1. Marie W. Schall This presenter has no conflicts to disclose November 5, 2013 Sustaining and Leveraging your Improvements

2. By the end of this session, you should be able to: Identify key strategies for sustaining improvements (holding the gains) Apply reliability science to strengthen implementation and ability to sustain improvements Manage a portfolio of initiatives to leverage improvements across hospitals and systems

3. Sustaining Improvements Our information system makes it easy for us to monitor how we are doing! The new way is much easier than the old way…I would never go back! We started this new process with a few patients but now we do it for all!

4. Creating a New System Part One: Make improvements Part Two: Sustaining Improvement (Holding the gains) Part Three: Spread the improvements to others

5. The Sequence for Getting (and Sustaining!) Results at Scale Scaling up and Spreading a change Developing a change Implementing a change Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations

6. Testing - Try and adapt ideas to learn what works in your system Implementation - Make a change a permanent part of the day to day operation of the system Spread: Have individuals outside the pilot adopt (and adapt) the changes Scale-up: Identify and overcome the infrastructure issues that arise during spread Some Common Language…..

7. Improvement Hold Gains Test Implement I. During testing II. During implementation III. After implementation Taking Action to Hold the Gains

8. Improvement Hold Gains Test Implement I. During testing II. During implementation III. After implementation Taking Action to Hold the Gains

9. Improving Likelihood that We Will Hold Gains: During Testing Purposefully test the changes under a wide range of conditions (robust design) – Day shift/night shift, experienced/ inexperienced staff Foolproof the new process/procedure – Look for ways to use constraints, affordances, reminders, differentiation Use technology where appropriate – Look for opportunities to use computers, bar coding,etc. Acknowledgement: Sandy Murray

10. During Implementation: Exercise when an improvement was implemented Think of a time in your experience when an improvement was implemented. Are the gains from that change still there? ─ If yes, what was done that resulted in the gains being held? ─ If no, why did the gains fail to be held? What got in the way?

11. Implementation The change is a specified part of daily work - need to develop all support infrastructure to maintain change High expectation to see improvement (no failures; but eagerness to continue testing if needed) Increased scope will lead to increased resistance (value of evidence from successful tests)

12. To Implement... Use PDSA cycles to test implementation steps Establish buy–in, build consensus Create an infrastructure and support Build communication channels Create education and training Review policies & procedure Assign accountability Cultivate leadership

13. Testing Vs. Implementation PDSA Cycles Cycle 1: Recruit one volunteer for one shift, draft duties Cycle 2: Recruit two volunteers for one week (day shift) revise duties as needed Cycle 3: Recruit another volunteer, one day two shifts Cycle 4: Two volunteers for one week of day and evening shift. Cycle 5: Three volunteers for one day, all shifts. Cycle 1: Create job descriptions or alter other job descriptions as needed Cycle 2: Conduct market salary study Cycle 3: Post and hire positions Cycle 4: Training for current employees Cycle 5: Orientation and training for new employees Cycle 6: Formalize measures and required reports

14. Improvement Hold Gains Test Implement I. During testing II. During implementation III. After implementation Taking Action to Hold the Gains

15. After Implementation: Key Components of Strategy Continue Communication – Publicize benefits, document improvement, keep contact w/ team after initial improvement effort Continue to Build Infrastructure – Job descriptions, policies, hiring, orientation, supply stream, etc. – Assign ownership for improvement and maintenance work of the new process – Senior leaders held responsible for efforts to sustain Design an Effective Control System – Use your internal QA/I resources and integrate activities into hospital-wide control system – Plan to standardize new process and verify conformance to the standard – Graphically monitor data for performance/outcomes

16. Example of Continuing use of Run Chart to Hold the Gains From Safety BTS (Quantum Leaps) Holding the Gains Collaborative John Whittington OSF Healthcare

17. Cycle No. Change Tested or Implemented LeadJune July August September October November 24 1 8 15 22 29 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25 Policies Documentation Hiring Procedures Staff education/training Job descriptions Information Flow Equipment Purchases PROJECT TEAM WORKSHEET: Redesign of Support Processes for Implementation of Change Change Implemented: ________________________ Date:

18. Improvement Hold Gains Test Implement I. During testing II. During implementation III. After implementation Taking Action to Hold the Gains

19. Holding the Gains 20

20. Reliability Science Can Help Our EMR includes information about the process and what the patient understands We use data to check for “failures” so we can find the problems and make adjustments We can all define the steps in the Teach Back process

21. Levels of Reliability Chaotic process: Failure in greater than 20% of opportunities (5 front line users cannot describe the process) 80% or 90% success: 1 or 2 failures out of 10 opportunities (5 front line users cannot describe the process) 95% success: 5 failures or less out of 100 opportunities (5 front line users CAN ALL describe the process)

22. The IHI Three-Step Model Prevent Failure: Design the system to prevent a breakdown in operations or functions Identify & Mitigate Failure: Identify failure when it occurs and intercede before harm is caused or mitigate the harm caused by failures that are not detected and intercepted Redesign: Take steps to redesign the process on the critical failures identified Source: Nolan, T., Resar, R., Haraden, C., Griffin, F. Improving the Reliability of Health Care. Institute for Healthcare Improvement, Innovation Series, 2004, page 1.

23. Intent, Vigilance and Hard Work (will generate performance with < 95% reliability) Process Design to Prevent Basic Failures: Common equipment, standard orders Personal check lists Working harder next time Feedback of information on compliance Awareness and training

24. Use of Human Factors and Reliability Science (will generate performance with > 95% reliability) Process Design to Identify and Mitigate Failures Standardize work processes Build job aides and reminders Take advantage of preexisting work and habits Make the desired the default rather than the exception Create redundancy Bundle related tasks

25. Build Job Aides and Reminders Some examples… Reminder in EMR to ask patients how they learn best Patient-friendly teaching materials Auto reminder to record who is learner besides patient White board to notes re: discharge date and what needs to be done before then Easy access lists of who to call for scheduling at the physicians’ offices

27. Bronson: Standard Work Product Supervisor assigns bed: pages clerks in ED & unit & monitoring tech 5 min lapsed time - ED unit clerk prints SBAR report to admit unit Admit unit clerk assures charge RN got SBAR 10 min lapsed time - charge RN on unit gets SBAR to assigned nurse 15 min lapsed time – assigned RN reviews SBAR and calls ED RN with questions 25 min lapsed time – ED PCA prepares patient for transport, calls unit, “we’re on the way” 30 min lapsed time – patient transported to unit bed Bronson Hospital, Battle Creek Michigan

28. Take Advantage of Pre-existing Work and Habits Some examples: Multidisciplinary rounds have standard discussion around going home preparations Change of shift reports include patients and key hand over elements Teach Back is built into patient and family education documentation Medication reconciliation offers going home patient-friendly medication list

29. How Standard is your Work? On a scale of 1 - 5 with 5 being the highest level of confidence: How confident are you that a process you select occurs the same way every time? Share with your partner….. – What accounts for the variation? – What steps might you do to reduce variation and improve the reliability of your process so that the process is done the same way every time?

30. Small sample – “Go Ask 5” Pick a process you want reliable that has been taught to frontline staff Review what was taught Ask 5 people who do the process to describe – Why the process is important – How they do the process How many of 5 got it right? – 4 of 5 means only 80% reliability is possible

31. Observe the Actual Process Go see (don’t just talk about it in meeting rooms) Check assumptions Learn what really happens compared to what is described − Observe and ask “why?” five times − Get to the root causes of current performance Identify what gets in the way of reliability Discuss changes that your team would like to test

32. Specify the Existing Work Precisely specify the work YOU SEE: Who does it? What do they do? When do they do it (and for which patients)? Where do they do it? How do they do it? (include tools that are used) How often do they do it? Why do they do it?

33. Specify Improvements to Tackle Select a process to work on Specify the changes in the documented existing work the team would like to test ‒ who, what, when, where, how Use iterative PDSA cycles (tests of change) to try the changes Use process measures to assess progress over time (aim to achieve > 90% reliability)

34. Example: Observing the Current State of Patient Teaching Identify a staff member to observe while teaching a patient Get permission from the patient Observe 1) staff teaching, 2) from the patient and family caregivers perspective Consider what went well and what could be improved?

35. Reliable Use of Teach-back www.teachbacktraining.com Toolkit A. Involve all learners in patient education B. Always Use Teach-back! throughout the hospital stay Provide Effective Teaching and Facilitate Learning 35

36. 36 www.teachbacktraining.com

37. Help Mid-level Managers Coach Honor the current work through observation Understand that change is hard and uncomfortable Resistance to change is natural; comes from fear of change Promote new skill development Build confidence to integrate the new habit into work patterns Build reliability Manage relapses www.teachbacktraining.com

38. Teaching New Processes NEW WAY (TWI) Test to reliable process Specify the process Design education Include help aids Teach test group in workplace Stick around to see if they can do it as taught If needed, redesign education, process or both Teach the next group; can they do it as taught? OLD WAY Teach & leave Death by slides During busy staff meetings Teach in remote conference rooms Gail A Nielsen 2012

39. Using Process Measures to Evaluate the Reliability of Processes Process measures tell us whether the specific changes we are making are working as planned. When displayed in annotated run charts, the data gives us feedback on the relationship between our theory (the changes we are making) and the outcomes for our patients (readmissions and overall experience).

40. Example of an Annotated Run Chart: Process Measure for Using Teach Back

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42. Outcome Measures: Readmission Data

43. Reliability vs. Sustainability Sustainable The process never deteriorates over time regardless of the participants Reliable The process provides the best care for every patient every time

44. Managing a Portfolio of Projects Our leaders have assigned clear responsibility for leading the work We don’t try and do everything at once….but have a plan for building our work We understand how each of our improvement initiatives fits together

45. Sequencing Methods Identify the high leverage skills or capabilities; Use data to identify problem areas; Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates; Start with units with improvement capability or champions; Start in areas where you are likely to see early success. 45

46. Complexity CLABSISSICA-UTIVAPVTE PUCA-UTIFalls OB VTECA-UTI ADE Reliability and Teamwork Rounding and Prevention Risk Assessment Monitoring & Titration Working Across Microsystems Care Transitions Time Sept’ 10 Sept’ 13

47. Work AreaAimProgress Care Transitions  Just started  25% progress  50% progress  100% progress  Sustaining CLABSI  Just started  25% progress  50% progress  100% progress  Sustaining SSI  Just started  25% progress  50% progress  100% progress  Sustaining CA-UTI  Just started  25% progress  50% progress  100% progress  Sustaining VAP  Just started  25% progress  50% progress  100% progress  Sustaining VTE  Just started  25% progress  50% progress  100% progress  Sustaining OB  Just started  25% progress  50% progress  100% progress  Sustaining PU  Just started  25% progress  50% progress  100% progress  Sustaining Falls  Just started  25% progress  50% progress  100% progress  Sustaining ADE  Just started  25% progress  50% progress  100% progress  Sustaining

48. Portfolio of Projects ProjectAreas of Focus Cardiac CareAcute Myocardial Infarction (AMI), Congestive Heart Failure (CHF) Med. SafetyHigh Alert Meds., Med. Reconciliation Med/Surg Unit Spread Pressure ulcers, Med. Rec., High Alert Meds. AMI, CHF, Infection Control Infection Control Methicillin-Resistant Staphylococcus Aureus (MRSA) ICU SafetyRapid Response Teams (RRT), Ventilator-Acquired Pneumonia (VAP), Central Line Infections (CLI) Surgery SafetySurgical Site Infections (SSI), Surgical Care Improvement Project (SCIP)

49. Portfolio of Projects & Skills Needed ProjectResources and Responsibilities Lead Sponsor Driver Skills Cardiac CareSenior cardiologist Director of cardiac service line Nurse manager Reliability and Flow Improvement DC planning Med. SafetyDirector of pharmacy COOPharmD Measurement ADE Triggers Improvement MD Engagement Med/Surg Unit Safety VP NursingCOONurse Manager Spread Improvement Infection Control Manager infection control CMOSenior infection control RN Behavioral change Human factors Improvement ICU SafetyMed. Director ICU CMONurse manager Reliability Cooperation Improvement Surgery Safety High Volume Surgeon Director of surgery RN manager surgery Coordination Cooperation Improvement

50. Objectives - Reflection Identify key strategies for sustaining improvements (holding the gains) Apply reliability science to strengthen implementation and ability to sustain improvements Manage a portfolio of initiatives to leverage improvements across hospitals and systems

51. Reflections What ideas did you hear that you might apply? What may have been confusing? What might you need more information about….?

52. Resources Improving the Reliability of Health Care (IHI White Paper) http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ImprovingtheRelia bilityofHealthCare.aspx The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. Execution of Strategic Improvement Initiatives (IHI White Paper) http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ExecutionofStrate gicImprovementInitiativesWhitePaper.aspxhttp://www.ihi.org/knowledge/Pages/IHIWhitePapers/ExecutionofStrate gicImprovementInitiativesWhitePaper.aspx. 52