Model for Improvement Karen O’Keeffe

From Charles Darwin: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”

Three Fundamental Questions for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? To be successful, any improvement effort must start by addressing the three basic questions shown here.

G. Langley, et al The Improvement Guide G. Langley, et al The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996: xxi.

Aim: What are we trying to accomplish? What are we trying to improve, in what time frame ? However, these statements are too broad. These represent the 30 thousand foot view of what you want to do.

Value of an Aim Statement? Answers and clarifies “What are we trying to accomplish? Creates a common language to communicate about the improvement project Provides opportunity to engage others in conversations and understanding of the improvement work In order to gain clarity and something that seems achievable, it is important to define your AIM with some specificity. This is called an Aim Statement and by doing this you can create a shared language and understanding of where you are going with the project.

Aim Statements include: What is expected to happen The system to be improved or the population of patients Specific numerical goals Time frame Guidance for activities, such as strategies for the effort, or limitations Here are the specific things to put into an Aim statement. An example of this from a personal perspective might be something like: I am going to improve my health and energy level by losing 10 pounds in the next two months. I will achieve this by walking with my friend around the lake three mornings a week, cutting out ice cream, and doing yoga on Thursday evenings. Very different than, I am going to lose weight.

Aim Statements – We aim to reduce harm and improve patient safety for all of our internal and external customers. By June 2013 management requires us to reduce the incidence of pressure injuries in A & R by 50% Our most recent data shows we only complete med rec on 35% of disharged patients. We intend to increase this average to 50% by 5/1/13.

2nd Question How will we know that a changes is an improvement Develop measures that reflect the improvement efforts. Use Measure over time – run charts Make measurement intervals as short as possible – weekly instead of monthly – (learn quicker)

Measurement: How Do We Know a Change is an Improvement? Improvement is about making changes to systems; it is about changing an organization’s approach to improving the health of patients. It is not solely about measurement. But we know that improvement is about making changes – not about measurement. So why do it?

3rd Question What changes can we make that will result in improvement ? "All improvement will require change, but not all change will result in improvement!” G. Langley, et al The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996: xxi.

Change Ideas: What changes can we make that will lead to improvement? Key Changes for improved care based on: The best available evidence Knowledge of front line workers Experiences of experts Creative thinking The change concepts are based on the evidence, knowledge and experience we have at this point.

The PDSA Cycle for Learning and Improvement Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection What changes are to be made? Next cycle? Act Plan Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data What do we do in each step of a PDSA cycle? … G. Langley, et al The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996: xxi.

Use the PDSA Cycle for: Developing a change Testing or adapting a change idea Learning how a change will work in different environments or systems Creating belief that changes be effective Learning more about the system

Why test ? Increase belief for team that change will work Learn how to adopt changes in your environment. Document effect change making to overall aim. Develop broader knowledge of your system and effects of changes.

PDSA: Break it Down/Simplify… Plan - Figure out the questions you want to answer, plan a way to answer the questions, and predict results Do - “Just do it” (i.e. do the plan); collect the data Study - What did you learn? Act - What will you do with the knowledge you learned? What do you want to do next? We are going to do a little activity. There is a magical green glass door that will allow some things through and other things not. Your job is to figure out the rule. Sandy will unmute everyone and I will call on people to test different items to see if they will work. If/when you think you know the rule – raise your hand. (Click on the little icon on the bottom left of your screen.) Do not say it out loud. I will start you out with an example.

Revise and Re evaluate Remember that the first changes tried do not always work. (this is a great source of learning) Use another PDSA cycle until it works as expected / predicted.

Tips for Testing Changes Identify changes that will assist the team to reach goals Harvest good ideas and adapt them to your setting Solicit team members ideas Start with changes that are easy to test Collect and study useful data during each test Learn from “failed” tests Eventually test over a wide range of conditions Let’s see how these guys did…

Uh oh!

Well, that didn’t work.

What next?

Hmmm…seems they didn’t learn from the first failure Hmmm…seems they didn’t learn from the first failure. Failures are really important when we are in the testing phase and shouldn’t be something we necessarily try to avoid. In fact…

Failure is just succeeding at learning what doesn't’t work!

Objectives of Cycles for Testing Decide if change will work in actual environment Decide on combination of changes for desired effect Evaluate cost, social impact, side effects Evaluate how much improvement we can expect Increase degree of belief

Successful Cycles to Test and Adapt Scale down size of test (# of patients, location) Conduct the test over a short time period Test with volunteers Do not try to get buy-in or consensus for the test Collect useful data during each test Think a couple of cycles ahead Plan multiple cycles to test and adapt change In later cycles, test over a wide range of conditions

Initially use Smaller Scale Tests: The power of “one” Conduct the initial test with… one facility one office one doc one patient / resident 1

Move Quickly to Testing Changes Year Quarter Month Week Day Hour “What tests can we complete by next Tuesday?” “If you think we can test the change in a month, what can you test a day from now?” Assumptions about Time: 2 Orders of Magnitude LESS teams are most effective when they move quickly to testing changes (& maintain momentum) best to first test innovative changes on a small scale okay to test multiple changes at once test under a variety of conditions importance of linking tests of change don’t try to get buy-in or consensus for tests (but will be necessary for implementation)

On-line Model for Improvement To review the Model for Improvement or share with colleagues, visit the IHI’s website http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

Thank you! Madlen Caplow, Neil Heffron, Brandon Bennett, Lloyd Provost, NICHQ, the IHI and others from whom I ‘shamelessly’ stole some of these slides.

References “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997. “Building Measurement and Data Collection into Medical Practice”, Eugene Nelson, Mark Splaine, Paul Batalden, Stephen Plume. Annals of Internal Medicine Vol 128; no16, March 15, 1998. “How to Take Multiple Measures to Get a Complete Picture of Organizational Performance.” Provost, Lloyd and Leddick, Susan National Productivity Review. Autumn 1993. pp. 477-490. Quality Improvement Through Planned Experimentation. 2nd edition R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. “The Three Faces of Performance Measurement: Improvement, Accountability and Research.” Solberg, Leif I., Mosser, Gordon and McDonald, Susan Journal on Quality Improvement. March 1997, Vol.23, No. 3. “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990. A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.