.eng.cam.ac.uk/research/dstools/graphs-gantt-histograms-bar-charts/


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Activity Dependency Diagram

A dependency network to map the activities required to deliver a programme of improvement

Top tips:

  • Identify the key activities and deliverables
  • Order the activities taking account of their precedencies
  • Determine the critical path required to deliver the programme

https://www.ifm.eng.cam.ac.uk/research/dstools/pert/


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LoMo

A fundamental shift in thinking about the meetings required to deliver a programme of improvement

Top tips:

  • Value the way other people see the world
  • Empower individuals to take more responsibility
  • Make the purpose visible earlier to help people contribute

http://lomomeetings.co.uk/


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