Several years ago I was in a workshop facilitated by Paul Plsek. Paul has a great way of cutting to the chase. In the introduction to flow diagrams he asked the question: "What percentage of your work day is spent doing real work?" He defined real work as all the things that add value to patient and families' care; when everything goes perfectly, the first time. Then what's non-real work? All the things you do that do not add value, the problems you deal with, wasted time, errors, mistakes, time you spend searching for things, bureaucratic processes... etc. In other words: waste. I was amazed at how low the percentage estimates were for real work - no higher than about 80% - many much lower. That stuck with me and I've repeated that pop-quiz many times, with similar results.

 

Of course, this is not formal rigorous study, but I believe people are never too far off with their intuition on things like this. The UK's NHS now has a program called Releasing Time to Care which "focuses on improving ward processes and environments to help nurses and therapists spend more time on patient care thereby improving safety and efficiency." Apparently this follows a period of intensive development and testing. Other examples that reinforce the need to reduce waste can be found in the emerging stories about the application of Lean to healthcare (such as ThedaCare, the Pittsburgh Way and Virginia Mason, who've turned their pioneering work into an institute).

The diagram shown here is a gross simplification, but provides the basis for our improvement opportunity: how to eliminate B, move the time saved to C or D and design and execute systems that reliably optimize time spent on A.

 

In this magazine article Jonah Lehrer cites the work of Kevin Dunbar and others who study how scientists study things - how they fail and succeed. As we work to raise safety and quality improvement work to scientific standards, we might do well to understand what he has learned and how it could be applied to sharpen our improvement acumen. This article is worth reading - I think you will easily see some possible pitfalls of improvement as with science. From the pitfalls come some simple messages about learning from failed improvement, modified from Lehrer's summary:

1. Check your assumptions. Does the result you observe contradict your theory? How might you change your hypothesis?
2. Seek out the ignorant. Ask someone who is unfamiliar with your improvement what think - explaining it to them will help you see it in a different light.
3. Encourage diversity. Form a diverse team around quality improvement work and value all input. Include family and non-clinical team members.
4. Beware of failure-blindness. Be careful that you do not filter the result you see with bias and preconception.

Several years ago I attended a lecture by Kurt Vonnegut.. During the talk he used a chalkboard to graphically explain using a story arc why people have such a need for drama in their lives. Recently I stumbled upon a blog post that describes this Vonnegut lecture nicely and it occurred to me that the use of a story arc could be a valuable way to reflect on and improve improvement.

Below is an story arc based on an imaginary improvement - it's not a real graph, but rather a conceptual one on which we can consider some typical quality improvement stories. It might be possible to use this as a language to aid collaborative learning and to discover ways to improve your improvement practice.

 

First, the axes. The x-axis is elapsed time - this could be days, weeks, months or years, but typically would be in the order of months for most improvement reported in NICQ. When evaluating your improvement performance you might consider time to achieve aim (T1). What are you doing during this stage of improvement? How long does it take to get to the first real test of change? What strategies do you use to determine what to change? Or, your might ask: during T2 what happens to create A, B or C? what can we do to be sure that C does not happen?

 

The y-axis is normalized to correlate with your key outcome measure, it's not the actual measure. I've set the limits as poor and excellent, which are relative and qualitative. The important points on this axis are what I've called aim and acceptable. The aim is a milestone level of accomplishment that's the target for an improvement initiative. It's different than acceptable in that, for instance, you may agree that any infection is unacceptable and the only real goal must be zero, but for practical or motivational purposes you are willing to set an aim below this point. In other cases aim and acceptable may be the same. Acceptable may also prompt "acceptable to whom?" Good point, a parent may have a different answer than staff. This axis is also germane to how much of a stretch goal the aim provides or, once an aim has been achieved do you 'raise the bar' to set a further improvement aim.

 

Over time an improvement moves from the setting of aim through testing and making change (T1) to reach a point at which the aim is achieved. T2 is a period of stability necessary to conclude you've made improvement (special cause). Condition B represents a stable level of performance at or above the aim. Condition A is what one might call continuous quality improvement. Condition C is a regression or slip to below the aim and back to the pre-improvement level (see discussion in this article). Is condition C a function of how the improvement is made (e.g. the change relied exclusively on education) or some fundamental flaw in culture (e.g. lack of practice discipline)?

All improvement stories have an arc for which these dimensions are important and every team has a range of experience to learn from. Take the time to reflect on your stories in these terms - learning from experience to become better improvers. What makes one improvement an A and another a C? Is a B a C waiting to happen? Should all improvement be A? How can you manage the improvement you're working on now so it's more likely to be B or A? What does a current story of yours look like right now? Where are you on an improvement story arc, what shape is it?