Step by step guide to using the Model for Improvement

Before starting an improvement project at your service, it is helpful to consider the key ingredients for effective improvement work. Taking this time to prepare will increase the success of your work. there are a number of things to consider.

This section will guide you through the foundations of quality improvement and how to use the Model for Improvement. 

This section includes information on:

• The Model for Improvement
• Building your team
• Defining the problem and opportunity for improvement
• Setting your goal and area of focus
• Measuring improvement
• Introducing changes

About the Model for Improvement

At Safer Care Victoria we use the Model for Improvement, developed by the Associates in Process Improvement, as the framework for our improvement work. Guided by simple but effective improvement science principles, the Model for Improvement helps us deliver results-based outcomes and support improvement in healthcare.

The Model for Improvement asks you three questions to help you plan and undertake improvement work. Thoughtful, collaborative consideration of the three questions helps you deeply understand the problem or opportunity for improvement, identify high-quality change ideas, and construct an effective measurement strategy to capture learning and track progress.

The model also includes the plan-do-study-act or PDSA cycle as the engine for developing, testing and implementing change in your system. 

Build your team

Teaming up

Effective improvement in our complex healthcare system requires a team approach. Working in a team rather than on your own means you can share the workload and gather diverse knowledge and experience.

Ideally, your team will include:

• A team leader responsible for coordinating and driving the work
• At least one consumer with lived experience of your system
• Someone with quality improvement knowledge and experience
• Representation from relevant clinical areas, for example, surgical nurses, physiotherapists, obstetricians
• A senior sponsor.

Helpful tool: IHI QI Team member matrix  
This worksheet from the Institute for Healthcare Improvement will help you form a QI team that represents a range of perspectives and expertise. You’ll need to create an account to download the worksheet.

Partnering with consumers

Involving consumers in the redesign of both the systems of care and the care they receive can improve outcomes. When patients, caregivers and families contribute to the design and development of interventions, local solutions to local problems are created based on their needs.

Applying an equity lens

When forming your team, consider how you will draw in diverse perspectives and experiences. For example, the view of Aboriginal and Torres Strait Islander people, people who are culturally diverse, people from non-English speaking backgrounds, women and gender diverse people, and others who may be experiencing disadvantage. Including a diverse range of people can ensure solutions work across the population.

Helpful tools

• SCV Partnering in healthcare framework
• Department of Health Cultural Responsiveness framework – Guidelines for Victorian health services
• Department of Health Designing for Diversity framework
• IHI Achieving Health Equity - A Guide for Health Care Organizations

Appointing a senior sponsor

Support from your health service leadership is critical to help you access time, resources and organisational commitment. Your senior sponsor is also essential in championing your work and helping you sustain will and energy throughout the work.

Explore  the problem and opportunity for improvement

You  may know which area of care you wish to improve, but now you need to dig a little deeper. What does the problem look like in your unique context? Gathering data, investigating key processes and engaging the people in your system will help you answer this question.

What does the data tell you? 

At this stage of your work, data is key to understanding your problem or opportunity for improvement. Data will help you understand how significant the problem may be and how consistently and reliably practice is delivered.

Tips when using data to explore your problem

• Collect data across a number of measures relating to practice in the clinical area of focus in your service to create a baseline before you start testing changes.
• Take a ‘deep dive’ by reviewing recent cases to identify gaps in care.
• Remember to view the data with an equity lens – segmenting data by social group can help you identify gaps and target improvement. 

For example, if you were working on reducing stillbirths, data can show you the rate of stillbirths in your service and the consistency and reliability of care in key areas of clinical practice connected to stillbirth.

What do you know about the processes driving current practice?

To really understand your system, you need to work together as a team to identify all the steps in the process from a consumer and service provider perspective. Understanding this in detail will help you and your team identify where there are problems, gaps, duplications or delays.

Helpful activities include:

• Process mapping
• Affinity mapping
• Cause and effect (fishbone/Ishikawa) analysis 

What are people telling you?

Change is an integral part of improvement work, but this is not always embraced by individuals or teams. It can be challenging to build and maintain momentum in the face of the resistance that change can provoke.

What do you know about the culture, communication and teamwork in your context? Do you know who might be your champions for change? 

Helpful tool: IHI Psychology of change framework
This IHI white paper is a great resource for improvement teams, helping you understand the psychology of change and leverage its power to drive success in your improvement work.

What will you try to accomplish?

What is the SMART goal for your team?

It’s important to set a goal – or aim - to motivate and energise your team and to know when you’re successful.

Consider:

• How much do you want to improve by (without seeming too far out of reach or too easy)?
• What is your time frame? Is it a realistic match for how much you want to improve by and the complexity of your system? 
• Is there a particular part of your service you want to focus on?

For example, your aim might be:

We will reduce harm to women and families by reducing the rate of stillbirth in our women with complex needs service by 25 per cent, by December 2023.

What will you focus on?

In quality improvement work, the ideas and potential solutions we want to test in our system are referred to as change ideas. A change idea is an actionable, specific idea for changing a process.

These ideas can come from research, best practice or other organisations that have achieved improvement for a similar problem. 

You can use change ideas that you believe might work in your local context for initial testing and then revise the test based on the results.

It’s helpful to start with the ‘low hanging fruit’, to build belief in your work. 

Helpful tool: IHI Changes for Improvement
These tools will help you develop, test, and implement changes.

How will you know that change is an improvement?

Measurement is essential to help you learn:

• About the impact you are having as you test changes in a wide range of conditions
• Whether changes are leading to improvement
• What the next steps could be. 

You and your team will collect and learn from data in real time, using annotated run charts to understand your impact, adjust your hypotheses along the way and see progress towards your aim.

Collecting data: when and how much?

The focus of data collection for improvement is specificity and frequency: is your data directly connected to your project and are you collecting it frequently enough to learn and respond quickly?

You will need to collect just enough data to learn whether your changes are having an impact on your system. Too much and all your time will be taken up with data collection. Too little and you won’t learn effectively. A good place to start is to sample 10 patient records per week – noting that your data collection opportunities will vary depending on the size of your service.

A small ‘family’ of measures will help you track progress:

• One or two outcome measures, aligned to your aim.
• Up to five process measures, aligned to activities or practices logically connected to your aim.
• One or two balancing measures, monitoring potential indirect impacts in your system.

You may wish to use measures from work undertaken by others or develop measures to suit your context.

The frequency of data collection may look like:

• Outcome measures – weekly/fortnightly/monthly
• Process measures – weekly
• Balance measures -– monthly

For information about the types of measures used in the Model for Improvement visit the IHI.

Making sense of your data

Displaying your data on run charts will help you understand the impact of your changes, assess progress, and communicate progress with stakeholders.

A run chart is a line graph of data over time, demonstrating the performance of a process and enabling you to determine between expected (common cause) and unexpected (special cause) variation. Annotating your run charts to show when tests of change happen will increase your understanding of how these changes are influencing practice.

Run chart example: process measure

Helpful tools:

• IHI Measurement for Improvement

Testing changes in your system

Testing change using the plan-do-study-act or PDSA cycle enables teams to learn what works and what does not in their efforts to improve processes. Initially, cycles are carried out on a small scale to see if they result in improvement (for example one patient on one day). 

Teams then expand tests and gradually incorporate larger samples until they are confident that changes will result in sustained improvement.

Helpful tool: IHI Plan-do-study-act (PDSA) worksheet
Use the Plan-Do-Study-Act (PDSA) Worksheet to help your team document a test of change.