1. NHS
CANCER DIAGNOSTICS HEART LUNG STROKE
NHS Improvement
First steps towards quality improvement:
A simple guide to improving services

2. IMPROVEMENT. PEOPLE. QUALITY. STAFF. DATA.
STEPS. LEAN. PATIENTS. PRODUCTIVITY. IDEAS.
REDESIGN. MAPPING. SOLUTIONS. EXPERIENCE.
SHARE. PROCESSES. TOOLS. MEASURES.
INVOLVEMENT. STRENGTH. SUPPORT. LEARN.
CHANGE. TEST. IMPLEMENT. PREPARATION.
KNOW-HOW. SCOPE. INNOVATION. FOCUS.
ENGAGEMENT. DELIVERY. DIAGNOSIS. LAUNCH.
RESOURCES. EVALUATION. NHS. PLANNING.
TECHNIQUES. FRAMEWORK. AGREEMENT.
UNDERSTAND. IMPLEMENTATION. SUSTAIN.
FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
CONTENTS
4 Introduction
6 Chapter 1 - Improvement models
8 Chapter 2 - Defining the change idea and developing aims
11 Chapter 3 - Managing a successful project
14 Chapter 4 - Levers and drivers – framing the work for a wider audience
16 Chapter 5 - Getting the right people involved
18 Chapter 6 - Involving patients and carers in service redesign
22 Chapter 7 - Communicating the right things to the right people
24 Chapter 8 - Improvement Tool: Process mapping
28 Chapter 9 - Improvement Tool: Plan Do Study Act Cycles
30 Chapter 10 - Measuring your efforts
34 Chapter 11 - Improvement Tool: Using statistical process control charts
37 Chapter 12 - Human dimensions of change
40 Chapter 13 - Sharing your success
44 Resources
44 Acknowledgements
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3. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
INTRODUCTION
If you are involved at any level in improving health or Before implementing a solution and changing your service, it is
social care, this resource will provide the information essential to understand your current system by mapping the
you need for your first steps towards making quality process, collecting and analysing the service data, along with
improvements, giving your improvement project the asking patients and staff for their views in order to determine
best possible chance of success. where improvements can be made. Don’t rush into
implementing whole system changes without testing and
Whether you are experienced at running improvement measuring small incremental changes. Learn from experience
projects or not, this blend of project management and and be prepared to be flexible as your first idea may not be the
improvement tools, combined with practical know-how best or the right solution.
and first hand experience gained from working with NHS
teams, should prove invaluable. This resource is not intended as a complete guide but provides a
short overview with the most relevant tools and other resources
signposted for further exploration.
If you want to deliver sustainable improvements with greater
speed and confidence, this resource will help you take the first
steps.
“ Every system is
perfectly designed
to get the results it
achieves”
Paul Batalden
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4. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
Do I really need a model to
CHAPTER 1 improve things?
Very often, it is clear that we need to
get on and improve things and you
Improvement models may be tempted to leap in and do so.
However, a very high proportion of
There are many models which can support understanding what you are going to projects fail, and one way to increase
your improvement project; however, we accomplish, identifying a core team to the chances of your own project
promote two such models: a five step undertake the work and a team to support succeeding is to adopt a more
approach to successfully manage the the direction of the work along with systematic, tried and tested approach
change project from initial concept to identifying patients and carers to be such as those outlined on this page.
completion, and the Model for Improvement involved. Work should be aligned to both Quality improvement requires the will,
to provide a framework for developing, local and national objectives together with
the ideas and the execution of those
testing and implementing changes. structured plans to measure improvements.
ideas to succeed – very often, we have
Five step improvement approach The launch phase is the official start of the the will to make things happen, but by
NHS Improvement has defined a five step project. The team should be formed; project using models such as these, we can
improvement approach to provide a plans, communication plans and data ensure we develop the best possible
systematic framework from the beginning collection plans should be in place and an change ideas and approach
to the end of your improvement project executive sponsor identified to support the implementation in a planned and
which will give your project a greater project.
systematic way to enhance our
chance of sustainable success.
The diagnosis phase is about chances of success.
• Preparation understanding the current process,
• Launch dispelling assumptions, using data to define
• Diagnosis the problem and to build upon the baseline
• Implementation data.
• Evaluation
The implementation phase tests and The final phase is evaluation where
The preparation phase incorporates measures potential solutions using a Plan Do achievements are celebrated, learning and
everything you need to do before the Study Act cycle (chapter 9), implements the principles are captured and the improvement
official start of your project. This includes best solution and introduces standard work becomes the norm.
defining your project aims and objectives, and mistake proofing for a quality
collecting baseline data for your service, sustainable process.
The sum of all of the change ideas that are • Measure regularly during testing – what is
Model for Improvement
tested and successfully implemented will be the impact immediately, and what is the
What are we trying to accomplish? the effective redesign of processes or ways impact over a period of time?
How will we know that a of working. • Continue to measure after the
change is an improvement? improvement is implemented, to ensure
What changes can we make that will
The framework, which was developed by a that the change is sustained.
result in the improvements that we seek? team at the Institute for Healthcare
Improvement in the USA, includes three key What changes can we make that will
questions to ask before embarking on a result in improvement?
change programme, supported by a process • Many change ideas are generated at
for testing change ideas using Plan, Do, process mapping events (See Chapter 8)
Study, Act (PDSA) cycles. • Use techniques of creative thinking and
ACT PLAN innovation to generate ideas and to sort
What are we trying to accomplish? them into those to be tested
• Clear and focused goals that focus on • Learn from your colleagues – we know
STUDY DO problems that cause concern for patients that there are many examples of good
and staff practice currently available.
• Consistent with local and national
outcomes, plans and frameworks The Model for Improvement is a tried and
• Bold and aspirational tested approach for implementing any
• With clear numerical targets. aspect of change in health services. Address
the three questions before embarking on
How will we know if a change is an service redesign, to keep the work focused
The Model for Improvement improvement? and relevant and to ensure that you can
The model for improvement is incorporated • What can we measure that will change if measure the impact of changing the system.
into the five step approach and was the system is improved? Use PDSA cycles (chapter 9) to test out ideas
designed to provide a framework for • How can we obtain this data? Is it on a small scale and to win commitment
developing, testing and implementing available in existing information systems, before implementing changes across whole
changes that lead to improvement. To or will we need to collect this manually? departments, processes and systems.
achieve improvements we need to take the • What is the best way to display the data
time to plan change and test it out and we collect so that we can decide whether Further explanation of the Five Step
resist the temptation to rush into wholesale we are improving the system and whether Approach and Model for Improvement is
changes to systems. This way, we will know the improvement is sustainable? detailed in later chapters.
what is working well, and what is not so • Measure the baseline – how is the process
successful. Small scale changes can be or system performing before the change
undone and replaced by alternative ideas. is made?
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5. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
What is the purpose of a clear aim
CHAPTER 2 or objective?
To ensure everyone is working
towards the same goal and everyone
Defining the change idea and has the same expectations. It is
important to define this clearly, so
developing aims that you can also identify what it is
relevant to measure and to help avoid
A clear and accurate project definition is one project creep as your work progresses.
of the most important tasks to ensure the A good aim statement can help to
success of any improvement project. motivate people about your project as
being something worthwhile,
When starting out, begin by focusing on the measurable and achievable.
problem you are trying to solve, rather than
a solution you are trying to implement - no
one likes change for change sake!
Analyse the problem by talking and listening
to those involved, collect baseline data and
recognise the impact of not changing
anything at all. Once you have a clear
understanding of the problem, it is vital to
obtain agreement and support from those
Examples of poorly written project aims
“ If you don’t know where
involved as you will find that different
people have different knowledge based on
We will improve cancer services
This aim doesn’t clearly state what the you are going, you are
their past experiences. Agreement will also
increase team engagement and will provide
change will actually improve and who would
be responsible in improving the services. Are likely to end up
somewhere else!”
a stable platform to take the next step in the improvements are for every cancer
developing the scope of your project with patient or just patients with certain types of
focused aims and objectives. cancer (e.g. breast cancer) or for all types of
cancers for a specific group of patients (e.g. Yogi Berra
Project scope children and young people)? The project
When defining your change idea, take time aim must stipulate how much the service is
to consider and clearly document what is going to be improved, when it is going to be
within the scope of your project as well as completed and what is the impact of the
what is out of scope. improvement.
The scope should include information about We will achieve a 20% reduction in Ensure your scope and aim is clear to
the project boundaries and key deliverables, emergency admissions for heart failure everyone involved. The language we use in
however be cautious of the size of the patients by July 2013 the NHS is sometimes ambiguous and can
project scope. A large wide ranging project This example does provide a clear a be interpreted in different ways by different
scope may mean the work does not have numerical target to aim for, but what is the people, for example “Self Management
enough focus or detail, or may achieve very 20% measured against? Is it 20% reduction Plan” - Is this a piece of paper with generic
little by trying to do too much; whereas a from the previous year? Is it realistic? Could information given to all symptomatic
narrow focused scope may lead to a project it be achieved? patients or a personalised care plan for each
that does not make a significant difference patient? It is really important that you are
and cannot be transferable or able to scale All practices need to use a care planning clear in your aim and don’t leave anything to
up. approach for all patients with a long chance.
term condition
A well defined project scope is critical to ‘Need to’ is not an improvement aim. Is this
prevent a project creeping out of control. all practices across the country or all
‘Project Creep’ is when the scope of a practices in the consortia? Which care Why should I get consensus about
project grows from its original parameters planning approach should be used? When the problem before starting the
into something more or different from the should this be completed and what will it project?
original intention. Implications of a achieve?
changing scope could include project failure, There are numerous reasons why you
unclear deliverables, confusion, increased A good aim may look like this should discuss the problem and
budgets and expanding timeframes. 100% of patients on our list with a
achieve a consensus before starting
confirmed diagnosis of COPD will have a
Project aim comprehensive review and will have an your project. Different people will
A project aim should be aspirational, individualised care plan developed with the have different ideas about the
measureable and consistent with local and lead GP or practice nurse by March 2013. problem, so it is important that you
national priorities and plans. This will ensure that they are optimally cared understand their perspective (as you
for and better able to manage their might learn something new) and for
A good aim statement should include: condition, thereby reducing the frequency others to understand your perspective.
• What we are trying to achieve and severity of exacerbations and the need
See the elephant analogy in chapter 3;
• For whom for possible future hospital admissions.
• How much very few people will understand the
• By when full story as their perspective is based
• Compared to what on their own experiences. This process
• And why? of gaining consensus, talking and
listening to the people involved in the
process will assist with engagement
and support for the project.
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6. An adaptation of a Hindi proverb
Five visually impaired people touch an elephant to learn
what it is like. Each one feels a different part.
"Hey, the elephant is like a tree trunk," said the
first man who touched the elephant’s leg.
"Oh, no! The elephant is like a snake" said the
second man who felt the trunk.
"Oh, no! It is like a rope," said the third man who
touched the tail.
"It is like a brush" said the fourth man who
rubbed the elephant ear.
And the fifth man said "It’s soft and mushy…"
They began to argue about the elephant and they all
insisted they were right. They all were right in what they
were saying as they had all developed an understanding
based on their own experiences and perspective. However,
they did not have an understanding of the whole elephant.
Imagine the elephant to be a patient. Different
clinicians and health care staff see the patient in
different ways, all of them correct, but by not seeing
the whole patient pathway, their understanding is
limited. Make sure you understand the entire
process/patient pathway before starting any
improvement project.
FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
What makes successful projects?
CHAPTER 3 • Getting the right people
involved from the start of the
project
Managing a successful project • Having a clear aims statement
• Planning, monitoring and control
• Having a real understanding of
Starting out on any improvement project is • Collecting baseline data and having a the current issue or problem
an exciting time, and you are likely to be full data collection plan (Chapter 10 and 11) • Measurable improvements
of enthusiasm and optimism. However, • Understanding your customer which are achievements not just
things don’t always go entirely to plan and it requirements (Chapter 6). activities
can be hard to maintain impetus and • Having clear links to local and
progress with enthusiasm alone. A project plan is fundamental to the national objectives i.e. a clear
establishment of the project. It sets the reason to do it
For a project to be successful, it is important contract for improvement and establishes • Involving patients and carers,
that an adequate amount of time is spent the mandate, priorities and resource (ideally) from the beginning
on managing the project. availability. In other words, it spells out • Displaying effective
clearly what, how and when is to be done, communication.
Spending time getting the preparatory work so that everyone is aware of their
right first time will be beneficial later in the commitments and how they will impact on
project. Preparatory work includes: the project’s success. It can be tempting to
ignore this element as “bureaucratic” or The plan is developed in the preparation
• Getting the right team (Chapter 5) “administrative” but it is an essential tool phase of the project and enables decisions
• Having a good relationship with your for ensuring there is clarity about the project to be made with regard to modifying or
executive sponsor (Chapter 5) and that expectations are managed. This cancelling the initiative in situations where
• Having a solid project plan (Chapter 3) need not be an onerous process, but the the required support for the project either
• Having a robust communication plan plan does need to clearly spell out the key changes or is lacking. The plan is used
(Chapter 7) areas. throughout the project for monitoring
• Understanding the current service and control.
(Chapter 2 and 8)
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7. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
Why do projects fail?
A project plan should specify: • Project aims and objectives not
• Aims and objectives clearly defined or articulated
• Background to the project • Little or no top level support
• Scope of project and leadership for the project
• Expected deliverables • Lack of effective engagement
• Timescale with key players and patients
• Analysis of risk • Poorly planned projects
• Resources • Inadequately monitored,
• Budget controlled and managed
• Method/process • Failure to take account of local
• Accountability and national priorities e.g. QIPP
• Identification of the project sponsor • Poor communication
• Data and measures • Failure to divide the project into
• Dependencies (i.e. links between one small manageable tasks
action and another) • Unable to collect and analyse
• How the work is going to be sustained data.
and spread to other areas.
Project plans come in many different styles, but
each should set out all the actions that have to
occur to achieve the improvement, as well as
clearly stating when these will happen and
who is responsible for doing them.
Does someone need to project
manage for a project to be
successful?
Is my work a project? Yes, within the project team, someone
A project is a temporary piece of work needs to be responsible for the role.
with a defined start and finish, and will Without someone to undertake this
not continue indefinitely. Project work role, it is unlikely that even the smallest
is also designed to deliver a defined project team will deliver what it sets
outcome or benefit from doing the out to achieve within the agreed
work. parameters.
Isn’t project management just What is the difference between a
unnecessary bureaucracy and research and improvement project?
administration? An improvement project is about
Good project management is not just testing ways to implement evidence
bureaucracy. It is about ensuring there based care and find out the best way
is consistent co-ordination, drive and for a service to be organised and
evaluation of the project so that it delivered. It is about testing innovation
remains focused and effective. Not or new ways of working and not about
having someone to manage the testing whether treatments or
project usually means that no one interventions actually work.
takes overall responsibility for ensuring
that all the components are being
delivered – and the project may then
falter or fail.
What is the role of a project
manager?
The role of a project manager is to
have oversight of the entire project
and take responsibility for controlling
and monitoring each aspect, along
with reporting the successes, learning
and failures of the project. Not every
project needs to a dedicated project
manager, but every project requires
someone to undertake the roles and
responsibilities of a project manager
(see chapter 5).
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8. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
What is QIPP?
CHAPTER 4 QIPP stands for Quality, Innovation,
Productivity and Prevention and
originates from the White Paper
Levers and drivers - framing the ‘Equity and excellence: Liberating the
NHS’ which sets out the government’s
work for a wider audience vision for the future of the NHS. The
QIPP agenda is all about ensuring that
each pound spent is used to bring
Changing established systems of any kind is
difficult. It is particularly challenging within maximum benefit and quality of care
healthcare because of the complex to patients. The QIPP initiative has
relationships between a wide range of been increasingly important in
organisations, professionals, patients and healthcare and looks set to continue
What levers and drivers could be
carers. relevant to my work? as the NHS needs to make savings
You might need to do some research because of increasing demand from an
Certain factors may help to foster an about local and national priorities. Quite
environment that is conducive to change ageing population and the increasing
often these are obvious and you can
and improvement. An organisation where need for long term condition
begin to ‘frame’ your work to align to
there is strong leadership and everyone is these. For example, you might be management. The NHS needs to
focused on improving patient care is more undertaking a project in primary care to achieve value for money and the best
likely to develop motivated staff with a reduce the number of emergency possible quality of care so that patients
desire for continuous quality improvement. admissions to hospital where the local get the greatest benefit.
However, barriers to changing established priority is to reduce bed days. There
practice may prevent or impede progress in would be a clear link to the local
all organisations, whatever the culture. initiative and the work you would then More information can be found on
undertake. www.improvement.nhs.uk/qipp
Sometimes a great idea can be presented
with various barriers and challenges to
change. Often taking time to identify the
barriers in order to overcome these is How do I link my work to local priorities?
essential to securing engagement and Talk to the local stakeholders about the work you propose and understand how it fits in. A
sustainability of the work. It is also number of these stakeholders may already be part of your project steering group, so take
important to look at the context of work time to discuss and explore this further with them. Your local clinical network may also be
you may be undertaking in terms of able to help you link to local priorities.
understanding both the local and national
drivers for change and levers for improvement.
Drivers are those forces for change that are There are a number of local and national
outside the projects scope of control. initiatives looking to improve local services What is a clinical network?
Drivers derive from a variety of sources, including calls for case study examples of A clinical network is a local NHS
including policy, that will change the way in good practice. It is worth spending some organisation made up of clinicians,
which the service may operate. Levers are time investigating what drivers are aligned managers and commissioners who work
those forces for change and improvement to your work, similar work within your together to improve care. They provide a
that are within the projects scope of control. organisation and opportunities to gain forum to share multi professional advice,
additional support where it may be influence and learning, to maximise
In parallel, linking with what is first seen as appropriate. knowledge and deliver better outcomes
primarily a small improvement project with for patients. They do this by bringing
local and national drivers for change can together primary care, secondary care,
enable a project to be further supported, commissioners, patients, social care and
How can I get wider engagement to other stakeholders with a common
successful and sustainable. Quite often
support my work? interest, to enable the local NHS to work
teams undertaking improvement projects
Raising the profile of the work, in a collaborative and co-ordinated way
focus purely on delivering isolated outcomes for its population, to best meet local
particularly if the work is aligned to local
for their work areas. Levers such as needs and priorities.
priorities will increase the chances of
reducing admissions or length of stay may wider engagement and support for the
be a local priority for a number of work. Talk to the service stakeholders
organisations in your area. It will help raise and try to secure project sponsorship
the profile of your improvement work if the from the chief executive or board level How can a clinical network help?
work is aligned to such initiatives, however director within your organisation. Also Networks focus on solving problems for
small. discuss the work with other patients wherever they are in the system,
management and clinical colleagues but stepping outside organisational
Look for similar current work already remember that these individuals may boundaries and seeking instead a whole
underway within your organisation. span wider than your immediate project system approach to service
Consider framing your work to the National group and include, primary care, social improvement. Networks will also share
QIPP agenda in terms of quality care, acute care, commissioners and the information, best practice, guidelines,
improvement, innovation, productivity gains ambulance service where relevant. Your and clinical learning to achieve greater
and prevention work. You may be surprised local clinical network may also be able to impact than would otherwise be
by how much difference your improvement assist with wider engagement and support possible. They can also influence
work contributes towards reducing costs, for your work. commissioning decisions about priorities,
availability and use of resources, to
enhancing productivity, enhancing quality
deliver optimum care to local people.
and increasing patient safety.
If your project demonstrates significant
scope to improve care, efficiency and
outcomes a network can help you
spread and sustain your work.
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9. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
How do I keep colleagues
CHAPTER 5 engaged?
Once you have built the relationship
and engagement has been achieved,
Getting the right people continue to work at it by:
involved • Staying in regular contact
• Keeping people involved and
updated
Some of the biggest risks to any project can • Having meetings with a
come from within the team. It is important Why do I need an executive sponsor? purpose, actions and outcomes
that the team has people with the right skills Executive sponsors should be chosen • Delivering what you have
and abilities to do the job and will be able to from the top of your organisation, ideally agreed to do.
give continued support to the improvement the chief executive or someone from the
initiative. executive team. This person will
champion your project, provide strategic
Having the right people involved from the support to the project, help to discuss
beginning with the right expertise will give and resolve issues, celebrate
achievement and provide access to HR,
your project the best chance of sustainable
Finance and IT teams when required.
success. If the right people are not involved
from the start, it will be much harder to
engage and involve these people at a later
date. Why is clinical and managerial
leadership important for my work?
A project sponsor and involvement from Clinicians and managers provide
the top of your organisation (Chief Executive different perspectives, experience and
or Executive Team) is necessary to champion support to your project. They will help
your project and provide strategic direction ensure that your project is appropriately
to the project. This type of involvement also targeted and relevant. Also they can
provides support to discuss issues, celebrate ensure that the changes you are testing
achievement and provide access to human are practically supported and promoted
resources, finance, analysts, communications, across different staff groups.
estates and IT teams when required.
Every project should have someone with an Involve all stakeholders and grades of staff
overview of the project who is responsible (clinical staff, GPs, porters, commissioners,
for the role of project manager. You reception staff, managers, pharmacists,
might be fortunate to have a dedicated clinical support staff, data analyst, medical
project manager to support your project, secretaries etc) as they will have different
however a project member may be required experiences, knowledge, skills, opinions,
to take on the responsibilities of this role ideas and concerns.
where this is not possible. It is advisable for
just one person to be accountable and have The involvement of patients, carers and
ownership to lead the project, ensuring charities is vital as they will be able to give a
decisions are made, actions taken, and different perspective on your service and
measurable, timely progress is made. proposed improvement plans.
Within the project team it is necessary to
have a variety of individuals, some whose
role will be to make decisions and others to
carry out actions.
When establishing a project team, consider
individuals or groups who are interested and
enthusiastic about the work, and those who
are in a position of power and influence. It
is also worth involving people or groups
who do not have direct interest in your
project but have a key position of power or
authority to make decisions.
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10. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
Why should I involve patients
CHAPTER 6 when I know what I need to do?
Patients’ experience of what we say,
do or mean can be very different to
Involving patients and carers that which we intend. By actively
involving patients, we can find out
in service redesign how what we do actually affects
them, what really happens day to day
and what we could do to improve
patients’ experience, reduce wasteful
processes and improve quality.
Patients and their carers are the reason
the health service exists and therefore
they should be at the heart of our
services.
Service improvement and redesign
generates opportunities to involve users
and their carers who can provide a different
perspective to enable a better understanding
of whether our improvements make any
difference.
A patient’s experience of our service can be
very different to what we intend or assume
it to be and they can tell us what works,
what doesn’t and what could be done
better. We might ‘know’ we are doing a
good job, but it needs to meet the patient’s
requirements.
Only when we understand a patient’s needs
– by asking them, not second guessing – can
we work in a way that meets those needs
and ensures they get maximum benefit from graham@ogilviedesign.co.uk
our service.
Why should patients and carers be Planning before involving Where can I find patients and carers
involved in the improvement of Planning is imperative to ensure that the who may support my work?
services? healthcare provider fully understands what There are many ways in which you can
• Raised awareness of how the service really they want from the interaction and how interact and contact patients and carers who
runs from the patient point of view, not they are going to meaningfully involve would like to be involved in service
just how the service providers think it runs patients and carers. improvement work. You can approach
• Different perspective on improvements people in your clinic, through hospital
and priorities The following planning steps should be departments, nurse specialists and patient
• Opportunity to discover what really makes undertaken before interaction with patients groups.
a difference to a patient’s experience and carers:
• Understanding what makes it difficult or • Be clear about what you want from Some organisations which can support the
easier for the patient to manage their interaction and what you are trying to placement of volunteer patients and carers
condition effectively achieve in service improvement work in the NHS
• Suggestions to make things quicker, • Address any staff concerns about patient include:
cheaper, easier or better to improve involvement/engagement • Local Involvement Networks (LINks) / Local
services and experience for patients and • Consider what previous patient HealthWatch (www.nhs.uk)
carers involvement has taken place and if this
• Learning more about the patient’s actual was successful. If not, why not?
experience and so providing a better • Decide on the type of patient – someone
understanding of their needs and priorities who is well informed about their
• Improved service user relationships with condition, newly diagnosed patient, I want to know more, where can I
healthcare professionals recently discharged etc. find detailed information?
• Opportunity to raise issues of importance • Decide where are you going to enlist this
to patients, carers and the public type of patient?
NHS Improvement has years of
• Improved and increased staff morale from • Decide on the level and method of
providing care to patients that they want, involvement you are going to use – i.e. experience in involving patients and
in a way they want direct, indirect questioning their carers. Information can be
• Ensure you have enough resources in found on our website:
place, e.g. time, finances, training (www.improvement.nhs.uk/ppe)
• Consider any practical arrangements that along with information about
need to be made Discovery Interviews™ which is an
• Test the method you propose to use, then
innovative technique designed to
amend where necessary
• Establish plans for evaluating your improve care by gaining insight into
approach. patient and carer needs and
experiences:
www.improvement.nhs.uk/
discoveryinterviews.
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11. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
• Charitable organisations such as the
Stroke Association, MacMillan Cancer
Support and Asthma UK (find local
information on the charity websites)
• Local support groups
• Patient Advice and Liaison Service (PALS).
You may also like to consider advertising
your improvement work and asking for
volunteers through:
• Posters in GP surgeries, outreach clinics,
hospitals or other NHS settings
• Posters in libraries and pharmacies
• Social networking sites such as Facebook
and My Space.
What are the considerations for
involving patients and carers?
Sensitivity – the patients actually suffer
from and live with their conditions / illnesses
and sometimes service redesign work may graham@ogilviedesign.co.uk
take a depersonalised approach. This should
be considered if patient representatives
attend meetings or improvement events.
Cost – undertaking some forms of patient Examples of techniques to involve patients and carers
involvement may incur a cost for the patient.
It is reasonable to expect that patients and Direct methods Indirect methods
carers should receive reimbursement for the Interviews Questionnaires
costs they incur – travel, parking etc.
Focus groups Surveys
Representative sample – there is often a Workshops Suggestion boxes
challenge in finding patients who are
Face to face meetings with individuals Analysis of complaints
representative of the service you are working
to improve. For example, if meetings are Patient reps on project groups Public meetings / open days
arranged during working hours it is highly Patients attending service improvement events Social networking
unlikely that people of working age would
be able to attend because of other life
commitments such as work and children. If
you wish your patients to be truly Top tips for involving patients
representative you may have to consider a • Listen
number of methods. • Find ways to involve the seldom heard groups, those who find it difficult
to access health services or people who may not routinely get involved so
A range of opinions – patient engagement that you get a real understanding of different experiences
may elicit a different or even opposing • Take time to understand the issues, don’t assume you know the answer or
opinion to the work you are undertaking. It the solution
is important to know from the outset how • Use appropriate language, not jargon
to manage expectation realistically but also • Be clear about why you are undertaking involvement work and
to genuinely incorporate views and make how you will deal with what it reveals
change. • Be clear about any areas that can not be changed or are not for discussion
(e.g. national guidance), this ensures that the valuable time is spent
discussing what can be changed and that patients expectations are not
unduly heightened
• Always provide feedback to the patient and what has happened as a
result?
20/21

12. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
Why should I invest time to
CHAPTER 7 communicate what I know?
Don’t assume that other people
Communicating the right things (including your staff and colleagues)
know what you know. Everyone
to the right people connected to the service needs to
understand what you are doing and
why, and the impact it is having.
Keeping the improvement at the
forefront of people’s minds when
Communication not only keeps How often are you going to
everyone up-to-date on the project communicate? things are going well will ensure they
progress, but raises the profile of your • Daily, weekly, monthly. remain engaged and committed
project and facilitates engagement and which will make it easier for you to
ownership of the vision and service Who is going to be responsible for the gain support when you need it.
changes. To ensure the success of a communication?
project, information including the aims, • Project manager
Don’t expect people to drop
objectives, expectations, deliverables, • Executive sponsor
everything to help you if they have
timescales, progress, risks, challenges and • Named people
achievements need to be communicated on • Everyone. heard nothing from you for the last
a regular basis. six months! By communicating what
you are doing to others in your
Through two way communication, you
will probably find that the staff who work “ You can have brilliant department or organisation, you
might also find out information
in the area are fully aware of changes that
can improve the service. Through ideas but if you can't get which you were not already aware of
that may have a positive or negative
involvement, empowerment and listening,
staff generated ideas and solutions are them across, your ideas impact on your work.
generally most effective and sustainable.
Following meetings with staff, make sure won't get you anywhere.”
you take action and communicate the
Lee Lacocca
progress you have made. Small
improvements can ignite momentum for the
project and start to get people interested.
The first step to effective Communication Plan
communication is to understand who Team: Completed by: Date:
you need to communicate with
Who are you going What are you going How are you When are you Who is responsible
• Who do you need to keep informed and
to communicate to communicate to going to going to for communicating
obtain information from? Staff/patients/ with? them? communicate? communicate it? the message?
carers/executive board? e.g. Project teams, e.g. Improvements, e.g. Weekly e.g. Daily, weekly, Name and role
• Who needs to know what is happening / exec sponsor, NHS risks and issues, meetings, fortnightly,
changing? Improvement, steering measures, data, presentations, monthly, annually
• Who do you require support from? group, SHA lead, project scope, news events, email,
stakeholders, patients etc. letters, handouts
• Who will be directly and indirectly etc. etc.
affected?
What do you need to tell or ask? What Communication plan
does your audience need to know? A communication plan is an easy way to
• What the current service looks like actively address the interests and concerns
• The vision, aim, deliverables of the key stakeholders and ensures this is
• The problems, issues, risks done in a timely manner. What is the best way to
• Changes to the project communicate the progress and
• The benefits. In a changing environment with outcomes of my work?
organisational structures being transformed
How are you going to communicate to and staff moving roles, a documented Remember that you will need to
all the relevant people? communication plan will support the adopt different approaches and styles
• Regular meetings progression of an improvement project. for different audiences and
• Internal and external newsletters
stakeholders. Try not to develop a
• Memo’s Example of how a team at Hinchingbrooke
• Local press Hospital communicated their work in the
whole industry of reporting around
• Websites local press your project but use existing channels
• Emails wherever possible. Involve your local
• Letters communications team as they will be
• Reports able to suggest some possibilities.
• Presentations Regular reports to your executive
• Support from the communications
sponsor, board or management
department?
committee are useful at the higher
level, but make sure you also use
local newsletters, forums and
meetings to provide ongoing
updates.
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13. FIRST STEPS TO WA RD S Q U A L I T Y I M P RO VE M E N T: A S I M P L E G U I D E T O I M P RO VI N G S E R VI C E S
CHAPTER 8
Improvement tool: Process
mapping
A process is made up of series of actions or People’s views about the process tend to process is an important step in moving
steps taken to achieve a specific result. change and develop following a process forward to redesign and developing a new
Process mapping is a technique used to mapping exercise as individuals have an idea process that will work better for patients
identify all the interconnected pathway steps (a ‘mental map’) of the process, but as the and staff.
and decisions in a process and coverts this process map is developed, it becomes clear
information into a highly visual that their personal view is different from What does a process map look like?
diagrammatic form. that of others in the same process. The map The map below is of a diagnostic pathway
of the current process may differ from the for chronic obstructive pulmonary disease
Process maps can cover a short and simple mental maps that individuals in that process (COPD) and asthma.
sequence of actions by one person (such as have always believed. Agreeing the current
point of care testing or phelbotomy) or it
could be a complex set of activities involving
many different people over time, (such as COPD and Asthma Diagnosis
the End of Life patient pathway).
If referral doesn’t meet set standards,
more information is requested from GP
or if does not meet the triage standards,
What are the benefits of mapping letter back to GP
the process?
Patient contacted
• An overview of the complete process from GP referral to Referral triaged by
by community team
to arrange an
Communication Community team Clinic referrals
Secondary care
manager (band 6)
community nurse community specialist letter sent to book secondary care sent to secondary
beginning to end, helping staff to specialist team team
appointment which
is close to patients
patient with PIL to staff to run clinics care
arranges staff to
cover clinics
home
understand, often for the first time, how
complicated the system can be for Spirometry x3
(which need to be Measure oxygen Check Check Check height Patient called Secondary care
within 5%) by band sats medication demographics and weight into clinic attended for clinic
patients 2 or 6 staff
• Allows staff to see the pathway from the
If spirometry
patient’s perspective 400mg salbutamol
20 minute wait
(for medication Repeat spirometry Explain results
Results taken
back to secondary
conducted by band
2 staff results
Indication and
comments
(via volumatic) x3 to patient documented and
• A starting point for your improvement to work) care interpreted by
band 6
printed
project
Write to GP and Decisions for Results sent to
Review and
patient for treatment and primary care nurse
interpretation
management management specialist team
• The opportunity to bring together people Once the above map was completed, the team could see that the process was over-
from primary, secondary, tertiary and complicated, and included many unnecessary steps, bottlenecks, wasteful activities and
social care from all roles and professions avoidable delays. The process was redesigned following the mapping exercise the new
• Identifies problems, delays, areas for error process below was created. As well as being simpler, the new process is much quicker for
and confusion, blockages and bottlenecks the patient, takes less administrative and clinical time and costs less.
• A point to create a culture of ownership,
responsibility and accountability for
improving the process
Community Spirometry Management
• An aid to help plan where to test ideas for
improvements that are likely to have the If referral doesn’t
meet set standards,
most impact on services more information
is requested from GP Interpretation in
• Draws out ideas to help redesign the or if does not meet
the triage standards,
Band 2 staff secondary care by
band 6 or above
letter back to GP
pathway – which particularly from
members of staff who don’t normally have Patient contacted Communication Indication and Proactive approach
by community team letter sent to Spirometry with comments to treatment and
the opportunity to contribute to service GP referral to
community nurse
Referral triaged by
community specialist
to arrange an
appointment which
patient with a
patient information
reversablility, SpO2
by secondary care
documented and
sent to primary
management which
specialist team team may include tier 3
planning, but who really know how is convenient in
proximity and time
and instruction
leaflet
team care specialist
nurse team
clinic attendance,
MDT discussions
things work
• An interactive event that gets people Band 6 staff Interpretation and
or above
involved, motivated and talking to each results explained
to patient
other
• An end product – the process map –
documents who does what, when, and
how long it takes, is highly visual and easy How to organise an event and • Meet with managerial, clinical and service
to understand. generate a process map leaders beforehand so that they feel
involved in the process. Use these
Preparation meetings to agree the scope that you will
• Define the objectives, scope (start and end work on and the three or four basic steps
points and level of detail) and the focus of that you will explore in detail at the
the process mapping workshop workshop
• Start is with a process that involves high • If you have the opportunity, an
numbers of patients independent facilitator, not connected
• Organise a half day event to draw the with the pathway, can be really useful.
map and a half day to analyse and look Choose someone with service redesign
for improvement opportunities. You can skills and experience.
run these together as a full day event or as
two half days but not more than two
weeks apart
24/25