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Improving Improvement

A toolkit for Engineering Better Care

 

Introduction

This introduction describes an iterative model that forms the basis of a systems approach to health and care design and continuous improvement.

 

The engineered world is full of systems. From the simple water heater to the fully integrated international airport, from ancient irrigation systems to modern communication networks, all systems share one key feature: their elements together produce results not obtainable by the same elements alone. These elements, or parts, can include people, processes, information, organisations and services, as well as software, hardware and other systems.

A system (or system of systems) is a set of elements: people, processes, information, organisations and services, as well as software, hardware and other systems that, when combined, have qualities that are not present in any of the elements themselves. A system is delineated by its spatial and temporal boundaries, surrounded and influenced by its environment, described by its structure and purpose, and expressed in its functioning. In other words, the whole is very likely to be greater than the sum of the parts. The layout of the system, defining all the elements and their interconnections, needs to be carefully considered to ensure that each element on its own and in combination with others performs as required. In response to this challenge and the ever increasing complexity of modern systems, a new discipline of systems engineering has evolved as an interdisciplinary approach to enable the realisation of successful systems.

“Systems that work do not just happen —
they have to be planned, designed and built ”

Engineers routinely use a systems approach to address challenging problems in complex projects. This allows them to work through the implications of each change or decision they make for the project as a whole. They consider the layout of the system, defining all the elements and interconnections, to ensure that the whole system performs as required. One example is the successful delivery of the London 2012 Olympic and Paralympic Games. Physical infrastructure and practical organisation were brought together, with innovative physical engineering, modelling and simulation of people flows, early testing of venues, and extensive risk management. A systems approach, combined with tried and tested engineering methods and tools, delivered real success on a massive scale.

As already seen in the Improving Improvement section of this toolkit, the heart of this toolkit integrates the key questions from the Engineering Better Care report together with an Improvement Model that contains seven activity strands and a stage-based view of the improvement process.

As described previously in the Engineering Better Care section, the activity strands that focus on particular aspects of a successful improvement process include:

  • Understand the Context — describes the circumstances or setting that surround a system and all the factors that could influence the system and its improvement.
  • Define the Problem — describes the detail of a particular challenge within a system and all the requirements for change necessary to improve the system.
  • Develop the Solution — describes a way of solving a particular problem within a system and all the elements of change necessary to improve the system.
  • Collect the Evidence — describes the information and all the measures used to evidence the validity of a particular solution(s) to a problem within a system.
  • Make the Case — describes the set of facts or arguments in support of improving a system and delivering a particular solution(s) to a problem within the system.
  • Manage the Plan — describes a detailed proposal for enabling change to a system and delivering a particular solution(s) to a problem within the system.
  • Agree the Scope — describes the context of the improvement envisaged in terms of the extent of the ambition for improvement and the boundary of the system of interest.

These strands will be present throughout the improvement process, but the emphasis given to each one should vary. At different stages of the improvement process there will be different targets for each of the strands, with early focus more likely on the context and problem and later emphasis on the solution and evidence. The strands will be delivered through the selection of specific, individual activities supported, where appropriate, by the use of standard tools.

An initial set of activities and tools are included in this toolkit, along with resources to assist with the overall planning of the improvement process and the planning and execution of individual activities. They are divided into two types: Preliminary Activities, to assist with the planning of the improvement stage; and Stage Activities, to enable the team to bridge the gap between what is learned from the preliminary activities and what is required to achieve the next stage-gate targets.

The Preliminary Activities are intended to be flexible and tailored to the planning needs of each stage of the improvement process. Similarly, the Stage Activities are not designed to be rigid, rather they are intended to inspire enquiry across all stages of the improvement process in order to understand the context of the improvement challenge and the gap between the current performance of the system and its desired performance.

A set of Preliminary Activities for the Understand stage of the improvement programme were proposed in the Improving Improvement section of this toolkit.

Similarly, a set of Stage Activities for the Understand stage of the improvement programme were also proposed in the Improving Improvement section of this toolkit.

The following sections describe the contents of this toolkit relating to the context, problem, solution, evidence, case, plan and scope strands associated with improvement process. In each case, a brief introduction to the strand is provided, along with details of all the activities related to that strand and tools that may be used to support those activities. An introduction to the literature related to each strand is also provided.

Reference is made throughout to the contents of the Improvement Resources section of this toolkit and to the cards, posters and worksheets included in the toolkit. The methotrexate and Esther case studies described in the Improving Improvement section of this toolkit are also reintroduced and extended to provide insight as to how the strands might have been addressed in these studies.

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