Quality Improvement Tools
You have come to the right place if you are looking for the following:
- Help to solve a quality issue
- Help to introduce a quality improvement
Below is the Trust’s recommended “steps to quality improvement”. Follow these steps to ensure you are making sustainable improvements in healthcare.
If you are tempted to go straight to step 6 (implementing ideas - PLEASE STOP!).
If you are tempted to solve the problem without the involvement of a team – PLEASE STOP!)
Click on each step to find out more. Remember; invest in steps 1-5 to ensure success in steps 6-8 Steps to quality improvement
Follow these steps to ensure you are making sustainable improvements in healthcare.
Identify, Communicate, Engage and support Stakeholders
Throughout the improvement project you will need to actively involve a wide variety of people. These people are called “stakeholders” and may come from within your department, within your organisation or beyond. They may be impacted by your change or may have the power to influence the change.
Why? Actively engaging stakeholders will help you with your change project.
Stakeholder Analysis Tool
The Stakeholder Analysis tool enables you to identify everyone who needs to be involved. Use the tools to avoid inadvertently failing to involve key people.
With a group of well-informed people, brainstorm a list of all the people or groups likely to be affected by the proposed change. You may wish to group your stakeholders according to the following the 9Cs TOOL to help ensure you have included all relevant stakeholders.
- Commissioners: those who pay the organisation to do things
- Customers: those who acquire and use the organisation’s products
- Collaborators: those with whom the organisation works to develop and deliver products
- Contributors: those from whom the organisation acquires content for products
- Channels: those who provide the organisation with a route to a market or customer
- Commentators: those whose opinions of the organisation are heard by customers and others
- Consumers: those who are served by our customers: ie patients, families, users
- Champions: those who believe in and will actively promote the project
- Competitors: those working in the same area who offer similar or alternative services.
Once you have generated a list of stakeholders, you can prioriotise them. This can be achieved by analysing in terms of power / influence and the extent to which they may / may not be affected by the change. Use the FOUR SECTOR TABLE TOOL (template below) to write each stakeholder into the relevant sector of the table. This will help you prioritise communication and engagement activities.
If some of your stakeholders are senior clinical leaders, remember the top tips for clinical engagement (also refer to for non-clinical engagement):
- have a well-prepared project plan with clear objectives to benefit patient care
- focus on quality improvement rather than delivering targets
- be well informed with accurate facts and figures
- get to know your clinicians
- listen to clinicians and respond to their concerns – they have knowledge and experience,
- insight into patient services and the power to help your project succeed or fail
- engage individually with clinicians rather than just in a group. This will enable detailed
- discussions of the ideas proposed
- meet at a convenient time to minimise loss of clinical activity
- share examples of how the proposed change works elsewhere. This may include use
- of patient stories
- communicate regularly about progress and see the project through.
Carrying out improvement means doing something differently. This may lead to uncertainty and tension. You may wish to add further depth to the stakeholder analysis above, particular regarding the influence of leaders.
Continuum of Commitment Tool
The continuum table provides insight into the level and type of influence needed from the leaders.
How? Think about where each stakeholder is currently in terms of their commitment and where you need them to be in order to achieve you project aims. Commitment ranges are: obstructing; no commitment; let it happen; help it happen; and make it happen. Use the analysis to determine how much time you need to spend engaging.
Remember that resistance is not bad. Your reaction to resistance can determine the success of the project. Listen to resistance and then engage and inform.
Where to find more information?
Step 1 – Developing Your Aim Statement
Developing Your Aim Statement
An aims statement is a written document of what you want to achieve from your improvement project and a timeframe for achieving it.
Documenting an aims statement with your stakeholder helps to identify and articulate a clear goal
With your stakeholders, use the template below to help develop your aim statement.
- Check you aim is SMART – specific; measurable; achievable; relevant; timescales
- Check that your aim does not include a SOLUTION. Avoid the temptation of jumping to conclusions about what changes you need to make.
- Check that your aim aligns to the Trust strategic objectives.
- Check your aim is able to be understood by someone who has not helped develop it
A template for setting your aims can be found here
Where to find more information?
Step 2 – Problem Identification
Understand the current problem/issue/opportunity
Use your stakeholders’ range of knowledge and experience to identify, understand and think through the current situation. A range of tools are available to identify the root cause of the problems (root cause - the fundamental reason a problem keeps occurring).
The tools below ensure that your approach to solving problems is factual and evidence based. It is important to understand the problem before making assumptions and jumping to solutions.
“Brainstorming” is a useful technique to gather and sort information from your stakeholders to understand the current situation and problem.
Gather the right people in the room (stakeholders), inform them of the problem, ask people to call out reasons for the problem spontaneously and quickly, get the responses down on paper (sticky notes placed on flip chart). Use the brainstorming rules below
Affinity Diagram Tool
This helps review and analysis ideas generated during brainstorming sessions by grouping based on similarity or theme.
With stakeholders, groups the sticky notes created from brain storming into groups that are similar or of same theme. Gain consensus for a header for each grouping to encapsulate the main theme.
‘Five Why’s’ Tool
Get to the root cause of the problem by asking "why?" five times. It’s simple but surprisingly effective!
A template for the Five Why's can be found here
With stakeholders, select one of the problems identified and write it at the top of the template. Brain storm why that problem occurs and write it down in the next section of the template. Does this identify the source of the problem? If not, ask “why?” again. Keep asking until you have the root cause documented.
Fishbone (Cause and Effect) Diagram
The fishbone is used to think through the causes and create a diagram showing all possible causes of the problem.
Write down the identified problem in a box on the right of an A4 landscape page and draw an arrow from the left side pointing to it. Identify the major factors and draw branches off the large arrow to represent the main categories of potential cause (label each line). You could use the results of the affinity diagram tool above. Identify any further causes of the causes by adding more branches.
A template of the Fishbone Diagram can be found here
Conventional Process Mapping Tool
A visual picture of the process, exposing areas of duplication, waste, unhelpful variation and unnecessary steps.
Plan your mapping session (see link below). On the day of the mapping session, clarify the problem, define the start / end of the process and agree any symbols that you will use during the mapping. Using post-it notes, work with stakeholders to map each step and each decision point. With your stakeholders, identify where the process can be improved by redesigning or removing steps.
Step 3 – Measures for improvement
Agree Measures for Improvement
Before you make any changes, you need to agree what to measure and then collect and analyse data (analysing data just means looking at it to see what it tells you). You need to collect data over time (before and after the change) in order to have objective evidence of improvement.
You need a way to check whether your improvement is working or not. Without measuring the right things, you may find that your improvement actions are wasted or might make things worse (without you even realising it). Measuring will give you the factual evidence you need to determine if a change is an improvement. A number of measuring for improvement tools exist to help you to agree measures, collect data and analyse data.
Three Components Approach Tool
This is a tool will help your stakeholders to agree measures for improvement. It identifies different TYPES of measures, each with a different purpose in determining whether the improvement project has had the desired impact.
- Outcome measures – the voice of the patient / the result?
- Process measures - the voice of the workings of the system / steps performing as planned?
- Structure Measures – the voice of the organisation, input measures?
- Also: Balancing Measures – the voice of other parts of the system / new problems?
With your stakeholders, think about the types of measures above and agree a set of measures. Remember to include a balancing measure to help monitor any unintended consequences of your change.
Seven Steps to Measurment For Improvement
This tool will help you go through the steps to ensure you are measuring for improvement. The steps are: 1) decide aim, 2) choose measures, 3) define measures 4) collect data, 5) analyse and present data, 6) review measures, 7) repeat steps 4-6.
When you choose and define your measures, think about what level you need i.e. daily, hourly.
Use the measures checklist to guide you through the steps. Refer to run charts and SPC charts below for data analyis.
You already collect vast amounts of data that can be used to measure quality improvement. Utilise data that you are already collecting, whenever possible. All data should, where possible, be collected in existing core system. Separate systems should not be set up.
SQuID is the Safety and Quality dashboard. This dashboard is a Ward to Board reporting tool and is used to support and monitor the progress of the Trust Quality Improvement Strategy. The dashboard shows figures over the last 12 months and figures are locked down on the 7th working day of the month.
WREN is a reporting portal which provides a library of links to reports developed by the Information Department, grouped by Division/ Area. There is a Quality and Safety section on WREN which provides more detailed analysis of our quality indicators such as VTE, NEWS, Incidents, Falls, Friends and Family etc. WREN also includes sections such as Urgent Care, Womens & Childrens , Surgery, SCSD, Theatres, Data Quality, Waiting Lists etc
Existing data collection / analysis may not be at the right level to measure improvement (i.e. daily, hourly) so you may need to contact the information department to ask for the data to be provided in a way that allows you to measure improvements.
You can create surveys using the SNAP survey tool.
You can sign up to a free survey tool on www.surveymonkey.co.uk
Run Chart Tool
A run chart is a data analysis tool. It is a graphical display of data over a period of time (at least 10 points of data are needed). The chart will help you and your stakeholders to see variation in your data and to analyse whether this is caused by something “special” or if it is just “normal” (common cause) variation. In order to identify if your change is making an improvement, you need to understand your current data (both “normal/common cause variation” and “special cause variation”) before you make a change.
Agree the time axes and the measures you are plotting. Start to collect your data (at least 10 data points before you make the change – this is your baseline). Find the median of the data by sorting the data in number order and finding the middle number. Using the template below (or similar), record the data in the table then plot the dots and the median line using the graph paper. Analyse the variation and ensure you understand any existing “special cause variation” (for example, data changes at the weekends). Make your change and plot the data. Watch the dots as you make the change. If things get worse, stop the change. After 10 data plots, analyse the data using the rules (see below). If any of these rules apply, there is a “special cause variation” to investigate. This may mean your change has made an improvement, or that some other factor has influenced your normal variation in data.
Rule 1 – shift. Seven or more dots either all above or all below the median
Rule 2 – trend. Seven or more consecutive points all going up or all going down
Rule 3 – runs. Not enough points crossing the median line
Rule 4 – astronomical point. Obviously different data points from the rest of the points.
A run chart template can be found here
Statistical Process Control Tool (SPC)
SPC is a data analysis tool to allow you to understand if a change is an improvement.
This tool will enable you to:
- record your data on a daily, weekly or monthly basis and plot it on an SPC chart automatically
- indicate when a process may have changed by automatically applying SPC rules to the data
- annotate your chart and when appropriate apply step changes to your mean and process limits
The difference between a run chart and an SPC chart is that the SPC chart allows for statistical interpretation. The SPC tool has rules to indicate if there has been an improvement.
Below is a video guide about SPC charts:
NOTE: RAG (red, amber, green) is not an effective measure for improvement. It is a measure for performance management. Improvement measures must capture and analyse a series of data over time.
NOTE: No data is allowed out of the Trust without independent approval by the Information Department.
Where to find further information?
Step 4 – Generating the change ideas
Generate some change ideas
This section is to help you and your stakeholders to think creatively to solve problems.
It is important to meet with stakeholders and use tools to help them think creatively about ideas for change before deciding what specific solutions will be tested. There are techniques to help creative thinking and decision making.
You can use the brainstorming technique you learned in Step 02, so that you and your stakeholders are fully involved in coming up with a range of ideas to solve the problem.
Fresh Eyes Tool
This is an innovation provocation tool. The tool prompts for stakeholders to look at things from perspectives that are different from our own.
Define the problem with your stakeholders and randomly select alternate viewpoints. Viewpoints can be from all walks of life: child, farmer, politician, business owner, pensioner etc. Document the ideas.
“That's Impossible!” Tool
This is an innovation provocation tool. It can be used to challenge stakeholder’s beliefs that some ideas are impossible. If all the ideas are simply variations on what already exists, use the tool to stretch stakeholder’s thinking.
With stakeholders, make a list of things related to the issue that are currently accepted as being impossible. For each, ask the stakeholders a series of challenge questions such as “how could we make that possible”, “how could we do it at least some of the time”, “how could we come close to doing it”? Document the ideas.
Simple Rules and Breaking Them Tool
All complex systems have simple rules, which can sometimes provide a barrier to improving services. This tool makes these rules explicit and then prompts to break them in order to seek more radical ideas for improvement.
With stakeholders, identify the current simple rules that relate to the identified problem. Challenge the simple rule by asking what aspects of the rule can be broken or try proposing an alternative rule. Think about challenging rules regarding where, who, when.
Simple Rules – Provocations Tool
This is an extension of the simple rules tool above where offbeat ideas are stated to act as catalysts for fresh thinking.
As above, identify the simple rule and then provoke thinking by suggesting elimination of the rule or drastically modifying the rule.
Driver Diagram Tool
It is important to review all the ideas before agreeing priorities to test on a small scale. The Driver Diagram can be used to visually show how your change ideas will likely cause the desired effects and achievement of your aim. A driver diagram summarises the proposed change strategy to accomplish your aim, on one page. Use a driver diagram to seek approval to: test your ideas; to communicate; to clarify how the ideas matter to accomplishing the aim.
The diagram can be created using either an excel tool, a word template or hand written. The diagram has three or four levels similar to a tree structure. With stakeholders, document your aim on the far left (level 1). Then think of the high level factors (primary drivers) that you need to influence in order to achieve your goal. These primary drivers “drive” the achievement of the aim. Break down the primary drivers to show some secondary drivers. Breakdown the secondary drivers to define the range of actual change initiatives that you want to undertake. Note: it is not essential to have secondary drivers.
Ask “in order to achieve this aim we need to ensure…….?.”, “which requires…….?.” and “what ideas for change to ensure this happens……?”.
Below is a video about driver diagrams:
Step 5 – test the change ideas
The PDSA Tool is used for testing out change ideas. PDSA is a rapid testing of change process involving 4 stages - Plan, Do, Study, Act.
Before implementing it is essential to test out your change ideas on a small scale, so your stakeholders can see what does and doesn’t work. This needs to happen BEFORE implementing changes, so that you can check if the idea will definitely help achieve the agreed aim.
With your stakeholders:
1. PLAN - using the template below, plan out how the test will run and predict what will happen
2. DO - complete a test (series of rapid tests) and gather data.
3. STUDY - analyse the results. Will this idea help you meet your aim? Are you measuring the right things?
4. ACT - agree what changes to be tested next or agree a plan for implementation of a successful change idea
Repeat the above PDSA cycle until you have optimised the change idea ready for implementation or have decided that the change idea is not going to be implemented
Below are the four stages to the PDSA change testing cycle:
Reminder: complete the necessary cycles of testing and analysis on a small scale before planning to implement or roll out on a wider scale.
Step 6 – implementing and sustaining the successful changes
Implement successful, sustainable changes
The tool to use is the Sustainability Model. This is a self-assessment tool with multiple questions covering key areas that determine the likelihood of sustainability. The questions relate to process, staff and organisation (see below). The outcome is a diagram showing potential opportunities to improve your plan (see below)
This tool will identify strengths and weakness in your implementation plans and predict the likelihood of sustainability for your improvement idea.
With stakeholders, go through the full set of questions in the tool (see questions document below or electronic tool below). Select one level (a,b,c,or d) for each answer. The level you select should be the one that comes closest to your current situation. The outcome of completing the self-assessment is a score and a visual diagram to show you the potential for improvement of your implementation plan. With stakeholders, review the outcome and take the necessary action to develop your improvement plan to improve likelihood of sustainability.
The paper version of the self-assessment tool is available here
The Electronic (Excel) version of the self-assessment tool is available here
Step 7 – scale up and spread
Scale up and spread
There is no recognised NHSI tool for this step. A self- assessment CHECKLIST and PLANNER is available for you to use.
Stakeholders need to be sure that the new ways of working and improved outcomes are the norm before scaling-up and spreading across the whole system / organisation.
With your stakeholders, use the SPREAD Checklist Tool to see if you are ready to implement changes into wider areas (template adapted from another Trust).
If the checklist indicates you are ready to spread a successful change, you then need to plan how to do this. With your stakeholders, use the SPREAD Planner Tool (template adapted from another Trust) Seek the appropriate sign off before implementing into wider area (s) outside of your successful test area.
Remember to continue to monitor the agreed measures during and after implementation into other areas.
Step 8 – celebrate, and keep checking
Celebrate and keep checking
Once you have implemented improvement(s), ensure that you are continuously checking that the improvement(s) is sustained. Use the improvement measures as this will alert you to any unexpected changes, as well as opportunities to continue to improve.
At the end of the project, please let the QI team know the outcome. The team will then support you to create your “QI Success poster” (see template below). This poster can be a great way to celebrate your success with stakeholders, patients and visitors. You can use it for your QI department displays, external regulators, conference presentations, PDRs etc.
Download QI Poster Template here
Use the internal tools below to share your success
Tweet - @qualitywaht
Facebook - www.facebook.com/WorcsAcuteNHS/
The size of the change will determine the level of project management required.
A key step for implementing a successful improvement project is Developing an Action Plan for improvement
It helps stakeholders to identify tasks that need to be completed. Documenting tasks in a plan, with jointly agreed timescales, will help you to manage the process. It can also help you understand any dependencies (actions dependent on others actions).
With stakeholders, define all necessary actions (all actions must have an action verb such as to meet, to write, to design, to agree). Then, work with stakeholders to assign responsibility to complete the actions to specific individuals. Then, jointly agree timescales for completion. Document these into an action plan. The team then reviews progress of the actions at agreed intervals.
This excel template can be used
If the implementation requires financial resources, a case for change will need to be submitted. If implementation is a change to service, a Quality Impact Assessment is required. Please refer to the Corporate Project Team for advice.