“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 Change||Fundamental Change|
|Changes required to maintain the system at its highest level of performance previously achieved||Changes made to exceed the highest level of performance previously achieved|
|Made routinely to solve immediate problems or react to a special circumstance||Fundamentally alter how the system works and what people do.|
|Typically take the form of a trade-off among competing interests or characteristics||Often result in improvement of several measures simultaneously|
|Impact is usually felt quickly||Impact 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.
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
Source: 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
- 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
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!!
Don’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!!
Source: IHI Open School
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 process.
Here are examples of changes concepts that are translated into specific Change Ideas:
|Change Concept||Change Idea|
|Reduce or Manage Overkill||The 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 Used||Print brochures|
|Adjust to Peak Demand||Staffing|
|Manage Time||Reduce 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.
Changes developed need to be tested to determine if they
actually result in improvement (Step 7)