Model for improvement

Developing change ideas

Federal Ministry of Health

Outlines
 Introduction
 Generating change ideas
 Traditional problem solving
 Fundamental and reactive changes
 Avoiding type 3 error
 Methods to develop change ideas
 “Not all changes lead to
improvement, but all improvement requires change”

So, what kinds of changes will lead to improvement?

 A change idea is specific idea that if introduced may lead to an

improvement.
 Where do changes come from?
 Sometimes it is luck!
 But, we don’t always rely on luck. Rather pursue purposefully.
Federal Ministry of Health Health Service Quality Directorate
 Generating Change Ideas

“It is not the strongest of the species that survive, nor the
most intelligent, but the ones most responsive to change.”

- Charles
Darwin
Generating Change Ideas

 If we have to improve, we need to alter existing activities/products

or develop something new (design or redesign)
 When making changes,, the focus should be on the benefits of the
customer/patient (matching service or product to a need)
 Fundamental changes requires knowledge of how the current
system works
 Common Problems In Generating Change Ideas

 Restoring more of the same – more resources

 More inspection/supervision for low performance
 More procedure or defining them more rigorously for problem of

adherence to procedure
 Utopia syndrome – looking for perfection due to fear for failure

(paralysis of action)
 If improvement occurs, usually it is costly and not sustainable.
…
 Insanity: Doing the same
thing over and over again
and expecting different
results”
 Traditional Problem Solving

 When facing quality challenges, practitioners often think that the cause
is obvious
 The tendency is to jump in and make improvements without exploring
the situation
 This increases the risk of a mismatch between the intervention and the
true cause of the quality problem
 The perfect solution to the wrong problem(“Type 3” Error)
 Example : Type 3 Error

 Quality challenge: Very long wait times for HIV test results
 Intervention: Increase number of technicians in lab, but a more
immediate problem was stock-outs and shortages of latex gloves in the
lab
 So to avoid type error 3 “Every improvement project must start with a
thorough understanding of the quality issue”

Federal Ministry of Health Health Service Quality Directorate

Reactive vs Fundamental changes
 Developing a change that is an improvement from the view point of the
customer is not always easy.
 Two types of changes;
Reactive change: changes needed to keep the system to run at the current level of
performance(reset the system)
Fundamental change: changes needed to create a new system level of performance.
(redesign the system)
Reactive vs Fundamental changes

 Quick fix to certain problems  Result from design or redesign of

 Often return the system back to some or all aspects of a system –
where it was prevent problems from recurring
 Impact is felt immediately or in  Alter how the system works and
near future what people do
 But, usually has the tendency to
 Often result in improvement of
recur several measures simultaneously
 Impact is felt in the future
 Applied on a stable system

Reactive changes Fundamental changes

Reactive vs Fundamental changes
 Once a fundamental change is made, unanticipated problems could occur
which might result in undesirable outcomes.
 It is important in such circumstances to make reactive changes to keep the

system in that level of performance.

Methods to develop
fundamental changes

1. Logical thinking about the current system

2. Benchmarking
3. Using technology
4. Creative thinking
5. Using change concepts

Federal Ministry of Health Health Service Quality Directorate

Logical thinking about
the current system
 Making connections to things we know, hear, read or see and link
it to the new situation to come up with solutions
 These normal thought patterns are what we call logical thinking.

It comes in two forms:

 Logical positive thinking: reasoning on ways to make a new

idea work
 E.g process map, fishbone diagram, Pareto chart, 5 WHYs, line graph, run
chart, driver diagram, literature, benchmarking, best practice, ask expert
etc
Federal Ministry of Health Health Service Quality Directorate
Logical thinking about
the current system
 Logical negative (critical) thinking: finding problems to the new idea,
why it might fail
Root cause analysis - Direct, Contributing & Root Causes
Direct Cause
Directly results in the
problem

The Problem
Poor patient Contributing Cause
outcomes Part of the problem, but
not enough to cause the
problem on its own

Root Cause
If fixed, would prevent the
problem from happening
 Root Cause Definition

“The most basic cause (or causes) that can reasonably be identified that
management has control to fix and, when fixed, will prevent (or
significantly reduce the likelihood of) the problem’s recurrence.”

- Paradies (2005)
Examples of Root Causes

 A process that is not working

 Gaps in knowledge
 Lack of established standards
 Lack of guidelines
 Others?
QI Tools: Root Cause Analysis

 Makes issues less ambiguous

 Minimizes bias
 Incorporates the perspective of multiple team members
 Allows for a full understanding of all processes
 Provides baseline data
 ‘’55 minutes analyzing the problem and 5 minutes to find a solution’’
The “Five Whys” Technique Why

Repeated question-asking technique used to Why

explore cause-and-effect relationships
Why
 Primary goal is to
determine the root cause
why
why
 May require more than five!
 Often uncovers layers of
problems why
why
5 Whys

 Why is this problem occurring? Answer 1

 Why does Answer 1 occur? Answer 2

 Why does Answer 2 occur? Answer 3

 Why does Answer 3 occur? Answer 4

 Why does Answer 4 occur? Answer 5

 You continue asking “Why?” until you get to what you believe to

be the root cause of the problem

Federal Ministry of Health Health Service Quality Directorate

 Example: 5 Whys
 Why don’t HIV+ women bring their babies back for a PCR test at 6 weeks?
They don’t want to know if the baby is HIV+
 Why don’t they want to know if the baby is HIV+?
They think the baby will die and they feel guilty
 Why do they think the baby will die and they feel guilty?
They don’t understand that ARVs and NVP are effective in keeping a child HIV negative. They feel guilty because they
may have passed the virus on to their child.
 Why don’t they understand ARVs ?
Root Cause: No one explained it to them during pregnancy, labour and delivery.
 In identifying the root cause of the problem we can start to develop interventions to address it

Federal Ministry of Health Health Service Quality Directorate

Example 5 Whys:

1. Theatre was running very behind today, starting with the first
patient. Why? 
2. There was a long wait for a trolley to bring them in. Why? 
3. A replacement trolley had to be found. Why? 
4. The original trolley's wheel was worn and had eventually
broken. Why?
5. It had not been regularly checked for wear. Why? 
Root Cause: Because there is no equipment maintenance schedule.
Exercise

 In your teams, do the root cause analysis for the problem

you identified earlier

24
Using a Fishbone

 Also known as Cause & Effect Diagram or Ishikawa Chart

 It’s a more structured way of doing brain-storming.
 The headings in the boxes force more thinking across a broader range of topics
 As a facilitator, you control the topics that go in the boxes.
 You can guide people’s thinking to help them come up with the most likely causes
of poor performance
 Used in this way, the fishbone diagram helps you to analyse the problem but it doesn’t
automatically generate change ideas.
 You can use the fishbone to organise ideas around themes/topics

25
 Building a Fishbone Diagram
Major Cause Category Major Cause Category

Cause
Cause

Cause

Cause

Cause
Caus Caus Effect
e
Cause e Proble
Caus Caus
e e m Event

Cause Cause
Cause Cause
Major Cause Major Cause
Category Category

Federal Ministry of Health Health Service Quality Directorate

 Building a Fishbone Diagram

• The problem statement is placed at the head of the “fish”

• Brainstorm the major categories of the problem
» People. What staff behaviors and characteristics lead to the prob
» Process/Policy. What procedures lead to the problem?
» Equipment/Supplies. Is there equipment that leads to the
problem?
» Environment. Does the immediate environment contribute?
(6Ms) Manpower, Machines, Management, Measurement, Methods & Materials
(8Ps) Price, Promotion, People, Process, Place, Policy, Procedure & Product
Federal Ministry of Health Health Service Quality Directorate
Root Cause Analysis - Fishbone
Leadership Data Clinic System

Effect
CAUSE
Problem
or Aim

Community Patient/ Family Guidelines/Standards

Federal Ministry of Health Health Service Quality Directorate

 Building a Fishbone Diagram
For each major causes identified, ask variations of why?
Other options could include:
• Cost • Patient
• Culture factors/characteristics
• Measurements • Team factors
• Methods • Individual factors
• Education and • Organizational factors
training • Task factors
Federal Ministry of Health Health Service Quality Directorate
 Root Cause Analysis or Cause & Effect Diagram or Fishbone Diagram
Leadership Data Health Facility
Lack of
funds Poor record-keeping Poor staff attitude

Lack of
commitment No data analysis No privacy

Lack of Strict rules about

motivation birthing position

Inadequate equipment Low

and supplies
Skilled
Cultural Fear of facility Long distance from Delivery
beliefs environment health facilities

Poor risk Lack of means of

awareness Lack of funds transport
Require permission
from family heads Bad road
conditions

Community Patient/ Family Geographical Barriers

Federal Ministry of Health Health Service Quality Directorate
Reverse fishbone diagram for solutions and outcomes
what do we need in place to ensure this solution or outcome is met?

improve the
institutional
delivery from
30% to 80%

Federal Ministry of Health Health Service Quality Directorate 31

 Fishbone Diagram Summary
Strengths
 Weaknesses
 Cannot be used to define the
• Because “bones” represent
importance or frequency of a
multiple factors, many team particular issue
members will have
knowledge to freely engage  As a result, teams will need to
and participate use complementary methods
• Great brainstorming and tools to prioritize problems
technique
 Doesn’t always capture all of
 elicit multiple opinions the issues related to a process
• Quickly categorizes or problem
problems

Federal Ministry of Health Health Service Quality Directorate

 Driver Diagrams

 Help to answer the question, What change can we make that will lead to
improvement?
 Conceptualize a quality issue and generate change ideas linked to root causes
 Explore systems and process mechanisms through primary and secondary
drivers
 Generate theories and hypotheses about change initiatives that can lead to
improvement aim
Federal Ministry of Health Health Service Quality Directorate
 Driver Diagrams: Purpose
 Strategic planning and analysis tool that is updated systematically throughout an
entire project
 Breaks down an aim into the drivers that contribute to and the detailed actions that
could be done to achieve the aim
 Helps to focus on the cause-and-effect relationships that exist in complicated
systems
 Provides a pathway for change which identifies the types of interventions that can
bring about the desired outcome
Federal Ministry of Health Health Service Quality Directorate
 Driver Diagrams

 Logically links change ideas to drivers

 Often used with Fishbone Diagrams and Process Maps as part of the
participatory improvement process to utilize the list of identified causes and
organize them into action steps that will lead to improvement aim.

Federal Ministry of Health Health Service Quality Directorate

 Driver Diagrams
 Where possible, driver diagrams should be measurable and SMART
 Can serve as both a change and measurement framework for tracking progress
towards aim
 Driver diagrams represent the team’s shared mental model
 Developing a Driver Diagram
 Team approach: Gather key stakeholders
 Start with the improvement aim
 Brainstorm: What main factors influence the aim?
» Where? What? When? Who? Why?
 Group drivers into primary or secondary
 Generate change ideas related to the drivers
 Link the drivers and change ideas with arrows
 Include indicators and measurements
Federal Ministry of Health Health Service Quality Directorate
 Primary Drivers
 High-level factors that directly influence aim
 Can form the basis for outcome indicators
 Examples can include the major categories in a fishbone
diagram:
Manpower, Machines, Management, Measurement, Methods & Materials

Price, Promotion, People, Process, Place, Policy, Procedure & Product Surroundings, Suppliers,

Federal Ministry of Health Systems & Skills

Health Service Quality Directorate
 Secondary Drivers

 Lower-level, more actionable drivers

 Drivers that can form the basis for specific interventions
 Situation-specific causes or factors that are related to the primary driver
 Measurable components are usually process indicators
 Determining Driver Category

 Is This a Primary or Secondary Driver?

 To differentiate between drivers, ask: If I made an improvement in this driver what
would it achieve?
 If the answer closely describes the improvement aim, it is most likely a primary
driver
 If the driver is very closely linked with a specific intervention, it is likely a
secondary driver

Federal Ministry of Health Health Service Quality Directorate

 Reducing U5
mortality in
children

Federal Ministry of Health Health Service Quality Directorate

Examples of driver diagram

Outcome Primary Drivers Secondary Drivers Change Ideas

Reduce
carbohydrate
Food rich of
intake
carbohydrate
Increase
Calories IN vegetable/
fruits

Soft drinks/ Avoid

Reduce my
Alcohol Alcohol
weight by 10
kg
Walk to work
instead of
car
Calories OUT Exercise
Go jogging
trice weekly
Exercise:

 Develop a driver diagram for your project. Hint: Use the fish
bone diagram you had developed to develop your driver
diagram.
THANK YOU!!