Four components of QI
QI has many theories and methods. S.A.F.E 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.
Model for improvement
S.A.F.E uses this model, which 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.
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:
- Errors are human nature and will happen because humans are not infallible
- The microsystem is the key unit of analysis and training
- Design systems to identify, prevent, absorb and mitigate errors
- Create a culture of safety
- Talk to and listen to patients
- 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
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.
The microsystem has a clear idea of its purpose and you can use the 5 Ps to assess its effectiveness.
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.
Godfrey et al., Clinical Microsystem Journal Joint Commission. 2003, Volume 29, Number 1.
Developing your 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.
- You can download a presentation on introducing quality improvement below - this 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.
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.
- You can download the driver diagram template below.
- You may also like to download Bennet and Provost's "What's Your Theory" (PDF), which provides a detailed description - an indispensable tool for mapping out the theory of change.
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.
- You can download the measurement plan template below.
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.
The template for this 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.
- You can download a stakeholder and influence map template and GOSH example below.
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 your driver diagram, linking them to the overall aim of the project. Downloadable checklist and log templates, as well as a worked example from GOSH, will assist you.
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.
- You can download a PDSA checklist template, PDSA log template and GOSH example below.