1. Quality Improvement 101 Barbara DeBaun, RN, MSN, CIC Kathleen Carrothers, MPH, CPHQ Cynosure Health

2. Today’s Objectives  Describe the elements of process design  Explain how to flow chart a process  Describe the Model for Improvement  Demonstrate 2 Performance Improvement tools  Describe the elements of process design  Explain how to flow chart a process  Describe the Model for Improvement  Demonstrate 2 Performance Improvement tools

3. How Hazardous Is Health Care? (Leape)

4. 4

5. 2001

6. 2003: Duke University Medical Center

7. 2007

8. Complexity of Healthcare 90,000 people in an ICU every day Five million Americans will receive care in an ICU in a year Average LOS in ICU is 4 days Survival rate is 68% Average patient requires 178 individual actions per day (suctioning, medication, wound care, etc.) An error is made 1% of the time Average of 2 errors/day/patient Gawande, A. (2007, December 10). The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker.

9. Why We Come To Work Pick a dot – Goals, measure, current performance Move the dot – Select intervention, PDSA Share the dot The Heart Motivates Share a Story Data Drives Decisions

10. 10 Years Ago Central Line Blood Stream Infections were a part of doing business Ventilator Associated Pneumonia was an unfortunate consequence of being sick Sepsis was defined as shock from infection and carried a 50% mortality rate

11. 2012: Zero Tolerance

12. The Tennis Ball Exercise

13. How To Play Break up into groups of 4-5 people Select - Timer, Scribe, Leader Using your tennis balls, spend 5 minutes designing a process that meets the following specifications: – Each ball must be touched by each person at least one time – The ball cannot be passed to the person directly next to you – The balls must be moved from person to person Time your process The goal is to build a process that meets the design specifications in the shortest amount of time After 5 minutes we will get the best time from each team You will then have another 5 minutes to improve your process Break up into groups of 4-5 people Select - Timer, Scribe, Leader Using your tennis balls, spend 5 minutes designing a process that meets the following specifications: – Each ball must be touched by each person at least one time – The ball cannot be passed to the person directly next to you – The balls must be moved from person to person Time your process The goal is to build a process that meets the design specifications in the shortest amount of time After 5 minutes we will get the best time from each team You will then have another 5 minutes to improve your process

14. What Did You Do? – Formed a team – Designated roles – Brainstormed – Designed a process – Measured its performance – Benchmarked its performance – Analyzed the process design – Redesigned your process – Measured your new process, etc. – Formed a team – Designated roles – Brainstormed – Designed a process – Measured its performance – Benchmarked its performance – Analyzed the process design – Redesigned your process – Measured your new process, etc.

15. Learning PI From Tennis Balls Before you can improve a process you need to know how it works Listen to all members of your team Especially those who are closest to the process Share improvement ideas Try them

16. More Learning’s If at first you don’t succeed, try, try again Look at others who perform the process well both within and externally Borrow their ideas Keep going It’s the best process not the best people If at first you don’t succeed, try, try again Look at others who perform the process well both within and externally Borrow their ideas Keep going It’s the best process not the best people

17. Performance Improvement Tools

18. Facts About Flowcharts Used to visually explain a process and the interrelationship between process steps Allows analysis and better understanding of a process Great way for a workgroup to better understand their environment Excellent training documents

19. Commonly Used Flowchart Shapes Indicates starting or ending points of process Names or describes an individual task or procedure Indicates a conditional branch; a question or a decision; a variation in the process Start or End Task or Procedure Branch

20. Start Gather ingredients Preheat oven to 325  F Prepare baking pan… Blend water, oil, and eggs in medium bowl Add mix Spread evenly Bake as directed below Cool completely in pan Cut and serve Spoon batter into prepared pan Stir until moistened Yummy Example

21. Start Gather ingredients Preheat oven to 325  F Prepare baking pan… Blend water, oil, and eggs in medium bowl Add mix Spread evenly Cool completely in pan Cut and serve Spoon batter into prepared pan Stir until moistened Are you at high altitude? No Add ¼ cup flour and add’l 2 Tbsps. water Yes Pan type? Bake 45- 50 minutes Glass Metal Bake 40- 45 minutes

22. Flowcharts Identifies parts of the process where data can be collected Serves as a training tool to understand the complete process Identifies parts of the process where data can be collected Serves as a training tool to understand the complete process

23. Flowchart Analysis What does your process look like? What does the desired process look like? Compare both charts, looking for areas where they are different Focus improvement efforts on the differences or areas of rework and delays What does your process look like? What does the desired process look like? Compare both charts, looking for areas where they are different Focus improvement efforts on the differences or areas of rework and delays

24. 24 Call between MDs office & OR Room is booked MD’s office faxes paper work Complete? Pt. arrives Paperwork checked again Complete? Office called & reminded Pt. taken to OR Pt. held in pre-op for MD to complete paperwork

25. Give It a Try At your table pick one of the following processes to flowchart: – Packing for the last trip you took – Preparing the last meal you cooked – Getting here today Determine the start and ending point of the process At your table pick one of the following processes to flowchart: – Packing for the last trip you took – Preparing the last meal you cooked – Getting here today Determine the start and ending point of the process

26. Decisions to Make Decide on the level of detail – Simple macro-flowchart shows only the general process flow – Detailed flowchart shows all actions and decision points

27. Go For It Identify the major steps in the process Write each step on a post-it note Arrange the post-it notes in the desired sequence Add directional arrows and decision diamonds – Keep all yes choices in the same direction Identify the major steps in the process Write each step on a post-it note Arrange the post-it notes in the desired sequence Add directional arrows and decision diamonds – Keep all yes choices in the same direction

28. Flowchart Analysis What does your process look like? What does the desired process look like? Consider flowcharting to compare the ‘real world’ with ‘the policy’ Focus improvement efforts on the differences or areas of rework and delays What does your process look like? What does the desired process look like? Consider flowcharting to compare the ‘real world’ with ‘the policy’ Focus improvement efforts on the differences or areas of rework and delays

29. Fishbone Also called cause-and-effect diagram Can reveal key relationships among various variables, and the possible causes provide additional insight into process behavior Often used in root cause analysis – People – Processes – Equipment Also called cause-and-effect diagram Can reveal key relationships among various variables, and the possible causes provide additional insight into process behavior Often used in root cause analysis – People – Processes – Equipment

30. Investigating Practices to Prevent CR-BSI

31. The Model for Improvement So You Think You Can Change?

32. While all changes do not lead to improvement, all improvement requires change. » Thomas Nolan, The Improvement Guide While all changes do not lead to improvement, all improvement requires change. » Thomas Nolan, The Improvement Guide

33. 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 ActPlan StudyDo AIM MEASURE Selecting Change Small Tests of Change

34. What Are We Trying to Accomplish? Developing the team’s Aim Statement 34

35. in From Alice in Wonderland One day Alice came to a fork in the road and saw a Cheshire Cat. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know, “ Alice answered. “Then,” said the cat, “it doesn’t matter.” Lewis Carroll One day Alice came to a fork in the road and saw a Cheshire Cat. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know, “ Alice answered. “Then,” said the cat, “it doesn’t matter.” Lewis Carroll

36. BIG BOLD

37. WHAT? HOW MUCH? WHERE?

38. By WHEN?

40. Clear and Unambiguous Target

41. AIM Statements Reduce heart failure mortality rate by 40% by September 1, 2012 Reduce falls with injury on 4 West to zero by November 30, 2012 Reduce heart failure mortality rate by 40% by September 1, 2012 Reduce falls with injury on 4 West to zero by November 30, 2012

42. What Are You Trying to Accomplish? At your tables, for the next 5-10 minutes create an AIM Statement for a project you are working on or planning to start

43. Evaluation and Sharing Did your AIM statement: – Have a clear numerical goal? – Have a bold but realistic goal? – Clearly articulate what you want to achieve and by when? Can your AIM statement be given in any elevator? Would you change your AIM statement? If so, what would you change and why?

44. How do you know if a change is an improvement?

45. 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 ActPlan StudyDo AIM MEASURE Selecting Change Small Tests of Change

46. Why Measure? How else will you know that the change(s) you made resulted in improvement?

47. Limitations One Voice Useful, not perfect Sample

48. Select right measures Rapid results Adapt interventions

49. Types of Measures 49

50. Process Measures What you get Outcome Measure Balance Measures

51. Outcome Process Balance MEASURES

52. How Will We Know If A Change Is An Improvement? At your tables, for the next 5-10 minutes decide what measure(s) will help you know if you have made an improvement

53. Evaluation and Sharing Does the measure(s) you selected allow you to understand if you have made a change? Would you change your measurement plan? If so, what would you change and why?

54. 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 ActPlan StudyDo AIM MEASURE Selecting Change Small Tests of Change

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

56. What changes can we make that will result in an improvement?

57. Brainstorm Rank Construct Plan to Test

58. Time to Brainstorm…

59. Rules of Brainstorming & Multi-voting Brainstorm – Each team member gives an idea – No debate of value – Continue until there are no more ideas Multi-voting – Each team member gets 3- 5 votes – Use all on one idea or split them up Brainstorm – Each team member gives an idea – No debate of value – Continue until there are no more ideas Multi-voting – Each team member gets 3- 5 votes – Use all on one idea or split them up

60. Guidelines for Testing Change

61. Fail Early, Fail Often

62. What can I do by next Tuesday/Thursday?

63. Work with the willing

64. Aim BIG Test Small

65. Forget about consensus

66. Be Innovative

67. Collect Data

68. Wide range of conditions

69. Steal Shamelessly

70. Why Test?

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

72. Back to Work Over the next 5-10 minutes, create 1-2 small tests of change you can implement by next Tuesday. Describe the who, what, how and the study approach. What do you want to happen? How will you know if it did? Over the next 5-10 minutes, create 1-2 small tests of change you can implement by next Tuesday. Describe the who, what, how and the study approach. What do you want to happen? How will you know if it did?

73. Evaluation and Sharing Does your test of change: – Include a description of the test? – Indicate who will do what, when and where? – Describe what you want to or think will happen? Would you change your test of change? If so, what would you change and why? Does your test of change: – Include a description of the test? – Indicate who will do what, when and where? – Describe what you want to or think will happen? Would you change your test of change? If so, what would you change and why?

74. The Value of “ Failed ” Tests “I did not fail one thousand times; I found one thousand ways how not to make a light bulb.” Thomas Edison

75. Common Traps Plan Do, Plan Do Do Act, Do Act No testing, only data collection No ramps of tests, random PDSAs Undisciplined PDSAs, no documentation Prediction – what are we going to learn Beware of Cycles longer than 30 days

76. Mistakes Made In Improvement Teams Failure to state a measurable, specific aim Failure to tie measures to aims Over-reliance on education and awareness Failure to state a population focus Failure to abandon a change that does not lead to an improvement Failure to engage process owners on a team and solicit their ideas Failure to make data visible to all engaged in the process Failure to state a measurable, specific aim Failure to tie measures to aims Over-reliance on education and awareness Failure to state a population focus Failure to abandon a change that does not lead to an improvement Failure to engage process owners on a team and solicit their ideas Failure to make data visible to all engaged in the process

77. Useful Websites www.jointcommission.org www.healthgrades.com www.calhospitalcompare.org www.ihi.org www.ahrq.gov www.apic.org