Improving Improvement

This guide is part of the University of Cambridge Improving Improvement Toolkit, which develops the approach presented in the Royal Academy of Engineering report titled “Engineering Better Care — a systems approach to health and care design and continuous improvement”.

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.

This particular guide assists in the definition, visualisation, planning and execution of the Understand Stage of the Improvement Programme. The questions and activities highlighted here provide a minimum suggested set for the stage and may be supplemented with other familiar activities.

The following steps, described in more detail below, describe possible elements of a systems-based approach for planning the Understand Stage of an improvement process — leading to a description of the current system (now), a common understanding of the problem, a consensus view of what the future system might look like (better) and a clearly articulated case for changing the system.

1. Improvement Canvas — Describe the context and nature of the challenge and current ideas for improvement and measurement.
2. Agree the scope of the proposed improvement or decision-making process and identify the team required to deliver it.
2. Stakeholder Influence — Identify key stakeholders, their interest in the system and potential to influence the outcome of the process.
3. Stakeholder Needs — List the full range of stakeholders’ essential needs and their particular reasons for these needs.
4. System Boundaries — Highlight the extent of the systems of interest and influence relating to the scope of the proposed improvement.
5. Rich Picture — Sketch details of the systems of interest and influence specifically relating to the scope of the proposed improvement.
6. Design Themes — Translate the essential needs into key design themes and a prioritised, clearly articulated set of design requirements.
7. Persona Descriptions — Co-design a representative set of personas to capture and characterise key users and/or stakeholders.
8. Stage Plan — Define the outputs or outcomes required for the each of the elements of the improvement or decision-making process.
9. Select the activities and tools required to deliver these outputs and the critical dependencies between them.

There is particular value is completing a preliminary Improvement Canvas and draft Stage Plan early in the stage to facilitate the building of an appropriate team for this and/or subsequent stages. Individual outputs for this stage can be recorded at the end of the guide and may then provide the basis for a stage-gate review.

Use the Improvement Canvas Poster to investigate the team’s current knowledge about the system and agree the scope of the change required.

A clear articulation of the scope helps to define the boundary between what is in and what is out of the system of interest. It also reflects the prioritised needs of the stakeholders that should drive any improvement. The scope will also be influenced by the context of the system, primary focus of the challenge, core themes of possible solutions and level of detail required to describe the system and its stakeholders.

At the beginning of each stage of the improvement programme it is important to reaffirm the content of the canvas and scope of the challenge. This helps to define the gap between what is known at the start of the stage, the needs to be met by the end of the stage, and the plan to move between them.

The questions of particular interest to the Understand Stage of the Improvement Programme are highlighted in colour above.

Use the Improvement Canvas Worksheet to describe the team’s current knowledge about the system and agree the scope of the change required.

The canvas may be completed in any order, with input from the stakeholder influence and stakeholder needs worksheets informing the stakeholder and team boxes, from the system boundaries and rich picture understanding the context, and from the design themes and persona descriptions defining the problem.

All entries are important in capturing the team’s current knowledge about the challenge, and in determining a sensible starting point and scope of interest for improvement. Ideas of solutions inspire a deeper understanding of the problem, and evident may provide context or evaluation of existing solutions.

The case for support provides a rational for stakeholders to support the proposed change, while the plan and team describe the necessary resource and steps required to deliver the change.

Use the Stakeholder Influence grid to identify key system stakeholders’ interest and influence.

Successful improvement depends on a wide range of stakeholders and system users who, at any point in time, will have different levels of interest in and power to influence such improvement. They will bring a range of perspectives to any programme and through their action or inaction can enable, actively encourage or frustrate progress.

There is value in characterising stakeholders, in terms of their interest and power, to ensure that they are sufficiently informed, engaged or managed at all stages of an improvement programme. Understanding them and their relative importance is an essential element of managing change.

Use the worksheet to remind the team of the stakeholders related to the improvement process, to capture the particular needs of the individual stakeholders, and to highlight the range and diversity of stakeholder needs.

Use the Stakeholder Needs table to list the system stakeholders’ needs and reasons for those needs.

Stakeholders are defined by their role, needs and reasons for those needs. It is useful to capture this information in the form “ As a … … I need … … so that … ” where these statements provide insights into needs and the rationale for them.

Stakeholders may have multiple and diverse needs and associated rationales, which provides the basis, with their interest and influence, for early conversations to prioritise these needs. Such needs may also vary with time and, therefore, in importance to other stakeholders over time.

Use the worksheet to remind the team of the stakeholders related to the improvement process, to highlight the range and diversity of potential stakeholders, and to accentuate the importance of understanding stakeholders needs.

Use the System Boundaries worksheet to highlight the limit of the system of interest and the system of influence.

Understanding the context of the system to be improved is crucial, from the external factors to the system of interest to the system of influence. These boundaries define what is in and what is out, and are closely linked to the scope of the improvement programme and the stakeholders.

The system of interest defines the boundary of all that is important to the understanding, co-design, delivery and sustaining of change; whereas the system of influence defines the boundary of influence or control. Both may change, or need to be changed, with time.

Use the template to provide a summary of key system boundaries and external factors, to identify the wider system of interest for the improvement programme, and to highlight the [usually] smaller system of influence for the programme.

Use the Rich Picture worksheet to sketch details of the system of interest, system of influence and external factors.

Rich pictures were developed as part of Checkland’s Soft Systems Methodology. They use drawings or pictures on a single piece of paper to capture a complex messy situation, and can depict people, objects, parts, systems, journeys and so on, along with structure, relationships, connections, influences, issues and arguments etc.

These pictures assist a team in capturing a common understanding of a system, its boundaries and characteristic and behaviours as a prior to improving or transforming the system into something measurably better.

Use the worksheet to capture images that represent multiple perspectives of the system, to visualise connections between the collected images of the system, and to understand the inherent and emergent behaviour of the system.

Use the Design Themes worksheet to translate the prioritised needs into agreed themes and system requirements.

The delivery of an effective improvement process requires careful translation of the aim of the improvement into realisable system requirements. This is a complex, iterative process, critical to the success of the whole programme.

A clear aim should align with the existing or proposed purpose of the system and the desired improvement in quality to be delivered by the system. It should be expressed in terms of the prioritised needs it will satisfy and the agreed themes that represent the essence of the things the system must do. These can then be translated into the individual system requirements.

Use the worksheet to present the prioritised needs in the context of the programme aim, to highlight the agreed themes derived from the prioritised needs, and to summarise the systems requirements related to the agreed themes.

Use the Persona Descriptions worksheet to co-design a set of personas representing patient groups and/or service providers.

Personas are fictional characters which are created, based upon appropriate research, to represent the full range of different user types that might use a service, product, site or brand.

Personas can help a team to understand stakeholders’ and users’ needs, experiences, behaviours and goals. The process required to create them can also help the team to recognise that different people have different needs and expectations, and help them to better identify with the stakeholders and system users.

Use the worksheet to capture the diversity of people within a chosen stakeholder group, to identify the key characteristics that are should be recorded, and to provide a simple means to describe stakeholder diversity that matters.

Use the Stage Plan worksheet to select the most important elements of the improvement process that are required to deliver the desired outputs.

This model underpins the stage gates of an Improvement Programme, where progress is driven by clear objectives for each of the key elements at each stage of the programme.

The desired outputs or outcomes should be identified, based on the content of the Improvement Canvas for the Understand Stage of the Improvement Programme and the particular objectives of this stage.

The stage plan should identify the questions and activities that are required to achieve the specific understand stage deliverables. They are more likely to focus on understanding the context of the challenge and on defining the problem. Later stages will see a shift in focus to developing the solution and collecting the evidence. All stages should reflect the need to make the case and manage the plan.

The Questions Map poster can be used to identify the key questions that would help to deliver the outputs required.

The Stage Activities poster can also be used to identify the improvement activities that would help deliver the outputs required.

A sample of possible Activities which may be added to the understand stage plan.

A sample of possible Tools which may be added to the understand stage plan.

Activity summary