Developing Change

Introduction

“Insanity: Doing the

same thing over and
over again and
expecting different
results”

- Albert Einstein
 Module Objectives

 Answer the second question of the Model

for Improvement: “What change can we
make that will result in an improvement?”
 Differentiate between fundamental change and
reactive change, change concepts and change
ideas
 Apply logical thinking methods such as root-
cause analysis, process map and driver
diagram for generating change ideas
 Use creativity methods to generate new ideas
 Generating Change for
Improvement
“Every improvement needs change, but
not every change is an improvement”

Avoid:
- More of the same
- Utopia syndrome
- The perfect solution to the wrong
problem
The Improvement Guide, 2nd Edition – p110-111
 Reactive vs. Fundamental Change

2 3
 Two Types of Change

 Reactive Change (1st order Change)

 Response to sudden problem in the system
 Returns the system to prior condition
 Impact only a few parts of the system
 Short term impact
 Fundamental Change (2nd order Change)
 Create a new system of performance
 Redesign processes
 Impacts various part of the system
 Long term impact
The Improvement Guide, 2nd Edition – p111-116
Developing Change Ideas

How do you get

new ideas?
 Standards/
Protocols
 Literature
 Benchmarking
 Ask experts
 Brainstorming
 Change concepts
 Creativity
techniques
The Improvement Guide, 2 Edition – p120
nd
 Ways of Generating New Ideas

THOUGHT PATTERNS

LOGICAL LATERAL
THINKING THINKING

Logical Logical Creativity

Positive Negative
Process Map, Fishbone Diagram, Provocation, 6 Thinking
Pareto Chart, Line graph/ Run Chart, hats, Random Entry, Use
driver diagram, literature, of Concepts, etc.
benchmarking, etc.
Creativity and Improvement: A vital Link by Lloyd P. Provost and R.M. Sproul, 1996
 How many
squares can
you see
here?

GENERATING CHANGE IDEAS

THROUGH LOGICAL
THINKING
 Brainstorming and Affinity
Diagram
 Brainstorming is one
of the simplest tools
 Commonly know
technique

Affinity Diagram
 Grouping ideas in
thematic areas

How to Guide for Quality Improvement, Aurum Institute

 Benchmarking

 Compare yourself to others

 Identify high performers or best practices
 Understand what they are doing different
 Not limited to organizations working in the
same field
 E.g. Improve patient-centered care, learn from
the hospitality industry (hotels)
 E.g. Improve patient safety, learn from the
aviation industry
 Appreciation for the System

Process vs. System ~~~W. Edwards

Deming~~~

 Process: a sequence of
steps/actions through which
inputs from suppliers are
converted into outputs for
customers

 System: the sum of all the

part (including processes) that “If you can’t describe
what you are doing
interact together to produce a as a process, you
common goal
Adapted from Institute for Healthcare Improvement, QILM presentation don’t know what you
are doing”
Appreciation for the System
 What is a Process Map?

 A pictorial presentation of a process

 A series of connected actions used to
achieve an output, with a defined start
and end point
 Also known as flow chart
 Often used to represent a patient’s care
pathway

Adapted from Institute for Healthcare Improvement, QILM presentation

 Complete each of the steps in this
process
NO

Step 3: Do
Step 1: Step 2:
Add 12 to the you have
Pick any number Multiply your
number from step 2 a 2-digit
from 3 to 9 number by 9
number?
YES

Step 6:
Step 7:
Step 4: Step 5: Convert your
Write the name of a
Add your 2 Divide # from step 4 Number to a letter:
the fastest mammal
digits together by 4 to get a 1 1=A 2=B 3=C
in the world that
digit number 4=D 5=E 6=F
begins with your letter
7=G 8=H 9 = I

Step 10: Step 11:

Step 8:
Step 9: Convert your Write down the name
Write down
Add 8 to your Number to a letter: of a country in Africa,
the color of
# from step 5 1=A 2=B 3=C beginning with the
your animal
4=D 5=E 6=F letter from step 10
7=G 8=H 9 = I
 A “brown-dotted” Cheetah in
Kenya

“Every
system is
perfectly
designed
to get the
results it
gets”
 Uses of a Process Map

 Visual representation of activities and their

interactions
 Helps understand process
 Helps identify opportunities for
improvement
 Helps standardize procedures
 Identify value for patient and reduce
waste
 Process Map Symbols

task transport
BASIC SYMBOLS

SYMBOLS
SPECIAL
decision delay

direction of flow
docume
nt
boundaries
(start & end) connect
or

Adapted from Institute for Healthcare Improvement, QILM presentation

Steps to Construct a Process Map

1. Define the process boundaries - beginning and

end
2. Spell out the focus of the process map: a
Patient/Client; an expenses claim form; a
patient folder etc.?
3. Be clear on what you are mapping: current or
ideal process
4. Show the steps of the process
5. Follow one path at a time at decision points
6. Defer for future completion if team lacks the
detail understanding to complete a section
7. Review the completed diagram
 Process Map in Action

Big Bang Theory – Season 2, Episode 13 21

 Small Group Exercise

 Work in small groups of 5-6 participants

 Map a work process you are all familiar
with
 e.g. current triaging system in your facility (45
minutes)
– Beginning: Patient arrives at the gate
– Ending: First dose of medication administered
 Write each step on a sticky note, connect
with arrows
 Prepare to share with the group
 Time: 45 + 15 minutes
 Process Map Analysis

 Aim at reducing waste and improve value for the

patient/client
 Look at for the steps that:
i) Definitely add value

ii) Add no value, but are unavoidable

iii) Add no value, but are avoidable

 Under-performance

 A poor performing system

is often due to inefficient
processes or poor
interaction between
processes
 However, usually we
blame the people
involved without
addressing process failure
– fundamental attribution
error
Adapted from Institute for Healthcare Improvement, QILM presentation
 Look out for…

 Is the process standardized, or are the

people doing the work in different ways?

 Are steps repeated or out of sequence?

 Are there steps that do not add value to

the output?

 Are there steps where errors occur

frequently?
 Look out for…

 Steps that do not add value to the patient

 Look for opportunities to run steps in

parallel

 Re-order steps

 Reduce hand-offs

 Identify bottlenecks
Prioritization of Bottlenecks

Adapted from Institute for Healthcare

Improvement, QILM presentation
 Small Group Exercise

 Continue working in the same groups

 Analyze your process map (30 minutes)
 Identify any steps that do not add value to
the patient
 Put a circle around these steps
 Map the ideal process, taking out the
waste
 Write down the generated change idea(s)
 Prepare to share with the group
 Time: 30 + 15 minutes
 Root Cause Analysis

 Identify the underlying “In health care, it's easy

to understand the
reasons (causes) for the difference between
problem treating the symptoms
and curing the
 Change for improvement condition. A broken
to be targeted towards wrist, for example, really
hurts! But painkillers will
the causes only take away the
 Two commonly used symptoms; you'll need a
different treatment to
methods help your bones heal
 5 WHYs properly”
 Fishbone (Ishikawa) MindTools

Diagram or Cause and

Effect Diagram
 How to apply the 5 WHYs?

 Write problem statement in the form of a

question
 Write the answer/response (provide one
response, not multiple options)
 Restate the each answer as a question and
ask again “why?”
 Every question and response must be
written down
 Asking approx. 5 times why will lead to the
root-cause of the problem
 Example of 5 WHYs

 Why don’t women exclusively breast feed for 6

months? Because they think when the baby cries
after a feed it is still hungry
 Why do they think when the baby cries after a
feed it is still hungry? Because that’s what their
mother-in-law is telling them
 Why is their mother-in-law telling them this?
Because when she had her babies this is what
everyone believed
 Why is this what everyone believed? Because
babies died of malnutrition in their villages so
people feared that inadequate breastmilk supply
Aurum Institute – How to Guide for Quality Improvement,
was the cause
 What is a Fishbone Diagram?

 Or Cause and Effect diagram

 A visual way to look at a problem and its
causes
 A tool that helps to organize contextual
knowledge about a problem
 Involves brainstorming

 Encourages group participation

 Utilizes group knowledge

 Fishbone Structure

Cause Cause Cause

3 2 Sub-Cause
1 1
Why 1
Why 2

Sub-Cause 2
Why 1
Why 2
Proble
m

Cause Cause Cause

6 5 4
 How to Construct a Fishbone
Diagram?

1. Define problem (negative form)

2. Draw a line horizontally along the page. This line

will be the ʺspineʺ of the fish.

3. Draw the head of the fish and write the problem

inside.

4. Brainstorm and identify the main categories

(causes) contributing to the problem (ensure to
include internal and external causes)
 How to Construct a Fishbone
Diagram?

5. Draw the “bones” – label each bone with a main

cause using a noun
6. Brainstorm on sub-causes and why for each of
cause – write them alongside the bones
7. Review the diagram
8. Give an appropriate title
9. Identify areas where immediate changes can be
tested
Example Fishbone Diagram
 Small Group Exercise

 Form groups of 4-6 participants

 Construct a Fishbone Diagram on flipchart
for the following problem: “Delay in
Health Care seeking at the facility”
 Identify 1-2 areas for improvement and
generate a change idea
 Prepare to share with the group
 Time: 45 minutes
 Reverse Fishbone

THEMATIC AREA THEMATIC AREA THEMATIC AREA

CHANGE CONCEPT

CHANGE IDEA

CHANGE IDEA

AIM/
SOLUTIO
N
(EFFECT
)

THEMATIC AREA THEMATIC AREA THEMATIC AREA

 Driver Diagram

A pictorial display of a system

 Helps us to understand the system we are
trying to improve
 Defines the boundaries of the system
 Show factors (processes, structures, norms)
that cause the outcome (aim)
 It captures the primary and secondary drivers
that drive the achievement of the aim
 Based on theory, hypotheses and contextual
knowledge
Adapted from Institute for Healthcare Improvement, QILM presentation
 Driver Diagram Structure
Outcome Primary Drivers Secondary Drivers Change ideas

Change 1
S. DRIVER 1
Change 2
P. DRIVER S. DRIVER 2 Change 3

S. DRIVER 3
AIM

S. DRIVER 4
P. DRIVER
S. DRIVER 5

S. DRIVER 6

Adapted from Institute for Healthcare Improvement, QILM presentation

 What are Drivers?

 Primary Drivers
 System components which will contribute to
achieving the aim
– Structures, processes or cultural norms that
contribute directly to the desired outcomes
 Secondary Drivers
 Elements affecting the Primary Drivers and
ultimately the aim
– Elements (steps of processes, root causes) that can
be used to generate change ideas

Adapted from Institute for Healthcare Improvement, QILM presentation

 A “New Me”

Outcome Primary Drivers Secondary Drivers Change Ideas

Ethiopia: Driver Diagram for MNH

IHI Ethiopia, MNH project

 Summary Logical Thinking

Methods/Tools Application Generate Change Ideas

Benchmarking Learn from high Use change concept and
performance generate ideas
Driver Diagram Define the system Based on secondary
drivers
Process Map Pictorial presentation of a Identify areas that do not
process add value and generate
ideas to increase value
Prioritization tools Prioritize areas with Ideas that impact the
(Pareto Chart, focus greatest impact major contributors
matrix)
Root Cause Analysis Contextual knowledge Potential solutions to the
(Fishbone and 5 WHYs) about a problem and its root cause(s) of the
causes identified problem
 Connect the 9 dots
with 4 straight
lines, without lifting
your pen from the
paper

LATERAL THINKING
 Lateral Thinking

What change can we make that will result in

an improvement?
 New ideas are needed
 Methods/tools for lateral thinking
 Provocations
 Random entry
 6 Thinking hats
 Change concepts
 Supplementary to Logical Thinking
Creativity and Improvement: A vital Link by Lloyd P. Provost and R.M. Sproul, 1996
 Provocations
Reversal – go in
opposite direction to the Distortion – make
norm changes to current
e.g. patients treat the staff relationships &/or time
e.g. the clinic staff can only
Exaggeration - greatly work for 4 hours a day

exaggerate current situation

e.g. you can rely on no data Wishful Thinking – an
generated by the HMIS
system
impossible fantasy
e.g. patients follow the
Escape – from what you
instructions they’ve been
take for granted given
e.g. we have no shortages of
staff Institute for Healthcare Improvement, Improvement Coaches Training Manual
Harnessing Local Ideas for Change

Before After change

change
Exercise

 Work in pairs
 Generate change
ideas to improve the
situation on the photo
using Provocation
methods
 Root cause identified:
delay in patient
discharge due to
incomplete claim
forms
 5 minutes
 Random Entry

 Use a random word (noun) to provide a

totally new starting point outside the
mainstream pattern.
 The mind is allowed to move forward to try to
connect the random word to the subject.
 This occurs naturally because of the tendency
of the mind to form patterns.
 There are various methods to get random
entry word.
Institute for Healthcare Improvement, Improvement Coaches Training Manual
 Exercise

 Work in pairs
 Open the Participants’ Manual on a
random page with text
 One person to close eyes and point with
his/her finger on the page
 Use the nearest noun to the finger as an
entry
 Generate change idea to improve the
scene on the picture and its identified root
cause
 Time: 5 minutes
 Change Concepts

A change concept is a general description

on what to change, the specific interventions
is the change idea.
 Existing lists of change concepts
 Turn change idea in a concept to generate
new ideas (often used method for benchmarking,
affinity diagram)

Institute for Healthcare Improvement, Improvement Coaches Training Manual

 Concept vs. Idea

Change Change Idea

Concept
General, Specific,
Vague, Broad, Actionable
Strategic

Adjust to Provide Get General

peak patients supportin nurse to
demand with g staff in support
patient the records
file/ morning dept.
records from 8 to
faster 10 am.
 Large Group Exercise
CONCEP

Match
Do tasks the
in Amount
T

Parallel to the
Need

Color ATM to give

coding of the card Provide
emergenc before the reminder
IDEA

y cases to money to calls a day

identify avoid that before the
cases people appointmen
who need forget to t to TB
to be take the clients
prioritized card
 6 Thinking Hats

 A tool that helps to generate new ideas

 Whole team thinks at the same time with the
same perspective – color of hat
 Enables to look at things in a collaborative
way, from different perspective to see new
opportunities
 More complete look on the ideas and their level
of success

Six Thinking Hats, Edward de Bono, 1985

IQ Matrix – 6 Thinking Hats
Blue Hat – Leader/Facilitator

 Role: facilitator/ moderator

 Think about the process of thinking
 Improve efficiency and effectiveness of
thinking process
 Clearly define problem
 Determines sequence of hats
 Timekeeper, determines time per hat and topic
 Oversees facts, arguments and opinions of all
hats
 Decide/Summarized discussion with plan of
action
IQ Matrix – 6 Thinking Hats
White Hat – Data/Facts

 Role: “detective” is search of facts &

data
 Collecting, collating, organizing and
presenting information neutral and
unbiased
 Asks: What? Where? When? How?
 Expands thinking and awareness about the
problem due to facts
 Does not conclude or judge the information
presented
 No beliefs or opinions, facts only!
 Possible logical solutions based on hard facts
IQ Matrix – 6 Thinking Hats
Green Hat – New Ideas

 Role: brings unique, creative ideas

and perspectives
 Bend the rules of reality, no constrains
 Expands thinking and awareness
 Daydreaming, manifesting crazy ideas that
may not make logical sense
 New perspectives
 Avoids criticizing or judging the ideas that
come to mind

IQ Matrix – 6 Thinking Hats

Black Hat – Critical Negative

 Role: pessimistic and gloomy

 Evaluate, judge, caution and criticize
 Try to find weaknesses, flaws and
dangers within ideas
 Critical negative
 Build suitable contingency plans for possible
barriers/obstacles
 Avoid bringing to mind personal biases that
build on negative emotions such as fear, anger
and jealousy

IQ Matrix – 6 Thinking Hats

Red Hat - Feelings

 Role: emotionally and intuitively

present effective solutions
 Based on personal feelings and hunches
 Seeks other people’s feelings
 Seeks emotional understanding of the problem
 Can be both positive and negative about the
idea
 Avoids rationalizing or trying to justify feelings

IQ Matrix – 6 Thinking Hats

Yellow Hat – Critical Positive

 Role: positivism, welcoming, breathes

l life into every idea
 Seeks positive benefits through a logical
means
 Enhances motivation and opens doors to new
opportunities and understandings
 Realistically and optimistically seeks for
effective solutions
 No boundaries or limitations
 Making the impossible, possible
 Avoids pessimistic thoughts
IQ Matrix – 6 Thinking Hats
 Individual Reflection

IC CR NAL
I ST EA T I O
I M T IV E MO
E SS E
P

What color of hat do you naturally wear

when trying to resolve a problem?

T IC LEA
M I S DE
OP TI R
ANALYTIC
 Rules For Using “Thinking Hats”
 All people think with the same hat at the
same time
 Make sure your thinking reflects the hat you are
wearing
 Use short bursts of thinking (3-5 min)
 If the thinking is flowing and on color, you may
extend the time. Do so intentionally and in small
increments
 May limit lengthy discussion
 Use a focused and simple sequence of hats
 View thinking as a skill – a serious activity

Institute for Healthcare Improvement, Improvement Coaches Training Manual

 Role Play

Your facility has a problem with long

waiting time at the laboratory

 7 volunteers
 Select one person who will wear the blue
hat
 Generate a change idea to address the
problem
 Time: 15 minutes
 Discussion Role Play

 To the players:
 What went well?
 What was challenging?
 Did you get new ideas?

 To the observers:
 What went well?
 What could be improved?
 Is the change idea likely to work?
 Summary Lateral Thinking

 Just like Logical

Thinking, there are
different methods and
tools available to
guide the thoughts
 Provocations
 Random Entry
 Change Concepts
 6 Thinking Hats
 Etc.

Creativity and Improvement: A vital Link by Lloyd P. Provost and R.M. Sproul, 1996
Quality Improvement Project Work

Section II: Developing Changes

 Continuing on the section I (problem
Identification, prioritization and aim
statement) component of your quality
improvement project at your facility
(module 4 activity). Develop changes
using the fishbone and driver diagram.
 N.B.: Use your project workbook
 Time: 20 minutes
 Summary
 Work in groups of 5
 A QI team has attempted to improve the
waiting time at the Outpatient Department
of the facility for several months. They
have tested various change ideas but
without much success.
 What would your recommendation be?
 What tool(s)/method(s) to use
 How to use them (summary)
 How will it help to generate ideas
 Time:15 minutes