S.A.F.E. 1: About Quality Improvement

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Quality Improvement (QI) is a process that aims to continually improve the outcomes for children and their parents when they engage with healthcare. QI is the responsibility of all who engage in healthcare.

About QI and its four components

QI has many theories and methods. The S.A.F.E programme draws on the theories of W. Edwards Deming, an American management consultant who developed the "System of Profound Knowledge" and championed core concepts in QI such as statistical process charts and the precursor to PDSA (Plan Do Study Act) cycles.

These theories look at four components:

  • systems that we work in
  • variation in the systems
  • psychology - how people think and behave
  • theory of knowledge - the method of change.

Components of QI: Systems; Variation; Psychology; Theory of knowledge                        

Figure 1a: The components of Quality Improvement 

The Model for Improvement

S.A.F.E uses this model, asks three questions:

  • What are we trying to accomplish?
  • How will we know if a change is an improvement?
  • What changes can we make that will result in an improvement?

This model tests small changes within a PDSA cycle (see more below).

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Figure 1b: The Model for Improvement

You can find more in Health Foundation Quick Guide: Quality Improvement Made Simple (PDF)

Microsystems and S.A.F.E

In order to improve, you could consider the microsystem theory. The clinical team is a microsystem that interacts with each component as well as with other clinical microsystems. The S.A.F.E programme is, in essence, working to improve the functioning of different clinical microsystems.

Some key principles to consider:

  1. Errors are human nature and will happen because humans are not infallible.
  2. The microsystem is the key unit of analysis and training.
  3. Design systems to identify, prevent, absorb and mitigate errors.
  4. Create a culture of safety.
  5. Talk to and listen to patients.
  6. Integrate practices from human factors engineers into microsystems functioning.

Mohr et al., Microsystems in Healthcare: Part 6. Designing Patient Safety Joint Commission Journal on Quality and Safety. August 2003, Volume 29, Number 8; p401

1k - Microsystems Theory

Figure 3: Microsystems Theory

The successful microsystem has good leadership that is distributed to the front line, staff who are empowered to improve, a person-centred approach that involves patients in improvement and a way to measure the performance of a system.

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Figure 4: Who is in the microsystem

The microsystem has a clear idea of its purpose and you can use the 5 Ps to assess its effectiveness.1m - The 5 Ps of a microsystem: Purpose; Patients; People; Processes; Patterns

Figure 5: The 5 Ps

Your improvement journey starts with an assessment of your microsystem. You can then develop ideas that can lead to an improvement. These are then tested through PDSA cycles and when the solution is found, the process is standardised.

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Figure 6: The improvement journey

Godfrey et al., Clinical Microsystem Journal Joint Commission. 2003, Volume 29, Number 1

Developing your S.A.F.E programme

Your local S.A.F.E programme will need a good foundation. First, you need to answer:

  • What is the specific issue you want to address?
  • What are the things you can do to make improvements?

Some staff may be reluctant to change. The S.A.F.E programme can help overcome those barriers. It gives people, especially frontline staff, a way to 'own' the problems and help develop solutions. 

This presentation gives more detail on how to set up and run tests of change in one or more small areas before you implement them more widely.

Presentation 1: Introducing Quality Improvement (PPT, 704KB)

Tool 1: Driver diagram

This diagram shows how to solve complex problems. You start with your aim statement. You then break down the solution into parts, each of which can be divided in to potential changes. Primary drivers describe the broad themes which need to be addressed to achieve your aim, while secondary drivers are the specific activities to be delivered under each of the broad themes.

Here is an example of a driver diagram.

Driver diagram example

S.A.F.E Driver Diagram - Template (MS Word, 287 KB) - you can use this for your own diagram

Driver diagram reference - Bennet and Provost's "What's Your Theory"

Tool 2: Measurement plan

This provides a framework for your S.A.F.E programme:

  • Outcome measures - what happened to the patient (eg decrease in deterioration or decrease in transfer to higher level of care)
  • Process measures - how the system is working to produce the outcome (eg how one communicates and identifies deterioration)
  • Balancing measures - unintended consequences that may result from the intervention, both positive and negative

When you create your driver diagram, you can integrate it into your driver diagram. The aim is for the outcome and primary and secondary drivers to lead to process measures.

S.A.F.E Measurement plan - template (MS Word, 20KB)

Tool 3: Stakeholder and influence map

Introducing S.A.F.E will need some cultural and behavioural change. It is useful to map out the people in the team that may promote or oppose change. Everyone has a different position and sphere of influence.

This template allows you to show who is on board and who needs to be persuaded to change. This will change, and you can update as you implement change.

S.A.F.E Stakeholder and influence map - template (PPT, 86KB)

S.A.F.E PDSA log - worked example from GOSH (PDF, 122KB)

Tool 4: PDSA checklist and log

The key to change in quality improvement is the Plan, Do, Study, Act cycle (i.e. small tests of change that allow you to test ideas without disrupting the system). The tests are all linked to refining the activities of the secondary drivers in the your driver diagram, linking them to the overall aim of the project.

S.A.F.E PDSA checklist - template (MS Word, 183KB)

S.A.F.E PDSA log - template (MS Word, 166KB)

S.A.F.E PDSA log - worked example from GOSH (PDF, 95KB)

It's important to keep a record of the tests so that you can see which work and which do not. This will be useful when you spread the success of the huddle. Always remember the context which changes from ward to ward.

PDSA cycle - NHS Improvement

PDSA cycle - NHS Scotland Quality Improvement Hub

 

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