2. Using the Model for Improvement to Improve Reliability of Care Processes Jennifer Lenoci-Edwards, RN, MPH Director, Patient Safety, Institute for Healthcare Improvement (IHI) Yvonne Cheung, MD, MPH, CPPS Chair, Department of Quality and Patient Safety, MAH September 25, 2015 Mount Auburn Practice Improvement Program (MA-PIP) Community Learning Session #2

3. Learning Objectives Learners will be able to:  Demonstrate the use of the Model for Improvement and small tests of change to identify and solve problems  Describe strategies to improve the reliability of care processes.  Identify strategies to effectively engage patients in improvement work Using test results management as our example

4. Disclosure Statement All Presenters and Content Developers have no significant financial interest/arrangement with any organization(s) that could be perceived as a real or apparent conflict of interest with the subject matter of the presentation.

5. 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 Ac t Plan StudyDo Aim of Improvement Measurement of Improvement Developing a Change Testing a Change Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996. 4

6. 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 Sequential building of knowledge under a wide range of conditions Spread 5

7. Plan Compose aim Pose questions/predictions Create action plan to carry out cycle (who, what, when, where) Plan for data collection DoStudy Act Carry out the test and collect data Document what occurred Begin analysis of data Complete data analysis Compare to predictions Summarize learning Decide changes to make Arrange next cycle Adapt, Adopt, or discard Plan-Do-Study-Act (PDSA) Cycle 6

8. Principles & Guidelines for Testing Changes  A test of change should answer a specific question  A test of change requires a theory and prediction  Test on a small scale  Collect data over time  Build knowledge sequentially with multiple Plan-Do-Study-Act cycles for each change idea  Include a wide range of conditions in the sequence of tests

9. Getting Started  Select process you want to make more reliable  What keeps you up at night?  How could a patient be harmed in your practice?  Where are the Pain Points for your team?  Select subset or segment of population  Develop a high level flow diagram  Identify defects in each step  Select which defect you will fix first  State your reliability goal  At least 95% reliable 8

10. Our Test Case: Test Result Management Test Result Management  Delayed Diagnosis  Poor Outcomes to Patients  Medical Malpractice 9

11. Where do I begin? Let’s break it down  Did patient get the test I requested?  Did the test come back?  Did the team review the test?  Did the Physician interpret the test correctly?  Did the Physician order the correct follow up test or treatment or referral?  Was the test result communicated to the patient?  Did the follow up occur?  Who will watch my test queue when I am on vacation? 10

12. Back to the Model For Improvement Aim: What is the process we are focused on improving? By what? By when? Measurement: What is a metric that we use to assess our AIM? Tests of Change: What can we test to improve our system? 11

13. Back to the Model For Improvement Aim: Increase to 80% the number of (Radiology, Echo, High Risk, High Risk Patients) test results that are communicated to patients within 48 hours of receipt, by the end of September. Measurement: Weekly review of 10 random charts with pending test results to determine if information was communicated to patient (via phone or letter.) (On Wednesday check the next 10 test results that came starting Monday, to see if they have been communicated to the patient) Tests of Change: How to identify tests of change 12

14. Working toward your Tests of Change  Select process you want to make more reliable  What keeps you up at night?  How could a patient be harmed in your practice?  Where are the Pain Points for your team?  Select subset or segment of population  Develop a high level flow diagram  Identify defects in each step  Select which defect you will fix first  State your reliability goal  At least 95% reliable 13

15. Flow Mapping: Visualize the Steps  High level (work) flow diagram  3 to 5 Steps-keep it simple  Identify defects  Is there a cascade?  Which is the biggest defect?  Identify what you will fix 14

16. Flow Mapping – Making the Process Visual Make Coffee Make Kids Lunches Pack their Back Packs Wake up the kids 15 Get Up Rock in my Shoe: We keep missing the bus!

17. Tool: Ask “Why?” Five Times Curiosity! To help you understand the underlying reasons for the defects Why? 16

18. Your turn – Flow mapping for Test Result Management  Pick one process that you want to improve around test result management  Work with 3-4 people near you to develop a flow map for test results management  Use “stickies” to identify 4-5 key steps in the process  Identify potential defects/problems in process 17

19. Discussion 18

20. Principles & Guidelines for Testing Changes  A test of change should answer a specific question  A test of change requires a theory and prediction  Test on a small scale  Collect data over time  Build knowledge sequentially with multiple Plan-Do-Study-Act cycles for each change idea  Include a wide range of conditions in the sequence of tests

21. 20 Selecting a Change to Test ----- Building Systems for Reliability

22. How Reliable is Your Test Result Process When compared to:  Airline industry  Automobiles  Starbucks 21

23. Why Are Processes Not Reliable?  Individual Autonomy  Expecting that a policy will result in improved reliability  Focus on benchmark performance  Over-reliance on training, vigilance and hard work 22

24. QUALITY is Job #1 Lecture at Noon Work harder. Pay more attention. Photo Credit: St. Barb by Matt MacGillivray (CC BY)St. BarbMatt MacGillivray

25. Changes that can Improve Reliability  Simplification  Are there Steps in your processes that can be eliminated?  Standardization  Best known process to achieve desired results  But known today-may change with new knowledge or new context 24

26. Why Standardize?  Makes it easier to fix a defect when one occurs  Reduce variation  Makes it easier to train  Supports care we expect our patients receive  Makes it easier to assess competency  Easier for patients to identify when there is a failure in the system 25

27. How do I make this Reliable? Make Coffee Make Kids Lunches Pack their Back Packs Wake up the kids 26 Get Up Rock in my Shoe: We keep missing the bus! What changes might you test?

28. Testing on a Small Scale What can you do by Tuesday? What can you by this afternoon? “The Power of One” – one patient, one clinician, one visit 27

29. Your Turn – Small Tests of Change  What are some changes that could be tested to improve your process?  Who would the tests entail?  Do you have a hunch? Do the reliability principles give you ideas to test?  How do you make sure you are testing on a small scale?

30. 29 Discussion

31. What Makes an Effective Change? Human Factors Engineering and “Actions”  Warnings and labels (watch out!)  Training (don’t do that)  Procedure changes (work around that)  Interlock, lock-in,, lock-out, etc. (let me design it so you cannot do that – forcing functions)  Is there one right action??? 30 Weaker Stronger Source: NPSF National Patient Safety Foundation www.npsf.orgwww.npsf.org See detailed version in handouts: Action Hierarchy

32. 31 Engaging Patients in Your Improvement Work

33. Engaging Patients How do we engage patients in this work?  Patients’ perspective – identifying defects  Patients’ suggestions for improvements  Patients’ reaction to changes tested  Patients on your improvement team 32 “The greatest asset we have underutilized is all the assets of the patient.” Maureen Bisognano President and CEO Institute for Healthcare Improvement

34. Your turn Think about your workflow  How could you involve patients in identifying and testing changes? 33

35. Discussion 34

36. Plan Compose aim Pose questions/predictions Create action plan to carry out cycle (who, what, when, where) Plan for data collection DoStudy Act Carry out the test and collect data Document what occurred Begin analysis of data Complete data analysis Compare to predictions Summarize learning Decide changes to make Arrange next cycle Adapt, Adopt, or discard Learning from Tests of Change: Plan-Do-Study-Act (PDSA) Cycle 35

37. 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 Sequential building of knowledge under a wide range of conditions Spread 36

38. Using the PDSA form 37 PDSA Worksheet for a Small Test of Change Practice Name: _ _________________ Cycle start date: _________ C ycle end date: __________ PLAN: Area to work on: Describe the change you are testing and state the question you want this test to answer (If I do x will y happen?) What do you predict the result will be? What measure will you use to learn if this test is successful or has promise? Plan for change or test: who, what, when, where Data collection plan: who, what, when, where DO: Report what happened when you carried out the test. Describe observations, findings, problems encountered, special circumstances. STUDY: Compare your results to your predictions. What did you learn? Any surprises? ACT: What will you do next? Adopt, adapt, or abandon the change? AP SD

39. 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 Ac t Plan StudyDo Aim of Improvement Measurement of Improvement Developing a Change Testing a Change Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996. 38

40. Review: The Key Steps of Improvement Work  Pull together the team and build the will  Set the aim  Be sure to engage patients  Testing, Testing, Testing 1.Select a process you want to improve 2.Develop a high level flow diagram 3.Identify Defects/Select which defect you will fix first 4.State your reliability goal - At least 95% reliable 5.Identify changes to test 6.Test your changes - keep it small 7.Use PDSA cycles to learn from your test change  Measuring, Measuring, Measuring 39

41. To Be Successful …  Leaders insist that teams focus on developing capable processes/making care safe for patients  Teams include front line workers – experts in the process  Teams engage patients in the improvement work  Teams use the Model For Improvement and Reliability Principles rather than training and education, vigilance and hard work  Teams review share improvement data  Improvement projects have a reasonable time line  Teams ask for help –  Mount Auburn Coaches, Practice Manager Meetings and Community Learning Sessions 40

42. Keep in mind….  “What keeps you awake at night? (How could a patient be harmed in your practice?)”  “Not all changes lead to improvement; all improvement requires change.”  “What can you do by Tuesday? What can you by this afternoon?”  “The Power of One” – “one patient, one nurse, one visit”  “Just enough measurement to support improvement.”  “See problems, Solve problems.” 41

43. Those who lead healthcare in patient safety  Do not necessarily have access to some unique or bountiful resource.  Do seek to constantly learn and apply what is learned, along with maximizing the effective use of existing resources.  Their willingness to learn and creatively use available resources allows them to be successful in changing their safety culture Source: Steve Spear Senior Fellow, Institute for Healthcare Improvement Senior lecturer, Massachusetts Institute of Technology, Sloan School of Management Faculty for the PROMISES

44. Organizations that are exceptional create this superior learning dynamic by: 1.Incorporating the detection of problems as part of everyone’s job 2.Being prepared to identify and solve problems 3.When something works, planning how to spread it throughout the organization 4.Leadership that ensures that all staff are actively included, motivated, encouraged and given time Source: Steve Spear

45. 44 Questions/Discussion Thank You!

46. Wrap up and Next Steps Lora Gross-Kostka, RN, BSN, Ambulatory Risk Manager/Patient Safety Advisor, MAH Paula Griswold, MS Executive Director, Massachusetts Coalition for the Prevention of Medical Errors September 25, 2015 Mount Auburn Practice Improvement Program (MA-PIP) Community Learning Session #2

47. Ambulatory Risk Management and Patient Safety Program (ARMS)  ARMS major goal- facilitate a Culture of Safety and improve quality of care for patient & providers  How? Integration of existing Q &S initiatives within Office Practice setting with the hospital based infrastructure, i.e.:  Ambulatory Quality and Patient Safety Committee,  Quality Review Committee,  On-line rL Safety Reporting

48. Mount Auburn-Performance Improvement Project (MA-PIP) How does this work fit into the ARMS program initiative? Empowers the frontline staff at the point of care by: training Coaches and Teams to “see a problem/solve a problem” using the IHI Model for Improvement to standardize systems & processes and shared learning

49. Next Steps  Please complete your evaluation and suggestions and turn in at registration table (MAH will process CMEs)  Upcoming meetings:  October 30 th – Practice Managers  December 4 th – Community Learning Session  Thank you to teams, coaches, faculty, staff, and to all of you for your focus on safety and improvement