First PDSA Cycles Improvement Advisor Program NES IA Wave...

Copyright © Institute for Healthcare Improvement

First PDSA CyclesImprovement

Advisor ProgramNES IA Wave 33

Wednesday,26th March 2014

2:00 – 3:30 pm, GMT

Call time amended due to US daylight savings time start.

Copyright © Institute for Healthcare ImprovementSlide 2

Please Check In IA Wave 33:

IA IA IA

April MassonEYC – East Ayrshire CPP

Gavin RussellEYC – East Renfrewshire CPP

Michelle AffleckEYC -NHS Greater Glasgow and Clyde

David MaxwellHealthcare Improvement Scotland

Graham MacKenzieEYC – NHS Lothian

Michelle CochlanEYC - Perth

Dawn MossEYC – NHS Borders

Hamish FraserEYC – Midlothian CPP

Penny BondHealthcare Improvement Scotland

Derek KildayScottish Government

Judith CainEYC – North Lanarkshire Council

Sacha WillEYC – Aberdeen City Council

Diana BeveridgeScottish Government

Kerstin JornaEYC – Dundee City Council

Sally HallNHS Scotland

Donna MurrayEYC – City of Edinburgh Council

Kirsty EllisHealthcare Improvement Scotland

Shalani RaghavanScottish Government

Eileen McGinleyNHS Lanarkshire

Marie-Claire StallardEYC – East Dunbartonshire CPP

Stephanie FrearsonNHS Ayrshire & Arran

Emma LevyNHS Education Scotland

Marsha ScottEYC – West Lothian Council

Stephanie MottramNHS Dunfries and Galloway Royal Infirmary

Gareth AdkinsHealthcare Improvement Scotland

Michele DowlingEYC – South Lanarkshire Council

Wendy TonerEYC – NHS Greater Glasgow and Clyde D


N

1. NHS Ayrshire & Arran

2. NHS Borders

3. NHS Dumfries & Galloway

4. NHS Fife

10. NHS Lothian

9. NHS Lanarkshire

8. NHS Highland

7. NHS Greater Glasgow & Clyde

6. NHS Grampian

5. NHS Forth Valley

14. NHS Western Isles

13. NHS Tayside

11. NHS Shetland

12. NHS Orkney

12

3

45

6

7

8

9

10

11

13

14

12

15. Golden Jubilee National Hospital

D


IA Program Faculty and Staff Team: NES Wave 33

Lloyd ProvostFaculty WS3

NHS Education for Scotland

Dr. Robert LloydLead Faculty

Brandon BennettFaculty WS1

IHI Faculty and Staff

Beth O’DonnellProgram Mgr.

B

Sandy MurrayFaculty WS2

Debbie RayFaculty/Director

Dr. Lesley Anne SmithQI Programme Director

Dr. Elaine PacittiEducational Projects Mgr.

Louise CavanaghQI Project Officer

Samantha SmithQI Administrator


IHI Support Staff for Wave 33

Brian Sanderson,

Project Assistant

bsanderson@ihi.

org

Tom Charlton,

Project Assistant

[email protected]


IA Graduates and Their Role during the Program

Bernadette McCullochScottish Patient Safety Programme

Maternity & Children Quality

Improvement Collaborative

IA Wave 28

Laura AllisonDG Health and Social Care

Scottish Government

IA Wave 15

Assist your professional development by serving as teacher, coach,

and fellow learner.

B


Agenda – 26th March 2014 – “PDSAs

Time Agenda Lead

2:00 pm GMT Welcome and Check-In Debbie

2:10 pm GMT Paired Charter Reviews – Assignment Revisited and Insights from the Exercise

Debbie

2:15 pm GMT Paired PDSA Review AssignmentPreparation for SPC Assignment and upcoming WebEx on SPC 23rd April 2014

Debbie

2:25 pm GMT Presentation of PDSA Cycles 10 min each-learning from each other, questions, insights: Michelle Cochlin, Marie-Claire Stallard, Penny Bond

Bob

3:00 pm ET Accelerating the Rate of ImprovementCascading Driver DiagramsDriver Diagram Priority Setting

Bob

3:25 pm ET Additional Questions/ Next Steps Debbie


Reminder: Paired Charter Review Due Friday, 21st March 2014

The purpose is to review a colleague’s Project charter offering feedback for improvement and to receive feedback or improvement on your Project Charter.

1. Post your updated Project Charter to your Extranet homepage under Newest Resources tab.

2. Send an email to your partner letting them know that you have posted your Charter.

3. Use the Charter Feedback form as a guide and the skills learned during IA Workshop 1 to offer feedback for improvement to your partner. You can send your feedback in an email or make edits to the Posted Charter making sure to save it as a separate document, leaving your partner’s original Charter intact.


Charter Review Pairings

April Masson David Maxwell

Dawn Moss Derek Kilday

Diana Beveridge Donna Murray

Eileen McGinley Emma Levy

Gareth Adkins Gavin Russell

Graham MacKenzie Hamish Fraser

Judith Cain Kerstin Jorna

Kirsty Ellis Marie-Claire Stallard

Marsha Scott Michele Dowling

Michelle (Shelly) Afflect Michelle Cochlan

Penny Bond Sacha Will

Sally Hall Shalani Raghavan

Stephanie Frearson Stephanie Mottram

Wendy Toner


Insights Conducting the Charter Review

1. How did you give feedback to your partner – email, notes on

their charter, completed the Charter Feedback Form?

Email Notes on Charter Feedback Form

2. What did you find useful about the Charter Feedback Form?

3. What did you learn about your own project as the result of

reviewing your partner’s charter?

4. If you did not conduct your Paired Charter Review, what was

the barrier – partner didn’t have a Charter posted, I didn’t

understand the assignment, I couldn’t find time to do the

assignment?

No Charter Posted Didn’t Understand No Time


IA ---PDSA Review Assignment

Purpose: Learn about, and provide

feedback related to PDSA cycles Time estimate: 20 minutes & 4 Easy Steps!

1. Make sure you have your next PDSA cycle posted to your

Extranet team page.

2. Check to see who you are paired with (next slide).

3. Review your colleague’s most recent PDSA cycle using PDSA Cycle Feedback Form by making comments right on the Feedback Form (Extranet –> Resources –> Forms –> PDSA Cycles).

4. Send an email to your colleague with the Feedback Form attached and copy Brian Sanderson at [email protected] Thursday, 3rd April 2014.

mailto:[email protected]


Paired PDSA Review Assignment

Wendy Toner David Maxwell

Stephanie Mottram April Masson

Derek Kilday Stephanie Frearson

Shalani Raghavan Dawn Moss

Diana Beveridge Sacha Will

Sally Hall Donna Murray

Michelle Cochlan Eileen McGinley

Penny Bond Emma Levy

Michelle Dowling Gareth Adkins

Graham MacKenzie Marie-Claire Stallard

Michelle (Shelly) Afflect Gavin Russell

Kirsty Ellis Hamish Fraser

Judith Cain Kerstin Jorna

Marsha Scott


SPC Software Call: Set Up

Next WebEx: Wednesday, 23rd April 2014, 3:00 –5:00 pm GMT (Note this call is 2 hours)

Prior to this call: Email Brian Sanderson [email protected]

to let us know which SPC software you have decided to use. We need this information from each of you. We’re assuming QI Charts but need to verify successful installation.

We will send a prompting email to which you can reply with this information.

mailto:[email protected]


SPC Software Call: Set Up (cont.)

We will post to the Extranet (Resources-Action Period Materials-SPC Assignment):

An Excel database with data and an assignment to build:− a run chart and− a Shewhart control chart using your software and this

data− You do not need to know Control Chart theory to

complete this assignment. You’ll be getting familiar with the Excel macro QI Charts.

Please post your completed run and Shewhart control chart to your home page (chart imported to PowerPoint or Word) No later than Wednesday, 16th April 2014. Please title your document with your name Wave 33 SPC Assignment Run or Shewhart Chart& date.


Appreciation

of a System

Understanding

Variation

Building

KnowledgeHuman

side of

change

First PDSA Cycle Sharing!

IG Ch. 4, p. 77


CHAPTER 7 TESTING A CHANGE

“Testing changes builds knowledge about the causal mechanisms at work in a system. A process of building knowledge emphasizes the importance of rational prediction. If during testing a prediction is incorrect, the theory that was used to generate the prediction must be modified.”

p. 140


Our Observations

Confusion about purpose of the cycle versus overall Aim

Test is a small change to the system

All PDSA cycles collect data—that doesn’t make it the purpose of the cycle

Qualitative data may be all you can get at first

What questions are you trying to answer?

Theory & Predictions required

Scale-sometimes a test is too big! 1: 3: 5: All

Record what happened (documentation)

Study-many didn’t go back and make sure each question/prediction had an answer in the study

Act-plan the next cycles

Test under different conditions


The PDSA-o-meter!How Many PDSAs since WS 1?

0

1

4

3

2

5

6 or more


IG page 24

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Used with permission: Associates in Process Improvement

The activity was planned, including a plan for collecting data.

The plan was attempted.

Time as set aside to analyze the data and study results.

Action was rationally based on what was learned.

IG page 97


Repeated Use of the PDSA Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

Very Small

Scale Test

Follow-

up Tests

Wide-Scale

Tests of

Change

Implementation

of Change

How will we know that a

What change can we make that

What are we trying toaccomplish?

change is an improvement?

will result in improvement?

Model for ImprovementReduce Per-op harm by 30%

Peri-op Harm Rate

DVT Prophylaxis

Beta Blockade Prop

SSI interventions

Use clippers

Instead of

Shaving site


Successful Cycles to Test Changes

Plan multiple cycles for a test of a change:

Think a couple of cycles ahead

Initially, scale down size of test (# of patients, clinicians, locations)

Do not try to get buy-in or consensus for test cycles

Test with volunteers

Use temporary supports to facilitate the change during the test

Be innovative to make test feasible

Collect useful data during each test

In latter cycles, test over a wide range of conditions

IG-p.143


Use a Concept Design:Multiple PDSA Cycle Ramps

Triage Diagnostic

TestingFast Track

Patients

Capacity /

Demanding

Flow Change Concepts


Act Plan

Study Do

Act Plan

Study Do

MODEL FOR IMPROVEMENT DATE __________

Objective for this PDSA Cycle:

Is this cycle used to develop, test, or implement a change?

What question(s) do we want to answer on this PDSA cycle?

Plan:

Plan to answer questions: Who, What, When, Where

Plan for collection of data: Who, What, When, Where

Predictions (for questions above based on plan):

Do:

Carry out the change or test; Collect data and begin analysis.

Study:

Complete analysis of data; Compare the data to your predictions and summarize the learning

Act:

Are we ready to make a change? Plan for the next cycle

Short

form:

We have different PDSA Forms on Extranet:


Long

form:


Wave

28

Tested

Form:


As we listen to our colleagues-let’s add value!

What could improve this PDSA cycle?

Size? Complexity? Questions? Predictions? Plan?

What did you learn that will help you with your future PDSA cycles?


Michelle C., Marie-Claire, and Penny

Marie-Claire

Stallard

East Dunbartonshire

Council

Preschool Referrals

Michelle Cochlin

Perth and Kinross

Council

Bedtime Reading

Enrichment for

Vulnerable Children

Penny Bond

Health Improvement

Scotland

Identification and

Management of

Delirium


28

Cascade

of

Building a

Learning

What system are you trying

to improve?

The key question, however, is do you fully

understand the complexity of these

systems and which aspects of the system

you want to improve?

You need to start drilling down from the…

Macro

Meso

Micro levels and build a cascade.

Most

cascades

start at the

top!

And,

trickle

downward…

A typical top-down cascade

Board &

CEO

Sr VPS &

VPs

Departments/Staff/Patients

Departments/Units/Wards/Service

Lines

The Big Dots

Mesosystem

Macrosystem

Microsystem

Which way does (should) your

cascade flow?

Top Down?

Bottom Up?

Spread from

the Middle?

IOM Chasm Report Chain of Effect

(it all starts with the patient)

1. Patient (start here)

2. Physician

3. Clinical Unit/Microsystem

4. Clinical Service Line/Mesosystem

5. Health System/Macrosystem

Information System Design Principle: Capture data at lowest level and

aggregate up to higher levels for cascading metrics throughout system.

Think about reversing the

cascade!

Inverted

Pyramids

Traditional

Pyramids

Adapted from the work of Dr. Gene Nelson, Dr. Paul Batalden and Marjorie Godfrey

Quality By Design: A Clinical Microsystems Approach, Jossey-Bass, 2007.

So, think about building an inverted pyramid

Micro: Patient & the provider of

care

Meso: Clinical Units,

Departments and Service

Lines

Macro

Level 1

Level 2

Level 3

Adapted from R. Lloyd & G. Nelson, 2007

Micro Level

Macro Level

Start with the Little Dots

36

Building a Cascading Set of Driver Diagrams

• Review the Driver Diagram you just

made to improve a particular outcome.

• Review the Secondary Drivers you

identified on this initial Driver Diagram.

• Select one of the Secondary Drivers

and make it the Outcome of your new

Driver Diagram.

• Identify the Primary and Secondary

Drivers of this new outcome.

Mesosystem

Macrosystem

Microsystem

Nursing

Services

Nursing

Divisions

Frontline

Nursing Units

Jönköping's System Level Cascade

Source: G. Henriks & Bojestig, Jonkoping County Council, Sweden, 2008

A Cascading Approach to Improvement

Percent compliance

with “bundles”

Hand washing

bundle

Pressure

ulcer bundle

CL bundleVAP bundle

Hospital Acquired

Infection rates

+ ++

Percent inpatient

mortality

Prevent VTE

Hamad Medical Corporation Best Care Always Change

Package: Critical Care Driver Diagram

2014-03-26

Improving Care for Colon Cancer Patients

You begin the adequate treatment

within four weeks

The diagnosis and treatment with ’best

method’ is offered

The best possible health promotion

measures and efficient screening

program is offered

Equally good palliative care is provided

no matter of the place of residence

Prevention

Early detection

Investigation/Treatment

Investigation/Treatment

Patient’s Involvment

Multi-disciplinary Collaboration

Palliation

Our promise to

patients with colon

cancer

Good health care

Regional cancer center should

prioritize patient-oriented research in

oncology

Interactive research approach in

several parts of the project

You are well informed / involved in the

entire healthcare chainPatient’s involvment

The primary effect

"What?

Secondary effect

"How?’’

Goal/

objectives

Patient

Involvement

Dialogue

Cascading Systems Does your organization approach improvement as an

interrelated cascading system or as a bunch of singular

events that are unrelated and fragmented?

Do senior managers and the Board or Governance (Non-

Execs) regularly discuss how your systems of care are driven

by many interrelated factors? Or, do they approach issues of

quality and safety as if one solution will produce better results?

Does your organization have dashboards of measures that

cascade from the macro, through the meso and down to the

micro levels?

Do your measures cascade down from the top or percolate up

from the places where patient care is actually delivered (the

inverted pyramid)?

Prioritizing the Drivers

© Richard Scoville & I.H.I.

Limitations of resources, attention, and will

usually mean we cannot work on everything.

• Which drivers do we believe will deliver the biggest

impact?

• Which ones will be easiest to work on?

(Factors include personnel, culture, resources)

• What is our current level of performance on these

drivers?

Scope

Co

mp

lexity

Pilot Unit Department Intitution System

Multiple

Primary

Drivers

One

Secondary

Driver

Significant system level

• Priority

• Sponsor

• Resources

Department-level

• Priority

• Sponsor

• Resources

What is your level of ambition?

What level of

ambition do you have

for your project?

Institution

44

Oral Health

Clinic Project

Source: Richard Scoville, Ph.D.

At OHC over 16 months, we will

1) increase the % of pts completingcaries control within 2 month by

X% and

2) decrease the % of “riskmanagement” pts who need

treatment for new caries by Y%

(active pt = 18+ w/ >=1 visit in past 2years, not withdrawn)

Risk Management

(no active caries)

Timely Scheduling ofAppointments

Caries Control

(all active cariesrestored)

Treatment Planning & Execution

Patient Education & Support

Risk assessment, communicationof risk status

Patient Self Management (hygiene& preven. Products)

Patient Sense of Urgency,Acceptance of Protocol

Ability/Willingness to Pay

Population Management

Patient Diet

Risk-based preventive care(cleaning, etc)

Timely restorative care for newcaries

Timely

Resore

Prev

CareRisk

Assess

Pt Ed

Diet

Self

Mgmt

Popn

Mgmt

Ability

PayPt

Involved

TxScheduling

0

0.5

1

1.5

2

2.5

3

3.5

4

2.5 3 3.5 4 4.5 5

Impact

Sta

tus

High ImpactLower

Impact

Process WELL

defined

Process NOT

defined

Oral Health Care Prioritization

46

What’s The Status of This Driver/Process?

LEVEL DEFINITIONAPPROXIMATE

RELIABILITY

0Driver is not defined or status is unknown

1

There is an informal understanding about the driver

by some of the people who do the work. No widely

recognized or formal written description of the driver.50%

2

Driver is documented. driver description includes allrequired participants (including families where

appropriate). The driver is understood by all.80%

3

The driver is well-defined, and enacted reliably.

Quality measures are identified to monitor outcomes of

the driver and may be in use by few/some.90%

4

Ongoing measures of the driver are monitored

routinely by key stakeholders and used to improve the

driver. Documentation is revised as the driver is

improved.

95%

5

driver outcomes are predictable. driveres are fully

embedded in operational systems. The driver

consistently meets the needs and expectations of all

families and/or providers.

99%

DRIVER STATUS

.

D

Driver outcomes are predictable. Drivers are fully

embedded in operational systems. The driver consistently

meets the needs and expectations of all families and/or

providers.

Driver is documented. Driver description includes all

required participants (including families where

appropriate). The driver is understood by all.

47

What Is It’s Predicted Impact?

LEVEL DEFINITION

0This driver has no impact or does not apply to our system

of care

1

This driver has only minimal or indirect impact on patient

services and outcomes

2

This driver will improve services for our patients, but

other driveres are more important

3

This driver has significant impact on outcomes for our

patients

4

This driver is necessary for delivering patient services It

has a major, direct impact on the outcomes.

5

This driver is absolutely essential for achieving results.

Improvement in this driver alone will have a direct,

immediate impact on outcomes

PREDICTED IMPACT

This driver has no impact or does not apply to our system of

care.

This driver has only minimal or indirect impact on patient

services and outcomes.

This driver will improve services for our patients, but other

drivers are more important.

This driver has significant impact on outcomes for our patients.

This is necessary for delivering patient services. It has a

major, direct impact on the outcomes.

This driver is absolutely essential for achieving results.

Improvement in this driver alone will have a direct,

immediate impact on outcomes.

Results of OHC Prioritization

Timely

Resore

Prev

CareRisk

Assess

Pt Ed

Diet

Self

Mgmt

Popn

Mgmt

Ability

PayPt

Involved

TxScheduling

0

0.5

1

1.5

2

2.5

3

3.5

4

2.5 3 3.5 4 4.5 5

Impact

Sta

tus

High ImpactLower

Impact

Process WELL

defined

Process NOT

defined

Results of OHC Prioritization

Timely

Resore

Prev

CareRisk

Assess

Pt Ed

Diet

Self

Mgmt

Popn

Mgmt

Ability

PayPt

Involved

TxScheduling

0

0.5

1

1.5

2

2.5

3

3.5

4

2.5 3 3.5 4 4.5 5

Impact

Sta

tus

High ImpactLower

Impact

Process

WELL

defined

Process NOT

defined

High impact, not well defined

processes are key targets for improvement!

Exercise

Prioritizing Drivers

• Use the Prioritizing Drivers Worksheet.

• Plot your secondary drivers on the grid based on

your assessment of: (1) how well the process is

defined, and (2) the level of impact that the drive

can have.

• Discuss and select the drivers that are most

important for improving your system of care.

Prioritizing Drivers Worksheet

Timely

Resore

Prev

CareRisk

Assess

Pt Ed

Diet

Self

Mgmt

Popn

Mgmt

Ability

PayPt

Involved

TxScheduling

0

0.5

1

1.5

2

2.5

3

3.5

4

2.5 3 3.5 4 4.5 5

Impact

Sta

tus

High ImpactLower

Impact

Process WELL

defined

Process NOT

defined


Churchill on LearningMaking predictions slows up the “hurry”

“Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing has happened.” --Winston Churchill

Taken from: http://home.att.net/~quotesexchange/sirwinstonchurchill.html


Your Questions & Comments

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