Model for Improvement

What can we change that will

result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a

change is an improvement?

What are we trying to accomplish? AIM

MEASUREMENTCHANGE

PDSA –testing a change

MARUWhat is Maru trying to achieve?How many ideas does he try?Is he successful?What was the possible negative outcome?

From YouTube

Rapid Cycle Change

What can we change that will result in an improvement?

How will we know that a change is an improvement?

What are we trying to accomplish?

AIM of this change: PROBLEM :

AIM of this change:

Do a PDSA to solve a problem at home

AIM: unpack the dishwasher in a more efficient way

PROBLEM : unpacking the dishwasher is inefficient

Put half the cups and half the glasses in the cupboard just above the dishwasher

How easy it is to unpack the dishwasher

-Tom to rearrange cupboard today--Mary and Tom to unpack into one cupboard for 4 days

Mary – it will look horrible and I will hate itTom – it will be easy and Mary will like it

Model for Improvement

What can we change that will

result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a

change is an improvement?

What are we trying to accomplish? AIM

MEASUREMENTCHANGE

Measurement

Are we getting closer to our target?

Outcome measure

Measurement

Did we use the whole bundlein every patient every time?

Process measure (Bundle compliance)

Measurement

Was the change an improvement?

Measuring the impact of a change

Measuring over time

• a volunteer to write

• a volunteer to measure

• graph paper

Annotated Run Chart

Community Need

I Change Made in June

Interpreting Data: what is the story?

IBefore (Feb) After (Aug)

What is the real story?

Change Made

Change Made

Change Made

Change Made in June

Feb Aug

Feb AugFeb Aug

Feb Aug Feb Aug

I

Change Made

Prevention of Mother to Child Transmission.

A sub-district in a province in SA

Positive PCRs at 6 weeks (target <5%) Feb 2010 8.2%Feb 2011 3.2%

Improvement?

Positive PCRs at 6 weeks (target <5%) Feb 2010 8.2%Feb 2011 3.2%

Improvement?

Median

Shift: 6 points in row on same side of the median Note: A point exactly on the centerline does not cancel or count towards a shift

Median

Median

Trend: 5 points in row headed in same directionNote: Ties between two consecutive points

don’t cancel or add to a trend

Rule 3

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10

Mea

sure

or C

hara

cerist

ic

Median 11.4

Data line crosses onceToo few runs: total 2 runs

Run Chart: Rules for Identifying Statistically Significant Change

Rule 1 Rule 2

Rule 4Rule 3

I

Astronomical Point: a obviously, even blatantly different valueNote: Every set of data will have a highest and lowest data point. This does not mean the high or low are astronomical

Runs: too few or too many runs

Provost and Murray

Run Charts• One of the most powerful tools for improvement

• Describe a process over time

• Shows trends the process is experiencing

• Can be used to analyse whether the change was an improvement

• Data can be used to drive change

Outcome measurement

Are we getting to our target?

Was the change an improvement?

How do we measure HAIs?

Measuring infection rates

Lessons from an ICU

Quality Improvement 101

Problem?

Measuring Infection Rates

• Total number of infective cases per 1,000 device days:

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Definition of VAP

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

Overcoming Numerator Issues

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Patients with

Overcoming Numerator Issues – diagnosing the HAI (workbook)

Checklists forDiagnosing the HA Infectionused by theteam

Overcoming Denominator Issues

At the same time every day theUnit managercounts devicesin use in the ward

Working out the infection rates (workbook)