Developing Change

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, and driver diagram for generating change

ideas
 Use creativity methods to generate new ideas
“Insanity: Doing the same
thing over and over again
and expecting different
results”

- Albert Einstein
 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 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, 2nd Edition – p120
 Ways of Generating New Ideas

THOUGHT PATTERNS

LOGICAL LATERAL
THINKING THINKING

Logical Logical Creativity

Positive Negative
Process Map, Fishbone Diagram, Pareto Provocation, 6 Thinking
Chart, Line graph/ Run Chart, driver hats, Random Entry, Use of
diagram, literature, benchmarking, etc. Concepts, 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 : LOGICAL THINKING
 1. Brainstorming and Affinity
Diagram
 Brainstorming is one of the simplest
tools
 Commonly know technique

Affinity Diagram
 Grouping ideas in thematic areas
 2. 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

 Focus learning on the why something works more than the what
i.e. turn the what into a change concept so that it can be
generalised and applied to your situation
 3. Root Cause Analysis

 Identify the underlying

reasons (causes) for the “In health care, it's easy
to understand the
problem difference between
 Change for improvement treating the symptoms
and curing the
to be targeted towards condition. A broken
the causes wrist, for example, really
hurts! But painkillers will
 Two commonly used only take away the
methods symptoms; you'll need a
different treatment to
 5 WHYs
help your bones heal
 Fishbone (Ishikawa) properly”
Diagram or Cause and MindTools
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 was the
Aurumcause
Institute – How to Guide for Quality Improvement,
 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 11
Sub-Cause
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: (30 minutes)

“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

 Reverse Fishbone

THEMATIC AREA THEMATIC AREA THEMATIC AREA

CHANGE CONCEPT

CHANGE IDEA

CHANGE IDEA

AIM/
SOLUTIO
N
(EFFECT
)

THEMATIC AREA THEMATIC AREA THEMATIC AREA

 4. 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

 Appreciation for the System

~~~W. Edwards
Process vs. System 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
interact together to produce a what you are doing
common goal as a process, you
Adapted from Institute for Healthcare Improvement, QILM presentation don’t know what you
Appreciation for the System
 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”
Prioritization of Bottlenecks

3
Adapted from Institute for Healthcare
Improvement, QILM presentation
 5. 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

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 (Pareto Prioritize areas with Ideas that impact the
Chart, focus matrix) greatest impact major contributors
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
 Activity

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