The Improvement Model Chinook Health Region November 2, 2005 T. Rollefstad RN BN Safety Improvement Advisor Western Node

Purpose of Session –A basic understanding of the Improvement Model –Templates to use for creating an Improvement Charter and designing a PDSA Cycle –A basic understanding of process thinking –Some new LINGO! (just what you needed)

Why Quality Improvement? “Medicine used to be simple, ineffective & relatively safe. NOW medicine is complex, effective & positively dangerous!” Dr. Syrl 1999 English Physician

What Quality Improvement is NOT A work harder ethic A work harder ethic Not a top down edict Not a top down edict

What is Quality? Adopted from D. Ballard, Baylor Healthcare Organization S - Safe T - Timely E - Efficient E - Effective E - Equitable P - Patient Centered It’s a STEEEP Climb to Quality!

What is Quality Improvement? It’s about creating smooth effective processes

Problem Solving Process Analyze Current Process Improve the Process Trigger for Improvement Trigger for Improvement Breakthrough in Knowledge Breakthrough in Results Breakthrough in Culture Maintain Results Improvement Model 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? Plan Do Act Study Breakthrough in Attitude And Organization structure

The Improvement Model Three Questions for Improvement Aim Aim Measures Measures Ideas Ideas

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? Act Plan Study Do Improvement Model

What Are We Trying to Accomplish? Align aim with strategic goals of the organization Align aim with strategic goals of the organization Write a clear, concise statement of aim Write a clear, concise statement of aim Make the target for improvement bold and unambiguous Make the target for improvement bold and unambiguous Include deadline Include deadline Include what is needed to keep the team focused (strategies, patient populations, scale, scope, constraints) Include what is needed to keep the team focused (strategies, patient populations, scale, scope, constraints)

Bold Aim, Firm Deadlines “Some is not a number. Soon is not a time” - Donald Berwick, MD Institute for Healthcare Improvement

Components of Aim Statement Direction Direction Process Process Measure Measure Timeline Timeline Focuses the team on improvement Focuses the team on improvement Keeps the team on topic Keeps the team on topic Defines what success looks like Defines what success looks like Ensures an urgency to continue Ensures an urgency to continue

Example of Aim Statement We will endeavour to prevent pneumonia in the ICU by implementing the VAP protocol We will endeavour to prevent pneumonia in the ICU by implementing the VAP protocol Reduce ventilator-associated pneumonia (VAP) rate by 50% within 12 months. Reduce ventilator-associated pneumonia (VAP) rate by 50% within 12 months.

An unclear AIM statement can lead you astray!

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? Act Plan Study Do Improvement Model

How Will We Know a Change Is an Improvement? Choose 2-6 measures that are useful and manageable Choose 2-6 measures that are useful and manageable Include a balanced set of measures to avoid sub-optimization Include a balanced set of measures to avoid sub-optimization Purpose is for learning not judgment Purpose is for learning not judgment

How Will We Know a Change Is an Improvement? Include outcome, balancing and process measures –Outcome measures are driven by the specific objectives identified in the AIM statement –Process measures indicate whether a specific change is having the intended effect –Balancing measures are related measures to understand the impact of changes on the broader system

Example of Measures for VAP VAP rate VAP rate Compliance to a bundle Compliance to a bundle Patient/staff satisfaction Patient/staff satisfaction

Balancing Measures One or two of the following: One or two of the following: –Patient satisfaction –Family satisfaction –Provider satisfaction –Average or median Length of Stay – Hospital, ICU –Readmission rate within 30 days –Culture of Safety assessments – % of staff who report a positive safety climate

What Changes Can We Make That Will Result in Improvement? Change packages (starter kits) Change packages (starter kits) Critical thinking Critical thinking Creative thinking Creative thinking Hunches Hunches Best practices Best practices Asking process users and subject matter experts for ideas Asking process users and subject matter experts for ideas Insight from research and benchmarking Insight from research and benchmarking

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? Act Plan Study Do Improvement Model

Example of Changes Care “Bundles” and Care Components Care “Bundles” and Care Components –Ventilator bundle, Central Line bundle, 7 aspects of care for AMI, Medication Reconciliation, 4 components of SSI prevention Safety huddles Safety huddles Checklists Checklists Order sets Order sets Daily goal sheets Daily goal sheets Multidisciplinary rounds Multidisciplinary rounds Protocols/guidelines Protocols/guidelines Reliable processes Reliable processes

What are the 3 questions in the Improvement Model?

Your Improvement Charter Improvement Model 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? Plan Do Act Study Team Plan Project Name:Sponsor: Team Leader: Team Members: Author: Date:

The Improvement Model PDSA Cycles & Principles for Testing a Change

Creating a New System Hold the Gains Spread Improvement (test, implement)

Plan: State objectives Make predictions Make conditions explicit Develop plan Do: Carry out the test Document problems, observations. Begin analysis Study: Complete analysis Compare data to prediction What did you learn? Act: Adopt, adapt or abandon? Build knowledge sequentially Improvement Model - PDSA

3 Principles for Testing a Change 1. Test on a small scale 2. Collect data over time 3. Build knowledge sequentially and include a wide range of conditions in the sequence of tests

Principle 1: Test On a Small Scale Small-to-medium scale test Very small-scale tests MAJOR One cycle to implementation Medium-scale tests MINOR HIGHLOW CONSEQUENCE OF FAILED TEST DEGREE OF BELIEF IN SUCCESS OF THE CHANGE

Designing a Small Scale Test Simulate the change Simulate the change Have subject matter experts review the change Have subject matter experts review the change Test the idea with volunteers Test the idea with volunteers Use 1:1:1 rule – one clinician in one facility with one patient Use 1:1:1 rule – one clinician in one facility with one patient Use manual “pencil and paper” data collection Use manual “pencil and paper” data collection Use sampling Use sampling

Designing a Small Scale Test If appropriate, test the changes developed for different parts of a system separately If appropriate, test the changes developed for different parts of a system separately Conduct the test over a short time period– what COULD we do by next Tuesday? Conduct the test over a short time period– what COULD we do by next Tuesday? Incorporate redundancy in the test by making the change side-by-side with the existing process Incorporate redundancy in the test by making the change side-by-side with the existing process

Examples Educate next 5 patients on importance of “medication cards” Educate next 5 patients on importance of “medication cards” Incorporate safety huddle with volunteers on Monday morning at 9:00 Incorporate safety huddle with volunteers on Monday morning at 9:00 Borrow a clipper from another unit before purchasing Borrow a clipper from another unit before purchasing Ask for feedback from 1 daytime nurse and 1 nighttime nurse on head of bed education materials Ask for feedback from 1 daytime nurse and 1 nighttime nurse on head of bed education materials Try smoking cessation counseling on next patient being discharged Try smoking cessation counseling on next patient being discharged

Principle 2: Collect Data Over Time

Example of Annotated Run Chart Catheter Infection Rate

Principle 3: Build Knowledge Sequentially Include a Wide Range of Conditions in the Sequence of Tests

Sequential Building of Knowledge Breakthrough Results Theories, hunches, best practices & Change Concepts Learning and improvement AP SD Evidence & Data AP SD AP SD AP SD

Example of “Ramping PDSA ‘s” This team has conducted over 30 PDSA Cycles in less than 6 months.

Predictions “It is not enough to determine that a change resulted in improvement during a particular test…you will need to predict whether a change will be an improvement under different conditions in the future” Langley, et al. The Improvement Guide

Elements of the PDSA Cycle Plan: State objectives. Make predictions Make conditions explicit. Develop plan (5 W’s, How) Do: Carry out the test. Document problems, surprises, and observations. Begin analysis. Study: Complete analysis, synthesis Compare data to predictions. Record under what conditions results be could different. Summarize what was learned. Act: Adopt, adapt or abandon based on what was learned. Build knowledge into next PDSA Cycle

Your PDSA Cycle

Why Test? Increase belief that a change will result in improvement Increase belief that a change will result in improvement Document how much improvement can be expected Document how much improvement can be expected Learn how to adapt changes to local conditions Learn how to adapt changes to local conditions Evaluate costs and effects of the change Evaluate costs and effects of the change Minimize resistance upon implementation Minimize resistance upon implementation

“Failed” Tests Expected and important Expected and important Reasons for “failed” tests Reasons for “failed” tests –Change not executed well –Support processes inadequate –Hypothesis/hunch/theory not useful for conditions –Change executed but did not result in local improvement –Local improvement did not impact safety or specific aims in the Charter Collect data during the Do Phase of the Cycle to help distinguish between these different reasons. Collect data during the Do Phase of the Cycle to help distinguish between these different reasons.

Testing and Implementation Differences: Testing is temporary, implementation is permanent Testing is temporary, implementation is permanent Support processes Support processes Expectations of failure Expectations of failure Social impacts and resistance Social impacts and resistance Balancing measures Balancing measures

Example Results

Resources

Contacts Marlies van Dijk Western Node Leader Tanis Rollefstad Safety Improvement Advisor Western Node Bruce Harries Director, Canadian ICU Collaborative Improvement Associates Ltd

Acknowledgements The Improvement Model was developed by Associates in Process Improvement (API) and has been used by thousands of healthcare and industry teams around the world.

Team Plan Assignment Break out into groups as outlined by Lila Break out into groups as outlined by Lila Each group has a case scenario Each group has a case scenario Develop an AIM statement for the case scenario Develop an AIM statement for the case scenario –Direction, process, measure, timeline Pick a spokesperson to report out Pick a spokesperson to report out

PDSA Assignment Remain in your groups Remain in your groups From your AIM Statement, develop one test of change From your AIM Statement, develop one test of change Complete the PDSA form to ensure all aspects of plan outlined Complete the PDSA form to ensure all aspects of plan outlined What are some measures for your AIM and PDSA cycle? What are some measures for your AIM and PDSA cycle? Pick a spokesperson to report out Pick a spokesperson to report out