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Improving Improvement

A toolkit for Engineering Better Care


This Toolkit

This toolkit contains a pragmatic systems approach to health and care improvement that is based on the Engineering Better Care report.




This toolkit was developed as a means to translate the description of a systems approach from the Engineering Better Care report into an actionable programme of improvement. In its physical form the toolkit comprises two folders, entitled (1) Guide and (2) Resources, housed in a sleeve. The guide contains this document, while the resources folder contains cards, posters, worksheets and workshop materials that enhance the facilitation of the improvement programme.

Presentations are also available to provide an introduction to:

  1. The Engineering Better Care report - introducing the people, systems, design and risk perspectives and their respective improvement questions.
  2. This toolkit - introducing the ‘hexagon’ model of improvement, the components of this toolkit, and comparisons with alternative approaches.
  3. The worksheets, posters and cards — showing how these can be used to design and deliver specific programmes of improvement.

Interactive training courses that combine all of the above, with illustrative case examples, have been run by the authors on multiple occasions.

The Resources section contains cards, posters, worksheets and workshop materials to assist in the facilitation of improvement programmes.

These provide a starting point to embellish existing improvement approaches or may provide a standalone systems-based framework for improvement, and include:

  1. Eight sets of cards that describe service users, service stakeholders, service improvers, case studies, improvement questions, improvement activities, improvement tools and improvement terms.
  2. A set of posters to illustrate the concepts and tools for improvement, including the planning of the improvement process and the use of the worksheets.
  3. A set of blank worksheets, or working documents, to support the improvement process that are based on the posters and other supporting materials.

Improvement Model

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 support 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.

Useful toolkit resources: the Improvement Model poster can be downloaded from the Resources part of this toolkit.

Improvement Canvas

The current state of knowledge with regard to any of these stands can be summarised on an Improvement Canvas to allow the improvement team to see a snapshot of the progress towards a measurably better system. At the beginning of the improvement journey the canvas can be used to capture the purpose of the system to be improved, descriptions of service users, details of the improvement team, an initial case for improvement, a working plan, and early or existing information relating to the context, problem, solutions and evidence strands.

The key questions or a set of Preliminary Activities may be used as a prompt to encourage completion of the canvas, with the answers recorded on a blank version of the canvas. The Improvement Canvas is a living document which may be used in electronic form, as a large poster or an interactive worksheet.

Useful toolkit resources: the Improvement Canvas poster and Improvement Canvas worksheet can be downloaded from the Resources part of this toolkit.

Preliminary Activities

One approach to completing the Improvement Canvas is to undertake a series of Preliminary Activities, specifically targeted to ensure the team have a shared understanding of the system, which is then followed by the main activities required to enable them to define and achieve the targets and deliverables for the stage.

For the understand stage of an improvement programme, the preliminary activities may include:

  • Sketch the System — show the relationships between all the elements, people, locations, conditions, tasks and information
  • Tell the Stories — communicate stories of patient and stakeholder experiences that bring life to the improvement challenges
  • Describe the Big Idea — encourage people to think creatively and describe how the system could be improved
  • Identify the Big Wins — identify the big wins and justify the resources required to make the system changes proposed
  • Draft the Pitch — create a simple description of the problem, the process that will solve it, and the benefits that might be achieved
  • Decide the Next Step — choose the activities most likely to improve the system and enable progress to the next stage gate
  • Challenge the Scope — consider different levels of scope and pick the most appropriate level for the project to succeed.

These activities may be undertaken individually or as part of a longer meeting or workshop. While they are identified as individual activities they may also form part of a much more integrated narrative exploring the current state of the improvement programme. The particular order of the activities may vary in response to the state of knowledge at the start of the programme and there may also be considerable flexibility shown in moving between the activities.

Useful toolkit resources: the Preliminary Activities poster and Improvement Activity cards for each of these activities can be downloaded from the Resources part of this toolkit.

Questions Map

The Questions Map provides an alternative approach to completing the Improvement Canvas and capturing the current state of knowledge regarding an improvement programme. This can be particularly useful in the early stages of an improvement programme when the focus is on the context and problem, but can also offer insights relating to the other stands at any stage in the programme.

The activities required to answer these questions will likely take the form of a series of exercises, specifically aimed at building team ownership and commitment for a programme of improvement, targeted at the management team or a broader stakeholder team. The questions may be addressed in sequence or, more likely, out of sequence to encourage people to tell stories and talk about ideas for change before attempting to sketch the system or drafting the case for change. They may be formally presented or woven into the conversation with the team. They may be part of a formal project or be used simply to trigger a follow-on meeting.

In the later stages of the improvement process these early activities will take the form of a recap of the knowledge gained in the previous stage, a reiteration of the scope and direction of the programme and the planning of the now current stage.

Useful toolkit resources: the Questions Map poster and Improvement Questions cards can be downloaded from the Resources part of this toolkit.

Stage Plan

Each stage of the improvement programme can be divided into the seven activity strands, with the preliminary activities or key questions, through the Improvement Canvas, informing not only the scoping of each of these strands, but also identifying the desired outputs for the stage. Additional planning is then required to identify the key questions or activities to be pursued during the programme to deliver these outputs.

Planning involves not only the selection of the activities required to deliver the stage and strand outputs, but also the clustering, sequencing and scheduling of these activities based on the magnitude of the challenge and the resources available. Different programmes or different teams or different triggers are very likely to result in different plans for a given stage. Such plans will also vary considerably across the stages of a programme. In all cases, the plan(s) will need to be used as a guide to the timing of activities, which remains flexible to change as the programme progresses. The Stage Plan is a living document which may be used in electronic form, as a large poster or an interactive worksheet.

Useful toolkit resources: the Stage Plan poster, Stage Plan worksheet and Improvement Activities cards for each of the activities can be downloaded from the Resources part of this toolkit.

Selecting Activities

The Stage Activities enable the team to bridge the gap between what is learned from the preliminary activities and what is required to achieve the targets and deliverables for each stage-gate. These activities will in turn be supported by a number of generic tools which provide a range of options for the team in the execution of programme of work. The choice of tools will depend on the particular deliverables required and the competence and experience of the team to use them.

In the first instance, the choice of activities is part of the Decide the Next Step preliminary activity. Subsequently, the choice of process activities and tools for each stage of the programme is decided using the Plan Future Activities preliminary activity as part of the Manage the Plan strand, where the activities required for each strand of the programme, their detail planning, and their order, will critically depend on the particular challenges.

The Stage Activities are not designed to be rigid, rather they are intended to inspire enquiry across all areas 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. Each activity may also be supported by one or more tools to provide structure and assist the delivery of useful outputs. The same tools may also be used for more than one activity.

The task of the facilitator or programme management team is to identify those activities which are essential to the improvement process, and to configure and order them in such a way that they are most likely to deliver an effective improvement programme. The combination of preliminary and process activities is designed to enable the most effective tailoring of the improvement programme to the particular improvement challenge and resource availability. It also allow activities to be combined with exiting improvement approaches and models of change.

Useful toolkit resources: Stage Activities poster, Improvement Activities cards and Improvement Tools cards can be downloaded from the Resources part of this toolkit.

Preparing Activities

A systematic approach may be used to prepare for each activity, in terms of the actions required before, during and after its execution. Each description is bespoke, reiterating the purpose of each individual activity, identifying prior activities and useful tools, and providing tips for the execution of the activity. Together these descriptions will enable the planning details of each activity to be recorded as an aid to delivering the overall process.

A set of Activity Plans complement the Stage Plan and provide a summary of all intended improvement actions. Additional information may be added where one or more activities form the basis of a project workshop or meeting to enable detailed timing of such an event. These are living documents which may be used in electronic form, as large posters or interactive worksheets.

Useful toolkit resources: the Activity Plan worksheet, Improvement Activities cards and Improvement Tools cards can be downloaded from the Resources part of this toolkit.

Tools may be mapped to activities to assist in their selection. More than one tool may be used for any particular purpose and this is often encouraged. The mapping provides clear indication as to how tools might be used to support activities, but is not expected to exhaustively show where tools have actually been used in practice. Note that the activities themselves may be alternates, dependent on one another, or inter-dependent, and that it is not necessary to undertake all the activities within a particular programme strand to ensure success.

Useful toolkit resources: cards for each of the activities and tools can be downloaded from the Resources part of this toolkit.

Process Summary

The improvement process, informed by posters and captured by worksheets, may be summarised as:

  • Fill in the improvement canvas with known information
  • Identify possible knowledge gaps and outputs to be created
  • Select the activities (or questions) to be addressed
  • Prepare the activities (and associated tools) for use
  • Plan the improvement programme and iterate as appropriate

This process may be summarised as a linear, yet iterative process, that is designed to deliver improvement. It allows the improvement facilitator to weave interchangeably between focusing on the Questions and/or the Activities in order to successfully deliver an effective improvement process.

Useful toolkit resources: all the posters, worksheets and cards required to facilitate this process can be downloaded from the Resources part of this toolkit.


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