NoCVA Readmission Collaborative

October 25, 2012

Session Objectives

• Share and discuss what you learned from interviews with patients recently readmitted

• Understand and apply a model for driving improvement through small scale tests of change

• Identify one small scale test of change based upon your diagnostic work

Learning from Patient Interviews

What did you learn? Any surprises? What are you now curious about?

IHI FacultyRebecca Steinfield

Rebecca Steinfield, MA, has been with IHI since 1996.  She currently serves as an Improvement Advisor for IHI’s State Action on Avoidable Readmissions (STAAR) initiative, funded by the Commonwealth Fund; sits on the faculty of the Kaiser Permanente Performance Improvement Institute, mentoring Improvement Advisors-in-training; teaches IHI courses on improvement methods; and serves on IHI’s internal evaluation team.  She is also mother to two children Jacob, 15, and Susie, 12.

An Introduction to the Model for Improvement

“How wonderful it is that nobody need wait a single moment before starting to

improve the world”

Ann Frank

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

The Project AIM is:

• Not just a vague desire to do better

• A commitment to achieve measured improvement─In a specific system─With a definite timeline─And numeric goals

What are We Trying To Accomplish?

9

The Project AIM is:

• Not just a vague desire to do better

• A commitment to achieve measured improvement─In a specific system─With a definite timeline─And numeric goals

“Hope” is not a plan

“Soon” is not a time

What are We Trying To Accomplish?

“Some” is not a number

Shady Oaks Hospital will improve transitions home for all patients as measured by a decrease in the 30-day all-cause hospital readmission rate from 12% to 8% percent or less within 24 months.

We will start our improvement work with patients on 4W and 5S with a focus on improving our understanding of patients’ discharge needs and collaborating with community receivers of patients to ensure they have the information they need to care for the patient post-discharge. We will expect to see a decrease in the readmission rates for patients discharged from those units of at least 10% within 12 months.

• System:

• Goal:

• Timeframe:

• Guidance:

Example of an Aim Statement

“You can’t fatten a cow by weighing it”- Palestinian Proverb

• Improvement is NOT about measurement

• However…

How Do We Know if a Change is an Improvement?

Some Measurement Assumptions

•The purpose of measurement for improvement is learning not judgment•All measures have limitations, but the limitations do not negate their value •Measures are one voice of the system. Hearing the voice of the system gives us information on how to act within the system•Measures tell a story; goals give a reference point

Measurement is Central to the Team’s Ability to Improve

Improvement Project Measurement Guidance

• Need a balanced set of measures reported each month (at a minimum) to assure that the system is improved

• These measures should reflect your aim statement and make it specific

• Measures are used to guide improvement and test changes

• Integrate measurement into daily routine

• Plot data for the measures over time and annotate graph with changes

What Changes Can We Make That Will Result in Improvement?

• The How-to-Guide contains IHI’s best thinking on key changes needed to improve transfers

• Use this “change package” to identify the changes you want to make to your system to achieve your aim

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

The PDSA Cycle

Plan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

“What will happen if we try something different?”

“Let’s try it!”“Did it work?”

“What’s next?”

Building Confidence for Change

AP D

S

AP

D S

APD

SA P

DSChange pkg ideas, suggestions, intuition

System changes that will result in improvement

Learning from data

Change Idea: actively include patient and family in assessing needs (specifically, identify the learner on admission, and include them in discharge planning)

AP D

S

AP

D S

APD

SA P

DS

If we identify the learner on admission, we can engage them in discharge planning and have a better chance of adherence to plan

99% Reliability

Learning from data

Cycle 1: Day 1: On next admission, ask nurse to ask the patient to identify the person who should be involved in understanding their care plan after discharge

Cycle 2: Day 2: Get information on family caregivers for all patients admitted to Unit A

Cycle 6: Educate staff on new standards

Cycle 5: Standardize and document

Mini-measure tracks improvement cycles

Cycle 3: Day 3: Unit A is able to get useful information from all patients, continue with Unit A, all admissions, try Unit B

Cycle 4: Analyze failures, determine plans for patients without family caregivers

Percent of Admissions with Learner Identified

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10111213141516171819202122232425weeks

Percent

1 23

45

6

More Tips for Testing

• Test with volunteers

• Use simulation

• Do not try to get buy-in, consensus, etc.

• Be innovative to make test feasible

• Collect useful data during each test

• As cycles proceed, test over a wider range of conditions

• 1 patient

• 1 day

• 1 admit

• 1 physician

Start Small ~ 1:3:5:All

Why Test?Why Not Just Implement then Spread?

Why Test?Why Not Just Implement then Spread?

• Increase degree of belief in the change idea

• Document expectations and results

• Build a common understanding

• Evaluate costs and side-effects

• Explore theories and predictions

• Test ideas under different conditions

• Learn and adapt for the next test

What small scale test do you want to run before the

next call?

Resources: Free “On-Demand” Streaming Video taught by Dr. Robert Lloyd

Available on ihi.org:•An Introduction to the Model for ImprovementProvides a framework for organizing and guiding a team’s improvement journey•Building Skills in Data Collection and Understanding VariationDesigned to help teams successfully manage the milestones along the quality measurement journey•Using Run and Control Charts to Understand VariationAddresses the application of statistical process control (SPC) methods, with specific attention given to run and control charts

Assignment

• Using the PDSA form, plan and run one small scale test of change within the next two weeks (think 1 patient, 1 staff member, 1 admission)

• Share your completed PDSA form, with learning from your test, by sending it out on the Collaborative listserv