Scottish Improvement Skills Leading change: From testing to implementation

System of Profound Knowledge Appreciation for a System Understanding Variation Theory of Knowledge Psychology In this module we need to consider all four components of Profound Knowledge: Variation, because we need to interpret our data to help us decide whether we are ready to move on to the next stage of our improvement journey. Psychology, because we’re talking about how we lead people through an improvement journey, from one project stage to another Theory of Knowledge and Appreciation for a System because our progress depends on having a good understanding of our context and the features of our system. All of them because we are continually working through PDSA cycles. Deming 2000

Leading change: from testing to implementation By the end of this session you will be able to: Describe typical stages in an improvement journey - testing, implementation and spread Make decisions based on learning from PDSA cycles and data analysis Demonstrate understanding of when to move from testing to implementation Draft an implementation plan. Learning outcomes – Lead facilitator read out or participants read. Leading and managing improvement projects is a huge area – we worked on some issues in Workshop 1 eg influencing, communications, stakeholder management. Today we are going to focus on some issues directly relating to data and measurement for improvement: The improvement journey – we’ll look in more depth at PDSA cycles and the role they play at different stages of an improvement project

An improvement journey A P S D Identify opportunity for change Plan Test Sustain the change Implement Hold the gains Spread DISCOVERY Aim Participants can list the stages in an improvement journey and identify at any point in their project which stage they are at. Key messages Stages of an improvement journey, as in this slide and next. Features of the three key stages Timing 15 – 20 minutes (through to end of testing, implementation, spread activity) - 5 minutes (Improvement journey, Examples) 10 minutes (testing, implementation, spread activity) Materials Arrange the furniture so that there is space for all participants to stand in the middle, and to go to three different areas for the testing, implementation, spread activity. Corner labels TIC Blu tac Features of testing, implementation, spread Lead facilitator These are some of the steps that you may go through on an improvement project. Depending on the initial objectives of an improvement project, and their relevance beyond the team that initiated the project, you may go through some or all of these. Last time we focussed on the first 3 steps. Now we are briefly going to look at some of the others. PDSA cycles are a feature of ALL stages in the journey.

An improvement journey A P S D Identify opportunity for change Plan Test Sustain the change Implement Hold the gains Spread Now we’re going to look at some of the broad differences between these 3 stages in the journey, before looking at testing and implementation in some more detail.

Examples of change: medicines reconciliation Testing Implementation Spread 3 nurses on one ward use a new reconciliation and order form All 30 nurses on the unit use the new medication and order form Nurses from the ‘pilot’ unit assist all nursing units in the organisation to adopt or adapt the change Lead facilitator Examples – briefly talk through slide. Refer to these examples during the following ‘features’ task. Decide if each of the following features of an improvement journey is Testing, Implementation, or Spread (could be more than one)

Testing? Implementation? Spread? Failure is a useful, natural part of the improvement process. PRACTICE Lead facilitator Do this example in plenary while still seated. Is this a feature of Testing, Implementation, or Spread – or more than one of these? Elicit responses and ask participants to give reasons. Then all participants stand in the middle of the room. Facilitators put corner labels up ready for the next item – as far apart as possible in parts of the room that are accessible, where a large cluster of participants can gather Lead facilitator read out the feature. Participants go to the stage label where you think it most applies. You can be between labels if you think the feature is common to more than one. Discuss with others in the same place – do you have the same reasons for being there? Plenary debrief. Facilitators If a participant is on their own at any point, a facilitator join them and ask them to explain their reasons. Then bring all participants to the middle again, and repeat with the next item. It is unlikely that you will need to use all 7 items. 3 or 4 are usually enough. Decide which ones to use based on the discussion generated by previous items. At the end of the activity give out the Features document. Make sure that issues highlighted during this activity are consistent with this summary document. Ask participants to have a quick look at it and ask questions if anything is not clear.

Testing? Implementation? Spread? The change becomes part of the routine operation of the unit.

Testing? Implementation? Spread? Work out how to explain the benefits of a change beyond the unit.

Testing? Implementation? Spread? Use PDSA cycles.

Testing? Implementation? Spread? Learn what works in your system.

Testing? Implementation? Spread? Change is not permanent.

Testing? Implementation? Spread? Develop infrastructure (eg policies, job descriptions, SoPs) to maintain the improvement.

Test cycles: Act on your learning Abandon the change Modify the change Increase the scope of the change Test the change under different conditions Stop collecting data Implement the change DISCOVERY Aim Participants can recognise when their project (or one change idea in the project) is ready to move from testing to implementation Key messages Three criteria for implementation Timing 7 minutes, including PDSA ramps Lead facilitator Now looking in more detail at Testing, and Implementation. Once your have Studied your data in each PDSA test cycle, your Act stage should include a decision to take action in one of these ways. Your decision will depend on 3 things: see next slide

Three criteria for implementation High degree of belief that a change will result in improvement Small cost of failure The organisation is ready to make the change. Lead facilitator If these criteria are all true, you are ready to move on to the implementation stage. This slide is a summary – the next slide goes into more detail.

From testing to implementation Cost of failure Current commitment within the organisation None Some Strong Degree of belief that change idea will lead to improvement Low Large Very small scale test Small Small scale test High Large scale test Implement Lead facilitator Expand on the previous slide Moving to Implementation should only be considered if these 3 criteria apply: The team has a high degree of belief that the change will result in improvement The cost of failure is small ie risk is low, losses from a failed test are not significant The organisation is ready to make the change. Implementing a change includes (summarise some of the issues arising from T/I/S activity) Makes the change part of routine for the whole unit Continues to use PDSA cycles Requires more time than testing More people are involved, so challenges are often related to people’s reactions to change Adapted from: The Improvement Guide p146

Sequential building of knowledge A P S D Implementation cycles Learning and Improvement Wide scale tests Test new conditions Follow up tests For one change idea, we would expect to go through a series of PDSA cycles before we are ready for implementation. This is called a ‘ramp’ of PDSA cycles. Each change idea will have its own ramp. Some may never reach implementation, if you learn that this change doesn’t lead to the improvement you are looking for. Small scale test Very small scale test Develop a change

ICU: Reduce Length of Stay Aim Primary Driver Secondary Driver Change idea Reduce average length of stay in Central General ICU by 20% by March 2015 Assessment and management of sedation and agitation Improved management of delirium Validated sedation tool Appropriate sedation Incidence of acute cognitive dysfunction Structured daily sedation breaks Staff information leaflets Staff training sessions Improve multidisciplimary team communication Assess sedation and agitation using the RASS tool (Richmond Agitation Sedation Scale) Use ear plugs to improve sleep Use Dexmedetomidine as alternative to benzodiazipines Develop and follow guidelines for daily sedation breaks Assess for delirium using CAM-ICU (Confusion Assessment Method for ICU patients) Investigate and correct underlying causes Include delirium as part of safety brief Medical staff and family jointly keep an ICU diary Improved identification of delirium Validated delirium tool Staff education Care bundle initiated within 2 hours of diagnosis Engage with patient/family/carer Mobilise patients earlier and more frequently To contextualise an example of ramps: ICU Length of Stay Refer back to the module Planning with PDSA case study and project: we looked in detail at some PDSA cycles relating to staff training. Now we are going to look at how we might work on that and the other two change ideas highlighted here - more information about this on the following slide – PDSA ramps.

PDSA Ramps A P S D A P S D A P S D Education package RASS scoring tool Develop content Restructure content – 2 staff nurses Test with 1 staff nurse Revise wording – 1 nurse Test with all staff Education package A P S D Develop tool Amend tool (colour) & test at 1 bed space Test at 1 bed space Test at 2 bed spaces Amend tool (wording) & test at 1 bed space RASS scoring tool A P S D Develop poster Move poster so not obscured when doors opened Display outside ward Layout of poster more readable Size poster to fit space Poster for families Key messages To increase the pace of change test 2 or more change ideas at the same time – the different ramps may be at different stages ie one may reach implementation before others Collecting data for too many measures can reduce the time people have to devote to testing changes – so collect just enough data. Collect qualitative as well as quantitative data, particularly during very small scale tests - V small scale means that changes in quantitative measures may be v small

Building knowledge: your project How could you increase your degree of belief? What different conditions could you test your change under? Which change ideas could you work on at the same time? How could you minimise the cost of failure? How could you better make your department/organisation ready for the change? PROJECT (OPTIONAL) Aim Participants think through these questions in relation to their own project Timing 10 minutes Materials Ask participants to bring their own project documents including driver diagram and PDSA reports, and stakeholder analysis or communications plan Facilitators Check in with each participant to make sure their thinking will help move their project forward. If no time: this provides questions to consider about your own project, once back at work.

Components of Implementation Standardisation eg policies, procedures Documentation eg job descriptions Training Measurement Resourcing eg equipment purchases PRACTICE Aim Participants can list the tasks to be carried out as part of implementation Key messages PDSA cycles continue A lot of work still to be done Increasing importance of attention to Psychology as more people get involved Timing 20 - 30 minutes Materials Implementation planning template Example of this implementation planning sheet, completed. Implementing change People issues Lead facilitator These are the components of implementation that need to be addressed in all improvement projects, for any change idea.

Aim: promote staff wellbeing Aim 1 Driver 2 Driver Change ideas Staff complete safety climate survey Promote the physical, mental and emotional wellbeing of staff. By March 2017: (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. Environment Action planning from survey Lean visual management of cupboards, notice boards etc A workplace that is safe for staff Activity Use and location of hand gel dispensers Staff able to focus as required Schedule regular team huddles We are going to look at an example based on this case study, for the ‘hand gel’ change idea Leadership training for team leads People Staff engaged in health and wellbeing practices Offer Bereavement support programme for managers

Components of Implementation Standardisation eg policies, procedures Documentation eg job descriptions Training Measurement Resourcing eg equipment purchases Lead facilitator Participants work in groups of 3 - 4 Read the different items on the example that need action. Discuss: - Sequence – what are the interdependencies, what would need to be done before some others could be done? (depending on time available, you might ask for numbering of PDSA cycles across the whole list) - What issues would you need to consider, particularly with respect to the People issues, and how would you deal with these? Allow time for everyone to read the example, then elicit immediate ideas on sequencing, as an example of the kind of thing that groups should be discussing. Facilitators Monitor the room, respond to any participant queries, check in from time to time and intervene as necessary. Plenary debrief. Focus debrief on: Practical issues re sequence – what did participants identify? What are the key people issues, and how would participants deal with them? It may be too early in some participants’ projects to be applying this now, but highlight that they should start considering whether they are ready for this with a single change idea. Optional Activity if time and if participants are expected to be moving on to implementation soon: Use the Planning template to act as a checklist PDSA reports for each ramp that you identify. For example use the sequence of 5 PDSAs for the ICU case study (used in module Planning with PDSA case study and project), and the ramps above In pairs or small groups, use these to develop an implementation plan. Use the planning template, and refer to the example and Implementing a change docs. Do one example in plenary to get them started.

Leading change: from testing to implementation: summary An improvement journey Criteria for implementation PDSA ramps Components of implementation Aim To briefly recap the session content: - to support a sense of learning and accomplishment - to aid memory of the session later An opportunity for participants to ask any outstanding questions from any part of the session. Timing 2 – 5 minutes, depending on time available Lead Facilitator Elicit what content was covered for each of the bullets eg: What are the key stages in an improvement journey? What are the three criteria for implementation? How many of them need to apply to move on to implementation? How many PDSA ramps might you work on at the same time? (more than 1) What are the five components of implementation that you need to work on? How many PDSA cycles are you likely to need during implementation? (lots)