Health Quality Safety Commission Quality Accounts: Sector Capability Development Workshop
Welcome Sector Capability Development Programme 2012 Pw. C
Introduction to Quality Accounts Programme overview 2012 Pw. C
Introduction Over the last five years, the health environment has demanded more from its quality information and reporting. All District Health Boards must now be better equipped to deliver reporting that is: Practical Clear Reliable Strategically focused Relevant Future orientated Representative Consistent The challenge of encouraging and enabling each health and disability service provider to consistently report on their assessments of the quality and safety of healthcare services provided within their organisation should not be underestimated. The Health Quality and Safety Commission have recognised this and are providing a development programme for all DHBs to assist in the documentation and publication of a Quality Account. Pw. C 4
The Commission & Quality Accounts Shining a light Lending a hand Quality at the heart of healthcare Improvement starts with knowledge & clarity 5
Introduction to Quality Accounts Programme overview 2012 Pw. C
Two phased approach The first phase of this programme was successfully completed in June 2012 with the publication of a best practice advisory guidance manual, which provides a practical stepby-step approach to the preparation, documentation and publication of a Quality Account. The second phase of the programme has a stronger focus on knowledge transfer. Pw. C 7
Programme objectives To build the capability required to design, document and publish a Quality Account within each DHB To exchange sound, practical ideas throughout the sector on how to measure and report on quality and safety performance To provide a setting for deep discussion and shared learning among those charged the design and generation of their DHB’s Quality Account To support each DHB during the development of a Quality Account Pw. C 8
What we are trying to achieve Strategic Skills Capability Level Expert Skills Operational Skills Understanding “I understand the Quality Accounts programme will be rolled out and I am clear on what the programme is. ” “I have been briefed and trained on how to develop a Quality Account and know where to get help. ” “I am using the new ways of working, services and solution to its full capability and delivering maximum value. ” “I am further developing my health quality evaluation skills, in terms of understanding how the full capabilities of Quality Accounts can be used to best support and inform my DHB and consumer population. ” Time Pw. C 9
Who we are working with The nominated delegates for the workshops include physicians, nurses, managers, health care leaders and other health professionals that have a role in contributing to the development of their organisation’s Quality Account. Group 1: Rotorua Wed 26 th September Group 2: Auckland Thurs 27 th September Bay of Plenty Northland Group 3: Wellington Tues 2 nd October Group 4: Christchurch Thurs 4 th October Hawkes Bay Nelson Marlborough Whanganui Waikato Waitemata Mid Central Tairawhiti Canterbury Auckland Lakes Taranaki Pw. C West Coast Capital and Coast Hutt Counties Manukau Wairarapa South Canterbury Southern 10
Workshop objectives Module Know Think/ Feel Introduction The history and purpose of the New Zealand Health and Disability Sector Quality Accounts Programme “I understand the Quality Accounts programme will be rolled out and I am clear on what the programme is” Understand the benefits, specific goals and requirements of the programme Making sense of information How to choose and represent data in a transparent and effective format “I am confident in my ability to effectively choose and display my Quality Account data and commentary” Identify key clinical quality indicators and measures to document within the DHB specific Quality Account Making it happen How to lead a successful Quality Account development programme “I know how to develop a Quality Account and have clarity on how the programme will be successfully led in my DHB” Develop the DHB specific programme plan for the design, documentation and publication of a Quality Account Where to from here? The expectations from the Commission and support options available “I understand what additional support is available and how I can access it if needed” Pw. C Do Clarity on the next steps and the identification of potential future support requirements 11
Workshop contents & timeline Intro to Quality Accounts Making sense of information 08. 30 11. 00 13. 00 Registration & coffee Morning Tea Lunch Pw. C Making it happen 15. 00 Afternoon Tea 17. 00 Close 12
Learning objectives The pre-workshop survey indicated that as a sector your key learning objectives are to establish: Objective % How to develop Quality Accounts 46% What are Quality Accounts 20% A consistent approach to Quality Accounts 10% Networking opportunities with other DHBs 8% How to align with current reporting 4% How will HQSC use the Accounts? 4% Possible formats for the Account 2% How to convince others of the benefits 2% How to use the Account 2% How to involve consumers What are your top five learning objectives from this workshop today and how are you going to make the space and time to achieve them? 2% Pw. C 13
Introduction to Quality Accounts What is a Quality Account? 2012 Pw. C
Quality Accounts Overview • Quality Accounts are annual reports from health and disability service providers regarding the quality of the services provided, and how each provider is progressing in terms of continuous quality improvement, the consumer experience and health outcomes. Purpose • The primary purpose of a Quality Account is to encourage Boards and leaders of healthcare organisations to assess quality across all of the healthcare services they offer, and encourage them to engage in the wider processes of continuous quality improvement. Benefits • The publication of a Quality Account provides a mechanism through which health and disability service providers are able to share their successes, learnings and future improvements, essentially providing transparency and accountability for each provider regarding the quality of their performance. The introduction of Quality Accounts to all health and disability service providers within New Zealand marks an important step in putting quality at the heart of all healthcare activity. Pw. C 15
Definition clarity • What is your definition of quality? • What is your teams / departments / specialists / divisions and organisations definition of quality? • What is your patients/ consumers / communities definition of quality? • What definition of quality will be reported on in your quality account? “O how they cling and wrangle, some who claim For preacher and monk the honored name! For, quarreling, each to his view they cling. Such folk see only one side of a thing” Udana VI. 4 Tittha Sutta Pw. C 16
The journey so far…. August 2012 June 2012 January 2012 April 2010 Quality Accounts became a reporting requirement throughout the NHS (UK) Pw. C November 2011 The Commission started the New Zealand Health and Disability Sector Quality Accounts programme Waikato DHB published the first Quality Account in New Zealand The Commission published the New Zealand Health and Disability Sector Quality Accounts Guidance Manual Waikato DHB published their second Quality Account
National health service programme Areas of success • National programme participation • Consistent focus on the three domains of quality • Provision of a guidance manual • A balanced view of positive and negative data • Regular use of trend data Opportunities for improvement • Limited use of statistical tests • Significant variation in the measures used • Lack of context and interpretation of the data • Poor presentation of data • Limited providers were able to achieve the balance between rigour and clarity in their data reporting • Limited use of consumer feedback and participation Pw. C 18
Purpose Quality Accounts allow health and disability service providers to assess and publicly report on the quality of healthcare provided across all of the services they offer. They: What is your DHB’s purpose for designing, documenting and publishing a quality account? Provide a mechanism by which DHBs are able to transparently share their successes and future improvements; Allow boards, clinicians, managers and staff to demonstrate their commitment to continuous quality improvement, and explain their progress to the public; Provide a means by which the public is able to hold providers accountable for their overall performance. Pw. C 19
Principles The principles that should guide the development of each DHB’s Quality Account are: Accountability and Transparency Meaningful and Relevant Focused on Whole of System Outcomes Continuous Quality Improvement • Quality Accounts are intended to enhance responsibility and accountability within the system to deliver high quality health outcomes. • Accountability can only be effective if matched by transparency. Therefore, it is recommended that each Quality Account will be made publicly available so that the New Zealand public can see providers’ progress. • Each quality measure within Quality Accounts must assist in the understanding of performance within the individual provider and its services. • It is imperative that the development of Quality Accounts does not become a paper exercise with the main driver being “to simply make the numbers”; it must be to use the data to learn and improve. This means including meaningful and relevant quality measures on quality of care from a clinical perspective and also from the perspective of consumers. • All providers of health and disability services are encouraged to produce, or participate in the production, of Quality Accounts. This whole of system approach will ensure that patient accountability extends across care pathways and that the reporting is available across all sites and services within individual organisations. • The purpose of Quality Accounts will be to drive the New Zealand health system to continuously improve and strive for quality excellence, rather than simply achieving or maintaining minimum standards. Pw. C 20
The triple aim Transformation of health care delivery starts with a transformational aim and it is widely agreed that within the New Zealand health sector such a transformational aim should include a balance or optimisation of performance on three dimensions of care — which we call the ‘Triple Aim’. Improved quality, safety and experience of care Triple Aim Improved health and equity for all populations Pw. C Best value for public health system resources 21
Retrospective & future focused Retrospective • An education opportunity, ensuring a wide audience of providers can learn from instances where things went wrong and what improvement activities work well Pw. C Future focused • What has been identified as priorities for improvement over the coming financial year, and the plans to achieve and measure these priorities 22
Suggested content Opening Statements Foreword Statement of Endorsement Statement of Engagement Statement of Intent Regarding Feedback Performance Review Nationally Consistent Content Provider Determined Content Future Focus Priorities for Improvement Pw. C Capability Development 23
Tube game Objective • Lower the tube to the ground Rules • The tube must start at shoulder height • Everyone must have their two index fingers touching the tube at all times • Nothing else may touch the tube • You may not grip the tube, or hook your fingers round it • If anyone is spotted breaking any of the rules, the tube will be put back to chest height Pw. C 24
Review of the tube game Organisational objectives may be stated easily, yet despite everyone’s willingness and desire to achieve the objective, it is difficult to do. Why? – because of the difficulty of coordinating effort against the inertia of the organisation. • Need to understand the problem BEFORE coming up with solutions • Need to fully understand the desired outcome – tube on the ground – before you launch into implementation • Solutions got lost because people were talking not listening • Challenge constraints – some are real, but many are self-imposed • You succeeded because you worked together Pw. C 25
All of the system working together The process of producing a Quality Account mobilises managers, clinicians, front line staff and support staff to collect, review and analyse information relating to quality and to identify their areas of success and opportunities for improvement. This is done in such a way that quality excellence becomes a fundamental part of the health and disability service provider’s core business. Coming together is a beginning. Keeping together is progress. Working together is success. Henry Ford Pw. C 26
Making sense of information Integrated reporting 2012 Pw. C
www. pwc. com Quality Accounts: Capability Development National Quality and Risk Managers Meeting 16. 08. 2012
Calls for change in reporting Government Regulators Communities Reporting Employees Pw. C Patients 29
Drivers for change in business reporting Healthcare information needs to reflect the changing drivers of quality and safety in healthcare The International Integrated Reporting Committee has been established to create a new reporting framework Pw. C Growing consensus that current reporting is not fit for purpose Present reports are unduly focused on past financial performance Companies have a licence to innovate as the concept of ‘integrated reporting’ develops Forward-thinking companies are already innovating and changing the nature and scope of the information they use and report on 30
Benefits of effective information and reporting Internal Discipline Differentiation External Benefits Access to capital Reporting information aligned with investor and stakeholder needs Focus on strategy execution Future-facing Enhanced perception of the ‘quality of management’ Joining up the business – united purpose Better risk and opportunity identification The war for talent Improving quality and availability of information Better informed decision making Breaking down ‘silos’ Pw. C Clear and concise external reporting – effective communication Lower reputational risks Building critical relationships Lower cost of capital and better access to capital 31
Reporting maturity Integrated Reporting Bringing it all together Where is your DHB presently and where do you wish to be? Strategic Reporting Aligning reporting to what matters Effective Reporting most Doing it well and thinking about users Compliance Reporting Doing what you have to Pw. C 32
How is integrated reporting different? Current model Future model Reporting scope Legal ownership and control Value chain Dominant driver Financial, past Strategic, holistic, future Timeframe Short term Short, medium and long term Detail Long and complex Concise and material Rule bound Responsive to industry & company Presentation Paper based Electronic Trust Narrow disclosure Greater transparency Information construct Silos Integrated Financial capital All capital–intellectual, human, social Compliance Performance Source: International Integrated Reporting Council Pw. C 33
Making sense of information Measuring what matters 2012 Pw. C
Why should we measure? • The old adage “You can only manage what you measure” • Supplies motivation and focus • Is a catalyst for improvement • Allow the ability to evaluate what worked and what didn’t • Imparts a judgement of overall quality • Prompts the important questions Pw. C 35
Quality and safety performance indicators Nationally Consistent Content gives information to the public, which will be common across all Quality Accounts. Provider Determined Content will allow each provider to demonstrate the quality of care delivered and shows data relevant to specific services and specialities of the organisation, as well as what consumers and the public say matters most to them balanced against the Health and Disability Sector’s Triple Aim. Mo. H National Health Targets Pw. C Serious and Sentinel Events Patient Safety and Experience Indicators Regional & National Quality, Safety & Experience initiatives Clinical Indicators Quality, Safety & Experience improvement programmes 36
Indicator basics What is a performance indicator? • A measurement of performance against peers, or against a pre-determined benchmark or target • They are not just “statistics” - good metrics typically have a numerator and a denominator that allow for meaningful trending or comparisons over time What is a balanced scorecard? • A collection of individual metrics that collectively provide a “balanced” view of overall performance Structure of the scorecard is driven by how it will be used: • Measuring results, progress towards an “ultimate objective” • Motivating the “right” behaviours and actions that will lead to achievement of the ultimate objective • Quantifiable evidence for evaluating and/or rewarding performance Pw. C 37
Characteristics of good indicators Improvement starts with knowledge and clarity Well designed indicators measure the right data, in the right parts of the system, at the right time Indicators that help you understand what parts of the system to change and how In addition to being “fit for purpose”, each indicator should be “SMART” S Specific to the area being measured M Measurable, on an objective basis A Aligned with Health and Safety objectives and/or critical success factors Realistic and controllable by the area being measured R Collectively, the indicators used in the scorecard should provide a “balanced” view of overall performance. Timely – can be updated on a regular basis T Pw. C 38
Key Questions How many indicators? Segmental or group? Giving the reader multiple performance measures without explaining which ones are key to managing their business does not aid transparency. You will need to consider how your indicators are collated and reported internally – whether they make sense when aggregated and reported at a group level, or would be more usefully reported at an organisational segment level. The choice of which ones are key is unique to each company and its strategy; it is therefore impossible to specify how many KPIs a company should have. However, our experience suggests that between four and ten measures are likely to be appropriate for most DHBs. Pw. C In some instances, it may be more appropriate to report separately for each organisational segment if the process of aggregation renders the output meaningless.
Key Questions How rigid should they be? Does reliability matter? You should reflect on whether the indicators chosen continue to be relevant over time. As you are encouraged to move beyond the more traditional financial indicators in your public reporting, the issue of data and indicator reliability will inevitably be raised. Strategies and objectives develop over time, making it inappropriate to continue reporting on the same indicators as in previous periods. For the purpose of the first Quality Account, your choice of indicators is not set in stone for all time; but the reason for, nature of, changes in indicators and how they are measured and reported should be clearly explained. Pw. C In order to address this issue and provide readers with useful information, we believe it is more important that the limitations of the data and any assumptions made in providing it are clearly explained. Readers can then judge the reliability for themselves and make any necessary adjustments in their own analysis. Slide 40
Key Questions Should I disclose my source and assumptions? What about changes to my indicators? To enable readers to make their own assessment of the reliability of the information, it is important to identify the sources of the data used in calculating performance indicators and any limitations on that data. Comparability over time is a key principle of good corporate reporting. Any assumptions made in measuring performance should be explained so that readers can reach an informed view of judgements made by management. It is recognised that indicators may evolve over time as strategies change or more information becomes available. When such changes are made to the indicators being monitored, either in terms of the measures or how they are calculated, these changes need to be explained. An indication of the level, if any, of independent assurance of the data would also be valuable. Pw. C Slide 41
Quality indicators based on quality data You have selected your indictors, now the challenge is to ensure that the results are based on quality data. A quality indicator can only produce useful results if the data that it is based on is sufficiently relevant, complete and reliable. It is therefore important if you collect any data locally that you are able both to ensure that it is good data and able to recognise when it is not. Completeness: The more complete the data you collect, the more accurately your indicator will represent the quality of care in your organisation. You should monitor your systems and look out for missing data. If you find that large amounts of data are missing, you should revisit your procedures and talk to those collecting the data to identify why. Relevance: It will not always be possible to collect data on every relevant incident or procedure. In such cases you need to decide whether the data that you have collected correctly represents the whole Relev picture, or whethere is a systematic difference ant D ata between the incidents for which you were able to get data and those for which you weren’t. Data Complete Reliability: There will always be an element of le b lia Re Pw. C ta Da human error in collecting data. You should take steps to make your data more reliable by making sure that those responsible for data collection fully understand what they are expected to collect and 42 why.
Selecting the right indicators Asking questions can help you determine What questions are you trying to the right indicators, so think about the questions that you are trying to answer with answer in your organisation around Health Quality and Safety? indicators and ensure these questions are clear. • E. g. You may want to know whether a particular aspect of the quality of care in your DHB has improved since last year, or you may want to know whether your performance is better than, worse than or about the same as the national average. Think about the questions that your audience is likely to ask when they read your Quality Account and try to ensure that you provide the answers. Pw. C 43
Indicator development: step-by-step Guiding Principles Set a robust mechanism for selecting potential indicators- SMART objectives, combined with the ‘Good Indicator Guide’. Comms. Communicate your guiding principles for indicator development with your stakeholders. Walk them through the process. Long List Develop a ‘long-list’ of potential indictors as early as possible & from a wide variety of sources. Refine the long-list in discussions with stakeholders. This may be an iterative process. Make sure this is documented. Check Ensure that indicators are both locally and nationally relevant to your population and that they ‘stretch’ the organisation. Feedback Involve stakeholders and get critical feedback from them. Ensure feedback is challenging, reflective and absolutely invaluable. Socialise Exploit existing structures wherever possible. QAs are the way forward- ‘orientate’ the organisation around them… ‘this is how we work now’. Pw. C 44
Performance indicators Opening Statements Foreword Statement of Endorsement Statement of Engagement Statement of Intent Regarding Feedback Performance Review Nationally Consistent Content Provider Determined Content Nationally Consistent Content • Ministry of Health National Health Targets • Serious and Sentinel Events Provider Determined Content • Quality, Safety and Experience of Care • Health and Equity for the Population • Value for Public Health System Resources Future Focus Priorities for Improvement Pw. C Capability Development 45
New Zealand health quality measures In a new report, the Health Quality and Safety Commission (the Commission) presents the first set of health quality and safety indicators. The report presents the work towards developing 17 proposed indicators, displays findings where available, and welcomes feedback on how the indicator set could be further strengthened. Further detail on the definition and calculation In developing these indicators, the Commission has built upon existing quality of each of the indicators is provided in the and safety initiatives throughout the sector definition standards found on the Health Quality Measures website: hqmnz. org. nz and involved measurement experts and stakeholders in the process of selection and definition. Finalising a set of credible, robust and reliable quality and safety indicators will: Provide the public and the health and disability sector with a clear picture of the quality and safety of health and disability services in New Zealand, including changes over time Pw. C Inform the quality improvement activities of service providers by providing information to support learning and peer review in clinical settings Identify key quality and safety issues and prioritise improvements to the quality and safety of health and disability support services 46
Ten most frequently used measures by the NHS 92% • Health care associated infections 90% 82% • Waiting times 67% • Hospital standardised mortality ratio – overall 54% • Cancelled operations 49% • Stroke sentinel clinical audit 46% • Re-admission rates 44% • Delayed transfers of care 44% • Patient safety incidents/never events/prescribing errors 41% Pw. C • Patient experience What indicators could you use in your DHB? • Complaints 47
How to define & document an indicator Once you have selected your indicators it is vital to define and document them. Each indicator should be defined to the level of detail displayed in the example below, and should be agreed prior to carrying out data collection, baseline calculation and validation. Document this in your Quality Account in Section 2. Indicator ID IND-001 Indicator Name Percentage of Hand Hygiene Compliance Indicator Definition To be marked as “compliant” , each time a health professional comes in to contact with a patient, they must carry out hand hygiene steps: Before touching a patient, before a procedure, after a procedure or Body Fluid Exposure Risk, after touching a patient's surroundings Type National or Provider Objective To increase the number of compliant patient interactions Rationale There is a link between infections and hygiene, and we want to drive down infections Owner Head of Quality Improvement Measure Calculation No. of compliant in ward interactions / total number of in ward interactions Additional Information 3 wards to be audited with a minimum of 350 interactions audited per ward 3 audits should be performed every year by a qualified auditor Current Performance 85% Target Increase by 5% by December 2012 Review date Review on the 1 st of every month Data source This data will be manually collected Pw. C 48
Indicator Checklist Once you have selected your indicators, validate them by using this check list: Do the indicators address the important issues? Have you captured your local improvement priorities? Are they being captured /tracked/reported on somewhere else? Pick a couple of your indicators and work through a definition and documentation process for your Quality Account Are they aligned to the Triple Aim? Do know why are you are tracking them? Do they actually measure what they are claiming to measure? Do you know how you will collect the data? Do you understand the meaning? What is the indicator telling you? What are the implications? Pw. C 49
Why indicators fail - pitfalls & how to avoid them Pitfall Method of Avoidance Indicators chosen because they are immediately measurable or “comfortable” — even if they are of little value Start from a solid conceptual framework – agree first on what needs to be measured, expressed qualitatively Indicators drive unintended behaviors because they do not fully account for the inherent tradeoffs Use a balanced scorecard approach with multiple relevant dimensions, and objectives within each that address cost, quality and risk tradeoffs Indicators are not aligned with “the ultimate goal” and/or there are too many indicators and/or the metrics are “missing” key outcomes or drivers Use the strategy map framework as the starting point for developing “top of the house” metrics, then cascade related scorecards and metrics to lower level Lack of buy-in that the indicators are the “right” ones Include representation from affected areas in the development of the indicators Fear of transparency and accountability Define and implement an effective change management programme Pw. C 50
Why indicators fail - pitfalls & how to avoid them (cont) Pitfall Method of Avoidance Start with what you have, use proxies Don’t have the data required to implement where necessary, and develop a roadmap the “right” indicator for closing the data gap over time Lack of agreement about what the metrics mean Develop clear, easy to understand definitions and document an “indicator dictionary” Indicators are ignored and/or there is “green light thinking” (a good overall result that may be hiding significant underlying pockets of problems) Define an accountability framework, and a governance model, enabled by effective scorecard reporting, including “drilldown” mechanisms, trend indicators, “stoplights” etc. Focus solely on outcome measures (“lagging indicators”), failure to recognise emerging issues before it is too late Overall indicators structure should contain a good mix of leading indicators as well, to enable proactive recognition of emerging issues Pw. C 51
Making sense of information Presenting data 2012 Pw. C
Presenting Data: Key Principles Tailor your style and approach to your audience • Primary audience is the public, but also includes clinicians, DHB staff commissioners, academics and other experts in healthcare Focus on the key messages • • • These should be of interest to your audience and should matter to them Do more than just recite the data in words Explain to the reader what key messages the data contains Explain what this means about the quality of care provided by your organisation Explain what this means for them Use language that your audience will understand • If you need to use technical language, explain its meaning • Avoid overly long sentences and try to be as concise as possible • Stick to simple words and everyday English Pw. C 53
Using tables and graphs Tables and graphs provide a visual representation of your data that can be more effective than text in getting your message across. They can also break up text and make your Quality Account much more visually appealing and engaging for the reader. Smaller tables make it easier for the reader to understand the numbers. 2009 -10 2010 -11 9. 9% 9. 5% Your Region 11. 2% 11. 0% All of NZ 10. 6% 10. 3% Your Organisation Table 1: Percentage of patients readmitted to hospital within 28 days of discharge following stroke treatment Present data in a logical order to make it easier to digest Pw. C Right justify numbers so that their relative sizes are visually obvious Quote numbers only to accuracy required to illustrate the key message The title should contain all the information needed to understand the table. Avoid acronyms and abbreviations. 54
Tips for using graphs A good graph can be an extremely effective way of presenting the key results from your data, but a poor graph can be confusing or misleading. The following tips should help you to create graphs that are both engaging and revealing to the reader. Tip 1 Tip 2 Tip 3 One Clear Visual Message: A graph should have one clear visual message. Resist the temptation to attempt to convey more than one idea in a graph, as this is likely to confuse the situation. Clear Headings: Give your graph a clear heading that contains all the information that the reader needs to understand its content. Avoid acronyms and abbreviations and use proper grammar. Avoid Visual Clutter: Avoid unnecessary visual effects, as these can make the graph much harder to understand. Many common software packages can draw 3 -dimensional graphs – steer clear of these as they make it more difficult to see. Tip 4 Choosing the right type of graph: You should try to choose the most appropriate type of graph for the data that you want to present. Tip 5 Axes that don’t start at zero: You should usually start your vertical axis at zero so that the relative sizes of the values in your graph are visually apparent. Pw. C 55
Making sense of information Using graphs 2012 Pw. C
Question one Which graph makes it easier to determine whether the mid-cap US. Stock or the Small. Cap U. S Stock are the greater share? (A) Pw. C (B) 57
Question two Which of these line graphs is easier to read? (A) Pw. C (B) 58
Question three Which of these two tables is easier to read? (A) (B) Pw. C 59
Question four Which graph makes it easier to focus on the pattern of change through time, instead of the individual values? (A) (B) Pw. C 60
Question five Only one of these graphs accurately encodes the values. Which graph presents the data accurately? (A) Pw. C (B) 61
Question six Which map makes it easier to find all of the counties with positive growth rates? (A) Pw. C (B) 62
Question seven Which graph makes it easier to determine the R&D’s travel expense? (A) (B) Pw. C 63
Question eight In which graph are the labels easier to read? (A) Pw. C (B) 64
Question nine Which graph is easier to look at? (A) (B) Pw. C 65
Question ten Which table allows you to see the areas of poor performance more quickly? (A) (B) Pw. C 66
Test answer sheet Q 1. B Q 2. A Q 3. A Q 4. B Q 5. B Q 6. A Q 7. B Q 8. A Q 9. B Q 10. A Pw. C 67
Making sense of information Dashboard design 2012 Pw. C
Quality account dashboard overview One way of recording, monitoring and presenting the results of your indicators is through a dashboard. • Dashboards are visual displays • Dashboards display the information needed to achieve specific objectives • A dashboard fits on a single computer screen • Dashboards are used to monitor information at a glance • Dashboards have small concise, clear and intuitive display mechanisms • Dashboards are customised • Dashboards provide immediate insight into what’s going on • Dashboards enable quick recognition of what needs attention “A dashboard is a visual display of the most important information needed to achieve one or more objectives; consolidated and arranged on a single screen so the information can be monitored at a glance. ” Stephen Few Pw. C 69
Dashboard workshop & challenge Discussion Workshop Dashboard Design Challenge This group should discuss their understanding of a quality and safety indicator dashboard. The group should design a Quality and Safety Indicator dashboard. The group should come up with: 1. A high level definition 2. Key components 3. Design characteristics 4. What not to include on a dashboard Pw. C Each component on the dashboard should be labelled with an explanation of what it is and why it is required 70 70
Guiding principles of dashboard design Keep It Super Simple (KISS) Selecting the right data Organise it logically Single screen – keeping all data within eye span Don’t waste an inch of space & don’t sacrifice meaning Avoid unnecessary and distracting decoration Condense information in ways that don’t decrease its meaning Visual display mechanisms that even when quite small, can be easily read and understood Include only the information that you really need “Eloquence in communication is often achieved through simplification. Too often we smear a thick layer off gaudy makeup over data in an effort to impress or entertain, rather than focusing on communicating the truth of the matter in the clearest possible way. ” Stephen Few Pw. C 71 71
Understand your real estate Different degrees of visual emphasis are associated with different regions of a dashboard. Emphasised Neither – Emphasised Nor de-emphasised Pw. C De-emphasised 72
Essentials of dashboard design Design your dashboard to fit in one screen Supply adequate context in support of the data Display data through summaries and exceptions Choose your indicators and measures carefully Select simple, efficient charts and graphs Be consistent in your use of colour, fonts and display media Make sure the data is accurate Arrange the data logically so it information flows Highlight important data effectively Keep the display clean and clear Use colour sparingly and with meaning Create a pleasant, easy to view display Pw. C 73
Dashboard design checklist What level of summarisation should I express the measure? What means of display would best express this measure? At what point in the sequence of viewing the items on the dashboard might a Quality Board what to see this measure? What unit of measure should I use to express this measure? What complementary information should I include as context to enhance this measure’s meaning? How important is this measure to the Quality Account compared to the other measures? What other measures might you want to compare to this one? Get your audience involved in the design process and involve them in answering these questions Pw. C 74
Dashboard design step by step Determine the objectives of your dashboard Determine what decisions / actions will be made Determine how the information will be delivered (media) Determine who is the audience of your dashboard Confirm definition of metric Confirm how the metrics are being calculated Determine where these metrics will come Determine which metrics will be used Create a ‘wireframe’ using dashboard design principles Seek feedback on the ‘wireframe’ with a sample audience Review and revise design in light of feedback Implement your dashboard and test again Pw. C 75
Example dashboards Pw. C 76
Making sense of information Statistical process control 2012 Pw. C
There are four key applications of SPC for the health sector Examine a process for stability over time before starting a quality improvement intervention Find any special causes of variation & explain it or contain & mitigate it Why use SPC? Communicate process performance over a period of time Pw. C Monitor the progress of a process during and after intervention 78
A basic understanding of statistics • The mean (µ) is the arithmetic average of a set of data – calculated by adding together all data values and dividing by the number of values. • The standard deviation (σ) of a group of numbers can be thought of as the average distance from each data point to the mean, and is easily calculated using an Excel spreadsheet. • For a normal distribution, 99. 73% of points will fall within three standard deviations from the mean in either direction. 68. 26% 95. 46% 99. 73% µ-3σ Pw. C µ-2σ µ-1σ µ µ+1σ µ+2σ µ+3σ Slide 79
Variation exists in all processes – there are two main causes for this Common cause • Predicted or expected variation • Inherent in the process • E. g. age, gender, condition Special cause • Unusual or unexpected variation • Can be traced back to a special event or specific action • E. g. someone coded in the wrong number Pw. C Slide 80
These causes require different actions to be taken Type of variation What it means Appropriate action to take Common cause • Process is in control • Variation is inherent in the process • Change the process • Do not react to individual differences or try to explain differences between high and low numbers Special cause Pw. C • • • Process is unstable • and unpredictable • Identify and resolve special cause If negative, minimise or prevent If positive, build into process Do not react by changing the process, as it may not be the system at fault Slide 81
SPC uses Control Charts with three basic components to distinguish between the causes of variation 1. A centreline (CL), usually the mathematical average of the sample points plotted. 2. Upper and lower statistical control limits (UCL, LCL) that define the constraints of common cause variations. 3. Performance data plotted over time. Pw. C Slide 82
Creating and interpreting a control chart Determine quality measure you want to monitor and retrieve historical data (at least 30 data points) Collect the sample data (at least 15 -20 data points) Construct the chart in Excel and annotate the chart Investigate any areas of variation & take appropriate action Recalculate control limits when a permanent change has occurred in the process Pw. C Slide 83
Control Charts can be divided into six zones to aid interpretation and identify special cause variation UCL = µ + 3σ µ + 2σ µ + σ CL = µ µ - σ µ - 2σ LCL = µ - 3σ • The zone between the control limits represents common cause variation • The zone outside the limits is the area of special cause variation Identifying special cause variation: a. One data point falling outside the 3σ control limits = OUTLIER b. 2 out of 3 consecutive points outside the 2σ limit = TREND c. 4 out of 5 consecutive points outside the 1σ limit = TREND d. 6 points in a row steadily increasing or decreasing = TREND e. 7 points in a row on same side of the centreline = SHIFT f. 14 or more points alternating up and down = CYCLE Pw. C Slide 84
Control Charts can be divided into six zones to aid interpretation and identify special cause variation Common cause variation only UCL = µ + 3σ CL = µ LCL = µ - 3σ Special variation – needs to be investigated Variation can be explained by an event UCL = µ + 3σ CL = µ LCL = µ - 3σ Pw. C Slide 85
Control chart interpretation Using the previously explained rules, how would you interpret UCL = µ + 3σ this control chart? µ + 2σ µ + σ CL = µ µ - σ µ - 2σ LCL = µ - 3σ Pw. C Slide 86
Interpretation example Annotation should explain any special variation There are two months where the fall rate was unusually high. Investigation should begin to explore the special causes behind those identified months with high fall rates to help prevent this from occurring in the future. For example, one of the months may have been unusually high because a new, inexperienced nurse was added to the floor who had not yet been fully trained in fall prevention strategies. Pw. C Slide 87
Summary SPC is a useful tool for monitoring, controlling and improving a process over time through statistical analysis When and where will you use SPC in your Quality Account? • It is most effective when used as an ongoing monitoring tool with clearly defined actions and responsibilities – not as a reaction to problems. • Need to understand the type of variation that is occurring as this will determine how to address the issue. • Recalculate control limits only when a permanent, desired change has occurred in the process and using only data after the change occurred. SPC Template Pw. C Slide 88
Making sense of information Improvement identification 2012 Pw. C
Prioritisation matrix Many organisations struggle to balance a growing list of new and pending projects while the need for core services continues, often with less funding. A prioritisation matrix supports structured decision-making in the following ways: Multiple criteria • Helps prioritise complex or unclear issues when A prioritisation matrix is a simple tool that there are multiple criteria for determining provides a way to sort a diverse set of items importance into an order of importance. It also Consistency identifies their relative importance by • Provides a quick and easy, yet consistent, method deriving a numerical value for the priority for evaluating options of each item. Objective The matrix provides a means for ranking • Takes some of the emotion out of the process projects (or project requests) based on Quantifiable criteria that are determined to be • Quantifies the decision with numeric rankings important. This enables a department to see clearly which projects are the most Adaptable important to focus on first, and which, if • Is adaptable for many priority-setting needs any, could be put on hold or discontinued. Provides focus Pw. C • Establishes a platform for conversations about what is important Slide 90
Healthcare example Example Prioritisation Tool - Courtesy of Waitemata DHB Remember that the prioritisation matrix itself is just a tool, and the people scoring projects are using their best judgment. What is the criteria that you will use in your DHB to determine your improvement priorities? Upon review, your Quality Accounts programme team may decide that a project needs to move up or down in priority, despite the score it received. These types of adjustments are expected and help finetune the priority list. Be sure to vet the results with others in the organisation, as well as customers and stakeholders. Pw. C July 2011 Slide 91
Ball game Objective • Complete the ball circuit Rules • Everyone must touch the ball • You may only touch the ball once • The ball may not bounce, or touch anything other than your hands • If anyone is spotted breaking any of the rules, the circuit will be started again Pw. C 92
Review of the ball game Thinking differently was the only real, sustainable bridge to get you from where you were to where we would like to be. To succeed in this game you were able to progress your team through the following journey: Perceived issue Look at it differently Reframe the issue Creative refinement Apply criteria to select ideas Generate ideas and approaches Test revised process Tweak if necessary Success!! Pw. C 93
Looking at things differently "Here is Edward Bear, coming downstairs now, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop that bumping for a moment and think of it. ” AA Milne Pw. C 94
PDSA methodology & quality accounts PDSA is a great methodology to implement improvements using indicators. The Quality Account is where you document your plans, your results and what you plan to do next. There are four stages of the PDSA cycle: Plan the change to be tested or implemented Do carry out the test or change Study data before and after the change and reflect on what was learned Act plan the next change cycle or full implementation Note: You can use plan, do, study, act (PDSA) cycles to test an idea by temporarily trialling a change and assessing its impact Pw. C 95
PDSA methodology basics PDSA cycles form part of the quality improvement framework, which provides a model developing, testing and implementing changes leading to quality improvement. The framework includes three key questions and a process for testing change ideas. The answers to these questions should be documented in Section 1 of the Quality Account. Model For Improvement What are we trying to accomplish? How will we know if a change is an improvement? What changes can we make that will result in improvement? • What are we trying to accomplish? (The aims statement ) • How will we know if the change is an improvement? • What changes can we make that will result in improvement? Pw. C 96
PDSA basics: goal focused Set clear and focused goals relating to your quality improvement efforts. It is vital that you select relevant goals supported by the right mix of indicators. Goals should focus on quality and safety problems that cause concern to you, as well as to patients and staff. These quality improvement goals for your DHB are expressed in the “aims statement” and should be documented in section 1 of the Quality Account. Model For Improvement What are we trying to accomplish? How will we know if a change is an improvement? What changes can we make that will result in improvement? Top Tips for Aims Statements: • Be consistent with any national goals and relevant to the length of the project • Be bold in its aspirations • Have clear, measurable targets Note: We discuss indicator selection later on in the section Pw. C 97
PDSA Basics: recognising an improvement Recognising a change as improvement is a vital part of the PDSA methodology. You want to know whether your change has worked and the effort paid off. You will need to measure outcomes, such as reduction in the time a patient has to wait in order to answer this question. If you make a change, this should affect the measures and demonstrate over time whether the change has led to sustainable improvement. The measures in the model are tools for learning and demonstrating improvement, not for judgment. Model For Improvement What are we trying to accomplish? How will we know if a change is an improvement? What changes can we make that will result in improvement? You should collect data to demonstrate whether changes result in improvement. You should report improvement progress monthly on time series graphs known as ‘run charts' or statistical process control charts (SPC) and then document in the annual Quality Account in section 2, the Performance Review. Pw. C Slide 98 98
PDSA basics: selecting the change There are many potential changes your team could make. However, evidence from scientific literature and previous improvement programmes suggests that there a small number of changes that are most likely to result in improvement. These changes you have made and the reasons why should be documented in your Quality Account in section 2. Top Tips from the UK The Cancer Service Collaborative identified twenty eight change principles which they grouped into four areas that you may find helpful. These were their areas for changes. Each area had a series of change iterations associated with them in order to achieve their goal. • Connect up the patient journey • Develop the team around the patient journey • Make the patient and care experience central to every stage of the journey • Make sure there is capacity to meet patients' needs at every stage of the journey Pw. C Model For Improvement What are we trying to accomplish? How will we know if a change is an improvement? What changes can we make that will result in improvement? 99
Improvement priorities: consumer feedback Consumer feedback is a great input into the selection of improvement opportunities and also the future focus of the DHB. Consumer feedback can also help: • To improve communication and shared decisionmaking between consumers and staff How could you engage with your consumers and get their feedback? What feedback would ask them for? • To build trust and confidence in the DHB locally and nationally • To inform planning and service improvement • To provide accessible and responsive services, based on people’s identified needs and wants • Consumers to shape the services that they use If you engage with consumers to drive out future priorities for improvement, then document this in your Quality Account in section 3, Future Focus Pw. C 100
Making it happen Programme management 2012 Pw. C
Protected Quality Assurance Activity 1 (PQAA) • The coverage of the PQAA law will vary by DHB • It is recommended that you speak to your in-house legal council to determine ramifications for publishing Quality Accounts 1 Section 54 – Health Practitioners Competence Assurance Act 2003 Pw. C 102
Making it happen Feasibility 2012 Pw. C
Feasibility stage The feasibility stage recommends activities to make sure that each provider is ready to develop and implement their Quality Account. Main Activities Expected Outcomes Prepare a business case; develop estimates for the Completed business case including risk register costs and timescales Confirmation that the resources (people, budget Identify non clinical resources required to develop and time) required to generate and deliver the and implement the Quality Account are available Engage with clinical and executive leads to Approval gained from the board and executive establish and confirm senior level support team Consult individual clinical teams and provide a clear understanding of the practical benefits of the Strong clinical engagement and support Quality Account in improving health outcomes and local clinical care Identification of how the Quality Account will Consider how the Quality Account can address help to improve the quality of care and the service local concerns and difficulties provided to patients Gain an overview of existing systems and An understanding of the provider’s capability to reporting implement and accurately measure performance Identify target stakeholder groups for the Quality Completed stakeholder management and Account, including assessing their needs and communications plan expectations Pw. C Page 104
Create a programme aim The aim statement enables the organisation to have a Using the purpose you defined good understanding of why Quality Accounts are earlier today, develop an aim important and to engage key clinical staff and the statement for your DHB’s Quality wider workforce regarding both the benefits of Account Quality Accounts and the process for implementing them. Creating a clearly defined vision of the future that inspires and motivates the workforce is an important first step on the path of success for this programme. An effective aim statement should be concise, motivating, and memorable and should be easily understood by a wide variety of stakeholders and is written with the broadest grouping of stakeholders as the target audience. Pw. C 105
Obtain board sponsorship and buy in Addressing these demands needs to be treated as a project in its own right, with sponsorship from a member of the Board and ownership clearly taken by the Board or a Board sub-committee. Whoever takes responsibility will need to oversee a planned and transparent process. How will you obtain board sponsorship for this programme? A first step should be to nominate an individual with responsibility for understanding the implications of these demands for the accounts development. This individual should then brief the Board on what the implications are for their DHB. Pw. C 106
Business case A business case captures the reasoning for initiating a project or task. It is often presented in a well-structured written document, but may also sometimes come in the form of a short verbal argument or presentation. What activities will your programme team need to do to develop and have your DHB approve a business case for your Quality Accounts programme? The business case answers the question: ‘Is the investment in this programme worth it? ’ And is an aggregation of specific information about the programme: • Value of the benefits • Risks to achieving them • Costs of delivering • Timescales for achievement Pw. C 107
Programme risk As part of your business case, it is recommended that you identify any potential risks and issues to your programmes success and establish appropriate mitigation actions. Risks Aspect Affected What risks can you foresee and what actions would you need to put in place to mitigate these? Mitigations (e. g. getting (e. g. completion, (e. g. action, accept) stakeholder buyexecution) in) Pw. C
Stakeholder management & communications Engaging stakeholders is more than relying on planned communications that are little more than a task list with a bias toward outbound information. Successful communications are based on four core elements: • Message clarity and consistency: ensure relevance and recognition, and engender trust • Stakeholder identification and analysis: send the right message to the right audience • A system of collection: obtain feedback and assess the effectiveness of the communications process • A system of message delivery: get the right messages to the right stakeholders in a timely and effective way It will also be important at this stage to identify the relevant “information owners” who may be required to contribute to the annual report. Pw. C Identify who your key stakeholders for this programme are and how you will communicate with them
Making it happen Initiation 2012 Pw. C
Initiation stage The initiation stage involves defining the requirements for each set of Quality Accounts, and understanding what will be delivered, who will deliver it, and at what cost. Main Activities Establish governance structures and processes for the Quality Account project Produce a structured, detailed and resourced Project Plan for putting the Quality Account in place Share any existing metric information from previous prototypes, pilots or other processes that may be relevant Set up wider clinical teams and give them the appropriate background information. These teams should include multidisciplinary team members Pw. C June 2012 Expected Outcomes Documented and agreed governance and processes for the Quality Account project including sign-off requirements and change management processes Confirmed approach to generating the Account Project team and their availability confirmed Utilisation of existing reports and metrics, avoiding the ‘re-invention the wheel’ where possible To have consulted clinicians and to have attracted as much interest in the project as possible Page 111
Planning your programme Developing a robust programme plan is essential to ensure that all time, cost and quality requirements are delivered to. * Benefits • It manages the transition of the solution developed into business operations. • It provides a framework that integrates and reconciles competing demands for resources. • It recognises the people aspects of change that must be accommodated if the programme is to succeed. “He who fails to plan is planning to fail” Winston Churchill Pw. C 112
Planning and Control Checklist ü Budget – are we within our spending limits? ü Schedule – are tasks happening on time? ü Risk and Issue Management – are we mitigating risks and addressing issues? Develop a high level plan for the design, documentation and publication of your Quality Account ü Progress Monitoring and Reporting – are we communicating our progress? ü Change Control – are we tracking changes? ü Quality Management – are we following a quality-driven approach? Pw. C 113
Making it happen Scoping 2012 Pw. C
Scoping stage The scoping stage will ensure that requirements for the Quality Account are able to be agreed with the clinical teams. Identifying realistic and achievable areas to focus on will enable the planned benefits to be realised within the timescales set. This can be done through a number of workshops. Main Activities Engaging a broad range of clinicians from each speciality to attend requirements-gathering workshop(s) Carrying out research into the availability of data (inside and outside the organisation) Carrying out and supporting requirements sign-off workshop Conduct project scoping and create development plan Consulting clinical teams on any identified difficulties or changes to metrics and ensuring the clinical relevance and purpose of the metrics is maintained Pw. C Expected Outcomes Agreement on a balanced selection of indicators covering: • Quality, Safety and Experience of Care • Health and Equity for the Population • Value for Public Health System Resources An agreed estimate of resource and cost requirements for the generation and on-going management of the data measurement system Requirements signed off by the clinical leads for each specialty and the Board A detailed project plan to put the Quality Accounts in place and a key milestone development plan for each of the Accounts modules Ongoing engagement with the clinical leads
Performance indicators As discussed previously, there are two elements to the performance measures that are to be represented in your Quality Account: How will you engage across your organisation and community to identify the indicators in your account? Nationally Consistent Content • Ministry of Health National Health Targets • Serious and Sentinel Events Provider Determined Content • Quality, Safety and Experience of Care • Health and Equity for the Population • Value for Public Health System Resources Pw. C 116
Making it happen Development 2012 Pw. C
Development stage The development stage will typically start once the scoping stage is complete and the requirements for the Quality Account have been agreed with the clinical team. Main Activities Setting regular development checkpoints to help achieve the main aims Developing a training and user acceptance testing plan Developing and agreeing a communications plan Expected Outcomes Quality of the Account is assured, through a structured system test plan A defect identification and resolution plan developed Communications, testing and training plans agreed An understanding of the information management and information technology Produce a detailed data plan – outlining the resource implications for delivering the metrics that are needed and the systems Quality Account (e. g. if systems need to be that the data will be taken from changed to capture data required for the Account) Consulting clinical teams on any identified To continue developing useful metrics, difficulties or changes to metrics because of agreed by the clinical lead to be an data configuration and so on, and making appropriate balance between the metrics sure the clinical relevance and purpose of identified initially and any identified the metrics is maintained difficulties with local data flows Pw. C 118
Data plan Outline the metrics that are needed, the systems that What is your plan / approach to collecting data? the data will be taken from, and any resource implications for delivering the Quality Account (e. g. if systems need to be changed to capture data required for the Account). Metric Pw. C Data System or Manual? System Name Resource Implications 119
Publishing Below is a recommended approach to publishing a Quality Account: Where will you be publishing your Account? Pw. C Publish Communicate Final Edit Ensure that all employees Upload the within the Review with Quality organisation, Consumers, Account to the Health community organisation’s Literacy and the wider website and Specialists sector share the link and Content understand with The Editors where and Commission how to access the Account Consider the needs of the community and adopt relevant distribution methods as necessary. 120
Making it happen Writing for the reader 2012 Pw. C
Structured Thinking Tools “If you do not know where you are going, then any road will do” The Cheshire Cat to Alice, from Lewis Carroll’s Alice in Wonderland Pw. C Page 122
Good structures begin with thinking about what you need to write Your structure will help you: • prioritise and organise your ideas • check that your message has a logical flow • ensure completeness. These are some useful techniques for structuring your thoughts: • Minto • Mind-mapping • Storyboarding Generating, prioritising and organising ideas • Captive Moments • “The Ministerial Three” Writing with impact Pw. C Page 123
Minto’s structured thinking is a method of critical thinking designed to present ideas in a logical way SUMMARY IDEA We all seek structure, whether we realise it or not. The mind automatically sorts information into groups to understand it. These groups are pyramids: • A summary idea • Lesser ideas grouped logically below (e. g. in order of importance). IDEA 1 A B C IDEA 2 D E =Main idea/ Conclusion IDEA 3 F G H @ @ = Supporting arguments I = Supporting arguments @ # # # = Facts The Pyramid Principle: Logic in Writing and Thinking, Barbara Minto (2002) Pw. C Page 124
Structured Thinking Tools – Minto Imagine you receive this letter from Lucy. What does she want to tell you? Dear Shirley Remember last Saturday afternoon when I was playing in the park with my boyfriend and you came over, and he told me that when my back was turned, you kissed him? And also, on Sunday when you came to my house and my Mum made you a tuna fish salad for lunch and you said: “Yech! That’s the worst salad I ever ate!”? And yesterday, when my cat brushed against your leg, you kicked her and threatened to set your dog “Monster” on her? Well, for all of these reasons, I hate you, and I no longer want to be your friend. Lucy Pw. C Page 125
Structured Thinking Tools – Minto Wouldn‘t the message be far clearer if the letter were written according to Minto’s pyramid principle? Main idea / conclusion Dear Shirley I hate you. Here are my reasons: 1. You stole my boyfriend. 2. You insulted my mother. Reasons supporting the main idea/ conclusion 3. You scared my cat. Pw. C Page 126
Structured Thinking Tools – Minto In letter 2, Lucy’s thought hierarchy becomes explicit and can be considered as a fictitious question-answer dialogue Q: Why did Lucy write this letter to me? Lucy hates me A: Because… Q: Why? A: Because… Pw. C I stole her boyfriend I insulted her mother I scared her cat Page 127
Structured Thinking Tools - Minto To communicate effectively with your audience, you need to summarise your ideas into a pyramid that they can understand. The pyramid can guide the structure of your final document. IMPROVE BOTTOM LINE Improve Marketing Reduce Costs = Title Increase Output = Sections / chapters Increase Print Media Improve Website Increase Targeted Direct Mail Improve Look Improve Speed Increase Functions = Sub-paragraphs # = Bullet points/text Pw. C # # = Sub-sections/ paragraphs Page 128
Structured Thinking Tools - Minto Using inductive and deductive arguments in writing You Must Change Why? Here’s what is going wrong How? Here’s what is causing it Therefore, here’s what you should do about it How? A 1 Pw. C B 1 C 1 A 2 B 2 C 2 A 3 B 3 C 3 B 2 Why? A 2 - Cause of problem C 3 B 3 A 3 - What you should do B 1 C 2 C 1 A 1 - What’s going wrong Page 129
Structured Thinking Tools - Minto advocates avoiding deductive arguments in writing An example of inductive thinking/reasoning: You Must Change • • How? B 3 A 3 - What you should do Why? A 2 - Cause of problem Pw. C Situation Complication Question Answer C 3 How? B 2 B 1 C 2 C 1 A 1 - What’s going wrong Page 130
Structured Thinking Tools - Minto Supporting technique S–C–Q–A Situation: “For a long time we have been …. . ” - Something you already know - Sets up complication Complication: “Recently the situation has changed…. . ” - Triggers the question to be asked Question: “So what should we do? ” - Leads to the answer Answer: “We need to …. ” - Your main point - Summary thought for your introduction Pw. C Page 131
Structured Thinking Tools – Mind Mapping Mind mapping: a mind (or concept) map consists of a central word with related ideas radiating out from it Pw. C Page 132
Structured Thinking Tools – Mind Mapping Use a mind map to generate, prioritise and order logically the issues that you want to present in your document = main points to include in document Pw. C Page 133
Structured Thinking Tools – Mind Mapping 5 Steps to Making a Mind Map Pw. C Page 134
Structured Thinking Tools – Mind Mapping Seven tips for making a mind map Tip Rationale 1. Start in the centre of a blank page turned sideways. 2. Use an image or picture for your central idea. 3. Use colours throughout. Because starting in the centre gives your brain freedom to spread out in all directions and to express itself more freely and naturally. Because an image is worth a thousand words and helps you use your Imagination. A central image is more interesting, keeps you focussed, helps you concentrate, and gives your brain more of a buzz! Because colours are as exciting to your brain as are images. Colour adds extra vibrancy and life to your mind map, adds tremendous energy to your creative thinking, and is fun! Because your brain works by association. It likes to link two (or three, or four) things together. If you connect the branches, you will understand remember a lot more easily. Because having nothing but straight lines is boring to your brain. Because single key words give your mind map more power and flexibility. Because each image, like the central image, is also worth a thousand words. So if you have only 10 images in your mind map, it's already the equal of 10, 000 words of Page 135 notes! 4. Connect your main branches to the central image and connect your second- and third-level branches to the first and second levels, etc. 5. Make your branches curved rather than straight-lined. 6. Use one key word per line. 7. Pw. C Use images throughout.
Storyboarding: A good story has simple, logical elements Element Purpose Roadmap “Tell them what you’re going to tell them” What the problem is Set the stage What we did Outline approach or methodology; build credibility What we found Present findings What that means Interpret findings and make conclusions What we need to do Make recommendations What happens next Outline next steps Pw. C Page 136
Making it happen Structured writing tools 2012 Pw. C
Structured thinking tools • Minto’s Pyramid Principle • Captive Moments • “The Ministerial Three” Pw. C Page 138
Structured Writing Tools – Minto How to build your document according to the pyramid principle Step 1: Start with the pyramid foundations: Step 2: Create the pyramid outline: • Situation, problem and main idea must fit together • Ensure your pyramid forms a questionand-answer dialogue • Ensure all parts of the pyramid are formulated as proper sentences • Ensure your message is summarised in a one-sentence main idea/conclusion • Define your audience • Define your goals • Define the situation • Define the complication • Define the question (problem) Pw. C Page 139
Structured Writing Tools – Minto How to build your document according to the pyramid principle (continued) Step 3: Check the solidity of your pyramid construction: Step 4: Check proper relationships: • Ensure supporting elements are mutually exclusive and collectively exhaustive • • Ensure each statement has at least 2, but no more than 5 supporting statements Ensure supporting elements are of the same level of abstraction • Ensure supporting elements answer the same question • Ensure the supporting information is a group or valid chain • Ensure supporting elements are presented in a logical sequence • Ensure your question-and-answer dialogue is complete Pw. C Page 140
Structured Writing Tools – Minto How to build your document according to the pyramid principle (continued) Step 5: Writing your document: • Consider the pyramid’s foundations (step 1) • Ensure chapters have introductory paragraphs • Think about contents of text • Ensure the logical relationship between paragraphs is indicated • Ensure your text fits your goal and audience • What structure best suits your message? • Begin writing first draft • Ensure your text has a clear introduction • Pw. C Revise draft as needed Page 141
Structured Writing Tools – Minto Structure your document according to the pyramid principle The pyramid will guide the structure of your document. Major Thought/ Conclusion H 1 H 2 Paragraph H 1 Section Headings / Chapter 1. H 2 Sub-section Headings / Paragraphs 1. 1 Paragraph Numbered Sub-Paragraphs # Pw. C Title # # 1. 1. 1 Bullet points/text Page 142
Structured Writing Tools – Minto Tips and tricks on building your pyramid • You can build the pyramid two ways: - Bottom up - Top down • Start bottom up if you have a lot of information, but don’t know the main idea • If you know your main idea, but haven’t got lots of facts and figures, start at the top and work down Pw. C Introductions tell stories around: 1. The situation - quick, factual sketch of current situation 2. The complication - a problem that unsettles the situation in the story 3. The question - can be ‘what should we do? ’ or ‘how can we do it? ’ 4. The answer - your response to the question and your solution to the complication Page 143
Structured Writing Tools – Captive Moments Take advantage of your audience’s two moments of greatest interest to communicate main messages Level of Interest START Start of document: set expectations and create interest END End of document: summarise key points and actions Stage of Document Also known as: “Always put your best strawberries at the top of the basket. ” Pw. C Page 144
Structured Writing Tools – The Ministerial Three Ideas for structuring your content - using the “Tell Them” approach This well-known rule of thumb offers a useful starting point and reminds us that audiences need strong orientation and clear reminders of what has been covered: • Tell them what you're going to tell them (Introduction) • Tell them (Body) • Tell them what you told them (Conclusion) Pw. C Page 145
Structured Writing Tools – The Ministerial Three “The Ministerial Three”: use repetition to guide your audience through your document and emphasise important messages Step One Tell your audience what you’re going to cover (A, B, C…) Step Two Cover the information (A, B, C …) Step Three Summarise what you’ve covered (A, B, C …) No mystery tours! Pw. C Page 146
Structured Thinking Tools - Minto Some style tips Your audience, message and purpose of communication should determine the specific language you use. But all audiences will benefit if you follow these rules. • Use active verbs in place of passive • Avoid strings of nouns • “Own” your writing - e. g. . the personalised CV Create a sense of action and ownership • Use simple words and phrases • Limit jargon • Keep your sentences short Keep it simple • Grammar accuracy • Tables/diagrams to illustrate key points • Choose the right tone Pw. C Suit your tone to your audience Page 147
Structured Writing Tools – Summary Sample style checklist source: Plain English NZ Check the whole document It's simple, clear and concise The topic is obvious The main message is obvious It's obvious what action the reader needs to take Check the document structure Detailed, explanatory document title or page headline Summary or key message follows title or headline Content organised in a logical sequence for the reader Each paragraph starts with its topic Short paragraphs Sub-headlines and short lists break up solid text Check your sentences Mainly short sentences Mainly active verbs (I appointed you not You were appointed by me) Logically structured sentences (subject-verb-object) Only one main idea in each sentence Correct grammar, spelling and punctuation Pw. C Page 148
Structured Writing Tools – Summary Sample style checklist source: Plain English NZ Check your words Words that are common, simple, and familiar to your target audience Write you, I and we: speak directly to the reader No jargon (but technical terms are fine for a technical audience) No clichés or wordy phrases Consistent words: using the same word for the same thing throughout the document Only a few abstract nouns, e. g. words ending in -ment, -tion, -ance, -ence, -ancy, -ency, -ity, ism. Words positive in meaning and tone Check readability At least 60% score on Flesch Reading Ease Tip: Use the grammar checker in your word processor to check your document's readability. The Flesch Reading Ease score measures the percentage of adults who would be able to read your writing easily. At least 60% of adults should be able to read your document easily. Just check the prose, not data such as addresses. Check design The page looks orderly. Plenty of white space (in margins, between paragraphs etc), print so that's big enough to read Pw. C Page 149
Structured Thinking Tools - Minto Further reading The Pyramid Principle, Logic in Writing and Thinking Barbara Minto The Economist Style Guide Fowler’s Modern English Usage RW Burchfield Eats, Shoots and Leaves Lynne Truss Golden Bull Awards plainenglish. co. uk Plain English checklists plainenglish. org. nz Pw. C Page 150
Structured Writing Tools – Summary • Structured thinking tools - Minto’s pyramid principle - Mind-mapping - Storyboarding • Structured writing tools - Minto’s pyramid principle - Captive Moments - “The Ministerial Three”. Pw. C Page 151
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Disclaimer This document has been prepared solely for the purposes stated herein and should not be relied upon for any other purpose. In preparing this document and providing our recommendations, we have relied upon, and assumed the accuracy and completeness of, all information available to us from public sources and furnished to us by the Commission. We have evaluated that information through analysis, inquiry and review but have not sought to verify the accuracy or completeness of any such information. It should not be construed that we have conducted an audit of the information we have used. This document has been prepared solely for use by the Health Quality and Safety Commission. Our engagement did not constitute a statutory audit (the objective of which is the expression of an opinion on financial statements) or an examination (the objective of which is the expression of an opinion on management’s assertions). To the fullest extent permitted by law, Pw. C accepts no duty of care to any third party in connection with the provision of this document and/or any related information or explanation (together, the “Information”). Accordingly, regardless of the form of action, whether in contract, tort (including without limitation, negligence) or otherwise, and to the extent permitted by applicable law, Pw. C accepts no liability of any kind to any third party and disclaims all responsibility for the consequences of any third party acting or refraining to act in reliance on the Information. This document has been prepared with care and diligence and the statements and opinions within it are given in good faith and in the belief on reasonable grounds that such statements and opinions are not false or misleading. No responsibility arising in any way for errors or omissions (including responsibility to any person for negligence) is assumed by us or any of our partners or employees for the preparation of the document to the extent that such errors or omissions result from our reasonable reliance on information provided by others or assumptions disclosed in the document or assumptions reasonably taken as implicit. We reserve the right, but are under no obligation, to revise or amend the document if any additional information (particularly as regards the assumptions we have relied upon) which exists at the date of this document, but was not drawn to our attention during its preparation, subsequently comes to light. This document is issued pursuant to the terms and conditions set out in our Contract for services with the Health Quality and Safety Commission. © 2012 Pricewaterhouse. Coopers New Zealand. All rights reserved. Pw. C refers to the New Zealand member firm, and may sometimes refer to the Pw. C network. Each member firm is a separate legal entity. Please see www. pwc. com/structure for further details. Pw. C
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