1. NoCVA Readmission Collaborative October 25, 2012

2. Session Objectives Share and discuss what you learned from interviews with patients recently readmitted Understand and apply a model for driving improvement through small scale tests of change Identify one small scale test of change based upon your diagnostic work

3. Learning from Patient Interviews  What did you learn?  Any surprises?  What are you now curious about?

4. IHI Faculty Rebecca Steinfield Rebecca Steinfield, MA, has been with IHI since 1996. She currently serves as an Improvement Advisor for IHI’s State Action on Avoidable Readmissions (STAAR) initiative, funded by the Commonwealth Fund; sits on the faculty of the Kaiser Permanente Performance Improvement Institute, mentoring Improvement Advisors-in-training; teaches IHI courses on improvement methods; and serves on IHI’s internal evaluation team. She is also mother to two children Jacob, 15, and Susie, 12.

5. An Introduction to the Model for Improvement

6. “How wonderful it is that nobody need wait a single moment before starting to improve the world” Ann Frank

7. What are we trying to Accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? The Model for Improvement ActPlan StudyDo

8. The Project AIM is: Not just a vague desire to do better A commitment to achieve measured improvement ─In a specific system ─With a definite timeline ─And numeric goals What are We Trying To Accomplish?

9. 9 The Project AIM is: Not just a vague desire to do better A commitment to achieve measured improvement ─In a specific system ─With a definite timeline ─And numeric goals “Hope” is not a plan “Soon” is not a time What are We Trying To Accomplish? “Some” is not a number

10. Shady Oaks Hospital will improve transitions home for all patients as measured by a decrease in the 30-day all- cause hospital readmission rate from 12% to 8% percent or less within 24 months. We will start our improvement work with patients on 4W and 5S with a focus on improving our understanding of patients’ discharge needs and collaborating with community receivers of patients to ensure they have the information they need to care for the patient post- discharge. We will expect to see a decrease in the readmission rates for patients discharged from those units of at least 10% within 12 months. System: Goal: Timeframe: Guidance: Example of an Aim Statement

11. “You can’t fatten a cow by weighing it” - Palestinian Proverb Improvement is NOT about measurement However… How Do We Know if a Change is an Improvement?

12. Some Measurement Assumptions The purpose of measurement for improvement is learning not judgment All measures have limitations, but the limitations do not negate their value Measures are one voice of the system. Hearing the voice of the system gives us information on how to act within the system Measures tell a story; goals give a reference point Measurement is Central to the Team’s Ability to Improve

13. Improvement Project Measurement Guidance Need a balanced set of measures reported each month (at a minimum) to assure that the system is improved These measures should reflect your aim statement and make it specific Measures are used to guide improvement and test changes Integrate measurement into daily routine Plot data for the measures over time and annotate graph with changes

14. What Changes Can We Make That Will Result in Improvement? The How-to-Guide contains IHI’s best thinking on key changes needed to improve transfers Use this “change package” to identify the changes you want to make to your system to achieve your aim

15. What are we trying to Accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? The Model for Improvement ActPlan StudyDo

16. The PDSA Cycle “What will happen if we try something different?” “Let’s try it!” “Did it work?” “What’s next?”

17. Building Confidence for Change Change pkg ideas, suggestions, intuition System changes that will result in improvement Learning from data

18. Change Idea: actively include patient and family in assessing needs (specifically, identify the learner on admission, and include them in discharge planning) If we identify the learner on admission, we can engage them in discharge planning and have a better chance of adherence to plan 99% Reliability Learning from data Cycle 1: Day 1: On next admission, ask nurse to ask the patient to identify the person who should be involved in understanding their care plan after discharge Cycle 2: Day 2: Get information on family caregivers for all patients admitted to Unit A Cycle 6: Educate staff on new standards Cycle 5: Standardize and document Mini-measure tracks improvement cycles Cycle 3: Day 3: Unit A is able to get useful information from all patients, continue with Unit A, all admissions, try Unit B Cycle 4: Analyze failures, determine plans for patients without family caregivers Percent of Admissions with Learner Identified 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 12345678910111213141516171819202122232425 weeks Percent 1 2 3 4 5 6

19. More Tips for Testing Test with volunteers Use simulation Do not try to get buy-in, consensus, etc. Be innovative to make test feasible Collect useful data during each test As cycles proceed, test over a wider range of conditions

20. 1 patient 1 day 1 admit 1 physician Start Small ~ 1:3:5:All

21. Why Test? Why Not Just Implement then Spread?

22. Increase degree of belief in the change idea Document expectations and results Build a common understanding Evaluate costs and side-effects Explore theories and predictions Test ideas under different conditions Learn and adapt for the next test

23. What small scale test do you want to run before the next call?

24. Resources: Free “On-Demand” Streaming Video taught by Dr. Robert Lloyd Available on ihi.org: An Introduction to the Model for Improvement Provides a framework for organizing and guiding a team’s improvement journeyAn Introduction to the Model for Improvement Building Skills in Data Collection and Understanding Variation Designed to help teams successfully manage the milestones along the quality measurement journeyBuilding Skills in Data Collection and Understanding Variation Using Run and Control Charts to Understand Variation Addresses the application of statistical process control (SPC) methods, with specific attention given to run and control chartsUsing Run and Control Charts to Understand Variation

25. Assignment Using the PDSA form, plan and run one small scale test of change within the next two weeks (think 1 patient, 1 staff member, 1 admission) Share your completed PDSA form, with learning from your test, by sending it out on the Collaborative listserv