Sustaining and Leveraging your Improvements
description
Transcript of Sustaining and Leveraging your Improvements
Marie W. Schall
This presenter has no
conflicts to disclose
November 5, 2013
Sustaining and Leveraging your Improvements
By the end of this session, you should be able to:
Identify key strategies for sustaining improvements (holding the gains) Apply reliability science to strengthen implementation and ability to sustain improvementsManage a portfolio of initiatives to leverage improvements across hospitals and systems
Sustaining Improvements
Our information system makes it easy for us to monitor how we are
doing!
The new way is much easier than the old
way…I would never go back!
We started this new process with a few patients
but now we do it for all!
Creating a New System
Part One: Make improvementsPart Two: Sustaining Improvement (Holding the gains) Part Three: Spread the improvements to others
The Sequence for Getting (and Sustaining!) Results at Scale
Scaling up and Spreading a
change
Developing a change
Implementing a change
Testing a change
Act Plan
Study Do
Theory and Prediction
Test under a variety of conditions
Make part of routine operations
Testing - Try and adapt ideas to learn what works in your systemImplementation - Make a change a permanent part of the day to day operation of the system Spread: Have individuals outside the pilot adopt (and adapt) the changesScale-up: Identify and overcome the infrastructure issues that arise during spread
Some Common Language…..
Improvement
Hold GainsTest Implement
I. During testing
II. During implementation
III. After implementation
Taking Action to Hold the Gains
Improvement
Hold GainsTest Implement
I. During testing
II. During implementation
III. After implementation
Taking Action to Hold the Gains
Improving Likelihood that We Will Hold Gains: During Testing
Purposefully test the changes under a wide range of conditions (robust design) – Day shift/night shift, experienced/ inexperienced staff
Foolproof the new process/procedure– Look for ways to use constraints, affordances, reminders,
differentiation
Use technology where appropriate– Look for opportunities to use computers, bar coding ,etc.
Acknowledgement: Sandy Murray
During Implementation: Exercise
Think of a time in your experience when an improvement was implemented. Are the gains from that change still there?─ If yes, what was done that resulted in the gains being held?─ If no, why did the gains fail to be held? What got in the way?
Implementation
The change is a specified part of daily work - need to develop all support infrastructure to maintain changeHigh expectation to see improvement (no failures; but eagerness to continue testing if needed)Increased scope will lead to increased resistance (value of evidence from successful tests)
To Implement . . .Use PDSA cycles to test implementation steps
Establish buy–in, build consensus
Create an infrastructure and support
Build communication channels
Create education and training
Review policies & procedure
Assign accountability
Cultivate leadership
Testing Vs. Implementation PDSA Cycles
Cycle 1: Recruit one volunteer for one shift, draft dutiesCycle 2: Recruit two volunteers for one week (day shift) revise duties as neededCycle 3: Recruit another volunteer, one day two shiftsCycle 4: Two volunteers for one week of day and evening shift.Cycle 5: Three volunteers for one day, all shifts.
Cycle 1: Create job descriptions or alter other job descriptions as neededCycle 2: Conduct market salary studyCycle 3: Post and hire positionsCycle 4: Training for current employeesCycle 5: Orientation and training for new employeesCycle 6: Formalize measures and required reports
Improvement
Hold GainsTest Implement
I. During testing
II. During implementation
III. After implementation
Taking Action to Hold the Gains
After Implementation: Key Components of Strategy
Continue Communication– Publicize benefits, document improvement, keep contact w/ team after initial
improvement effort Continue to Build Infrastructure
– Job descriptions, policies, hiring, orientation, supply stream, etc.– Assign ownership for improvement and maintenance work of the new process– Senior leaders held responsible for efforts to sustain
Design an Effective Control System– Use your internal QA/I resources and integrate activities into hospital-wide
control system– Plan to standardize new process and verify conformance to the standard– Graphically monitor data for performance/outcomes
Example of Continuing use of Run Chart to Hold the Gains From Safety BTS (Quantum Leaps)
Holding the Gains
Collaborative
John Whittington OSF Healthcare
Cycle No.
Change Tested or Implemented Lead June July August September October November 24 1 8 15 22 29 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25
Policies
Documentation
Hiring Procedures
Staff education/training
Job descriptions
Information Flow
Equipment Purchases
PROJECT TEAM WORKSHEET: Redesign of Support Processes for Implementation of Change Change Implemented: ________________________
Date:
Improvement
Hold GainsTest Implement
I. During testing
II. During implementation
III. After implementation
Taking Action to Hold the Gains
Holding the Gains
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Reliability Science Can HelpOur EMR includes
information about the process and what the patient understands
We use data to check for “failures” so we can find the problems and
make adjustments
We can all define the steps in the Teach Back process
Levels of Reliability
Chaotic process: Failure in greater than 20% of opportunities (5 front line users cannot describe the process)
80% or 90% success: 1 or 2 failures out of 10 opportunities (5 front line users cannot describe the process)
95% success: 5 failures or less out of 100 opportunities (5 front line users CAN ALL describe the process)
The IHI Three-Step Model
Prevent Failure: Design the system to prevent a breakdown in operations or functions
Identify & Mitigate Failure: Identify failure when it occurs and intercede before harm is caused or mitigate the harm caused by failures that are not detected and intercepted
Redesign: Take steps to redesign the process on the critical failures identified
Source: Nolan, T., Resar, R., Haraden, C., Griffin, F. Improving the Reliability of Health Care. Institute for Healthcare Improvement, Innovation Series, 2004, page 1.
Intent, Vigilance and Hard Work(will generate performance with < 95% reliability)
Process Design to Prevent Basic Failures: • Common equipment, standard orders • Personal check lists• Working harder next time• Feedback of information on compliance• Awareness and training
Use of Human Factors and Reliability Science (will generate performance with > 95% reliability)
Process Design to Identify and Mitigate Failures• Standardize work processes• Build job aides and reminders • Take advantage of preexisting work and
habits• Make the desired the default rather than the
exception• Create redundancy• Bundle related tasks
Build Job Aides and RemindersSome examples…
Reminder in EMR to ask patients how they learn bestPatient-friendly teaching materialsAuto reminder to record who is learner besides patientWhite board to notes re: discharge date and what needs to be done before thenEasy access lists of who to call for scheduling at the physicians’ offices
Bronson: Standard Work ProductSupervisor assigns bed: pages clerks in ED & unit & monitoring tech5 min lapsed time - ED unit clerk prints SBAR report to admit unit Admit unit clerk assures charge RN got SBAR10 min lapsed time - charge RN on unit gets SBAR to assigned nurse 15 min lapsed time – assigned RN reviews SBAR and calls ED RN with questions25 min lapsed time – ED PCA prepares patient for transport, calls unit, “we’re on the way”30 min lapsed time – patient transported to unit bed
Bronson Hospital, Battle Creek Michigan
Take Advantage of Pre-existing Work and HabitsSome examples:
Multidisciplinary rounds have standard discussion around going home preparations
Change of shift reports include patients and key hand over elements
Teach Back is built into patient and family education documentation
Medication reconciliation offers going home patient-friendly medication list
How Standard is your Work?
On a scale of 1 - 5 with 5 being the highest level of confidence: How confident are you that a process you select occurs the same way every time? Share with your partner…..– What accounts for the variation?– What steps might you do to reduce variation
and improve the reliability of your process so that the process is done the same way every time?
Small sample – “Go Ask 5”
Pick a process you want reliable that has been taught to frontline staff
Review what was taught
Ask 5 people who do the process to describe – Why the process is important– How they do the process
How many of 5 got it right? – 4 of 5 means only 80% reliability is possible
Observe the Actual Process
Go see (don’t just talk about it in meeting rooms) Check assumptionsLearn what really happens compared to what is described− Observe and ask “why?” five times − Get to the root causes of current performanceIdentify what gets in the way of reliabilityDiscuss changes that your team would like to test
Specify the Existing Work
Precisely specify the work YOU SEE:Who does it?What do they do?When do they do it (and for which patients)?Where do they do it? How do they do it? (include tools that are used)How often do they do it? Why do they do it?
Specify Improvements to Tackle
Select a process to work onSpecify the changes in the documented existing work the team would like to test‒ who, what, when, where, how
Use iterative PDSA cycles (tests of change) to try the changesUse process measures to assess progress over time (aim to achieve > 90% reliability)
Example: Observing the Current State of Patient Teaching
Identify a staff member to observe while teaching a patientGet permission from the patient Observe 1) staff teaching, 2) from the patient and family caregivers perspectiveConsider what went well and what could be improved?
Reliable Use of Teach-back
www.teachbacktraining.com
ToolkitA. Involve all learners in patient education
B. Always Use Teach-back! throughout the hospital stay
Provide Effective Teaching and Facilitate Learning
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Help Mid-level Managers Coach
Honor the current work through observation
Understand that change is hard and uncomfortable
Resistance to change is natural; comes from fear of change
Promote new skill development
Build confidence to integrate the new habit into work patterns
Build reliability
Manage relapses
www.teachbacktraining.com
Teaching New Processes
NEW WAY (TWI)Test to reliable processSpecify the processDesign education Include help aidsTeach test group in workplaceStick around to see if they can do it as taughtIf needed, redesign education, process or bothTeach the next group; can they do it as taught?
OLD WAYTeach & leaveDeath by slidesDuring busy staff meetingsTeach in remote conference rooms
Gail A Nielsen 2012
Using Process Measures to Evaluate the Reliability of Processes
Process measures tell us whether the specific changes we are making are working as planned.
When displayed in annotated run charts, the data gives us feedback on the relationship between our theory (the changes we are making) and the outcomes for our patients (readmissions and overall experience).
Example of an Annotated Run Chart: Process Measure for Using Teach Back
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Outcome Measures: Readmission Data
Reliability vs. Sustainability
Sustainable
The process never deteriorates over time regardless of the participants
Reliable
The process provides the best care for every patient every time
Managing a Portfolio of Projects
Our leaders have assigned clear responsibility for
leading the work
We don’t try and do everything at
once….but have a plan for building our work
We understand how each of our improvement
initiatives fits together
Sequencing Methods
Identify the high leverage skills or capabilities;Use data to identify problem areas;Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates;Start with units with improvement capability or champions;Start in areas where you are likely to see early success.
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Com
plex
ity
CLABSI SSI CA-UTI VAP VTE
PU CA-UTI Falls
OB
VTE CA-UTI
ADE
Reliability and Teamwork
Rounding and Prevention
Risk Assessment
Monitoring & Titration
Working Across Microsystems
Care Transitions
TimeSept’ 10 Sept’ 13
Work Area Aim Progress
Care Transitions
Just started
25% progress
50% progress
100% progress
Sustaining
CLABSI Just started
25% progress
50% progress
100% progress
Sustaining
SSI Just started
25% progress
50% progress
100% progress
Sustaining
CA-UTI Just started
25% progress
50% progress
100% progress
Sustaining
VAP Just started
25% progress
50% progress
100% progress
Sustaining
VTE Just started
25% progress
50% progress
100% progress
Sustaining
OB Just started
25% progress
50% progress
100% progress
Sustaining
PU Just started
25% progress
50% progress
100% progress
Sustaining
Falls Just started
25% progress
50% progress
100% progress
Sustaining
ADE Just started
25% progress
50% progress
100% progress
Sustaining
Portfolio of ProjectsProject Areas of Focus
Cardiac Care Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF)
Med. Safety High Alert Meds., Med. Reconciliation
Med/Surg Unit Spread
Pressure ulcers, Med. Rec., High Alert Meds. AMI, CHF, Infection Control
Infection Control
Methicillin-Resistant Staphylococcus Aureus (MRSA)
ICU Safety Rapid Response Teams (RRT), Ventilator-Acquired Pneumonia (VAP), Central Line Infections (CLI)
Surgery Safety Surgical Site Infections (SSI), Surgical Care Improvement Project (SCIP)
Portfolio of Projects & Skills NeededProject Resources and Responsibilities
Lead Sponsor Driver SkillsCardiac Care Senior
cardiologistDirector of cardiac service line
Nurse manager
Reliability and Flow ImprovementDC planning
Med. Safety Director of pharmacy
COO PharmD MeasurementADE Triggers ImprovementMD Engagement
Med/Surg Unit Safety
VP Nursing COO Nurse Manager
Spread Improvement
Infection Control
Manager infection control
CMO Senior infection control RN
Behavioral changeHuman factors Improvement
ICU Safety Med. Director ICU
CMO Nurse manager
ReliabilityCooperation Improvement
Surgery Safety
High Volume Surgeon
Director of surgery
RN managersurgery
Coordination Cooperation Improvement
Objectives - Reflection
Identify key strategies for sustaining improvements (holding the gains) Apply reliability science to strengthen implementation and ability to sustain improvementsManage a portfolio of initiatives to leverage improvements across hospitals and systems
Reflections
What ideas did you hear that you might apply?
What may have been confusing?
What might you need more information about….?
ResourcesImproving the Reliability of Health Care (IHI White Paper)http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ImprovingtheReliabilityofHealthCare.aspx
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996.
Execution of Strategic Improvement Initiatives (IHI White Paper)http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ExecutionofStrategicImprovementInitiativesWhitePaper.aspx.
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