1. AMI Virtual Learning Collaborative Building on LS1-A Atlantic Node

2. LS1-A Re-Cap Introduced to WebEx technology Overview of Virtual Learning Collaborative and Expectations Expert presentation on Thrombolytic Therapy Process Mapping Atlantic Node

3. What Worked Well The content and presentations Sharing by Participants Engagement Use of Examples Polls/Feedback Being able to ask questions Atlantic Node

4. What Worked Well Being able to participate without travelling is a huge plus Easy Access/ able to access it almost anywhere, easy to follow Having presentation from specialist and then being able to apply to our specific practice Atlantic Node

5. What Worked Well Hearing while seeing, coordination Having interaction with colleagues from the provinces and regions Atlantic Node

6. Improvement Opportunities 1. Slides and handouts 2. Times listed only as ADT 3. Voice delay and overlap Change Ideas to Test 1.Post on CoP 2. Include NL time in correspondence 3. Use emoticon to flag issue Atlantic Node

7. Improvement Opportunities 4. Passing the ‘Ball’ 5. Voice clarity fluctuation 6. WebEx training before Session Change Ideas to Test 4. Establish Co-Host role 5. Speak directly into microphone; headset/ hands free 6. Next VLC pre sessions Atlantic Node

8. Comments/Questions Atlantic Node

9. AMI Virtual Learning Collaborative The Model for Improvement Atlantic Node

10. Measurement *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

11. Overview Measures & Targets Inclusion & Exclusion Criteria Individual Data Collection Form Elapsed Time by Patient Worksheet Measurement Worksheet Atlantic Node

12. What are Our Measures? % STEMI or new LBBB who received thrombolytic within 30 minutes of arrival at ED. % STEMI or new LBBB who received an ECG within 10 minutes of arrival at ED. Atlantic Node

13. What are our Targets? 90% STEMI or new LBBB receive thrombolytic within 30 minutes of arrival at ED. 90% STEMI or new LBBB receive an ECG within 10 minutes of arrival at ED. Atlantic Node

14. Why These Measures? Based on CCORT AMI Indicators (CMAJ 2008: 179: 909-15) Time is muscle (myocardium) Two measures which are key to timely thrombolysis We know there is room for improvement Atlantic Node

15. Measure 4.0A Lytic Within 30 Minutes of Arrival Denominator Inclusion: All STEMI or new LBBB confirmed by ECG Lytic within 6 hours of arrival at ED Lytic as primary reperfusion therapy Exclusion: Patients with NSTEMI, non-Q wave or subendocardial MIs Transfers in who received lytics in another acute care facility or ambulance Under 18 years of age Atlantic Node

16. Measure 4.0A Lytic Within 30 Minutes of Arrival Numerator All those in the denominator who received lytic within 30 minutes of arrival at ED Atlantic Node

17. Measure 10.0 ECG Within 10 Minutes of Arrival Denominator Inclusion: Patients admitted through Emergency with diagnosis of STEMI or new LBBB confirmed by ECG Exclusion: Received a lytic in ambulance Transferred from another acute care facility Under 18 years of age Atlantic Node

18. Measure 10.0 ECG Within 10 Minutes Numerator All those in the denominator who had an ECG within 10 minutes of arrival at ED –If ECG completed by EMS (pre-hospital) this is considered within 10 minutes of arrival at ED Atlantic Node

19. Additional Process Measures Time 1 st medical contact to 1 st ECG Time 1 st medical contact to arrival at ED Time diagnostic ECG done to read by MD Time diagnostic ECG read by MD to thrombolysis Atlantic Node

20. Individual Data Collection Form Use a data sheet for each month of data submission Each workbook has 2 worksheets – (1) Individual pt. times & (2) Elapsed time by pt

21. Atlantic Node Individual Data Collection Form Enter name of hospital, Select Month and Year from drop down box

22. Atlantic Node Individual Data Collection Form Enter individual pt data as they arrive in ED MRN = Medical Record Number - Use identifier of your choice

23. Atlantic Node Individual Data Collection Form Sequential pt. # Enter times in appropriate cols. optional comments about pt Pt. identifier

24. Atlantic Node Individual Data Collection Form Notes: 1.Walk-In (pt.#1) – “1 st medical contact” usually same as “Arrived ED” 2.Transport by Ambulance (pt.#2&#3) – “1 st medical contact” occurs before “Arrived ED” 3.ECG and Lytics in ED (pt.#2) – “1 st ECG” after “Arrived ED” and before “Lytics started” 4.ECG in ambulance and Lytics in ED (pt.#3) – “1 st ECG” before “Arrived ED” and “Lytics started” 5.If ECG and Lytics in ambulance (pt.not shown) – “1 st ECG” and “Lytics Started” before “Arrived ED”

25. Atlantic Node Elapsed Time by Pt Worksheet Automatic calculations Now on second worksheet = Elapsed Time by Pt.

26. Atlantic Node Elapsed Time by Pt Worksheet Classification of patient for measure 4.0A All elapsed times are automatically calculated from data entered on “Individual Times” worksheet

27. Atlantic Node Elapsed Time by Pt Worksheet Number of teams meeting criteria w/i 30 mins and those not meeting criteria w/I 30 mins

28. Atlantic Node Measurement Worksheet Enter data on “Data Entry Sheet

29. Atlantic Node Measurement Worksheet Enter name of hospital, region and description of patient sample in ‘windows’ outlined in red.

30. Atlantic Node Measurement Worksheet In column for appropriate month and year identify implementation stage and collection method 1. Baseline = 1 st month of data submission 2. Full = after reaching goal and holding it for 3 consecutive data submissions 3. Early = everything else.

31. Atlantic Node Measurement Worksheet Enter data from Elapsed Time / Individual Data Collection form in “red” outlined cells for Denominator Enter data from Elapsed Time / Individual Data Collection form in cell for Numerator

35. Atlantic Node Contact information Central Measurement Team Virginia Flintoft virginia.flintoft@utoronto.ca 416-946-8350 Alex Titeu shn.ea@utoronto.ca 416-946-3103

36. Model For Improvement * A simple yet powerful tool for accelerating improvement The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

37. Model For Improvement * The model has two parts: Three fundamental questions, Used to establish AIM; MEASURES, AND CHANGE IDEAS. The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of change to determine if the change is an improvement. *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

38. Action Oriented Trial and Learning Leadership Model For Improvement

39. Operationalizes the Improvement Model –Improvement theory –Project management Team Charter

40. To ensure a common understanding and focus by making explicit: –AIMS –Measurement targets –Changes –Timelines –Roles and Responsibilities To communicate effectively with senior leadership and other stakeholders Team Charter

41. Review your system: - Who does the patient see? - Who is needed to implement? - Who needs to know about the changes? - Who supports the changes? Work with those who will work with you Each member is a champion in their area Team

42. Core Team Members –Clinicians providing care i.e. nurses, technicians, therapists, paramedic –Clinical and administrative leaders i.e. Clinical Nurse Specialist, Nurse Manager Ad Hoc –Physician Champion –Quality Improvement personnel –Clerical Support Team

43. Team Leader Completing and clarifying the team charter in a manner that ensures the support of team members and team sponsor. Organizing and running effective meetings and maintaining team records ie minutes, correspondence, improvement data Facilitating work within the team and ensuring participation at and between meetings Communicate about the improvement work with the sponsor, team members, stakeholders and the larger organization. Roles and Responsibilities

44. Team Members Sharing content knowledge, skill and experience Communicating and developing a shared understanding within the team of the work process to be improved or changed. Testing change ideas within the team and in the real work context Leading and supporting coworkers to adapt the new process Completing tasks or assignments within and between meetings Establishing two-way communication with their colleagues and the team Roles and Responsibilities

45. Team Sponsor Clarifying the improvement mandate and aligning it within the organizations strategic and operational objectives Connecting and communicating with appropriate stakeholders Allowing time and other resources Establishing an accountability mechanism Facilitating the work of the team within the larger organization. Engaging a team leader and a coach Initiating the team charter Roles and Responsibilities

46. Team Coach Facilitating the use of improvement tools and techniques Monitoring and facilitating healthy team behaviors Providing technical expertise and guidance focusing on team process Supporting the team leader to plan effective team meetings Assisting with measurement for improvement eg data collection, submission, analysis and display Roles and Responsibilities

47. Identify your team members and assign Roles and Responsibilities. Exercise #1

48. Team Example Participant Sharing

49. What are you going to do? How much? By when? AIM

50. Bold Aim, Firm Deadlines Align aim with strategic goals of the organization Write a clear and concise statement of aim Make the target for improvement bold and unambiguous Include deadline Include scope, boundaries, constraints and anything else that is needed to keep the team focused

51. Example

52. Write your AIM statement Exercise #2

53. Team Example Participant Sharing

54. “Some is not a number. Soon is not a time” Donald Berwick, MD Institute for Healthcare Improvement Bold Aim, Firm Deadlines

55. Three Main Types : –Outcome Measures –Process Measures –Balancing Measures Measures

56. Model For Improvement Outcome measures: – Are driven by the specific objectives identified in the AIM statement, e.g. # decreased 30 Day AMI Mortality Rate –Are understood from the consumer’s perspective eg. Reduced discrepancies Process measures –Indicate whether a specific change is having the intended effect, e.g. ECG within 10 minutes; lytics door to needle within 30 minutes –Indicate if process changes are leading to improvements

57. Balancing measures: –Are related measures to understand the impact of changes on the broader system, e.g Patient/staff satisfaction –They can be the other effects of planned changes e.g. Increased admission time; decreased rework Model For Improvement

58. Measures Measures should be useful and manageable (2-6) Should be operationally defined e.g. Hospital Arrival = Arrival: The earliest documented time the patient arrived at the hospital; this may differ from the admission time Should be integrated into clinical documentation Purpose is for learning not judgment

59. Measures

60. Break & Networking Please be back in 15 minutes

61. What Changes can we make that will lead to an improvement? Changes

62. 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 combing these change concepts with knowledge about the specific work can help generate ideas for tests of change. PDSAs are used to test the specific ideas. Change concepts are usually at a high level of abstraction, but evoke multiple ideas for a specific process. –Examples: Reduce handoffs Consider all parties as part of the same system Improve work flow Eliminate waste Berwick, Boushon,& Roessner, 2007 Change Concept

63. Aim: Assure customers do not leave bank cards behind Change Concept

64. Aim: Assure customers do not leave bank cards behind Idea: Beeping sound Concept: Use reminder s Change Concept

65. Aim: Assure customers do not leave bank cards behind Idea: Beeping sound Concept: Use reminder s Electric shock Voice reminders Siren Based on Edward DeBono’s Concept Fan Change Concept

66. Change Package Getting Started Kits Creative and Critical thinking Hunches Best practices Asking process users and subject matter experts for ideas Community of Practice Insight from research and benchmarking Change Ideas

67. While all changes do not lead to improvement, all improvement requires change. Berwick, Boushon,& Roessner, 2007 Change

68. What’s in a Change Package? Change Package

69. Using the Change Package select, modify, or add change ideas and record them in your Charter. Exercise 3

70. Break & Networking Please be back in 15 minutes

71. Getting things moving: Plan, Do, Study,

72. What change will you implement by next Tuesday? PDSA

73. PDSA Testing Change Plan- a specific planning phase Do- a time to try the change and observe what happens Study- an analysis of the results of the trial Act- devising next steps based on analysis Berwick, Boushon,& Roessner, 2007

74. AIM: State your overall goal you would like to reach Example: 90% of eligible patients will have thrombolytic agents administered within 30 minutes of hospital arrival by March 2010 Describe your first (next) test of changePerson Responsible When to be done Where to be done Test Synchronizing clocks, watches and equipment (individual, departmental, and equipment) John RNOct 26/08 ED Rapid Cycle Testing

75. List the tasks needed to set up this test of change Person Responsible When to be done Where to be done 1.Identify time ‘data points’ in patient flow thru ED 2.Audit current clocks and equipment for current time 3.Audit a sample staff watch time 4.Design and test a protocol for daily synchronization of clocks, watches and equipment 5.Arrange a huddle 6.Complete the “testing” worksheet Mary RN Jane Team Lead Susan Unit Manager Mary RN with team Susan Unit Manager John RN 12-1230 Oct 22-09 Oct 22-25-09 10 am on Oct 23-09 Oct 26 1400 Sept 12 before 1500h Here ED ED Conference Rm ED Nursing Desk Conference Rm Med Unit #1 Plan

76. Predict what will happen when the test is carried out Measures to determine if prediction succeeds 1.Equipment, watches and clocks will need to be adjusted. 2.The protocol will need refinements 3.The huddle will identify new change ideas for testing 1.Self Report Y/N 2.Discussed and recorded in huddle 3.Yes/No Plan

77. Do: Describe what actually happened when you ran the test –Most clocks and watches were easily reset but equipment posed more of a challenge because some were off unit at the time.. Study: Describe the measured results and how they compared to the predictions –3 of 5 clocks; 4 of 6 watches; and evry piece of equipment needed the time Act: Describe what modifications to the plan will be made for next time. –All ED staff, EKG technicians and physicians will be asked to set their time in sync with the clock in the ED trauma room Completing Test of Change

78. The idea of using huddles, as opposed to the standard one-hour meeting, arose from a need to speed up the work of improvement teams. Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly. Berwick, Boushon,& Roessner, 2007

79. As you move thru cycles increase size of the test: 1-5-25 Getting it working well with one; Test it on five more; After 25, establish in organization Rapid Cycle Change

80. AP SD AP SD AP SD AP SD Change Ideas Learning From Data Very Small test Follow up tests Wide Scale tests of change Implementation of Change Changes Result in Improvement Moving From Testing to Implementing

81. Increase your belief that the change will result in improvement Opportunity for learning from “failures” without impacting performance Document how much improvement can be expected from the change PDSA Cycles for Testing

82. Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation PDSA Cycles for Testing

83. Why Test-Why Not Just Implement??

84. Select a change idea Complete the Plan Conduct the test in your work setting by NEXT TUESDAY Complete the Do, Study, Act sections Exercise

85. Parallel Ramps Testing ……………….Implementation…….Spread Aim PD S A Improve Work Flow Focus on Product/Service Change the work environment Manage variation Design System to avoid mistakes PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A PD S A Thrombolytic to eligible Patients within 30 minutes of ED arrival

86. Initiation of Rapid Cycle tests is dependent on getting the first test of change started Do Not try to Perfect the change then implement…consider your work a masterpiece in progress Failure is a great Opportunity to plan to do better next time… Frequency of Testing determines the speed of the process improvement ie daily testing = improvement in weeks; weekly = improvement in 3-4 months Rapid Cycle Change

87. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? ActPlan StudyDo Model for improvement Aims Measurement Langley, Nolan et al 1996 Change Ideas Trial & Learning

88. Questions? Rapid Cycle Change

89. Acknowledgements Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/GausModelforImprovement. htm?TabId=2 http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/GausModelforImprovement. htm?TabId=2 Harris, B. (2007). Change Concepts. Murray, M (2006). “Small Steps, Big Changes” workshop. Reasear, R. (2007). Institute for Healthcare Improvement “Designing Reliability Into Healthcare Processes: Based on the work of the Institute for Healthcare Improvement Innovation”