� Path to Zero Peer Learning Session:.

Quality Improvement Foundations.

Part 2: The Model for Improvement

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June 21, 2023

Who We Are.

Ian Fletcher

Denver, CO

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Rian Watt

Seattle, WA

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Series Overview.

Today’s Learning Objectives.

1. Understand the model for improvement as the ‘improvement theory’ underlying Built for Zero’s work
2. Break down each component of the model for improvement:
1. Components of an effective aim statement
2. Characteristics of a good measurement system
3. How to identify change ideas
3. Use examples to practice working with the model for improvement

Today’s Agenda.

A Short History of Improvement Science & Built for Zero

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The Model for Improvement

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Aim Statements

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Real-Time By Name Feedback

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Types of Measures & Equity Considerations

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Wrap-Up

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� Why You Should Care.

Because none of our communities have ended all homelessness yet, so that means we’ve got to change something.

The question is what.

W. Edwards Deming: Founder of:

Improvement Science:

Q. Why do complex systems so often produce such poor results for those they serve, even when the people involved sincerely want to do better?

A. Because they are bad at learning.

• Improvement Science is a reliable, bottom-up method for improving any system as you go.
• Improvement Science replaces traditional planning strategies with learning strategies.

What is Improvement Science?:

• The most important goal of any system is to learn
• When it comes to learning, the faster the better
• Human beings are generally poor at predicting the future in advance
• Instead, we should take small actions quickly with a prediction in mind, and then revise our thinking in light of the outcomes

What Do Improvers Believe?:

Core Concepts of Improvement

• Every system is perfectly designed to get the results it gets.�
• Be curious.�(this work is for improvement, never for judgment)

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Knowledge for Improvement

SUBJECT MATTER KNOWLEDGE

• Knowledge basic to the things we do in life. Professional knowledge. Knowledge of work processes. Lived experience.

SCIENCE OF IMPROVEMENT (SOI).

• The interplay of the theories of systems, variation, knowledge, and psychology.

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Used with permission from the Institute for Healthcare Improvement

Knowledge for Improvement

Improvement �Learn to combine subject matter knowledge and Structure of Intellect (SOI) knowledge in creative ways to develop effective changes for improvement.

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Used with permission from the Institute for Healthcare Improvement

� The Story of Zero.

Built for Zero.

An international movement of more than 125 global communities working to measurably end homelessness one population at a time.

The Key Lesson of 100khomes.

5%

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4%

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3%

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2%

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1%

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0%

Housing Placement

Rate

The 100,000 Homes Campaign proved that communities could increase their housing placement rates, but this did not automatically reduce homelessness. Only one metric mattered: monthly housing placements.

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Technical Approaches to Complex Problems

• Long-range planning or 10-year plans
• Standard operating procedures
• Embedded experts
• Pilot project obsession
• Summative evaluation followed by replication toolkits
• Criminalization and enforcement
• Meeting just to meet - but doing it weekly!

SOUND FAMILIAR?

The Fundamental Question.

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Are all our programs + investments

adding up to thing we really want:

equitable reductions in homelessness over time?

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And if not, how quickly would we know,

and how quickly could we pivot?

The Challenge of Counting Down.

1000

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750

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500

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250

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0

Built for Zero is designed to help communities count down to zero — �a more complex challenge that requires a clearly defined end state for communities to shoot for.

To end homelessness, communities must measure many variables, not just one.

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Definition: Improvement Theory.

A system of linked ideas about how to

improve some aspect of a system.

The Shift from Technical Solutions to Iteration.

The Model for Improvement was developed by Associates in Process Improvement

and taught to us by the Institute for Healthcare Improvement. Thank you!

� Questions?

Stretch and Screen Break

� The Model for Improvement.

The Model for Improvement

Aim: What are we trying to accomplish?

How will we know a change is an improvement?

What change can we make that will result in improvement?

Think about your commute to work

Improving your commute

Aim: What are we trying to accomplish?

What does a “better” commute mean?

• Are we minimizing time? or stress?
• Do we want to spend more time outside?
• Do we want less driving/more walking?
• Are we willing to spend more money?
• What are the non-negotiables/constraints?

Improving your commute

What measures will we use?

• Time spent commuting decreases?
• # of morning meetings I’m late to decreases?
• # of daily steps walked increases
• Self-rating of happiness increases

How will we know a change is an improvement?

Improving your commute

What change can we make?

• Leave 30 minutes earlier to avoid traffic
• Take a different route
• Take public transportation
• Bike to work
• Carpool with others
• Move Test the commute from a different neighborhood

What change can we make that will result in improvement?

The Model for Improvement

Aim: What are we trying to accomplish?

How will we know a change is an improvement?

What change can we make that will result in improvement?

Sample Improvement Area:�Reduce length of time from resource match to lease-up

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You want to reduce the length of time from identification to housing, but there are many parts of that process. You begin by choosing one segment—match to lease-up—and working to shrink its length of time. You decide to test the change with two or three navigators, in order to shrink the change and see what worked at a small scale.

Reduce time from match to lease

Aim: What are we trying to accomplish?

Improve average length of time from resource match to lease-up to less than one week by May 31, 2022.

Reduce time from match to lease

What measures will we use?

• Average length of time from resource match to lease-up drops below one week.
• Disaggregated by race and by project.
• Balancing measure: Housing placement rate.

How will we know a change is an improvement?

Reduce time from match to lease

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What change can we make?

• Change day of week for case conferencing meeting.
• Change pre-work for case conferencing meeting.
• Invite housing navigators to case conferencing.
• Invite housing providers to meeting.
• What else?

What change can we make that will result in improvement?

The Model for Improvement - Aims

Aim: What are we trying to accomplish?

How will we know a change is an improvement?

What change can we make that will result in improvement?

Components of a Strong Aim Statement

Example: Returns to Homelessness

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Metropolis will reduce returns to homelessness to 5% of the Active List (or 15 people) per month, whichever is larger, by September 1, 2023.

Action:

Reduce

Specific Challenge:

Returns to homelessness.

Number:

5% of Active or 15 people

Universe or Population

Metropolis

By When:

September 1, 2023

The Need for Clear Operating Definitions

• Knowledge is not objective — we all impose pre-existing values and aims onto every system or result
• If we don’t nail down what we all mean by the words in our aim, we may disagree about whether we have achieved, or whether new ideas are necessary at all
• Vagueness in our aims makes it impossible to decide whether any given strategy idea is relevant

Criteria of a Strong Operating Definitions

• All key terms are measurably defined
• Definitions can be applied the same way by anyone
• (The random observer test: “How likely would a random observer be to reach the same conclusion as you about whether your aim had been met?”)
• Definitions are usable and don’t make the aim so complicated that it’s impossible to measure
• Doesn’t have to be ‘right’ or ‘wrong,’ just clear.

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Example: Length of Time Homeless

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Gotham will reduce returns to homelessness to 5% of the Active List (or 15 people) per month, whichever is larger, by May 31, 2024.

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‘Gotham’

90%+ of Gotham Providers representing 90% of people.

‘Returns to Homelessness’

Return from permanent housing to homelessness within one year of being housed.

‘5% of the Active List’

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• 5% of the mean count on the actively homeless list for the three months before May 31, 2024.

Work to scope an effective aim related to something in your daily life in small groups.

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Now you try it!.