Improvement Advisor-20,000 Days Campaign How to Manage PDSAs Prem Kumar Improvement Advisor-20,000 Days Campaign

What VHIU need are more PDSA Cycles Yeah right.

Act Plan Study Do Model for Improvement What are we trying to Aim accomplish? How will we know that a Measurement change is an improvement? What change can we make that Develop Change/ Driver Diagram will result in improvement? Act Plan Study Do Improvement Guide, Chapter 1, p.24 Appendix C, p. 454

All Improvement requires change, but not all changes result in improvement

Act Plan Study Do Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Testing Study Do Improvement Guide, Chapter 1, p.24 Appendix C, p. 454

The Plan-Do-Study-Act Cycle Most Important Part of a PDSA cycle Because with out it we don’t have a comparison for the purpose of learning - Improvement Guide, Chapter 5, p. 97 8

Repeated Use of the PDSA Cycle Changes That Result in Improvement A P S D DATA D S P A Implementation of Change A P S D Wide-Scale Tests of Change A P S D Follow-up Tests Hunches Theories Ideas Very Small Scale Test Improvement Guide, Chapter 7, p. 146 9

The work of improvement Primary Driver 2 Change Idea 1 Change Idea 2 Change Idea 3 Primary Driver 1 Change Idea 1 Change Idea 2 Change Idea 3 Primary Driver 3 Change Idea 1 Change Idea 2 Change Idea 3

Challenges with Multiple PDSA A Visual track of each PDSA Alignment of PDSA to drivers Timeliness of PDSA Who is doing the PDSA How to manage the knowledge generated

PDSA Tree Adopt Abandon Adapt PDSA 1 PDSA 2 PDSA 3 PDSA 4 PDSA 5 Change Idea PDSA 4 PDSA 5

Establish GDD & Daily Review Transition of Care PDSA Tree Date: 27/11/2012 Reviewed 27/02/2013 Pt awareness on GDD Staff awareness on GDD Check consultant aware of GDD in mind Doc to use care plan to review GDD-Ruth/Michele 5/12 Is the GDD documented on care plan? GDD mentioned in notes # of clinical directors believe in establishing GDD GDD given to surgical pt and any plans documented Pt awareness on GDD-Surgical Patient & Family Drs Staff Other Services Update GDD on white board Update GDD on WiMS DOC to use care plan for updated GDD info Nurse to inform Pt- Ruth Ascertain ref process in ward 6 Delay in x-fer to AT&R Referral system assessment & documentation from acute to AT&R Early Dx if Pr referred to NASC earlier E-referral – Erin 5/12 Timely task referral GDD in MDT meeting Nurse setting the GDD GDD match with actual Dx date Reasons of Pt waiting on Bed CAT tool to indentify why Pt waiting CAT tool usefulness Post ward round delay in services for Pt > 7 days Pt less than 48 hour Repeat PDSA Active PDSA Adopt Adapt Abandon What's Happening PDSA box Identifying Pt need @ admission in EC (Ajay Kumar/ Fionna W) Staff to set a GDD based on the top 10 DRGs-Michele 5/12 GDD by Doc post acute ward round – Brian 17/12 Reason of GDD not met-Ruth& Michele 12/12 Cultural Support to inform – Maika/Ian 23/12 Doc reviewing /confirming GDD-Ajay 5/12 What ref system are available in service dir. Identifying Pt need @ admission in EC 4 pts (Ajay Kumar/ Fionna W) 13/1 GDD in ward 33 Janene & Michele 23/1 Discharge to HHC Process Map Janene/Michele 23/1 Known patient dx communication to HHC Owner: Prem Kumar HHC to receive Dx list twice daily Repeat with interventions 10/5 Dx Checklist Clivena/Helen 10/4 Visual Display of GDD-Surgical Test the checklist for ref to DN 27/3 Surgical Add time of Dx Surgical-17/4 To attend CN meeting Dx Summary ?? GDD orientation to HO rotation 17/4 Checklist/Process map in notes 17/4 Fionna GDD assigned in EC-Fionna Establish GDD & Daily Review To have a standardised process to provide each patient with a GDD How and what is the best way to establish a GDD? process to share GDD Best way to communicate the GDD to patient and interested parties? Achieving the GDD To have the processes in place to achieve the GDD How can we achieve the GDD as a team Sharing GDD Who, How, When? Focus Timeliness Responsibility Direction Meeting Minutes Focused learning Visual display PDSA Feedback Goal Discharge Date Aim: To improve the number of inpatients having GDD from 0% to 100% also To increase the number of inpatients achieving the GDD for from 0% to 100% by July 2013. Prediction: GDD will improve the patient experience and efficiency. Also this will reduce the LoS

Michael Jordon Failure- a learning opportunity “I missed more that 9,000 shots in my career. I’ve lost almost 300 games. 26 times I’ve been trusted to take the game-winning shot….and missed. I've failed over and over and over again in my life. And that is why... I succeed." Michael Jordon

Finding the right socks at right time problem solving Every morning find the right colour socks with in 5 seconds * Right Colour Right Socks * Time to find the socks * The mess created * My satisfaction* * After wash placement time Idea that worked

PDSA Simulation

Please decide at your table Who will be: Time Keeper Quality Assurance Officer Data Analyst

PDSA Measures Accuracy Time Start: When time keeper says go. Stop: When Assembly indicates last piece is in place AND removes hand. 3 – All pieces on Mr. P & positioned correctly 2 – All pieces on Mr. P, but one or more is out of place 1 – One or more pieces are not on Mr. P.

Plan   Do Study Act PDSA Cycle # Level Test Cycle Aim Test Cycle Measures/Learning Questions Predicted Cycle Outcomes Capture Relevant Data Observations expected/unexpected Results Test Cycle Learning Test Cycle successful Yes/No Action Taken Alternate Pathways Uncovered Test Cycle completed Yes/No If No, reason 1  2  Start with feet and work to top  Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy  Time = 120sec Accuracy = 3 2

Plan   Do Study Act PDSA Cycle # Level Test Cycle Aim Test Cycle Measures/Learning Questions Predicted Cycle Outcomes Capture Relevant Data Observations expected/unexpected Results Test Cycle Learning Test Cycle successful Yes/No Action Taken Alternate Pathways Uncovered Test Cycle completed Yes/No If No, reason 1  2  Start with feet and work to top  Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy  Time = 120sec Accuracy = 3  Time = 2.37  Struggled to get pieces organized in order. 2

Plan   Do Study Act PDSA Cycle # Level Test Cycle Aim Test Cycle Measures/Learning Questions Predicted Cycle Outcomes Capture Relevant Data Observations expected/unexpected Results Test Cycle Learning Test Cycle successful Yes/No Action Taken Alternate Pathways Uncovered Test Cycle completed Yes/No If No, reason 1  2  Start with feet and work to top  Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy  Time = 120sec Accuracy = 3  Time = 2.37  Struggled to get pieces organized in order.  Time improved by 20 sec. Accuracy improved from 2 to 3  Organization of parts helps time & accuracy.  Yes 2

Test Cycle Measures/Learning Questions Predicted Cycle Outcomes Plan   Do Study Act PDSA Cycle # Level Test Cycle Aim Test Cycle Measures/Learning Questions Predicted Cycle Outcomes Capture Relevant Data Observations expected/unexpected Results Test Cycle Learning Test Cycle successful Yes/No Action Taken Alternate Pathways Uncovered Test Cycle completed Yes/No If No, reason 1  2  Start with feet and work to top  Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy  Time = 120sec Accuracy = 3  Time = 2.37  Struggled to get pieces organized in order.  Time improved by 20 sec. Accuracy improved from 2 to 3  Organization of parts helps time & accuracy.  Yes  Next test to include ordering pieces. Need to set order before test.  None  N/A

3 – All pieces on Mr P & positioned correctly Time 140 X 120 100 Seconds 80 60 40 20 10 1 2 3 4 5 6 PDSA 3 – All pieces on Mr P & positioned correctly 2 – All pieces on Mr P, but one or more is out of place 1 – One or more pieces are not on Mr P. Accuracy 3 2 1 X 4 5 6 PDSA

PDSA Tree PDSA 1 PDSA 2 PDSA 3 PDSA 4 PDSA 5 Time Adopt Abandon Adapt Aim Time Adopt Abandon Adapt

We need a volunteer

Accuracy 3 – All pieces on Mr. P & positioned correctly 2 – All pieces on Mr. P, but one or more is out of place 1 – One or more pieces are not on Mr. P. Time Start: When time keeper says go. Stop: When Assembly indicates last piece is in place AND removes hand