Event blog: IS4L Workshop 2


IS4 is Haelo’s flagship improvement programme, developed and delivered in partnership with the Manchester Academic Health Science Centre (MAHSC), NHS Quest and Manchester Cancer, a bespoke team based training programme in improvement science that includes a blend of web-based learning, improvement coaching and site visits.

Follow the event blog for the latest updates and access valuable resources. To join the conversation on twitter use #IS4L

The focus of workshop 2 is innovation and measurement. Teams attended workshop 1 on 3rd-5th May 2015, where action period one followed. IS4 faculty member Judith Strobl opens the workshop.


We kick off the workshop with Team Presentations, where teams review the progress to date including project aim and overview, driver diagram, data collection and PDSA cycles. The presentations give teams the opportunity to summarise their monthly reports submitted since June and receive feedback from faculty and attendees.

First up, Marc Atkin from Royal United Hospitals Bath NHS Foundation Trust presents for the team Isaid who aim to reduce the insulin administration errors by 2017.

IS4 L Workshop 2

“Our original scope was huge. We have since cut this down to more achievable objectives but as a small team it is still a challenge whilst trying to maintain momentum and get the most out of the limited time we have together.”

Katharine Goldthorpe, IS4 Faculty member from Haelo and the lead of NHS Quest, congratulates the team who she personally visited as they have overcome great barriers to make such progress.

Fellow teams in the room give their feedback both verbally and via survey monkey to offer advice and share solutions.

Maxine suggests the room consider adding students and trainees to their workforce, as an invaluable resource. Haelo clinical fellows in the room support the involvement of juniors in their teams to create a lasting positive impact for both the team and individual.


From Salford Royal Foundation Trust, a MAHSC domain, Arun Abraham presents on behalf of the A-Team. Their aim is to ensure 85% of outpatients under the care of SRFT Intestinal failure rate their outpatient experience as positive by February 2017.

Always impressed with digital here at Haelo, the team has a Whatsapp group in an attempt to combat the issue of momentum!

Following short break, Maxine takes to the stage and encourages the teams to take the valuable feedback away from the session today.


We begin with a refresh of the System of Profound Knowledge, which links through all our learning throughout IS4, first developed by W. Edwards Deming as the basis for our scientific learning. With its roots in the 1930’s at the Bell laboratories in the USA this ‘system’ recognises four essential ingredients to improvement.

To read more about Deming and to refresh your knowledge, we strongly recommend you take a look at Maxine’s blog: ‘What is improvement science anyway?’

“The system of profound knowledge is dynamic. The experienced improver uses all four elements in unison to navigate towards a solution. I often refer to the four ‘elements’ as the improvers ‘toolkit’.”

So, who’s heard of Maslow? Maslow’s Hierarchy of Needs is the cornerstone of all of Deming’s works about incentives, and why they may or may not work for individuals and teams. There’s also a whole body of work about punishment and reward.

But today, our focus is innovation. Take a smart phone, or the internet, these are recent innovations that we had no idea how they would grow and globalise. Innovation is slow until it’s fast. You need to find one that’s fast.


When we talk about innovation, we’re talking about new ideas:

If we’re really busy just ‘doing’ how can we innovate, how can be more creative? In order to do better, more valuable and more meaningful work, we have to somehow pause and connect. And that’s essentially what today is all about?

When you’re doing your work, think, is this an innovation opportunity? Discussion begins abound the innovation concept, the ten faces: Learning persona, Organising persona and Building persona.


Kurt Bramfitt, Senior Improvement Advisor at Haelo and IS4 Faculty member, takes to the stage for the next session, Creativity Methods.

Three models of thinking present when changes are developed:

  1. Creative thinking – new ideas and possibilities
  2. Logistical positive thinking – how will we make the idea work
  3. Logical negative thinking – finding problems in the idea

Kurt queries the team who have come against ‘writers block’ with tests of change and innovative ideas.

IS4 L Workshop 2


Following lunch, David Warbuton from In touch with Health and sponsor for Haelo Hosts 2016, is our guest speaker today. Headquartered in Cirencester, UK, Intouch with Health is dedicated to delivering innovative patient flow management solutions for healthcare settings that work to help our customers make significant cost savings by increasing organisational efficiency and delivering an improved patient experience in a number of large trusts across the country.

In touch are an example of an innovative organisation who are using technology to improve healthcare systems.


Back to the team presentations. Stella Tims from Homerton University Hospitals, from team Hackney in ITT presents the aim: Increase the number of service users receiving multidisciplinary care within 72 hours of initial assessment by 50% by March 2017.


Next steps for the team are to review PDSAs currently being tested and organise time for NHS Quest support.

On reflection, Kurt highlights the need for the baseline data and query whether it has taken a back seat in other teams. Day 2 of the workshop will cover measurement in depth. Maxine praises their driver diagram and suggests linking measures in to create a ‘plan on a page’.

Next up, Wendy Makin from the DreaMs team, Manchester Cancer Vanguard, outlines their aim: 95% of patients (in the pilot disease groups) will feel they have had a conversation that addresses what is important to them when deciding on treatment. (Goals of care).


Fantastic insight into the data the team are working with, from this the team hope to develop measurement strategies.’Powerful’ qualitative data from a patient questionnaire that underlines the importance of this particular project.


Maxine is back to the front and asks the room who feels like they are doing ‘large scale change’? And what do we mean?

Task: Maxine introduces a large scale change programme that she has led and tasks the team to take the paper away, review as if you were as a critic and come back to the room to debrief: Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach.

Silver Strength are the final team to present today from Wrightington, Wigan and Leigh NHS Foundation Trust. Jean Ramsdale outlines the aim as: To undertake the CGA assessment on appropriate patients over75 within 24 hours of admission.


Judith delivers the take home messages from day one:

Remember: Deming’s Lens of Profound of Knowledge

Team presentations
– Most important, learn from each other
– Mine your data – just enough is good enough
– Match measurement strategy to driver diagram
– Enrol trainees, students

Innovation and creative thinking
– “Chance favours the connected mind” – pause and connect
– Where are your “Bright spots”

Large scale change
– “Must do – can do – want to”
– How do we get buy in / burning platform = common problem
– Keep it simple and clear and reiterate
– Importance of data
– Build improvement capability in your system
– Intrinsic motivation / rewards
– How do we learn to change complex adaptive systems


We’ll be back tomorrow for day 2!

Welcome back to Day 2 of Workshop 2 of the Improvement Science for Leaders programme.
Senior Improvement Advisor, Kurt Bramfitt opens Day 2 of IS4L Workshop 2 with a recap of yesterdays learning.

Kurt reviews Psychology and Systems lens of Demings System of Profound Knowledge and states that the main focus of today is the Variation lens. Kurt then introduces the first of the team presentation.

The first IS4L team are Broughton Believers from Salford Clinical Commissioning Group, led by Tina Dixon, Senior Manager Innovation and Improvement with their aim to improve flu vaccination uptake across the groups defined in the driver diagram by 3035 vaccinations from 2015-2016 baseline by end of March 2017.

Tina describes having reviewed baseline data from last year and compared geographically with close by neighbourhoods. Tina describes how there were 30,000 extra deaths last year linked to respiratory disease and that this data has encouraged participation from Broughton GP Practices.

Broughton Believers would like to see engagement and uptake increase. The team would also like to introduce standardise operating procedures and increased use of QI methodology.


Tina states that Broughton Believers biggest challenge has been engagement. ‘Engagement has got to run throughout all practices.’ Tina praises Haelo’s Project Manager Tazeem Shah who ‘has done a great job in building relationships and maintaining them.’

The team believe that data is going to be key in achieving their aim. Engagement through communications, focus groups and utilising Peoples Champions are also important to achieving the aim.

Dr Judith Strobl, IS4 Expert Faculty and Special Advisor at Haelo opens up the presentation for question and comments from other teams.


Judith congratulates the mini collaborative (9 practices) that Broughton Believers is undertaking and praises the team for capturing knowledge from across Manchester to inform collaborative. Other comments include; peer to peer learning advised and praise for Salford CCGs innovative flu film.

Prof Mohammed Mohammed, IS4 Expert Faculty, Professor of Healthcare Quality and Effectiveness, Deputy Director of Bradford Institute of Health Research, University of Bradford now takes to the stage to talk Understanding Variation.

“When your views on the world and your intellect are being challenged and you begin to feel uncomfortable because of a contradiction you’ve detected that is threatening your current model of the world…pay attention. You are about to learn something.”

William H. Drury, Jr. (1921-1992);
Professor, Author

Teams break away to discuss Colorectal Cancer data to see if teams can identify any trends or variation – what action would you take from looking at the data?


Professor Mohammed now opens up an exercise using Shewhart’s ConceptsTheory of Variation – quality improvement and the concept of a state of statistical control by carefully designed experiments – using a’s.


‘In terms of process the production of the a’s are the same.’ There is a need to recognise that the a’s all have a common cause and the action = process.



Professor Mohammed applies Shewhart’s theory to healthcare. He describes facing opposition for this application as other academics argued that the theory needed simplifying before being applied, Prof Mohammed discusses the reliability of league tables using IVF Treatment statistics. Concluding that ranking is not reliable.

We are back from lunch with the Screenology team presentation.


Leading the presentation is Graham Wardman, Screening and Immunisation Lead for Greater Manchester. Screenology aims is to increase uptake of the screening programmes by 10% by 2021, by focusing on improving the access to screening services across GM, specifically citing Breast Cancer screening in Wigan.

The team ‘already know the barriers’ which include organisational, wrong address, deceased. The team will address communication issues, getting peer support, drive up peoples champions.

There are also aspects of the system that need addressing. Equity needs to improve to see where patients are accessing services. The team aims to work with programme and primary care to discover what they do at the time of the screening. Screenology would like to ‘get improvement and improvement science into screening.’

Judith again facilitates questions and comments from the wider group. Screenology recognise the real barriers when dealing with diverse groups.


Next up is Query Cancer team, Maryna Lewinski, Radiology Lead, leads this presentation. Query Cancer aims to reduce current wait times for patient with suspected cancer from 14 days to 7 days for initial assessment and from 31 days to 14 days diagnosis, ideally performing diagnostics and discharge in a one stop scenario. The team have been implementing process mapping and PDSA however the team were not aware that they were implementing the cycles but recognise that they have after other team presentations.

The team have defined baseline measures, been organising patient engagement events and feel ‘encouraged by buy in from practices and commissioners.’ Faced challenges which range from team organisation to realigning their aim after learning and development.

Professor Mohammed now leads the Red Bead experiment. Dr. Deming used the Red Bead Experiment to clearly and dramatically illustrate several points about poor management practices. This includes the fallacy of rating people and ranking them in order of performance for next year, based on previous performance. The Red Bead Experiment uses statistical theory to show that even though a “willing worker” wants to do a good job, their success is directly tied to and limited by the nature of the system they are working within. Real and sustainable improvement on the part of the willing worker is achieved only when management is able to improve the system.

Professor Mohammed asks if his commentary throughout the experiment were valid? Delegates respond that it seems bias. Professor Mohammed then asks group whether this resonates with them with real life examples.

We’ve had a short refreshment break and now Professor Mohammed is guiding the teams through run charts.


What kind of measure? Process measures: how is this process performing. Data from one classroom. Could be nested within a bigger project.
Improvement or not?
– Distinguishing signal from noise. Things aren’t standing still when we are mucking around. Expect variation.
– Lasting effect—reliability
– Way of looking at data.


Distinguishing Characteristics: At least 10 points, median line.

  • Just one tool. Easily accessible tool.
  • Main job is to do just what you did… but to make visual analysis easier
  • Particularly good for process measures—data that you can track over time.
    Importance of looking at data over time!

Kurt now takes to the stage recapping Measurement Strategy from Workshop 1 with the teams new found knowledge of variation.

Kurt discusses the three types of measures using the surgical safety example below:



A good measurement strategy provides you with the ability to track and monitor the progress of your improvement efforts against your theory for change. Your strategy needs to be…

  • Linked directly to your driver diagram,
  • Include relevant outcome, process and balancing measures,
  • Articulate where and how often data will be collected,
  • Provide operational definitions,
  • Intended display of the data (chart type)

And we are back for Day 3 of Workshop 2 at #IS4L.

Our Senior Improvement Advisor, Kurt Bramfitt, welcomes delegates back and opens with feedback from the previous day. Teams describe an ‘appreciation for variation’ and that the day was ‘well paced’ and the flow chart work was ‘interesting and extremely helpful.’

We now welcome the first presenter of the day, David Shackley, Medical Director, Manchester Cancer who has undertaken his own Quality Improvement Journey. The aim of his presentation is to emphasis 5 key learning points – The Big 5!

    1. Everyone is an Improver
    2. You shouldn’t wait until everyone agrees to change  – spend energy on early adopters
    3. Show them the DATA!
    4. The gold medal comes from focussing on the aim, not the process
    5. Energy is finite





Kurt thanks David Shackley and now introduces Nick John, Lead Analyst at Haelo, who starts by describing the theory behind statistics. First Nick talks about the difference between data sets; attribute data – data that you can count, continuous data – data you can measure. Nick now leads a quiz based on the data theory test flow chart.



The teams are now working in their groups to identify and become more familiar with charts and data. Kurt is leading the exercise into identification of data and charts using clinical examples.

We’re back from the break and on to the next of our team presentations. Anne Barton leads the Imp4act team presentation with the aim to reduce self-reported non-adherence to Methotrexate as the exemplar drug by 50% by Dec 2017.

The team hope to ’embed this learning into routine practice rather than being just a project.’
Dr Judith Strobl, IS4 Expert Faculty and Special Advisor to Haelo begins feedback for the Imp4act team saying she ‘loves the patient involvement’ and level of clarity with driver diagram and measures.

Following that we have another team presentation, Gateway C, a part of cancer vanguard suite of interventions. Cathy Heaven and Ewan Jones lead their presentation with the aim of increasing the proportion of referrals for suspected cancer made by 6 pilot GP practices through the two week wait pathway by May 2017.


The team have been encouraged to refine their aim but have not yet got the baseline data. Working with ‘motivated and on board’ to build a ‘mega PDSA.’

Kurt now returns to discuss sampling and stratification exploring sampling strategies as the teams break to discuss their improvement projects including sample size.

Stratification is now being discussed including stratification with Shewhart I-charts and rational subgrouping.
‘Stratification is the separation and classification of data according to the selected variables or factors.’
Health Care Data Guide

We’re back after lunch with another team presentation. Music, part of the cancer vanguard, led by Roger Prudham aim to have 95% of patients discussed at MDT meetings will have an appropriate decision made about their care by May 2017. Roger admits that their aim needs refining. Judith now leads the feedback session; comments include capturing culture change.


Next up we have IMPS team presentation led by Chris Navin whose aim is to improve experience of antenatal care and outcomes of pregnancy for parents who have experienced a stillbirth in a previous pregnancy by May 2017.


Next up is our very own Evaluation Programme Manager Nadine Payne who is leading a session on Knowledge Management.

Nadine now talks the teams through Knowledge Management specifically the recording of data in reference to capturing knowledge and its management as well as PDSA cycles. Teams described how ‘useful’ and ‘fascinating’ the session was with one team requesting that the session be included earlier in the IS4 journey.

We are now having the final break and after that we have Haelo Chief Executive Maxine Power who finishes Day 3 of Workshop 2 with Overcoming Challenges – Improvement through Integration Research and Improvement Methods using Stroke 90-10 Case Study.


Maxine now divides the session up into two parts; Theory and Practice.
Theory included qualitative research; observation, focus groups, questionnaires and surveys. The model of improvement was then applied.

Maxine now leads a team exercise, dividing the team into four groups and asking the delegates to apply the model of improvement to the Stroke 90-10 Case Study. Fantastic reaction to Maxine’s Case Study! Room is energised!

Judith closes the third day of Workshop 2 by highlighting key learnings to take home from today and the past three days.
As mentioned by Maxine, the Haelo Science of Improvement masterclass with Senior Improvement Advisor Kurt Bramfitt and IHI Lloyd Provost is a perfect complimentary one day course to IS4. Find out more here.

See you online with the next WebEx on the 3rd November and at Learning Session 3 in February!

IS4 You Newsletters: July 2016 and August 2016
Maxine Power: What is improvement science anyway?
IS4L Workshop 2 Presentations: Day One Presentations – Day Two Presentations – Day Three Presentation 3.
Professor Mohammed Mohammed paper: Bristol, Shipman, and clinical governance: Shewhart’s forgotten lessons
Professor Mohammed Mohammed Slides – Day 2

What is innovation?
Stephen Johnson: Video and book (Johnson, 2011)
10 Faces of Innovation (book) (Kelley & Littman, 2005)
UMass Memorial (internet reference)– link to George Brenckle’s story and others.
The Influencer: The Power to Change (book)
Dan & Chuck Heath : Switch (Heath & Heath, 2011) (video)
Ideo: The Deep Dive (shopping trolley design video)
Clayton Christensen (Christensen, 1997): Innovator’s Dilemma – Disruptive Innovation (video).

Creativity methods
Tony Buzan: How to improve your creative thinking video.
SCAMPER (Eberle, 1971) – video.
Giovanni Corazza Creative Thinking TED Talk – video.

Diffusion of innovation
IHI White Paper on Spread (Massoud et al., 2006)
Kotter (1996)
Everett Rogers (2003)
Patient Safety Briefing

Large-scale change
(Power et al., 2016) available online.

(Provost & Murray, 2012)
(Deming, 2000 a)
(Deming, 2000 b)
(Mohammed et al, 2001)
(Perla et al, 2010)


Christensen, C. (1997). The Innovator’s Dilemma: When New Technologies Cause Great Firms to Fail. Boston: Harvard Business Review Press.
Deming, W. Edwards (2000) Out of the Crisis. Boston: MIT Press
Deming, W. Edwards (2000) The New Economics for Industry, Government, Education, Second Edition. Boston: MIT Press
Eberle, R. (1971). Scamper Games for Imagination Development: Dok Pub.
Grenny, J, Patterson, K, Maxfield, D, Mcmillan, R, & Switzler, A. (2013). Influencer: The New Science of Leading Change (2nd ed.): McGraw-Hill Education Europe.
Heath, C, & Heath, D. (2011). Switch: How to change things when change is hard. London: Random House Business Books.
Johnson, Steven. (2011). Where Good Ideas Come from: The Natural History of Innovation. New York: Penguin Books.
Kelley, T, & Littman, J. (2005). The Ten Faces of Innovation: IDEO’s Strategies for Defeating the Devil’s Advocate and Driving Creativity Throughout Your Organization. New York: Doubleday.
Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.
Massoud, MR, Nielsen, GA, Nolan, K, Nolan, T, Schall, MW, & Sevin, CA. (2006). A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper (available at www.ihi.org).
Mohammed A Mohammed et al (2001) Bristol, Shipman, and clinical governance: Shewhart’s forgotten lessons. The Lancet
Murray, S & Provost, L. P (2012) M20: Beyond Statistical Process Control: Advanced Charts for Healthcare. API and CT Concepts
Perla, R.J et al (2010) The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Quality Safety.
Power, M, Brewster, L , Parry, G, Brotherton, A, Minion, J, Ozieranski, P, . . . Dixon-Woods, M. (2016). Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. BMJ Open, 6, e011886. Retrieved from
Provost, L, & Murray, S. (2011). The Health Care Data Guide: Learning from Data for Improvement. San Francisco: Jossey-Bass.
Rogers, E. (2003). Diffusion of Innovation (5th ed.). New York: Free Press.


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