1. Scottish Improvement Skills
Leading change:
From testing to implementation
SIS: Group D Using the PDSA framework Measurement: Module – From testing to implementation: Participant

2. System of Profound Knowledge
Deming 2000

3. Leading change: from testing to implementation
By the end of this session you will be able to:
Describe typical stages in an improvement journey - testing, implementation and spread
Make decisions based on learning from PDSA cycles and data analysis
Demonstrate understanding of when to move from testing to implementation
Draft an implementation plan.

4. An improvement journey
A P S D
Identify opportunity for change
Plan
Test
Sustain the change
Implement
Hold the gains
Spread

5. An improvement journey
A P S D
Identify opportunity for change
Plan
Test
Sustain the change
Implement
Hold the gains
Spread

6. Examples of change: medicines reconciliation
Testing
Implementation
Spread
3 nurses on one ward use a new reconciliation and order form
All 30 nurses on the unit use the new medication and order form
Nurses from the ‘pilot’ unit assist all nursing units in the organisation to adopt or adapt the change

7. Testing? Implementation? Spread?
Failure is a useful, natural part of the improvement process.

8. Testing? Implementation? Spread?
The change becomes part of the routine operation of the unit.

9. Testing? Implementation? Spread?
Work out how to explain the benefits of a change beyond the unit.

10. Testing? Implementation? Spread?
Use PDSA cycles.

11. Testing? Implementation? Spread?
Learn what works in your system.

12. Testing? Implementation? Spread?
Change is not permanent.

13. Testing? Implementation? Spread?
Develop infrastructure (eg policies, job descriptions, SoPs) to maintain the improvement.

14. Test cycles: Act on your learning
Abandon the change
Modify the change
Increase the scope of the change
Test the change under different conditions
Stop collecting data
Implement the change

15. Three criteria for implementation
High degree of belief that a change will result in improvement
Small cost of failure
The organisation is ready to make the change.

16. From testing to implementation
Cost of failure
Current commitment within the organisation
None
Some
Strong
Degree of belief that change idea will lead to improvement
Low
Large
Very small scale test
Small
Small scale test
High
Large scale test
Implement
Adapted from: The Improvement Guide p146

17. Sequential building of knowledge
A P S D
Implementation cycles
Learning and Improvement
Wide scale tests
Test new conditions
Follow up tests
Small scale test
Very small scale test
Develop a change

18. ICU: Reduce Length of Stay
Aim Primary Driver Secondary Driver Change idea
Reduce average length of stay in Central General ICU by 20% by March 2015
Assessment and management of sedation and agitation
Improved management of delirium
Validated sedation tool
Appropriate sedation
Incidence of acute cognitive dysfunction
Structured daily sedation breaks
Staff information leaflets
Staff training sessions
Improve multidisciplimary team communication
Assess sedation and agitation using the RASS tool (Richmond Agitation Sedation Scale)
Use ear plugs to improve sleep
Use Dexmedetomidine as alternative to benzodiazipines
Develop and follow guidelines for daily sedation breaks
Assess for delirium using CAM-ICU (Confusion Assessment Method for ICU patients)
Investigate and correct underlying causes
Include delirium as part of safety brief
Medical staff and family jointly keep an ICU diary
Improved identification of delirium
Validated delirium tool
Staff education
Care bundle initiated within 2 hours of diagnosis
Engage with patient/family/carer
Mobilise patients earlier and more frequently

19. PDSA Ramps A P S D A P S D A P S D Education package RASS scoring tool
Develop content
Restructure content – 2 staff nurses
Test with 1 staff nurse
Revise wording – 1 nurse
Test with all staff
Education package
A P S D
Develop tool
Amend tool (colour) & test at 1 bed space
Test at 1 bed space
Test at 2 bed spaces
Amend tool (wording) & test at 1 bed space
RASS scoring tool
A P S D
Develop poster
Move poster so not obscured when doors opened
Display outside ward
Layout of poster more readable
Size poster to fit space
Poster for families

20. Building knowledge: your project
How could you increase your degree of belief?
What different conditions could you test your change under?
Which change ideas could you work on at the same time?
How could you minimise the cost of failure?
How could you better make your department/organisation ready for the change?

21. Components of Implementation
Standardisation eg policies, procedures
Documentation eg job descriptions
Training
Measurement
Resourcing eg equipment purchases

22. Aim: promote staff wellbeing
Aim  Driver  Driver Change ideas
Staff complete safety climate survey
Promote the physical, mental and emotional wellbeing of staff. By March 2017: (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month.
Environment
Action planning from survey
Lean visual management of cupboards, notice boards etc
A workplace that is safe for staff
Activity
Use and location of hand gel dispensers
Staff able to focus as required
Schedule regular team huddles
Leadership training for team leads
People
Staff engaged in health and wellbeing practices
Offer Bereavement support programme for managers

23. Leading change: from testing to implementation: summary
An improvement journey
Criteria for implementation
PDSA ramps
Components of implementation