1. Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement ? What are we trying to accomplish? AIM MEASUREMENTCHANGE

2. PDSA –testing a change MARU What is Maru trying to achieve? How many ideas does he try? Is he successful? What was the possible negative outcome? From YouTube

3. Rapid Cycle Change What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement? What are we trying to accomplish? PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT

4. AIM of this change: PROBLEM :

5. AIM of this change: Do a PDSA to solve a problem at home

6. AIM: unpack the dishwasher in a more efficient way PROBLEM : unpacking the dishwasher is inefficient Put half the cups and half the glasses in the cupboard just above the dishwasher How easy it is to unpack the dishwasher -Tom to rearrange cupboard today --Mary and Tom to unpack into one cupboard for 4 days Mary – it will look horrible and I will hate it Tom – it will be easy and Mary will like it

9. Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement ? What are we trying to accomplish? AIM MEASUREMENTCHANGE

10. Measurement Are we getting closer to our target? Outcome measure

11. Measurement Did we use the whole bundle in every patient every time? Process measure (Bundle compliance)

12. Measurement Was the change an improvement? Measuring the impact of a change

13. Measuring over time a volunteer to write a volunteer to measure graph paper

14. Annotated Run Chart Community Need I Change Made in June

15. Interpreting Data: what is the story? I Before (Feb) After (Aug)

16. What is the real story? Change Made Change Made in June FebAug FebAug FebAug FebAug FebAug I Change Made

17. Prevention of Mother to Child Transmission. A sub-district in a province in SA Positive PCRs at 6 weeks (target <5%) Feb 2010 8.2% Feb 2011 3.2% Improvement?

18. Positive PCRs at 6 weeks (target <5%) Feb 2010 8.2% Feb 2011 3.2% Improvement?

20. Run Charts One of the most powerful tools for improvement Describe a process over time Shows trends the process is experiencing Can be used to analyse whether the change was an improvement Data can be used to drive change

21. Outcome measurement Are we getting to our target? Was the change an improvement? How do we measure HAIs?

22. Measuring infection rates Lessons from an ICU

23. Quality Improvement 101 Problem?

24. Measuring Infection Rates Total number of infective cases per 1,000 device days: Total No. of VAP cases Ventilator days X 1,000 Numerator Denominator

25. Definition of VAP “VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions” “Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

26. Overcoming Numerator Issues Total No. of VAP cases Ventilator days X 1,000 Numerator Denominator Patients with

27. Overcoming Numerator Issues – diagnosing the HAI (workbook) Checklists for Diagnosing the HA Infection used by the team

28. Overcoming Denominator Issues At the same time every day the Unit manager counts devices in use in the ward

29. Measuring HAI Percentages and rates % (or rate) = Numerator/ denominator eg Rate of infection = readmissions for septic caesarian section wounds per week / number of Caesarian Sections performed per week Rate of infection = Number of VAP / 1000 device days

30. Safety Calendar Welsh 1000 lives campaign I Developed by Annette Bartley

31. Welsh Patient Safety Project

32. Measuring HAI The concept of ‘days between’ infections For measure ‘rare’ events (occur < 10%)

33. Off the internet, Google pictures

35. Off the internet, Google pictures

36. Off the internet, Google pictures

37. Maternal deaths – Malawi For the “NO Maternal Death” Campaign a colorful, laminated A4 paper that said “Days without a Maternal Death: ______”. were hung in every Labour Ward for all (providers, patients and guardians) to see and the number was filled in daily with a dry erase marker

38. Days between icecreams Days between icecream Icecream 1st2nd3rd4th5th 5 10 15 20 25

39. Days between events (infection) Days Between events (eg Infection) Sequence of events (eg Infection) 1st2nd3rd4th5th 5 10 15 20 25

40. Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana I

41. I Measuring rare events and time-between measures. James Benneyan IHI

42. JulyAugSepOct 5/713/87/95/10 5/79/98/10 6/712/915/10 11/715/919/10 25/720/10 27/721/10 25/10 ICU: Sequence of VAP infections by date 2010

43. Use the tools to Display the data JulyAugSepOct 5/713/87/95/10 5/79/98/10 6/712/915/10 11/715/99/10 25/720/10 27/721/10 25/10

44. Date of infection # Days since last infection Days Be- tween Infecti on Sequence of Infections

45. So far we have: 1.Mapped the size of the project in your facility 2.Prioritise a unit and bundle to start with 3.Written an aim

46. Now, write down: 1.Your aim 2. Process Measures (Bundle compliance) 3.The outcome measures i)Rate = numerator/denominator (describe) ii)Days between iii) Welsh Safety Cross calendar iv) Other 4.How you will feedback the data every month to i)The frontline staff ii)Management Mark with a * areas that you want to strengthen

47. Improving your Outcome Measure 1) Numerator Standardised diagnosis of infection 2) What is the measure for HAI? Rate = Infection/device day Days between (CLABSI, VAP, UTI) Days or cases between SSI 3) Collecting and collating data: What (definition)/ Where/ How (tools)/ Who/ When 4) Presenting the data: Format - Safety Cross, Graphs Feedback/presentation - Management platform

48. Note the areas that need strengthening 1.Your aim 2. Process Measures (Bundle compliance) 3.The outcome measures i)Rate = numerator/denominator (describe) * ii)Days between iii) Welsh Safety calendar * iv) Other 4.How you will feedback the data every month to i)The frontline staff * ii)Management * * Areas that need strengthening

49. Select a priority area for improvement resolving it will have a big impact it is under your control to test a change you can start on Monday Establishing or Improving your outcome measure/s

50. Plan a PDSA using the Model for Improvement What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement ? What are we trying to accomplish? aim measurementchange

51. AIM of this change: PROBLEM : Design a PDSA to improve one of the areas with a *

52. AI M: use the Welsh Safety Cross PROBLEM : staff aren’t engaged in the project What When Where Who How AIM increase awareness through measurement AIM: the Welsh Safety Cross is completed Staff know what it means Welsh Safety Cross will improve the profile of the project. Will need to engage staff with colouring it in or they won’t take any notice