1. August 21 st Track One Virtual Meeting Prepared and Presented by Institute for Healthcare Improvement Faculty Sue Gullo, Director Jane Taylor, Improvement Advisor

2. Session Objectives Objectives: (1)Review and discuss the Lens of Profound Knowledge and its related four components (2)Discuss the change concepts and ideas developed for selected HACs (3)Describe the data collection strategies and the variation that lives within your data. 2

3. Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2 nd edition, 2009 A Model for Learning and Change

4. The Shewhart Cycle for Learning and Improvement ActPlan StudyDo Act – Adopt the change, abandon it or run through the cycle again. Plan – plan a change or test aimed at improvement. Study – Examine the results. What did we learn? What went wrong? Do – Carry out the change or test (preferably on a small scale). (Deming, 1993)

5. Useful Ways to Develop Changes- OS Critical thinking about the current system 1 Sometimes, simply reflecting on problems within a system can generate some good ideas for change. If you make a flow chart of your current process, it may be possible to identify parts of the system that aren’t working or are needlessly complex. Another way to go about critical thinking is to gather and analyze data on the way your system currently works—for example, how you are communicating with people about the meeting—which can then help you identify problems and develop changes to address them. Benchmarking Comparing your own process to “best practice” can help you identify where your own system falls short. Take the patient’s perspective When you see the care system from a patient’s perspective, you’ll see opportunities for improvement that might not be apparent as a caregiver. Is it too loud when you’re trying to sleep? Do bright lights give you a headache? Do you have to wait too long to get your test results? Patient shadowing and interviewing are useful techniques when coming up with good ideas to change.

6. Useful Ways to Develop Changes- OS Creative thinking 1 Where do new ideas come from? You can spark creative thinking in various ways, including simply taking the time to do this sort of thinking; exposing yourself to situations (such as taking the role of a patient) that can spark new ideas; identifying the boundaries that limit the changes you can make and then finding ways to dismantle those boundaries; and temporarily considering unrealistic goals that can prompt you to break out of your old way of thinking. Using Change Concepts 6

7. Using Change Concepts to Come Up with Ideas- OS A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change. After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. If they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.

9. Guidance for Testing a Change Concept A test of change should answer a specific question! A test of change requires a theory and a prediction! Test on a small scale and collect data over time. Build knowledge sequentially with multiple PDSA cycles for each change idea. Include a wide range of conditions in the sequence of tests. Don’t confuse a task with a test! 9

10. To Be Considered a Real Test Test was planned, including a plan for collecting data Plan was carried out and data were collected Time was set aside to analyze data and study the results Action was based on what was learned

11. 11 The PDSA Cycle For Learning And Improvement What will happen if we try something different? Let’s try it! Did it work? What’s next?

12. Linking PDSA Cycles - Tips for Doing It Right Linking small tests of change helps ensure buy-in from all the people involved. Think Ahead You already know you’ll want to do multiple tests. So make your life easier by planning for it. Think a couple of cycles ahead, testing over a wide range of conditions and collecting useful data from each test to guide the next one. Start Small Keep it simple at the beginning. Scale down the size of the test (for instance, start with just a few patients in one location). Test with volunteers and don’t try to get consensus from everyone in the organization before starting. Get Started Don’t wait around! Ask, “What change can we test by next Tuesday?”

13. Hunches Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains Repeated Use of the PDSA Cycle for Testing 13

14. Hunches Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains Repeated Use of the PDSA Cycle for Testing- Falls 14

15. PDSA Tests- Falls Hunch/ Theory Very Small Scale Test Follow Up Tests Wide-Scale Tests of Change Implementation 15

16. Hunches Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains Repeated Use of the PDSA Cycle for Testing- HAPU 16

17. PDSA Tests- HAPU Hunch/ Theory Very Small Scale Test Follow Up Tests Wide-Scale Tests of Change Implementation 17

18. Appropriate Scope for next PDSA Cycle Current Situation ResistantIndifferentReady Low Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Very Small Scale Test Small Scale Test High Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Small Scale Test Large Scale Test Cost of failure small Small Scale Test Large Scale Test Implement

19. Be sure to distinguish the reason: – Change was not executed – Change was executed, but not effective If the prediction was wrong – not a failure! – Change was executed but did not result in improvement – Local improvement did not impact the secondary driver or outcome – In either case, we’ve improved our understanding of the system! Failed Test…Now What? 19

20. The Sequence of Improvement Sustaining improvements and Spreading changes to other locations 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

21. 21 Appreciation of a system Understanding Variation Theory of Knowledge Human Behavior Aim or Values The Lens of Profound Knowledge QI “ The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.” (Deming, Out of the Crisis) It provides an opportunity for dialogue and learning!

22. 22 What insights might be obtained by looking through the Lens of Profound Knowledge? Appreciation for a System Interdependence, dynamism World is not deterministic Optimization, interactions System must have an aim Whole is greater than sum of the parts Understanding Variation Variation is to be expected Common or special causes Ranking, tampering Potential mistakes Theory of Knowledge Prediction Learning from theory, experience Operational definitions PDSA for learning and improvement Human Behavior Interaction between people Intrinsic motivation, movement Beliefs, assumptions Will to change