1. GHA Hospital Engagement Network HAC-Learning Collaborative Webinar ~ June 20, 2012 Kelley Dotson, GHA Nancy Fendler, GMCF Anne Hernandez, GMCF Kathy McGowan, GHA

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Discuss evidence based practice elements of a prevention program for VTE Define process assessment and evaluation using specific tools & examples Review participation information & guidelines Learning Objectives

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Overview Education Process Assessment Process Evaluation Discussion

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. AIM What are we trying to accomplish? MEASURES How will we know that a change is improvement? CHANGES What changes can we make that will result in improvement? Key changes are then implemented in a cyclical fashion Performance Improvement Team Should Ask Three Questions:

5. Act What changes are to be made? Next cycle? Adopt, adapt, or abandon?? 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 The PDSA Cycle for Learning & Improvement:

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Rapid Cycle Change (Repeated Use of the Cycle) Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA TIME DIFFICULTY (Proactive Improvement that slowly changes the intrinsic noise over time)

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Skills Which Support Improvement: Challenge the boundaries (creative thinking) Visualize the ideal Remove the “current way of doing things” as an option (think outside the box) Always go back to the overall practice goals to guide the PDSA cycles

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. To Accelerate Improvement : Develop focused, relative objectives Strive for usefulness in the data collection and analysis To obtain “buy in” begin with evidence-based goals Test first on a small scale and spread the good or well- adapted plans for change

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Do. Small Tests of Change ALL improvement requires change, but not all changes lead to improvement The ability to develop, test, and implement changes is essential for continuous improvement 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 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

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Why DO small tests of change? To increase your belief that the change will result in improvement. To decide which of several proposed changes will lead to the desired improvement. To evaluate how much improvement can be expected from the change. To decide whether the proposed change will work in the actual environment of interest. To decide which combinations of changes will have the desired effects on the important measures of quality. To evaluate costs, social impact, and side effects from a proposed change. To minimize resistance upon implementation.

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. D S P A Cycle 5: Spread to other patients, physicians, units… Cycle 4: Implementation of system change(s) Cycle 3: Wider scale tests of change Cycle 2: Follow up Tests with larger study group Cycle 1: Very Small Scale Test AP SD D S P A A P S D AP SD DATA Changes that result in improvement Hunches, theories, ideas The PDSA Cycle for Learning and Improvement:

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. DATA Cycle 5: Make adjustments and implement protocol system wide Cycle 4: Test protocol on additional units with a larger patient population Cycle 3: Test protocol with one physician on one unit with one population Cycle 2: Establish draft protocol for ordering prophylaxis according to best practice Cycle 1: Develop system for regularly obtaining information regarding appropriate ordering and administration of prophylaxis for surgery patients (SCIP: VTE 1 & VTE 2) D S P A AP SD D S P A A P S D AP SD VTE Prophylaxis integrated into routine care for all Develop successful approaches to improve delivery of VTE Prophylaxis Aim Decrease the number of VTE occurrence during hospitalization

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. What you’ve ALREADY done Selected specific HAC to address Formed Team Set Aim Established Measures Selected Change Tested Change NOW WHAT?????

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. PLAN State the Objective of the plan Plan the Change (what, who, when, where?) Predictions (what is expected to happen?) Data Collection (who, what, when, where?) DO Describe what actually happened when you ran the test of change STUDY ASSESS the measured results and EVALUATE how they compare to the predicted results ACT Describe what changes to the plan will be made for the next cycle from what you learned Small Test of Change Worksheet

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. How Do We Know That A Change is an Improvement? Are specific measures tested during the PDSA cycles demonstrating desired results? Does the change facilitate the overall goal(s) of the practice? Can this change be attained (and maintained) without undue interference with other important practice goals?

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. What to do with the Tests of Change? Assess Evaluate

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. STUDY. What did the tests tell us??? ASSESS AND EVALUATE LEARN from Each Test….Was there improvement??? – NO. Make adjustments and repeat the test on a small scale – YES. Expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely NOW…change is ready for implementation on a broader scale (an entire pilot population or on an entire unit)

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. ACT. Implement & Spread Implementation is a permanent change to the way work is done – Involves building the change into the organization – Infrastructure are not heavily engaged in the testing phase Documentation & written policies? Hiring, training, and compensation? *Implementation also requires the use of the PDSA cycle*  Learn optimal sequencing of tasks  Work with people to help adoption and adaptation

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Spread is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of the organization *Spread efforts benefit from the use of the PDSA cycle*  Plan how to adapt changes to other area  Determine if the change resulted in the improvement HOW?????? ACT. Implement & Spread 2

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Sustained Change OVER TIME = IMPROVEMENT Improvement takes place over time Determining if improvement has really happened and if it is lasting requires observing patterns over time Run charts Graphs of data over time Tool for assessing the effectiveness of change

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. RUN CHARTS Run charts have a variety of benefits: Help improvement teams formulate aims by depicting how well (or poorly) a process is performing Help in determining when changes are truly improvements by displaying a pattern of data that can observe as changes are made Give direction to improvement with information about the value of particular changes

22. Learn. Act. Improve. Spread. Keep the Drum Beat Going. IHI RESOURCES RUN CHART TOOL http://www.ihi.org/knowledge/Pages/Tools/Run Chart.aspx TRACKER TOOL http://app.ihi.org/Workspace/tracker/

23. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Assessing Monitoring Improvement… RUN CHARTS

24. Learn. Act. Improve. Spread. Keep the Drum Beat Going. RUN CHARTS 2

25. Learn. Act. Improve. Spread. Keep the Drum Beat Going. RUN CHARTS 3

26. Learn. Act. Improve. Spread. Keep the Drum Beat Going. RUN CHARTS 4

27. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Useful Strategies to Hold the Gains: Establish and document new processes Make formal changes to job descriptions Use regular measurements and audits Factor new goals/processes into staff training and new hire orientation Assign ownership of new processes Address the “social aspects” of change

28. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Address the “Social Aspects” of Change: Provide and disseminate widely information on why the change is being adopted Give specific information on how the change will affect people Seek and use input from others, (especially those directly affected by the change), and encourage their support Publicize the PDSA results and what was learned from them Understand and address the causes of resistance to change

29. Learn. Act. Improve. Spread. Keep the Drum Beat Going. IMPROVEMENT Summary Step 1: Plan Plan the test or observation, including a plan for collecting data. State the objective of the test. Make predictions about what will happen and why. Develop a plan to test the change. (Who? What? When? Where? What data to collected?) Step 2: Do Try out the test on a small scale. Carry out the test. Document problems and unexpected observations. Begin analysis of the data.

30. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 3: Study Take time to analyze the data and study the results. Compare the data to your predictions. Summarize and reflect on what was learned. Step 4: Act Refine the change, based on what was learned from tests. Determine what modifications should be made. Prepare a plan for the next test. Summary

31. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Hospital Engagement Network (HEN) *Review* Hospital Acquired Conditions – Pressure Ulcer Prevention – Fall Reduction – VTE Prevention – Adverse Drug Events (ADE) Each Hospital will work towards improvement in all areas Initially, each hospital will identify TWO conditions of focus for reporting Hospitals will report data using defined measures upon request

32. Learn. Act. Improve. Spread. Keep the Drum Beat Going. *Review* June is CATCH-UP Month HAC Specific Learning Collaborative – Kelley to email summary sheet for progress Individualized for each hospital with completed items Defined guidelines for information needed – Each hospital representative will be contacted GHA/GMCF and hospital representative will walk through the progress sheet and discuss any concerns Review will assist communication and understanding – Access Telnet and Materials https://quality.gha.org/Home/HospitalEngagementNetworkHEN/LearningCollaboratives/HospitalAcquire dConditionsEventsHAC/Meetings.aspx – Complete Sign-in Sheets and Evaluations March 21April 18 May 16June 20

33. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Questions or Concerns Kelley Dotson, RN, MSN, CPHQ – kdotson@gha.org kdotson@gha.org – 770-249-4511