Understand - Flourish at Newcastle Hospitals

How do we do our work now?

Before you make a change, you should understand how work is done now – this is often called diagnosis (you’re diagnosing the problem).

Looking at how you work now can focus the team on priority areas and opportunities for improvement. This helps define the scope of the project, set boundaries to help focus the work where it’s needed and gets the team thinking about what they want to change.

It’s important to focus on what actually happens because how people think work is done and how it is actually done, are usually different things. When using tools to look at the current state of your work, you should focus on the ‘work as done’ (reality). To do this, people need to feel they can be honest about how they actually work – this helps us to get the solutions right.

Shorrock’s ‘Varieties of Human Work’, which demonstrates the 4 ways work can be shown: imagined – what we think we do; prescribed – what we’re told to do; disclosed – what we say we do; done – what we actually do. — Shorrock’s ‘Varieties of Human Work’, which demonstrates the four ways work can be shown: imagined – what we think we do; prescribed – what we’re told to do; disclosed – what we say we do; done – what we actually do.

This is why psychological safety is crucial for any organisation that wants to learn, and learning is central to quality improvement.

We want people to speak up, even if they disagree with the change ideas. We want the team to know that it’s okay if our ideas don’t work. We want to be transparent about how to discuss, debate and make our decisions.

You can find out more on psychological safety by watching these videos by Amy Edmondson:

What quality improvement tools can we use to understand how we work now?

The tool you use first depends on the problem you have. Each tool has a specific use and can be used in combination with another. Most have their origins in lean production but have been adapted for healthcare.

The strength of each tool lies in the involvement of your project team in its use – the tools are there to help us move from talking about a problem to acting on change ideas.

Tool	Use it when you need to….
Process map	Understand how a system or process works now (or to work out how things will work in the future)
Fishbone diagram	Understand and visualise all components of a problem
Gather evidence	Show that you need to make an improvement by gathering any available evidence (data)
Driver diagram	Visualise all aspects of your improvement project – the aim, the issues and the change ideas

Process Mapping

Process maps allow us to visualise how a system really works. They create a step-by-step visual of a clinical or non-clinical task or pathway, or a patient’s journey.

When process mapping, involve staff who actually do the process – they will be able to explain how the work is done. Using this tool enables everyone involved in the different steps of the pathway/process to see the overall picture. It can show how complicated pathways can be for patients, as well as staff. It helps identify points of inefficiency and duplication, highlighting any bottlenecks and constraints, as well as unhelpful variation – which you can work to reduce. It indicates how well the pathway/process is working, giving staff the opportunity to reflect on the way they work, diagnose any problems and identify areas for improvement.

The team should consider using process mapping before making any service changes to help gain a better understanding of how a pathway/process works first. Get your team together and learn from each other’s expertise. You may find that talking about how things work now inspires people to think about how things could work in future – remember to capture any problems or ideas as you go. Keep it simple – 6 to 10 steps at first.

A process map of a heart attack pathway – a step-by-step of what happens to patient’s who’ve suffered a heart attack, including a transfer from ED to specialist service at another hospital site

A cardiology team process mapping their patient pathway

Fishbone Diagram

Fishbone diagrams are a simple way of visualising cause/effect relationships for complex problems. It’s used for root cause analysis and is applied to a problem to identify and understand the different contributing factors to the issue to inform teams of possible areas for improvement.

The main ‘bones’ of the fish are four causes, usually: environment, people, equipment and methods (processes), although you can use any categories you like. You can change the headings/categories if they are not relevant to you.

The ‘head’ of the fish is the problem. Think about your problem, then under each category think about what causes this problem – the team can keep track of any priority areas or improvement ideas as they go.

A fishbone diagram breaking down the causes of waiting times in an NHS service – cause and effect of a complex problem

Gather Evidence

Gather evidence about the need for improvement, which may be data and information from a number of places.

Data is great for proving or disproving anecdotes, e.g. “This is a big problem.“ Using data allows us to visualise how much, how often and when something happens (and for how long it has been happening).

Maybe there are some national recommendations you need to implement, or a standard that you are not meeting – data can be used to help prove that something has to change. If you don’t have any data yet, just keep it simple and count the basics. Evidence also includes patient and staff stories, observations and 1:1 interviews – we call this qualitative data – it’s not just about numbers.

What could we measure?

Here are some examples of evidence you could gather:

Pentagram with titles - patient outcomes, productivity, financial statbility. environmental sustainability, staff experience

Quality and Safety – for example, infections, falls, errors/incidents, mortality, completed documentation

Patient Experience – for example, patient satisfaction, complains

Financial Stability – for example, costs, demand, capacity

Efficiency – for example, admissions/ discharges, theatre use, unused capacity, appointments

Staff wellbeing – for example, staff feedback/sickness/ satisfaction/ turnover

Environmental sustainability – for example, carbon footprint, impact of transport

Driver Diagram

Driver diagrams show our theory of change. They link together our project aim, the issues we need to work through, and the change ideas we want to test because we think they will improve things. We can visualise the whole of a complex system at a glance, including what we’re going to do about it. Driver diagrams bridge the gap between identifying the need for improvement and how to act on it.

We start with a project aim, thinking about what impacts it and what changes can be tested to achieve it:

Primary drivers are the main bits or key areas that you will need to work on to achieve your aim – usually 3 to 5 categories

Secondary drivers are the smaller parts that influence or make-up your primary drivers – they tend to be processes, places, points in time, behaviours

Change ideas are the things we want to test to see whether we can meet our aim – ideas that can be tested using a PDSA cycle to tackle one or more of the drivers

But remember: this is not a project plan – your drivers are issues and your change ideas are things to be tested. Don’t include your project tasks in this. For project planning, consider a project plan on a page or a Gantt chart.

Once the team understands how things work now, they can test out some change ideas. To learn more, click on the ‘Test’ link below.