Finishing What We Started Carol Haraden, PhD This presenter has nothing to disclose. April 11, 2014

Coverage and Completeness Coverage: the improvement has been implemented in every clinical setting that will benefit patients Completeness: the improvement creates the same superior results in every clinical setting that will benefit patients

How are we doing with this? What are the barriers? What helps? 3

4 Think of a change you have implemented. Have you been able to spread this change everywhere you want? (coverage) Were you able to sustain the initial improvements at all spread locations? (completeness) If you answered no to the second or third question, why didn’t your efforts succeed? Dialogue #1- 3 minutes

Improvement Hold Gains Spread Creating a New System Design Spread Improvement Hold Gains Spread Old Way New Way

The Sequence of Improvement Sustaining improvements and Spreading changes to other locations= coverage and completeness Developing a change Implementing a change: spread Testing a change: prototype, pilot ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations

How Can We Foster the Adoption of Successful Change Ideas? The Traditional Approaches Policy Manual Date: February 2014 To: All Staff From: Management Starting next Monday, all staff will be expected to implement the new procedure we just tested in the 3 West med/surg unit. It worked there so in order to save time, everyone will now start doing the new procedure like 3 West. Thank you for your cooperation.

An Early Adopter

Will this be one of your team members? SEPSIS Bundle

Clarify “Where” We Spread What is your level of our ambition? – Every unit or ward in a hospital? – Every service line (clinical & operations)? – Every hospital in a system or region? – All primary care clinics? – All inpatient and outpatient mental health? – All levels of care across a population?

1. Consider the change you discussed in Dialogue #1 OR a change you plan to make in the near future. 2. Identify all of the locations and/or people who will need to make that change. For example: all ORs, primary care practices, med-surgical units 3. Do you have a robust prototype that serves as an example of success? How do you know? If not, STOP HERE! 11 Dialogue #2 - 3 minutes

Sustaining improvements and Spreading changes to other locations= coverage and completeness Developing a change Implementing a change: spread Testing a change: prototype, pilot ActPlan StudyDo Teams test and improve Spread planned and executed by senior leaders Results tracked by front line and leadership Improve ment strategic

Focus at Each Step Sustaining improvements and Spreading changes to other locations= coverage and completeness Developing a change Implementing a change fully one clinical area Testing a change: prototype, pilot ActPlan StudyDo Focus: Stabilize process reliability, frontline notice and improve variation: measure outcomes Focus: spread to new and sustain at previous; frontline notice and improve variation Focus: Improve process reliability; reduce common cause variation; measure and reflect daily; outcomes when process

14 FocusVariationMeasure Testing in prototype and pilot Process ReliabilityFrontline notice and manage -Process daily and reflect daily -Outcomes: unlikely to see change until greater coverage Implement in one clinical area -Process reliability under varying conditions -Improved outcomes in clinical area Frontline notice and manage -Process daily and reflect daily -Outcomes unlikely to see change until greater coverage Spread to all relevant areas -process reliability sustained in previous areas -outcomes improving at scale -Leadership notice and manage across system -Frontline notice and manage in area See next slide

How long do we measure? Daily till stable Weekly x 6; if stable then: Biweekly x 4; if stable then: Monthly x 4; if stable then Quarterly, no less Variation within clinical area? Manage in area Variation across clinical areas? Leadership investigates and manages 15

The Seven Spreadly Sins (If you do these things, spread efforts will fail!) Step #1 Start with large pilots Step #2 Find one person willing to do it all Step #3 Expect vigilance and hard work to solve the problem Step #4 If a pilot works then spread the pilot unchanged Step #5 Require the person and team who drove the pilot to be responsible for system-wide spread Step #6 Look at process and outcome measures on a quarterly basis Step #7 Early on expect marked improvement in outcomes without attention to process reliability

Consider an example where a change has spread poorly. Did you commit any of the 7 Spreadly Sins? (see previous slide) Which one(s)? Dialogue #3 - 4 minutes

Maturity Model of Improvement (under development) Steven J. Spear – High Velocity Edge LevelCharacteristics 5 Leaders lead Leaders actively engaged in leading changes 4 Leaders cheer Systems change organically creating value as they do 3 Spectator x3 Systems stabilized; episodic process improvement 2 Spectator Adopting tools and systems 1 Buffers Some standard work 0 Chaos “Winging it”

Maturity Model of Improvement (under development) Steven J. Spear – High Velocity Edge LevelCharacteristicsDescription“Results” 5 Leaders lead Leaders actively engaged in leading changes Leaders work with teams to create improvement in the work areas. Leaders as coaches. Continuous improvement system throughout organization New levels of performance. Breakthroughs attained 4 Leaders cheer Systems change organically creating value as they do Local microsystems complete the work and solve problems and improve processes daily. Continuous PDSA cycles. Pockets of continuous improvement Leaders showcase work of top performers Islands of excellence 3 Spectator x3 Systems stabilized; episodic process improvement Repeated process re-build “Experts return Improvement occurs. Staff maintains, but does not continue Sporadic good results, many sustained 2 Spectator Adopting tools and systems Chartered teams, Kaizen’s, redesigns as organizational initiatives. “PI team leaves, project ends” No improvement beyond initial level Same projects repeated again and again 1 Buffers Some standard work People in roles standardize their individual work (ex. Charge nurses, chief residents, managers) Local order, system chaos; People and systems act as buffers. Small improvements –not replicable or sustained “Positive Deviants” lead small workgroups and units 0 Chaos “Winging it” Daily work, daily problems No processes, random variation No improvement

20 Adopters may need to “reinvent” the interventions. Key strategy to get early adopters from decision to action? Identify issues that are barriers to adoption and remove Goal: coverage AND completeness The spread process needs to be managed Langley J. Nolan K. et al. Improvement Guide. Jossey Bass, Some Thoughts on Spread

Develop the Measurement and Feedback System

Tracking the Spread of Specific Ideas Across Multiple Sites Pilot 1 Pilot 2 Spread 1 Spread 2 Spread 3 Progress Score ABCD ABCD ABCD ABCD ABCD VTE Prophylaxis x x x x x Sepsis x x x x x Unit Briefings x x x x x VAP x x x x 0 Hazard Drug/Area # 1 x x x x x Early Warning Systemx x Reconciliation x x x x x Pressure ulcers x x x x x Central lines x x x x x Patient Involvement x x x x x Simulation x NANA NANA NANA NANA Legend: A= Planning B= Start C= In Progress D= Fully Implemented

Don’t be a slave to the plan! You will learn a lot that may require a change to your plan Don’t be frustrated by having to back up and reevaluate - just don’t take forever! – Change takes longer than you thought! – Some units want the change NOW! – Some never want it!

25 Good luck with your journey! Spreadland