1. 1 So Now You Have To Lead Your Team Through the Model for Improvement Debbie Barnard, SHN PM, CPSI Dannie Currie, SIA Atlantic Node October / November 2007

2. Atlantic Node 2 Objectives Each participant will be able to: Coach others on the Model for Improvement structure Evaluate and critique aim statements Evaluate and critique a team’s measurement strategy Coach teams on the use of the PDSA cycle Help teams design small scale PDSA cycles for initial tests of change Help teams design a series of PDSA cycles to implement a change idea Source: Daniel, Donna, “Teaching the Model for Improvement” Collaborative Sponsor Training

3. Atlantic Node 3 Introduction Source: Daniel, Donna, “Teaching the Model for Improvement” Collaborative Sponsor Training

4. Atlantic Node 4 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

5. Atlantic Node 5 Model for Improvement* The model has two parts: - Three fundamental questions, which can be addressed in any order. - The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of a 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

6. Atlantic Node 6 Key Concepts Three Basic Questions Source: Daniel, Donna, “Teaching the Model for Improvement” Collaborative Sponsor Training

7. Atlantic Node 7 Does the aim statement include recommended elements? –What is expected to happen –The system to be improved –The setting or sub-population of patients –Specific numerical goals –Guidance for the activities such as strategies for the effort and limitations Is the aim specific enough to be accomplished in the Collaborative time frame? Does the team match the aim? Are the goals and population consistent with the mission for the Collaborative? Evaluating Aim Statements

8. Atlantic Node 8 The SHN campaign is about making changes to systems, not measurement. But measurement plays a key role role: Key measures are required to assess progress on team’s aim Specific measures can be used for learning during PDSA cycles Balancing measures are needed to assess that other parts of the system are not being negatively impacted. How Do We Know That a Change Is an Improvement?

9. Atlantic Node 9 An aim statement should include: What is expected to happen The system to be improved The setting or sub-population of patients Goals Guidance for the activities such as strategies for the effort and limitations What Are We Trying to Accomplish?

10. Atlantic Node 10 What Changes Can We Make That Will Lead to Improvement? Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

11. Atlantic Node 11 Types of Measures Type of measureExamples Outcome measures Process measures Balancing measures Rates Failures Re-admits Mortality, LOS % use order set, guideline, etc % treated in required time % receiving 100% of ‘bundle’ Times, durations Etc Costs Delays Resources % detected by redundant process Etc

12. Atlantic Node 12 Clinical measures of patients health Documentation of behaviors Questionnaires Assessments Summary of databases Chart audits Observations Methods of Measurement

13. Atlantic Node 13 Measurement Guidelines The Vital Few: a few key measures that clarify a team’s aim and make it tangible Balanced set of measures Process, Outcome, Balancing Integrate measurement into the daily routine How will we know that a change is an improvement?

14. Atlantic Node 14 Outcome vs. Process Measures Outcome = Represents the customer / patient: How is the system performing? What is the result? How is the health of the patient affected? What the CEO/Administrator/Director ultimately wants to know Process = Represents the workings of the system: Are the parts / steps in the system performing as planned? Are key changes being implemented in the system?

15. Atlantic Node 15 Conceptual, Vague, Strategic Specific Ideas, Actionable Improve Redesign process Move steps in the process closer together Move order receipt and warehouse closer together Move the fax that receives orders into the warehouse Write a work order to have the fax moved on Monday Concepts to Ideas

16. Atlantic Node 16

17. Atlantic Node 17 Key Concepts Plan, Do, Study, Act Source: Daniel, Donna, “Teaching the Model for Improvement” Collaborative Sponsor Training

18. Atlantic Node 18 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 the improvements we seek ? ActPlan StudyDo Model for improvement Aims Measurement The three fundamental questions for improvement The fourth question: how to make changes Langley, Nolan et al 1996 Ideas, evidence, hunches, Other people etc.

19. Atlantic Node 19 Cycles for Testing Increase your belief that the change will result in improvement Document how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation

20. Atlantic Node 20 To Be Considered a PDSA Cycle: The test or observation was planned (including a plan for collecting data) The plan was attempted (do the plan) Time was set aside to analyze the data and study the results Action was rationally based on what was learned

21. Atlantic Node 21 Attributes of Changes That Are Readily Adopted* The change has a clear advantage over the current system The change is compatible with current system and values The change is easy to try and reverse Understanding and adapting the change requires minimum complexity The change and its impact can be observed *From Everett Rogers “Diffusion of Innovations”

22. 22 What is the PDSA Cycle? Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

23. Atlantic Node 23 Tasks at Each Station Act Plan Plan a test (change, theory, prediction) Record plan on planning sheet StudyDo Modify your plane to Incorporate your changes; fly 3 times; record data, unusual events Plot data, interpret results. Compare data to predictions Keep changes, modify, abandon?

24. Atlantic Node 24 Testing on a Small Scale Have others that have some knowledge about the change review and comment on its feasibility Test the new product or the new process on the members of the team that developed the change before introducing it to others Incorporate redundancy in the test by making the change side-by-side with the existing process or product

25. 25 What is the PDSA Cycle? Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

26. Atlantic Node 26 Tasks at Each Station Act Plan Plan a test (change, theory, prediction) Record plan on planning sheet StudyDo Modify your plane to Incorporate your changes; fly 3 times; record data, unusual events Plot data, interpret results. Compare data to predictions Keep changes, modify, abandon?

27. Atlantic Node 27 Repeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change

28. Atlantic Node 28 Repeated Use of the PDSA Cycle to Improve LOS for ED patients with X-rays Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Cycle 1a: Pilot quick-look for extremity x-rays on one shift. Monitor LOS for patients with x- rays and error rate. Review results with Radiology Cycle 1b: Revise documentation process and try quick-look for two days Cycle 1c: Redesign viewing area and continue quick-look for two weeks Cycle 1d: Make quick-look standard practice and monitor EXAMPLE

29. Atlantic Node 29 Decrease the Time Frame for a PDSA Test Cycle Years Quarters Months Weeks Days Hours Minutes Drop down next “two levels” to plan test cycle!

30. Atlantic Node 30 Successful Cycles to Test Changes Plan multiple cycles for a test of a change Think a couple of cycles ahead Scale down size of test (# of patients, location) Test with volunteers Do not try to get buy-in, consensus, etc. Be innovative to make test feasible Collect useful data during each test Test over a wide range of conditions

31. Atlantic Node 31 Testing on a Small Scale Cont. Conduct the test in one facility or office in the organization, or with one customer Conduct the test over a short time period Test the change on a small group of volunteers Develop a plan to simulate the change in some way

32. Atlantic Node 32 Reasons for Failed Tests 1.Change not executed well 2.Support processes inadequate 3.Hypothesis / hunch wrong: Successful change did not result in local improvement Local improvement did not impact global measure Collect data during the “Do” phase of the cycle to help differentiate these situations.

33. Atlantic Node 33 Cycles for Implementation The change is permanent - need to develop all support processes to maintain change High expectation to see improvement (no failures) Increased scope will lead to increased resistance Generally takes more time than tests

34. Atlantic Node 34 EXERCISE Building Planes and Flying in the Alaska Bush Original Work Developed by IHI.org

35. 35 Key Activities Review baseline data Study change ideas Learn about Model for Improvement

36. Atlantic Node 36 What the Experts Know “Change Package” Problem Short flight distances Nose dives Wanders off-target Changes Use heavier paper Change launch angle Add tape weight to rear Reinforce plane body with clips

37. Atlantic Node 37 Debbie Barnard, MS, CPHQ Project Manager Safer Healthcare Now! Canadian Patient Safety Institute Suite 1414, 10235 101 Street Edmonton, Alberta T5J3G1 Phone: 780-498-7259 or 1-866-421-6933 Fax: 780-409-8098 Email: dbarnard@cpsi-icsp.cadbarnard@cpsi-icsp.ca Website: www.patientsafetyinstitute.cawww.patientsafetyinstitute.ca Questions/Comments The Canadian Patient Safety Institute would like to acknowledge funding support from Health Canada. The views expressed here do not necessarily represent the views of Health Canada