2. A practical guide to improving services.
Introduction.
One of the challenges faced by organisations in today’s environment is how to increase
productivity at reduced cost while maintaining high level of services. Organisations are
progressively coming to realise that their long established culture of customer services
principles, system structures and business methodologies are no longer competitive.
As organisations strive to be more competitive in today’s changing business environment,
more of them are looking at the key business processes and systems as a means of gaining
competitive advantage and cure for the debilitating hyper competition that drives margins
ever downward.
Recent research has indicated that an organisation is only as effective as its processes and
organisational goals can be achieved only through development of logical business processes.
Organisations that practice improvement of business processes are able to consistently
improve on performance, reduce cost, generate savings while increasing effectiveness and
efficiency.
Although there are many improvement models available, two will be discussed in this write
up: the first is a five step approach to successfully manage the change project from initial
concept to completion and the second is the model for improvement which provide a
framework for developing, testing and implementing changes.
Improvement Methodologies.
5 Step Improvement Approach.
The five step improvement approach as defined by the NHS centre for quality improvement
and innovation are to provide a systematic framework from the beginning to the end of the
project. Its main objective is to give the project a greater chance for survival.
The five steps are:
-Preparation
-Launch
-Diagnosis
-Implementation
-Evaluation
Preparation involves defining the project aim and objectives, collecting available data for
the project, understanding the purpose of the project and identifying the team members
needed to support the project.

3. Launch phase is the official start of the project, it is a stage where team should be formed
and all necessary plans (project plans, communication plans and collection plans) should be
in place including the identification of a sponsor to support the project.
Diagnosis phase involves understanding the current process, dispelling assumptions and
using data to define the problem. For example, Cause and effect analysis helps you to think
through the causes of a problem thoroughly, including its possible root causes. It is only by
identifying the main causes that you can permanently remove the problem, or reduce the
delay.
A cause and effect diagram is a tool that helps you do this. The 'effect' is the problem you are
working on, for example 'waiting time'. The tool can help you identify major causes and
indicate the most fruitful areas for further investigation. It will help you understand the
problem more clearly.
By going through the process of building the diagram with colleagues, everybody gains
insights into the problem, alongside possible solutions. The people involved benefit from
shared contributions, leading to a common understanding of the problem.
Implementation phase test and measure potential solution using a plan-do-study-act (PDSA)
cycle. It also implement the best solution and introduces standard work and mistakes proofing
for a quality sustainable process. Lean improvement process is also applicable here. Lean is
basically about getting the right things to the right place, at the right time, in the right
quantities, while minimising waste and being flexible and open to change. Waste is anything
which doesn't add value to a product or service in the office, ward, laboratory, etc. In the
healthcare context, value is defined as the provision of customer / patient service and
satisfaction. Any activity which doesn't contribute to this is classified as waste.
The 7 wastes are defined and can be translated into a healthcare context as follows:
1. Overproduction - undertaking activity ‘just-in-case' and / or in a batch. This also
contributes to constraining steps in the patient pathway by feeding in inappropriate work or
the wrong batch size. Examples include requesting tests and referrals to outpatient clinics
‘just in case'.
2. Inventory - this refers to materials but can be translated as the patient. Holding inventory
works against quality and effectiveness, making it hard to identify problems. Examples
include using inpatient beds for patients who are waiting for tests but could be discharged
safely, or ordering excess material because the supply is unreliable.
3. Waiting - refers to a patient or material waiting, instead of moving at the pace of customer
demand. Waiting can be a result of variation in the process (the dice game will illustrate this).
Examples are waiting in queues at the surgery, waiting for tests or making sure all the
equipment is ready for an operating list.
4. Transportation - any movement of a patient or material is wasteful. Although you can't
fully eliminate transport, you should aim to reduce it over time. When process steps are
located next to one another, it‘s easier for you to visualise, identify and resolve quality issues.
Examples include moving a patient to an inpatient bed for review at post-op ward round and
then to another ward for discharge, moving the patient for tests or to see the physiotherapist.

4. 5. Defects - a defect which is passed along the process can escalate the impact of the initial
defect. Aim for zero defects.
6. Staff movement - unnecessary movement in the workplace relates to layout and
organisation: How far do you move to get to a computer to input discharge information? Is
there a better way which will minimise your wasted time?
7. Unnecessary processing - using complex equipment to undertake simple tasks. Often the
equipment is large and inflexible i.e. a robot in the pharmacy. Whilst it can take hours for a
patient to receive their prescription, the task of dispensing takes a matter of seconds.
Evaluation phase is where achievements are celebrated, learning and principles are captured
and improvements becomes the norm.
The model for improvement is a tried and tested approach for implementing any aspect of
organisational change. The model includes three key questions to ask before embarking on a
change programme supported by a plan-do-study-act (PDSA) cycles.
The questions are;
What are we trying to accomplish?
This question addresses the need for clear and focused goals which is consistent with the
organisations outcome and with clear numerical targets.
How will we know if a change is an improvement?
It addresses the need for the measurement of the baseline, how is the process or system
performing before change is made? It also addresses the desire to know the impact of the
change immediately or over a period of time and continuity in the measurements after the
improvement is implemented to ensure that the change is sustained.
What changes can we make that will result in improvement?
It addresses ideas or changes that are generated at process mapping events. Using fresh eyes-
seek out and use the wisdom of others methods, fresh ideas are generated in addition to
changes revealed during the process mapping events. Techniques such as creative thinking
and innovation to generate ideas and to sort them into those to be tested.
Defining change leading to improvements.
It is important to understand the change that is being implemented and the first step to
achieving this is by communication with the stakeholders, examining baseline date and also
recognising the effect of no improvements. It is also vital to obtain agreement and support
from the stakeholders based on their experiences which is essential for building collaboration
and agreement within the team.

5. Developing Project Scope
The scope should include information about project boundaries and key deliverables. A well-
defined project scope is critical to prevent a project creeping out of control. Project Creep is
when the scope grows from its original parameters into something more or different from the
original intention leading to project failure, unclear deliverables, confusion, increased
budgets and expanding time frames.
The project aim should also be aspirational, measurable and consistent with the
organisational plans. For a project to be successful, it is important that an adequate amount of
time is spent managing the project. A good project plan is fundamental to the establishment
of the project, it sets the contract for improvement and establishes the mandate, priorities and
resource availability. It spells out clearly what, how and when is to be done so that everyone
is aware of their commitment and how they will impact on the project success.
A project plan should specify; aims and objectives, background to the project, scope of the
project, expected deliverables, timescales, analysis of risk, resources, budget, method /
process, accountability, identification of project sponsor and data and measurements.
Project team members: Having the right people involved from the beginning with the right
expertise will give the project the best chance of sustainable success. A project sponsor and
involvement from executive management team of the organisation is also necessary to
champion the project and provide strategic direction to the project. There is also a need for a
Project manager who will take ownership to lead the project, ensuing decisions are made,
actions are taken and measurable, timely progress is made. Within the project team, it is also
important to have a variety of individuals, some whose role will be to make decisions and
others to carry out actions.
Stakeholder’s involvement is also essential in service improvement through the generation
of ideas using techniques such as root cause analysis, five whys and 6 thinking hats to
generate ideas and opportunities. They also provide a different perspective to enable a better
understanding of whether the change (improvement) is making any difference. In the case of
healthcare organisation, involvement of patients and carers will raise awareness of how the
service really run from the patient point of view, not just how the service providers think it
runs. It will also present different perspectives on improvement priorities highlighting
suggestions to make things quicker, cheaper, easier or better to improve services to improve
services and experience for patients and carers (in the case of healthcare services).
Communication not only keep everyone up to date on the project progress, it also raises the
profile of the project and facilitates engagements and ownership of the vision and services
changes. To ensure the success of the project, information including the aims, objectives,
expectations, deliverables, timescales, project risks, challenges and achievements needs to be
communicated on a regular basis. A communication plan to ensure effective during the
course of the project is therefore needed. It is an easy way to actively address the interests
and concerns of the key stakeholders. In a changing environment with organisational
structures being transformed and staff moving roles, a documented communication plan will
support the progression of an improvement project.

6. Improvement tools: Process mapping is a process made up of series of actions or steps taken
to achieve a specific result. It is used to identify all the interconnected pathways steps and
decisions in a process and convert this information into a highly visual diagrammatic form.
The benefits of of process mapping includes an overview of the complete process from
beginning to the end, helping staff to understand often for the first time how complicated the
system can be for users, it also allow staff to see the pathway from the patient perspective.
People’s view about the process tend to change and develop following a process mapping
exercise as individuals have an idea of the process but as the process map is developed, it
becomes clear that their personal views is different from that of others in the same process.
If planning change or improvement on a large scale, plan-do-study-act (PDSA) can be used to
test out an idea on a small scale and assessing its impact. The four stages of the PDSA cycle
are;
Plan- The change or improvement to be tested or implemented.
Do- Carry out the test or change.
Study-Data before and after the change and reflect on what was learned.
Act-Plan the next change cycle or full implementation.
One may not get the results you expect when making changes to processes, so it is therefore
safer and more effective to test out improvements on a small scale before implementing them
across the board. The advantages are; it involves less time, money and risk, the process is a
powerful tool for learning from both ideas that work and those that don’t, it is safer and less
disruptive for stakeholders and because the change is temporary there is less resistance.
Measuring benefits.
It is important to measure the benefits of the change or how would one know that there’s
been a change. In the case of healthcare services, project measure might include, reduction in
admissions and readmissions, turnaround times, patient experiences, staff morale, waiting
days between interventions and reduction in prescribing.
Improvement projects benefit from current real time data to provide a clear understanding of
the service; these data for measurement can be used to frame improvement project and
compare if at all an improvement has been made. Individual patient level data is often
valuable for improvement projects as it will allow one to see the variation between patients
and can provide an insight into a process that are hidden within aggregated and averaged
data. For example, consider looking at the variation in length of stay, you might identify
unnecessary short stays in hospital or some particularly long stays both of which would be
hidden when using an average. It is essential to know the starting point i.e the current state
and standard of current performance also known as the baseline data against which you will
measure the impact of any changes that you make over the course of the project. This helps
determine the areas that’s needed to be to be focused on, what’s needed to be measured and
how much impact the project is having.
Statistical process control chart (SPCC); Having collected all available data, statistical
process control chart is now needed for analysing the data, this tool is also important for
monitoring and controlling the process. It usually provide a common language for discussing

7. process performance. It is a simple and visual way of observing variation in system and
processes. SPCC can be used to determine if an improvement intervention is directly
improving a process and to predict statistically whether a process is capable of meeting a set
target.
Overcoming resistance to change.
Different people have different reactions to change, some people are enthusiastic and look
forward to the challenge and new experiences offered by the change while others are however
much less enthusiastic and see change as threatening and destabilising- something to be
avoided at all cost and there are people who are somewhere in between. People’s response
will vary according to the situation or the change being suggested. Understanding human
dimensions of change can help teams to find ways of effectively implementing change,
respond to resistance to change and progress the improvement work in a timely manner.
Achieving service improvement will mean changes to many systems and the way many
people work. The implementation of change can often place stress on staff, this tool may help
in reducing this stress and it can alleviate the resistance to change and achieve acceptance
from the team members. Communication is a vital aspect in effectively managing human
dimensions of change. It is important to be inclusive and to communicate the message in a
way that will engage all the different types of people.
There are usually three different levels of resistance, they are;
Level 1: Resistance relates to information i.e a lack of information or confusion over
information or disagreement with key information.
Level 2: Resistance can be due to emotional and physiological reaction to change based on
fear of loss, incompetence or abandonment.
Level 3: Resistance goes beyond the immediate situation and is based on what the change
represent to the individual. It may be deeply entrenched and may also encompass personal,
cultural, religious and racial differences.
How to address resistance to change.
Spot resistance early and in its subtle forms. Gather evidences to determine if the potential
derailment is caused by technical, financial or human factors. These are the most common
sources of resistance to change, ability to identify the source help to avoid many of the
problems that comes with change.
Identify strategies that can be used to turn opposition reluctance into support. For example
by considering personal styles, different people have different personal styles that affect how
they respond to information and how they communicate thoughts and ideas. Having an
appreciation of the different personal styles can help to minimise conflict and ensure that
everyone gets the right message the first time.
Return on Investment calculator: This tool provides an overview of return on investment,
including examples of financial benefits and costs. It can be used at the start of a project to
provide an estimate of the costs for upfront justification and again toward the end of a project
as a measure for the success of the improvement project. It can also be used throughout the

8. life of a project to continually see if benefits are being realised and make decisions about
whether to continue, modify, amplify or terminate a project.
The formula for calculating return on investment is:
Benefits - Cost = Dividends
It can also be provided as a % figure showing the savings as a percentage of the total cost:
Benefits – Costs X 100
Costs
While ROI is usually thought of as being purely about financial benefits, it is helpful to start
thinking about the quality benefits of the investments. Many seemingly non-financial benefits
already have a financial element, for example reducing patient safety incident often result in
lower length of stay and / or less intensive treatment and improving the patient experience
results in a financial benefit. Though calculation of ROI only use benefits that can be
expressed financially, it is important that all benefits (both financial and non-financial) are
captured and recorded.
Last note!
At the end of a project, there can be mixed feeling for a project team including elation, pride,
satisfaction and may be even relief and there is a great temptation to take a break from the
intensity of the project work or even to move on to the next challenge especially when
resources are stretched and time is precious.
But before you do this, consider that the project end date is not necessarily the end of the
project. If improvement have been made then they should be recognised and celebrated for
the recognition and morale of the people who have been involved – whatever the aims and
objectives were, however big or small the project, success should be celebrated and shared.