Put First Things First

 

 

 

 

 

James Owen (programme partner) at the Royal Wolverhampton NHS Trust discusses how he uses Stephen Covey’s 7 Habits of Highly Effective People in his role. This is the third in a series of blogs James will be writing. Follow James on Twitter @jowen3101 and the Continuous Quality Improvement Team @RWT_CQI

 

After reading Stephen Covey’s 7 Habits of Highly Effective People I was minded that a lot of the concepts are important to think about when being a Quality Improvement (QI) practitioner.  This blog is the third in a series where I look at each of the 7 habits, and how I incorporate them into my role.

 

I work at the Royal Wolverhampton NHS Trust (RWT), which is an acute hospital trust in the West Midland. I have worked as an analyst in the medical division and also as the manager of the trust’s rehabilitation wards.  I have recently moved to the trust’s new Continuous Quality Improvement Team, which was formed in May 2019.

 

The third habit I am going to look at is ‘Put First Things First’. The ethos of this is to prioritise work effectively so you don’t waste time reacting to the unimportant, or work on projects that don’t affect many people. The book describes prioritising tasks by urgency and importance. Priority should be given in the following order (in brackets are the corresponding actions from the Eisenhower Matrix):

Quadrant I. Urgent and important (Do) – important deadlines and crises

Quadrant II. Not urgent but important (Plan) – long-term development

Quadrant III. Urgent but not important (Delegate) – distractions with deadlines

Quadrant IV. Not urgent and not important (Eliminate) – frivolous distractions

 

Looking at personal work in this way can be really helpful, especially when we are all so busy in the NHS. However, on reading this chapter of the book I was minded of how we should be doing a similar prioritisation of the improvement efforts we undertake on a day to day basis. Which projects are the most urgent and the most important? When looking at a system as a whole it is imperative that we understand this as we could waste time working on things that have little impact on the system. This is why measuring is such an important part of QI, as we need to know what to work on to improve and if that change is an improvement.

 

A good theory to reflect on when prioritising improvement work is from Goldratt’s ‘the Goal’ (which is a great book) and is called the theory of constraints. It states that there is a certain order to try things to ensure any changes you make are as efficient as possible. These steps are:

1. Identify the system’s constraint(s). – Find out what the biggest problem is in the process you are trying to effect. This could be the biggest delay for patients on a pathway, or something of this ilk.
2. Decide how to exploit the system’s constraint(s). – Exploit is a horrible word, but looking at what you already have is a great first step. This is not just ‘make people work harder’ it might be asking the people in the team what small changes we can make to effect the main constraint
3. Subordinate everything else to the above decision(s). – This means gearing up the system to the main constraint. If you’re main constraint in an emergency department (ED) is doctors time, for example, there is little point in having an amazing triage service which only ensures the queue before seeing the doctor is massive. You would be better off changing the triage step and giving those carrying out the triage process jobs to take work off the doctor and improve their time to see patients (obviously this would be the other way round if triage was the main constraint)
4. Alleviate the system’s constraint(s). – The last step, as this is usually the most expensive, is to alleviate the constraint, this usually involves added resource to remove the constraint
5. Warning! If in the previous steps a constraint has been broken, go back to step 1, but do not allow inertia to cause a system constraint. – This means, once you’ve done this, go back to the start, as there will likely be a different main constraint in the system.

 

You can see when you walk through these steps, in this order, that cheaper and faster ways to improve are investigated before more expensive and difficult things are tried.

 

This theory is helpful to think about when recording Red and Green bed days if we are recording constraints this is helpful in focussing our minds on the things that will provide us with the most gains in helping with patient flow. The ‘Huddle Data Collection Tool’ (which I discussed in my last blog) Start with the end in mind is the way we are recording constraints going forward. The tool then presents these constraints as a Pareto chart (below), so we can see where the biggest potential gains are in improvement efforts.

 

 

Without this information, we may focus our improvement efforts on something that has a smaller impact (i.e. Quadrant IV). In the coming months (now the tool is being used across our medical wards) we will use this information to help the Trust decide on improvements, that will fall into Quadrant I, to test to improve length of stay.