Segmentation in Reliability Design (Application of the Christensen Model) Roger Resar April 2006

Building of Descriptive Researcher must pass through it in order to develop more advance theory Consists of three steps Observation Classification Defining relationships Clay Christensen Harvard Business Review

Anomalies will need to be observed Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statements of association Categorization based on attributes of phenomena Anomalies will need to be observed Observe describe and measure the phenomena Descriptive Theory

Reliability Descriptive Theory 3 Tier approach when applied to radiology interpretations in the ED achieved a high level of reliability Nolan et al JAMA

Anomalies will need to be observed Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statements of association Categorization based on attributes of phenomena Anomalies will need to be observed Observe describe and measure the phenomena Descriptive Theory

Current IHI Normative Theory To Achieve a 10-2 Level Reliability Based on work by the IHI innovation team, some hospitals in the Pursuing Perfection and P4P work, and publications by Nolan et al, a three tier approach has been taught as a methodology when applied to CMS conditions can achieve 10-2 performance. (All or none measurement)

Anomalies will need to be observed Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statements of causality Categorization of the circumstances in which we might find ourselves Anomalies will need to be observed Observe describe and measure the phenomena Normative Theory

Reliability Community Observations When the Current Normative Theory is Used When the 3 tier model is applied to the broad CMS measures few hospitals are able to consistently achieve the 10-2 goal Those hospitals achieving the10-2 goal for all measures within a CMS condition commonly accomplish this with manpower and a very high level of vigilance Within a given condition when successful 10-2 performance occurs on a single measure a good three tier strategy can be observed (although commonly a deliberate 3 tier strategy was not as much designed as discovered)

Current Normative Theory Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statement of Causality We ought to apply the 3 tier approach to the CMS conditions Anomalies Observed Using 3 tier design to the CMS conditions approach 10-2 not consistently observed Individual measures within conditions achieved 10-2 with obvious 3 tier design Segments of the population achieve 10-2 in all or none measures 10-2 Performance will be observed when the 3 tier approach is used on the CMS conditions Current Normative Theory

Anomalies Observed Certain measures of the CMS conditions achieve 10-2 level of reliability. When studied the 3 tier design is commonly used not as a deliberate strategy, but as a haphazard design. Whenever applied to the broad CMS condition hospitals have difficulties Teams can predictably take certain segments of the population or certain measures and can achieve a 10-2 level of reliability

Examples of Anomalies Smoking cessation, pneumovax or flu shots when taken on as a hospital wide measure reaches greater than an 10-2 performance. Timed measures such as antibiotic administration or time to a heart catheterization laboratory reaches 10-2 levels of performance Certain segments of the population attain 10-2 reliability (admissions from the ED with a known diagnosis of CAP)

New Theory Based on Anomalies The work on the CMS conditions can achieve a 10-2 level of performance if appropriate segments are identified and each segment is designed using the 3 tier approach if necessary

New Descriptive Theory Dividing the CMS conditions into appropriate segments and applying the 3 tier design will achieve 10-2 for the whole condition Preliminary statement of causality Segments based on admission route, time of first case, responsible area are useful in design for 10-2 performance Observing the current reliability community suggests certain anomalies that draw questions to the 3 tier design for conditions. Observations the segments appear to be more reliable in design New Descriptive Theory

Anomalies will need to be observed Using the 3 Tier approach to the design on the segments of the condition and or measures will achieve 10-2 reliability in the whole Statement of Causality We ought to apply the 3 tier approach to the CMS conditions using a segmental approach Anomalies will need to be observed 10-2 Performance will be observed when the 3 tier approach is used on the appropriate segments of the CMS conditions New Normative Theory

Why Segments Allows for control of some variables Defines the boundaries around which expectations can be formed More likely to test the validity of the design rather than confront barriers Fosters a deeper understanding of the design complexity required Forces understanding of the differences between segments as design strategies Permits design beyond the disease Allows the formation of more predictable timelines

Applying Segments to the Normative Model The current work on reliability will stress the concept of segment definition tied to process and outcome measures Segment definition and relationships to improvement will be driven by a design table Observations of anomalies will be part of future community work to refine the normative theory

Design Table for Segment Theory Improvement Work Strategy Change/Rule Structure Change Process Change

Finding your first segment The segment must represent a reasonable volume The segment should have clear cut defined boundaries The segment should have willing participants so the barrier of agreeing is not a problem The segment should allow for key articulated variables or barriers to be neutralized

Using the Design Table for CAP Planning Using Segments Strategy Change/Rule Structure Change Process Change Patients admitted to the hospital through the ED with a diagnosis of CAP An organizational policy is developed to split the responsibility for the CAP measures to attain a combined 10-2 performance Smaoking,Pneumovax measures will be handled on the admitting floor as an institution wide protocol Timed strategy with a 3 hour call will be expected for the ED physicians on presumed CAP ED develops a unique protocol for all patients with a presumed diagnosis of CAP when admitted to the ED Hospital wide smoking cessation and immunization protocols are developed with appropriate training and support and applies to all patients admitted to the hospital ED sets up a 4 hour timeline from arrival to the ED with required antibiotic decision at 3 hours ED process in place. Feed back to the ED on the oxygenation, cultures, and antibiotic measures done on concurrently based on sampling Detailed processes set up out side of the ED and monitored by a responsible entity for smoking, pneumovax etc. Feedback to responsible entity Presumptive diagnosis at admission to ED starts a ED protocol with timer to accomplish 4 hours antibiotic. Feedback on time defects

Using the Design Table for CAP Planning Using Segments Strategy Change/Rule Structure Change Process Change Patients admitted to the hospital through the ED with a diagnosis of CAP See previous slide Patients admitted to the hospital with a challenging diagnosis which includes CAP and results in CAP being diagnosed later Patients with a possible diagnosis of CAP are monitored until a final decision is made Institutional agreement on the 4 hour rule starts when the diagnosis is made on the floor (even though for reporting this is a defect). Method developed to determine when a final diagnosis is made and how to communicate back to the required measures for CAP and subsequent baseline performance of the CAP measures. Feed back to the units responsible for care of the challenging diagnosis on performance done concurrently by sampling Patients admitted directly to the floor with a diagnosis of CAP All admitting diagnoses are required to be screened for certain key diagnoses with notification of the unit this is a key diagnosis A CAP diagnosis on any unit requires a baseline performance of the CAP measures. Feed back of performance to each unit Any patient discharged when key measures have not been performed Institutional policy that defects which still might be mitigated require a recovery. Resources made available to contact patients and correct the correctable defects Key processes to describe how mitigation will actually occur. Scripts to be developed. Feedback on follow-up reliability .

Next Steps Identify your first segment (If you have a first segment what is your level of reliability) Confirm that your segment has the key requirements for segmental definition and design Fill out the segment flow sheet and the design table Local customization will develop the structure changes and process changes The segments will vary depending on organization size Anomalies from the segmental design need to be studied to authenticate the new normative theory