Charter Template (Note: the charter portion of this template is Appendix 1 in Pre-work and is most often a word document) What are we trying to accomplish? General Description (briefly defines WHAT broadly) Reason for the Effort (Problem statement; defines WHY) Expected Outcomes (defines WHAT specifically, still not HOW) How do we know that a change is an improvement? Measures: define the measures that will be used to monitor the impact of this 3-6 MONTH improvement project What changes can we make that will lead to improvement? Team composition.

Driver Diagram Examples Includes template and definitions

Driver Diagram Definitions: A Driver Diagram is an improvement tool used to organize theories and ideas in an improvement effort. It displays visually, our theory about why things are the way they are and/or potential areas we can leverage to change the status quo. The driver diagram is often used to scope or size a project and to clarify the plan for reaching the aim. Primary Drivers: major processes, operating rules, or structures that will contribute to moving towards the aim Secondary Drivers: elements or portions of the primary drivers. The secondary drivers are system components necessary in order to impact primary drivers, and thus reach project aim. Specific changes /Change concepts: Specific changes are concrete actionable ideas to take to testing. Change concepts are broad concepts (e.g. move steps in the process closer together) that are not yet specific enough to be actionable but which will be used to generate specific ideas for change. Note: measures can be indicated on the DD as it becomes more mature.

Driver Diagram

Driver Diagram John W. Young, MBA RN National Association of Public Hospitals and Health System

Ann Brown, Wave 23

Improving Colon Cancer Screening at Internal Medicine Faculty Practice Specific Changes: Primary Drivers: Secondary Drivers: Link colonoscopy database with EMR for automatic result reporting into the flowsheet Generate bimonthly reports of colon cancer screening rates and actions taken by providers and work toward goal rate of 80% Identify patients who should have colon cancer screening and have not received it Aim Preventive care EMR flowsheet (individual patients @ each visit) Decrease Waiting time between referral and colonoscopy Waiting time for results of colonoscopy Increase Colon cancer screening rates Direct colonoscopy referrals through EMR Results of colon cancer screening in EMR Whole panel performance reports Create a referral form for Direct colonoscopy in the EMR Create a benchmark for time from referral to colonoscopy schedule (access to test), and time from referral to Navigator completed all necessary steps (efficiency of program) and work towards benchmark goal Increase access to colonoscopies Use Direct colonoscopy Navigators (facilitated communication, preps, directions, scheduling) Referral to Direct colonoscopy from inside the EMR Facilitate delivery of evidence-based care in colon cancer screening Communication/care coordination between GI and referring PCP (f/u interval, pathology findings) Review current workflowof result communication in the EMR Develop workflow that minimizes data entry by referring provider Calie Santana, Wave 21 9-22-07 IHI

Improve Severe Sepsis Care and Reduce Sepsis Mortality Primary Drivers: Secondary Drivers: Specific Changes: Uniform Sepsis Screening/Sepsis Screening tool Identify severe sepsis early in ED patients ?? Desired Outcomes: Education/communication to frontline staff Decrease Mortality Complications Costs LOS Improve Sepsis/Severe Sepsis Bundle Compliance Early recognition of severe sepsis/septic shock Recognizable, reliable language standards for sepsis care Provide appropriate, reliable and timely care to patients with sepsis/severe sepsis using evidence-based therapies Sepsis Algorithm and Standard Order Set Bundle elements: Antibiotics within 180 mins and after blood cultures Serum lactate w/in 30 min Fluid challenge eligibility/delivery Contingency team for 1st 24 hours of sepsis trigger Coordination of treatment services Organized team methodology for patient care transitions Pharmacy Create team process to support sepsis therapies Caregiver communication Lab Josephine Melchione, Wave 21

Medication compliance in stroke patients by 50% Primary Drivers Secondary Drivers Change Concepts Specific Change Ideas Knowledge of medications Discussing medication benefits and side effects Eliciting concerns and questions Focus on the outcome to a customer Listen to customers Reach agreement on expectations Coach customers to use a product/service Optimize level of inspection  Script to aid discussion Shared decision making model Document decision of patient/carer SALT assessment of identify best means of communication Patient/carer satisfaction and experience of medication discussions and usage Effective communication Communication aids for aphasic patients Involve carers Medication Delivery System For those with cognitive impairment For those with functional limitations Patient choice Use reminders Use differentiation Use constraints Use affordances   Follow up compliance check(need to decide OPD, telephone call, home visit, questionnaire, etc) Documentation of how medications will be taken and delivered Coordination of care Incorporate into weekly MDT meeting Ensure medications dose, frequency, route and patient decisions stated on discharge letter to GP Standardization Desensitize Improve predictions Develop contingency plans Manage uncertainty, not task Match amount to need  Document in case notes Document in discharge letter to GP Aim Improve Medication compliance in stroke patients by 50% Asan Akpan, Wave 21

Driver Diagram for Reducing In-Patient Falls Aim Primary Drivers Secondary Drivers Specific Changes to Test Reliable Assessment Good/reliable tools for assessment Staff awareness/education Reduce Inpatient Falls on 4Cand 6WReduce falls to <3.5/1000 patient days and reduce moderate or higher harm from falls to <0.1/1000 patient days Staff trained and know how to use assessment tools Falls noticed board/story board Process Measure % Pts with falls risk assessment every 8 hrs. Timely assessment Care plans are easy to use Reliable Care Fallsafe Care Bundle Care plans regularly updated Use of pressure pads Process Measure % of patients with evidence of hourly rounding Appropriate level of monitoring/supervision of patients cctv or mirrors in corridors Use of sitters for some patients Outcome Measures -Patient days between falls -Patient days between a harmful fall -The rate of falls per 1000 patient days -The rate of harmful falls per 1000 patient days -$ revenue loss avoided due to fall reduction Patient and Family Centered Care Willingness of patient and carers to cooperate Physical strength/stability Mental health Process Measure: % Pts who can verbalize their role in fall prevention Frailty Slipper socks Patient Condition Patient understanding of their own abilities New signs on doors easier to read Adapted from Gavin Sells, NHS Scotland, Wave 24 2011/2012 Used with permission. Patient understanding of their own abilities

Example: Another way to organize change package: Driver Diagram Driver Diagram: Improving Outcomes for High-Risk and Critically Ill Patients Specific Changes: Primary Drivers: Secondary Drivers: Rapid Response System Identify & rescue worsening patients See next page Early Warning System Provide appropriate, reliable and timely care to high-risk and critically ill patients using evidence-based therapies Protocols and Standing Orders Example: Another way to organize change package: Driver Diagram Desired Outcomes: Bundles Decrease Mortality Complications Costs Improve Satisfaction Care planning Create highly effective multi-disciplinary team Reliable communication Family involvement Clarification of wishes Integrate patient & family into care so they receive care they want End of life care Consistent care delivery Flow Develop an infrastructure that promotes quality care Driver Diagram IG: PP. 286,412,429 Leadership Financial Stewardship