You may have a great improvement idea, but remember that change usually affects lots of people. The first key step in any improvement work is to get the right people on board with your improvement work, to build a strong foundation for sustainable change.

Why do we need to start with co-production?

• Those closest to or most affected by a problem are best placed to identify workable solutions
• Involving people in the process helps them to feel engaged and create ownership of the changes
• Partnering with service users leads to the changes that are important to them
• A diverse range of people, professions and personality types increases the range of experience within a team
• Getting a team around a problem means the vision and strategy for change is owned by the group

Where should you start? Ask yourself:

• Who uses your service?
• Who works in the system where the problem occurs?
• Who you need to help change the system?
• Who is affected by the problem?
• What matters most to them?

Check out the following tools to help you:

• Co-production with service users
• Stakeholder mapping
• Psychological Safety

“Each system is perfectly designed to give you exactly what you are getting today”  - W. Edwards Deming

To make effective and sustainable improvements, first we need to identify the root causes of our problem. By increasing our understand of the system in which a problem occurs, we can make choices about how best to intervene and effect positive change.

Why do we need to spend time identify our problem and understanding our system?

• Understanding the problem helps design solutions that address the cause and not the symptoms
• The Healthcare system is built of many complex, interrelated processes and systems - changes in one area may impact another 
• It is often the underlying structures, values or beliefs embedded within a system that allow a problem to perpetuate 
• Understanding systems mean we can understand the identify possible barriers to change or possible unintended consequences elsewhere in the system
• We ensure we involve key stakeholders across different parts of the system

 Start improvement work by exploring:

• What is the root cause of the problem we are trying to improve?
• What factors will be a barrier to improvement?
• Do you have a good understanding of the current state?
• Has there been any work done before?
• What does the data tell you - are there any themes or trends?
• What does service user feedback tell you - do you have a focus group?
• What do staff think - do you need to survey or interview?

These tools can help guide you through this stage: 

• Process Mapping
• Observation
• Five Why Analysis
• Fish Bone Diagrams
• Measurement For Improvement

Once you have the right people on board with your project and have spent time identifying the problem and understanding the system, you will need to develop your strategy for change. 

The Model for Improvement helps structure improvement work by asking three simple questions to help you:

• Set a SMART aim statement
• Establish a measurement plan
• Identify change ideas to test

Agreeing these collectively ensures the vision and strategy for change is owned by the group. 

How to get started:

• Setting a SMART aim - can help you agree a clear aim statement for your project
• Driver Diagram - a useful tool to visually represent a strategy for change 
• Mind Mapping - to help brainstorm changes as a group  
• Benefits matrix - can help you focus on which change ideas to tackle first
• Measurement plan template - can help you identify and define your project measurement plan

Now you've set out your theory of change and generated your change ideas, it's time to start testing! PDSA cycles are used to test changes iteratively by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

Why do we use PDSA?

• Rapid cycle testing gives those involved the opportunity to see if the change will succeed on a small scale first, reducing the risk of implementing large scale changes that may not work or negatively impact service users, staff or the wider system.
• By making a prediction about the idea we are testing and using data and feedback to study the results, we can quickly generate knowledge about what works and doesn't work, allowing us to adapt our change ideas until they are fit for purpose.
• Testing ideas in real world settings and listening to feedback helps staff feel ownership over the changes, and ensures they work for the people closest to the problem

PDSA testing ramps

If you are seeing the improvements you hoped for from PDSA testing on a small scale, it's time to scale up and see if you see the same effects at a wider level.

For example, this might be moving from testing an intervention on one patient on one day to all patients that day, eventually spreading improvements across a whole team, service, or even wider still.

You may even have several PDSA ramps running at the same time while you test different change ideas. However, remember that if you have many different PDSA cycles running concurrently, you may not know which intervention results in the improvement.

How to get started with PDSA testing

• Download our editable PDSA cycle template to help you plan your PDSA
• Use the steps in the image above to plan and study your ideas

Once you have refined your ideas through PDSA testing and your measures are showing improvements, it's time to think about how to embed these into business-as-usual processes. 

We often find when the focus is not on a new idea, things can easily slip back into the old ways of working. It is important to properly plan how you will build changes into mainstream ways of working so that gains are sustained.

How to implement and sustain your changes

Consider these areas to help integrate and sustain new ways of working within the system and infrastructure:

• Has it been communicated widely across the team, service or trust?
• Are senior clinical and operational leaders aware of and promoting the change?
• Is it embedded within training and induction?
• Is it embedded within policy and procedure?
• Are systems in place to monitor whether improvements are sustained?

The psychology of change 

Changing behaviours is key to embedding change - it is often said change is 80% of change is human and just 20% technical. 

• Check out our Psychology of change page to find out more

Scale up and spread

Once your changes are sustained and new ways of working have been integrated into business as usual ways of working, it may be time to think about whether these changes can be scaled up to other similar settings, or spread as best practice across a whole system. 

Further reading around spreading improvements:

• Spreading Changes | IHI - Institute for Healthcare Improvement
• The spread challenge - The Health Foundation
• Guide to spread and sustainability (healthcareimprovementscotland.org)