Step 6: Develop Ideas for Change

“All improvement requires change, but not every change is an improvement”

 

Where do changes that result in improvement come from? Sometimes people are just lucky.  Unfortunately, we cannot count on luck, and people have a tendency to resort to some common, though often ineffective, ways of developing change.

Step 6 will guide you through the process of pursuing opportunities for change purposefully so that you can answer effectively the third question in the Model for Improvement:

“What changes can we make that will result in improvement?”

 

Reactive Versus Fundamental Change

Understanding the degree of improvement you are seeking will drive the types of changes you test and implement.

Reactive ChangeFundamental Change
Changes required to maintain the system at its highest level of performance previously achievedChanges made to exceed the highest level of performance previously achieved
Made routinely to solve immediate problems or react to a special circumstanceFundamentally alter how the system works and what people do.
Typically take the form of a trade-off among competing interests or characteristicsOften result in improvement of several measures simultaneously
Impact is usually felt quicklyImpact is felt into the future

Develop and Communicate Your Theory for Change

Using the information accumulated from the previous steps, it is valuable to develop and enumerate a theory for change:  hypotheses and assumptions about which changes are necessary to achieve your aim (developed in Step 3).   Communicating your theories about changes that will lead to improvement is an important function of an effective improvement team.

Driver Diagrams

The driver diagram is an indispensable tool for mapping out the theory of change.  Applicable in many contexts, a driver diagram visually illustrates the structures, processes, and norms believed to require change in the system, and the specific change ideas that are anticipated will lead to improvement.  Teams then test and revise the current theories and ideas and hunches with PDSA cycles (see Step 7).
>>> Click for instructions on developing driver diagrams

 

Step 6 - conceptual view of a driver diagramSource: Provost L, Bennett B. What’s your theory? Driver diagram serves as tool for building and testing theories for improvement. Quality Progress. 2015 Jul:36-43.Download Article

Additional Tools

  • Cause-and-Effect diagram:  collect and organize current knowledge about potential causes of problems or variation
  • Force field analysis: Summarize forces supporting and hindering change
  • Flow diagrams:  develop a picture of a process; communicate and standardize processes.

 

Approaches for Developing Fundamental Change

 

Use the information gathered in Steps 1-5 to reflect on how your system currently works, which will likely help you identify opportunities and generate ideas for improvement.

Comparing your own process to “best practice” can help you identify where your own system falls short. Based on that analysis, you can develop ideas for improving your performance. In its simplest form, look around at how others are doing things and trying to learn new approaches and possibilities.  You can benchmark other programs and services, other departments on your campus, look to other campuses, even branch out to other sectors.  A formal benchmarking process provides a method with some structure for making these observations, and then using this information for improvement.

tip

Be sure to understand the core theory of any best practices, but don’t try to replicate each process identically.  Use PDSA cycles to help you adapt best practices for within your own setting!!

  Think about opportunities in which technology – such as automation, new equipment, or new information systems — can lead to improvement.  Technology can be particularly effective when targeting bottlenecks.

tipDon’t digitize dysfunction:  Technology that isn’t reliable, or that simply makes a bad system more accessible to larger numbers of people, is not the fix you’re looking for!!

Where do new ideas come from? You can spark creative thinking in various ways, including simply taking the time to do this sort of thinking; identifying the boundaries that limit the changes you can make and then finding ways to dismantle those boundaries; temporarily considering unrealistic goals that can prompt you to break out of your old way of thinking; and exposing yourself to situations that can spark new ideas, such as taking the role of a patient to view health care in a different light.  Here are examples of specific exercises to help your team with creative thinking: http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/ideas-generation.aspx

  see below.

Source:  IHI Open School

 

Change Concepts

When you’re trying to think of a good idea for a change, you don’t necessarily have to start from scratch. Improvement experts have created a “cheat sheet ” — a robust list of 72 types of changes that often lead to improvement. You can use the list as a jumping off point to develop specific ideas for changes that could work in your setting.  Creatively combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change. After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement.

  • Eliminate multiple entry
  • Reduce classifications
  • Remove intermediaries
  • Schedule into multiple processes
  • Find and remove bottlenecks
  • Do task in parallel
  • Focus on core process and purpose
  • Develop alliances and cooperative relationships
  • Use reminders
  • Change the order of process steps
  • Manage uncertainty, not tasks


Change concepts can provoke new ways of thinking but are designed to be abstract and context-free.  Before they can be applied directly to making improvements, a concept needs to be turned into a specific idea that can be tested and implemented.  The figure below illustrates this this process.

Step 6 - Change Concept fig1

Step 6 - Change Concept fig2

Here are examples of changes concepts that are translated into specific Change Ideas:

Change ConceptChange Idea
Reduce or Manage OverkillThe current process for staff travel requires sign off by five people. Reduce to only those individuals who truly are “required”.
Eliminate Things That Are Not UsedPrint brochures
Adjust to Peak DemandStaffing
Manage TimeReduce wait time

Another way to use change concepts is to better understand best practices or bright spots on other campuses or settings.  If you observe a specific idea (idea A in diagram) in another context (like through benchmarking), you can extract the concept(s) behind the idea. You can then apply the concept to the concept to the context you are interested in, and create a new idea (idea B) that is potentially useful for improvement in your system.

 

tip  Changes developed need to be tested to determine if they
actually result in improvement (Step 7)

 

Improvement Journey Exercise #6

  1. Develop a driver diagram.
  2. Answer the question: “What changes can you make that will result in improvement?”