Demand and Capacity Management in services

quality and service improvement tools stakeholder analysis and difference between demand management and capacity management tools
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Institute for Innovation and Improvement The Handbook of Quality and Service Improvement ToolsIntroduction The Handbook of Quality and Service Improvement Tools brings together into a single resource 75 proven tools, theories and techniques for quality and service improvement. It is part of the Fundamentals for Quality Improvement from the NHS Institute for Innovation and Improvement – a suite of publications that will assist you in finding innovative ways to improve the quality, productivity and efficiency of patient care you provide. You can find out more about all of these publications at www.institute.nhs.uk/fundamentals. All of the tools, theories and techniques featured in the handbook and more are available online in our searchable library, available free of charge to the NHS in England at www.institute.nhs.uk/qualitytools. You may find it useful to use the handbook in conjunction with the Step-by-Step Guide to Tackling your Challenges, which maps some of the key challenges you have told us the health service is facing against a range of quality and improvement tools and products developed by the NHS Institute to support the NHS in improving the quality, productivity and efficiency of services. This guide is available in hard copy and as an interactive PDF via the website at www.institute.nhs.uk/challenges. How to use The Handbook of Quality and Service Improvement Tools The handbook is divided into the following two sections: Section one: Project management guide This step-by-step guide provides a suggested framework that will enable you to systematically progress through a quality and service improvement project. Each organisation is different and you may find that the stages described here are slightly different to the project management guide you are familiar with. However, there should be enough similarities between the two for you to match the stages outlined in this guide against those in your preferred framework for project management. 4 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsSection two: Quality and service improvement tools In this section you will find a comprehensive set of tools, theories and techniques that will enable you to expand your knowledge of tried-and-tested tools and techniques for improving quality and productivity. The tools have been grouped under the following headings, which relate to the type of task you may be addressing: 1. Project management 2. Identifying problems 3. Stakeholder and user involvement 4. Mapping the process 5. Measurement for improvement 6. Demand and capacity management 7. Thinking creatively 8. Human dimensions of change. Text highlighted in blue throughout the handbook indicates additional tools that will help you with your service improvement efforts. An A-Z index can be found at the back of the handbook to help you quickly find any additional tools you may need for the task in hand. The Handbook for Quality and Service Improvement Tools will be helpful for both clinical and operational staff involved in quality and service improvement/transformation. The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 5 www.institute.nhs.uk/qualitytoolsSection One Project Management Guide This six-stage project management guide provides a framework for service improvement within the NHS. We suggest you read through the whole project guide before you undertake any actions relating to the stages. This will help you get an overall picture of what all the stages involve. It is important to realise that this guide is a suggested framework. Each project is different and you may find that you do things slightly different for different projects. Section A provides an outline of the stages and section B covers them in more detail. Section A. Outline of the six stages 1. 2. 3. 4. 5. 6. Start Define Measure Design Pilot Sustain out and and and and and scope understand plan implement share One important fact to consider is that there are certain critical elements for success which should be continually considered throughout the life of the project. These are: i – Stakeholder engagement and involvement ii – Sustainability iii – Measurement iv – Risk and issues management v – Project documentation and gateway criteria Section B. Detail of the six stages The tables that follow show the different elements involved in each of the six project management stages and relevant tools for each of these stages. Tools in blue are contained within this handbook. Tools in red can be accessed via the project management guide stored in the online library of quality and service improvement tools (www.institute.nhs.uk/ qualitytools - under ‘P’ in the A-Z of tools). Tools and products in black can be found using the search engine on the NHS Institute’s homepage (www.institute.nhs.uk). 8 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsStage 1: Start out Aim of this stage: To establish a rationale for any improvement work and obtain support for this work from an appropriate sponsor. KEY STEPS RELEVANT TOOLS 1.1 Establish the service that is to be improved or the • Identifying frustrating problems particular area that is to be addressed. This may be identified by an individual, a team member, manager or from organisational strategy that has been informed by patient requirements. 1.2 Identify a small number of key individuals, both • Listening – importance of this skill at a senior and operational level, who it would be • Stakeholder and user involvement – worthwhile sounding out regarding this area of focus. an overview If you are unsure who these individuals are, you can • Stakeholder analysis use stakeholder analysis to help you identify them. This will help begin to establish the merits of focusing on this area and identify any important considerations there may be. These individuals may form part of your project structure in future stages such as the project team and project board. 1.3 Gather ideas from staff and patients on how this • Using an affinity diagram particular service may be improved. Establish which • Thinking differently ideas to take forward. 1.4 It may be worth testing whether the current idea could • Making a bigger difference be improved or stretched further, to make an even • Commissioning to make a bigger difference. bigger difference 1.5 To help get support for your improvement project, • Four columns: link your project to the it is beneficial to make clear how the aims of organisation’s aims the improvement work are aligned to the overall • Benefits realisation organisational aims. The potential short-term and • Methodology for measuring benefits long-term benefits should be articulated. 1.6 To give focus for the improvement you should • Performance management and set measurable targets for the aims that you want balanced scorecard to achieve. • Good indicators guide Tools in blue – in this guide (see A-Z index at back of handbook) Tools in red – in the online project management guide at www.institute.nhs.uk/qualitytools (under ‘P’ in A-Z) Tools in black – accessible via www.institute.nhs.uk and using the search facility on the homepage The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 9 www.institute.nhs.uk/qualitytoolsKEY STEPS RELEVANT TOOLS 1.7 The next step is to capture the information from the • Project charter template previous steps into a simple document. This can help • Project initiation document template gain support from an appropriate sponsor and initiate • Improvement Leaders’ Guide – Delivering the project to start to use resources. Improvement: Making it happen Depending on the complexity of the project, this • Steps to Success – Primary Care document can take different forms. For example, you may use a project charter. More technical and complex projects may use a project initiation document. For this guide we will use the project charter as the example that we follow. It is recommended that the project charter holds all of the key information on a single A3/A4 sheet. At this stage you may only be able to complete certain elements of the project charter, such as overall aims. You may decide to have a go at completing some other sections, but these will need to be refined in future stages as it becomes clearer what the project will actually entail. 1.8 Obtain agreement from the project sponsor that the • Gateway criteria example project can move to the next stage. In future stages, a more formal gateway process will be implemented. 10 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsStage 2: Define and scope Aim of this stage: To ensure the project starts in the right areas and to develop a project structure to provide a solid foundation. KEY STEPS RELEVANT TOOLS 2.1 Undertake root cause analysis to help identify the • Mapping the process underlying issues that are creating the current situation • Stakeholder and user involvement that is to be improved. • Identifying problems To achieve this, map the current situation and use • Cause and effect (fishbone) appropriate diagnostic tools to determine what the • Root cause analysis using five whys root causes of the situation are. You will need to involve the stakeholders who provide and use the • Using an affinity diagram services that are being improved. 2.2 Gathering patient experiences via feedback, • Patient perspectives complaints, PALS issues, serious incidents and patient • Staff perceptions and staff satisfaction surveys are all excellent sources to help identify underlying causes. 2.3 Once the true underlying issues have been defined, • Scope your project you can establish more detailed objectives that need to be achieved. This can help determine what is in scope and ensure that the project focuses on what have been deemed the most important things to tackle. All other issues are out of scope. In the work area you may outline the aims and objectives of the project that have now been determined on display boards. This can help engage everyone with what the improvement project is trying to achieve. Tools in blue – in this guide (see A-Z index at back of handbook) Tools in red – in the online project management guide at www.institute.nhs.uk/qualitytools (under ‘P’ in A-Z) Tools in black – accessible via www.institute.nhs.uk and using the search facility on the homepage The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 11 www.institute.nhs.uk/qualitytoolsKEY STEPS RELEVANT TOOLS 2.4 Identify key individuals who are critical to achieving • Stakeholder and user involvement – the aims and objectives defined. This can help an overview obtain the required buy-in for project success. Again • Stakeholder analysis stakeholder analysis can help determine who these key • Communications matrix individuals are. Obtain agreement from a small number of these key individuals to act as a project board for the progress of the work. This board should include the project sponsor and the project manager. Stakeholder analysis has the added benefit of displaying those individuals who will need to have a level of communication regarding the proposed change and at what detail. If there are many people to communicate with, you need to develop a simple plan of how and when you will update them. 2.5 At this stage you may want to consider the stakeholders • Resistance to change – understanding it who may challenge the change you propose. • Commitment, enrolment and compliance It is important to remember that often a challenge to • Force field analysis change can be positive. You should be considerate • Bullet proofing of potential reactions to the change that the • Listening – importance of this skill improvement work may lead to. Use tools and techniques to help reduce the risk of this impacting negatively on the project. 2.6 For small and simple projects you may simply pull • Improvement Leaders’ Guide – Delivering together individuals with the skills you require and Improvement: Making it Happen decide among yourselves progression through • Steps to Success – Primary Care the stages. For larger projects, you may need a more extensive project structure. This would include an identified project team who are going to do the work. The structure would also include a separate project board who would sign off progression from stage to stage. Membership of this board should be small in number and include the project sponsor. 12 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsKEY STEPS RELEVANT TOOLS 2.7 Establish a way of identifying all the issues and • Risk log template potential stumbling blocks (risks) that may occur. • Issue log template Develop risk and issue logs to record these. • Lessons learned log template Brainstorming is excellent for identifying potential risks. • Brainstorming A ‘lessons learned’ log should also be created. The logs • Sustainability Model and Guide should be updated throughout the life of the project. The NHS Institute’s Sustainability Model and Guide is excellent for establishing the areas that need to be strengthened (and how) in order for a project to be successfully sustained. 2.8 Update the project charter throughout this stage with • Project charter template new and updated information. Only key issues and risks should be reflected in the single A3/A4 sheet that you are using for the project charter. The information in the logs is mainly for members of the project team who require greater detail. 2.9 It is important at the end of this stage that gateway • Gateway review criteria are established for the remaining stages. The gateway criteria will help to ensure that the project only moves to each stage if certain criteria are met. This avoids projects carrying on unnecessarily and wasting resources. Ensure the criteria for this stage are actually met as well. Tools in blue – in this guide (see A-Z index at back of handbook) Tools in red – in the online project management guide at www.institute.nhs.uk/qualitytools (under ‘P’ in A-Z) Tools in black – accessible via www.institute.nhs.uk and using the search facility on the homepage The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 13 www.institute.nhs.uk/qualitytoolsStage 3: Measure and understand Aim of this stage: To measure the current situation and understand the level of change required in these measures to achieve the defined aims and objectives. KEY STEPS RELEVANT TOOLS 3.1 Having established the aims and objectives of the • Measurement for improvement project and the underlying issues that need to be • Good Indicators Guide addressed, it is important that baseline measures are • Measures record sheet established for these. Using these measures as indicators is the only way of tracking whether the project is making progress. With an indication of where you are currently and where you need to get to, you can understand and determine how far the baseline measures need to move to achieve the desired aims and objectives. 3.2 If the project is large and complex and there are many • Pareto measures to consider, you may focus on those that will have the biggest impact. Using the Pareto principle is an effective way of prioritising your areas for improvement. 3.3 Use tools and techniques such as Statistical Process • Statistical Process Control (SPC) Control to analyse the data that you have collected for the indicators defined. It is important that measurements for these indicators are recorded and analysed throughout the project and beyond to ensure that changes being implemented are having a positive effect. 3.4 Update risk log, issues log, lessons learned log, project • Project charter template charter etc. throughout this stage with new and updated information. Only the key measures should be reflected in the single A3/A4 sheet that you are using for the project charter. The other measures are recorded for the project team to use in their analysis. 3.5 With the help of the project board, confirm that the • Gateway review gateway criteria for this stage have been met to allow project to move forward to next stage. 14 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsStage 4: Design and plan Aim of this stage: To design and plan the activities required to achieve the objectives that have been established. KEY STEPS RELEVANT TOOLS 4.1 Having established start and end points of the project, • Brainstorming it is a good idea to break this down into tasks that are ® • Six Thinking Hats clearly identifiable. • Using an affinity diagram The use of creative thinking at this stage may help to • Thinking differently discover innovative ways of delivering these tasks and • Making a bigger difference making the design or redesign improvements that are required. • Commissioning to make a bigger difference • Action planning For each task, produce a list of all the activities required to deliver it. This is often called an action plan. 4.2 Having produced an action plan, the next stage is to • Responsibility charting put some target dates against these actions and decide • Master schedule template who undertakes them. This provides a scheduled plan. It may be helpful to convert this into a format that all participants can easily see. This should clearly state key milestones for the project. This may be done in a Word document or, if you prefer, the plan can be captured in an electronic format - for example, in project management software. Using software like this may make the plan appear complicated so make sure you have a simple visual version for those who do not need to see the detail. You may be able to fit a copy of this simple version in the single sheet project charter. Share this scheduled plan with the individuals involved in the project on a regular basis to ensure the project stays on track. 4.3 Update risk log, issues log, lessons learned log, project • Project charter template charter etc. throughout this stage with new and updated information. 4.4 With the help of your project board, confirm that the • Gateway review gateway criteria for this stage have been met to allow project to move forward to next stage. Tools in blue – in this guide (see A-Z index at back of handbook) Tools in red – in the online project management guide at www.institute.nhs.uk/qualitytools (under ‘P’ in A-Z) Tools in black – accessible via www.institute.nhs.uk and using the search facility on the homepage The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 15 www.institute.nhs.uk/qualitytoolsStage 5: Pilot and implement Aim of this stage: To test out proposed changes via pilots before the changes are fully implemented. KEY STEPS RELEVANT TOOLS 5.1 You may want to test the robustness of the changes • Bullet proofing you propose by opening them up to challenge by • Building trust relevant stakeholders before they are implemented. • Role redesign This can help to decrease the likelihood of issues occurring when you move into implementation. It is useful to build rapport and trust with those affected by the change to help the implementation go smoothly. 5.2 Once you implement the early steps, make sure you • Plan, do, study, act (PDSA) test them to ensure they are doing what they should do. This process can be done in continuous cycles (PDSA – plan, do, study, act) until the whole change is implemented. Doing implementation in the form of pilots can help this approach. 16 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsKEY STEPS RELEVANT TOOLS 5.3 When moving into the stage of full implementation, • Issue log template ensure all testing has been successfully carried out. Record any observed issues in the issues log. If results are positive, the project can continue in the same way. If results are not positive, however, consult the project board or sponsor about potential corrective action. This is an iterative process that should continue until full implementation has been achieved. An example of some popular areas that are tackled by improvement projects are: - Flow - Demand and capacity - Managing bottlenecks - Reducing variation - Lean - Care pathways - Day surgery - Reducing cancelled operations - Did not attends - DNAs - Waiting list validation - Discharge planning - Length of stay 5.4 Review the gateway criteria for this stage and ensure • Project charter template all aspects are complete before moving to the next • Gateway review stage. Remember to update the project plans, logs and project charter during this stage. Tools in blue – in this guide (see A-Z index at back of handbook) Tools in red – in the online project management guide at www.institute.nhs.uk/qualitytools (under ‘P’ in A-Z) Tools in black – accessible via www.institute.nhs.uk and using the search facility on the homepage The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 17 www.institute.nhs.uk/qualitytoolsStage 6: Sustain and share Aim of this stage: To ensure that changes which have been implemented are sustained and are shared to aid learning. KEY STEPS RELEVANT TOOLS 6.1 Once the change is fully implemented, monitor it to • Sustaining momentum ensure the original aims and benefits are continuing • Reviving a stalled effort to be realised - with new ways of working continuing • Human dimensions of change rather than the old ways being reverted back to. 6.2 Produce a brief highlight report for those involved. If • Highlight report template you have a project team, you may do this at agreed regular intervals. This is really useful in keeping the project team updated on progress. 6.3 To help the sustainability of the project, redo the • Sustainability Model and Guide Sustainability Model and Guide exercise. 6.4 Once the project is complete, share the learning - both • Human dimensions of change good and bad - with colleagues and other departments. This helps the organisation make the most out of learning from the experience of completed projects. 6.5 A key element of this step is to carry out a post project • Lessons learned log template review to ascertain what went well and to celebrate achievements. At the same time, objectively analyse the things that did not go well without apportioning individual blame. All of this learning should be reflected in the lessons learned log to aid future projects. 6.6 Review the gateway criteria established for this stage • Project charter template and ensure all aspects are complete before closing the • Gateway review project. Remember to update the project logs, project plans and project charter during the stage. Tools in blue – in this guide (see A-Z index at back of handbook) Tools in red – in the online project management guide at www.institute.nhs.uk/qualitytools (under ‘P’ in A-Z) Tools in black – accessible via www.institute.nhs.uk and using the search facility on the homepage 18 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools oolsSection Two Project management 1 Identifying problems 2 Stakeholder and user involvement 3 Mapping the process 4 Measurement for improvement 5 Demand and capacity management 6 Thinking creatively 7 Human dimensions of change 8 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 19 www.institute.nhs.uk/qualitytoolsProject management Project management – an overview 1 Purpose Project management and associated tools should be uppermost in your thoughts from the start to the end of a project. Regardless of the project management approach you use, it can be enhanced with the use of the tools in this section. When to use it The service improvement project guide in section one of this handbook provides an indication of the various stages these tools would be relevant for. The stages are as follows: 1. Start out 4. Design and plan 2. Define and scope 5. Pilot and implement 3. Measure and understand 6. Sustain and share How to use it The tools can supplement your existing project approach or be used with the project approach detailed in section one of this handbook. The specific details for each of the tools and techniques can be found in the relevant sub-sections: 1.1 Scope your project 1.5 Responsibility charting 1.2 Four columns: link your project 1.6 Sustaining momentum to the organisation’s aims 1.3 Benefits realisation 1.7 Reviving a stalled effort 1.4 Action planning 1.8 Learning from change Additional Resources Websites www.institute.nhs.uk – for the Thinking Differently Resource Guide and Commissioning to Make a Bigger Difference www.ogc.gov.uk – select the PRINCE2 section 20 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools1.1 Scope your project 1 Purpose This is a simple way for your team to define the scope of a project by identifying what will be included and what will be excluded. It helps to ensure that the entire team is focused in the same direction and understands the scope of the project. When to use it If an improvement is to succeed, everybody involved needs to understand the agreed scope of the project so they can focus specifically on the task in hand. How to use it Start by drawing up a table like the one in the examples section. • The project lead describes their view of the project. • For each of the categories (What? When? Where? How?) the team discusses and records the agreed definitions of what is within and what is out of scope. • Record any actions required in the final column. • Seek agreement of the scope with the project sponsor and stakeholders. Examples Parents of children with glue ear have commented that there is very little information about the condition and associated procedures. Staff in the ENT department came up with the following table so everyone was clear about what was in and what was out of the scope. The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 21 www.institute.nhs.uk/qualitytoolsIS IN SCOPE IS NOT IN SCOPE ACTION WHAT Information for parents of Information for Hold a review after we children with glue ear. professionals. Not complete this project to find information for the child. out if we need to develop information for the child. Detailed description of the surgical treatments for glue Hold a review after we ear complete this project. e.g. myringotomy and grommet insertion. Information about other conditions or procedures for parents. Not in other forms of communication (additional languages or Braille). A follow on project will look at this. WHERE This hospital, Other hospitals in Check for good material this department. the region. elsewhere. WHEN Use information and Sources older than 2004. Check what information is diagrams from 2004 available. onwards. WHO Paediatric ENT staff, All ENT staff. Recruit to seek their views communication staff, some about the content of parents of children with information. glue ear. SCOPE Information for parents of children with glue ear. No diversions. Your team may find it useful to refer to the results throughout the project so that extra activities outside the scope are not picked up (scope creep). This enables you to focus limited resources specifically on the current problem. What next? Revisit the service improvement project guide to understand what is involved after scoping your project. 22 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools1.2 Four columns: link your project to the organisation’s aims 1 Purpose Linking your project aims to your organisation’s aims is a key strategy for ensuring a successful project. Using the four column matrix can help you do this. It will allow you to multiply the benefits from a single project right across the hospital. As this approach has a strong focus on numbers, you may need some input from your information team and accounts department. Evidence suggests that senior leadership and clinical buy-in is instrumental in health service improvement. The ability to sell what you are doing and describe potential outcomes – for example improved clinical outcomes – will help achieve this. When to use it Four columns should be used at the start of your project once you have established your aims. How to use it The table below indicates how to use a four column matrix to help share your project aims. The established Project measures Link project to the Link measures to project aims bigger picture organisational aims (How you know your project is progressing (How you know your (How the project towards your aims) project is progressing contributes to towards your aims) improving patient care, resource savings etc.) “We guarantee that Pathology turnaround 70% of clinical How do we measure the results for all time decisions depend the impact this project specimens will be upon pathology. will have on speeding (e.g. time in minutes available within...” up clinical decision from receipt of making and help to specimen to results achieve the 18 week being available). pathway? Additional resources Websites www.institute.nhs.uk – for the Improvement Leaders’ Guide: Measurement for Improvement The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools 23 www.institute.nhs.uk/qualitytools1.3 Benefits realisation 1 Purpose Having a sound benefits realisation plan in place will increase the delivery of intended benefits from your project and ensure that any allocated resources are fully utilised. It will also help you to identify with colleagues how your individual service improvement project is contributing to the overall service improvement programme. By focusing on benefits realisation planning, you can track whether intended benefits have been realised and sustained after the project has ended. Furthermore, it helps to make clear who is responsible for the delivery of these benefits. When to use it A benefits realisation plan should be a fundamental part of any improvement project, running from beginning to end - and beyond. How to use it The first step is to ensure that all the foundations for benefits realisation are in place. • Identify and record the desired benefits; you may wish to discuss this with stakeholders. • Ascertain the stakeholders who will be affected by each identified benefit. • Identify the outcomes and enablers required for each benefit realisation. • Determine how you will measure whether a particular benefit has been realised. Ideally, try taking a baseline measure before the project starts and use this as a benchmark to determine realisation of the anticipated benefit. • Allocate responsibility for delivery of these benefits. • Prioritise the benefits so that the most important always has the most focus. This ensures that the project makes the greatest impact. • Identify dates for expected delivery of the benefits. Creating a benefits realisation plan Record the information that you have gathered from carrying out the initial steps in a table and store this plan with the other key project management work. 24 The Handbook of Quality and Service Impr The Handbook of Quality and Service Improvement T ovement Tools ools

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