Chunking Up The Problem

With thanks to Karen Chivers, Trainee Consultant Practitioner

Healthcare is complex and the challenges we face on a daily basis are often longstanding and difficult to solve. They’re what Mary Dixon-Woods[1] refers to as ‘big hairy problems: the type that require many different interventions being made in some or many different parts of our service, whether this is how we deliver direct patient care, how we support its delivery, how we commission its delivery.

Our trainees are often ‘assigned’ problems like this to ‘sort out’ whilst they are learning to use quality improvement methods and, because they are ‘too big and hairy’ our first task is to help them identify some aspect of the problem that they can make a start on. And this is just the situation Karen Chivers faced when she took up a new placement as a Trainee Consultant Practitioner in a busy Emergency Department.

Sorting out pain relief for patients may sound simple, but doing this for someone with frailty who has fractured their hip and is waiting in a busy Emergency Department in Winter is a challenge in itself. Add to this the pressure of meeting the A&E target, the need to move the patient to x-ray and back before admission, and the fact that the team that had recently been brought together from two different locations added many more layers of complexity.

It was clear that Karen needed to identify an aim for pain relief that was within reach of her and her team in the Emergency Department. To do this she firstly needed to acknowledge and exclude things that were outside of their control such as pain relief or physical assistance given by a doctor or paramedic before admission. Secondly she needed to establish an aim for patients that staff in her unit would aspire to and sign up to. After creating a process map and collecting some initial diagnostic measurements she decided that a reasonable aim would be ‘to establish a pain block within 2 hours of admission to the Emergency Department’.

The next step was for Karen to chunk up her aim into smaller pieces so that she would have a chance of identifying interventions that might, when combined, deliver the changes required to meet her aim. Karen’s QI Coach, Nikki Davey, asked her about the things that she knew needed to happen to drive care towards the agreed aim. Nikki then captured her answers in a Driver Diagram. Karen identified four primary drivers:

  1. Authority to administer a pain block.
  2. Enough competent staff.
  3. Suitable location.
  4. Equipment and medicine.

By doing this is became clear that the first two drivers had their own set of dependencies. Authority to administer the block had not been established with the new combined team: A new policy was required, procedures needed to be agreed, and alternative approaches such as Patient Group Directions would need to be considered. They also required sufficient staff in the new combined team with the knowledge, skills and confidence to give pain blocks in the way that was agreed – and of course this then highlighted some more dependencies: the need to define and assess competency, provide training and the opportunity to practice, possibly via simulation.

Faced with such a diagram, you may think that Karen felt overwhelmed. But this was not the case…. Instead she could see the size of the challenge, and work out which pieces she might be in a good position to influence, and which pieces she would have to escalate.

quality improvement clinic blog post - using driver diagrams

“I have found driver diagrams useful and feel confident in sharing with others to show the benefits of using a driver diagram to solve problems and create solutions”





Another benefit of using a driver diagram is that it helped Karen identify places in the change process where she could use measurement for improvement to quickly establish whether or not she was making progress. In this instance Karen chose to use the number of staff trained and the number of staff competent to perform the pain block. An outcome measure would of course be the number of patients receiving pain block within 2 hours, but this takes time – and so getting early sight of the process measure gave Karen confidence that she was making progress towards her goal.

“Even though the problem may seem insurmountable, by dividing the issues into separate compartments, it made all seem more achievable. It was surprising that there was an overlap in some issues but these were easy to sort out. The driver diagram could also identify areas where there could be a ‘quick win’ but would help the overall project.”


Whilst addressing these specific challenges may not be enough to guarantee meeting the aim on a regular and sustained basis, using this method allowed Karen to establish actions necessary to get the desired effect. She could also see why these types of diagrams are also known as ‘action effect mode diagrams’ – and read the literature to understand the concept and technique more deeply.

Karen appreciates how working with Quality Improvement Clinic has instilled confidence and belief in using quality improvement methods.

“Through coaching from the Quality Improvement Clinic I have been able to tease out pertinent points and therefore develop a quality improvement initiative which was successful. Even though there have been situations where I have felt that the project I was undertaking did not fit quality improvement methodology after discussion I have been able to apply learning into practice.”


[1] (6.01mins)