Leading Quality Improvement

Transcription

1 July 20, 2016 These presenters have nothing to disclose Leading Quality Improvement Essentials for Managers Lesson 5: Practice Improvement Essentials Janet Porter, PhD Kathy Duncan, RN

2 Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement work, particularly in the area of readmissions. She is also the clinical manager of the Tennessee Center for Patient Safety s PSO (patient safety organization). Rhonda has worked in the field of hospital quality management since 2006 and has a clinical background in trauma, critical care, oncology, and organ donation. rdickman@tha.com

3 Attendance 3 Chat name and organization into the chat box Rhonda Dickman that you attended rdickman@tha.com Log in to the webinar using your username and password: User name: address used to register Password: the password you set up when you registered

4 Lead Faculty 4 Kathy D. Duncan, RN, faculty, Institute for Healthcare Improvement (IHI), directs IHI Expeditions and manages IHI's work in rural settings. Previously, she provided spread expertise to Project JOINTS, co-led the 5 Million Lives Campaign National Field Team, and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She also served as the content lead for the Campaign's Prevention of Pressure Ulcers and Deployment of Rapid Response Teams areas. She is a member of the Scientific Advisory Board for the AHA NRCPR, NQF's Coordination of Care Advisory Panel, and NDNQI's Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the director of critical care for a large community hospital.

5 Supporting Faculty 5 Janet Porter, MBA, PhD, serves as consultant to hospitals and physician practices for Stroudwater Associates. She has 35 years of experience as a hospital administrator, teacher, consultant, and public health leader. Dr. Porter served as the Chief Operating Officer of Dana- Farber Cancer Institute; the Associate Dean of Executive Education at the University of North Carolina s School of Public Health; the Interim CEO of the Association of University Programs in Health Administration (AUPHA); and the Vice President, and then COO, of Nationwide Children s Hospital in Columbus, Ohio. Currently teaching strategic management in the Healthcare Executive MBA program at the University of Miami, she is also an active adjunct professor at the University of North Carolina at Chapel Hill and Ohio State University. Dr. Porter received her BS and MHA from Ohio State University, and her MBA and PhD in health care strategy from the University of Minnesota.

6 Tennessee Leading Quality Improvement: Management Essentials Course Leading Change/Influencing Others - Session 2 June 8 JP Manage the Work Time Management Session 3 June 22 JP Build the skills and capabilities needed to lead quality improvement efforts at the middle manager level of an organization Manage Improvement Project Management Session 4 July 6 JP Patient and Family Engagement Session 1 May 25 JP Practice Improvement Essentials Session 5 July 20 KD Identify and Spread Improvement - Session 6 August 3 KD Incorporating Finance in Improvement Session 7 August 17 Develop Teams Building and Creating Joy in Teams Session 8 August 31 KD Leveraging Teams with Partners Session 9 Sept 14 JP

7 Practice Assignment 7 For a current project or past project, ask yourself? What has gone well? What could have gone better? What have you learned? What would you do differently next time? Volunteers: Paige Barnes, Marshall Medical Center

8 Today s Objectives 8 Apply the Model for Improvement to at least one improvement opportunity. Use a PDSA cycle to test at least one change Identify which team members you need to engage in a specific test of change Demonstrate how to analyze data over time using a run chart and run chart rules

9 Reflection 9 Video: Model For Improvement Part 1 (2:55) and Part 2 (3:00) Video: PDSA Cycles Part 1 (4:45) and PDSA Cycles Part 2 (3:48) IHI Open School: The human side of Quality Improvement

10 Model for Improvement 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? Aim of Improvement Measurement of Improvement Developing a Change Act Study Plan Do 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.

11 4 Components of an Aim Statement State the aims clearly (What do you want to accomplish? How good, by when?) Define location or population Set stretch goals Include numerical goals/targets 11

12 Model for Improvement 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? Aim of Improvement Measurement of Improvement Developing a Change Act Study Plan Do 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.

13 Three Types of Measurement Outcome Measures Voice of the customer or patient. How is the system performing? What are the results? Process Measures Voice of the performance of the process or system. Are the parts/steps in the system or process performing as planned? Balancing Measures Looking at a system from different directions or dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome). Don t rob Peter to pay Paul

14 Key Points of Measurement The purpose of measurement in Improvement is for learning not judgment! All measures have limitations, but the limitations do not negate their value for learning. Measures tell a story; goals or targets provide a reference point to evaluate performance. These measures should operationalize the Aim Measures should be integrated into the team s daily routine Data should be plotted over time on annotate graphs Focus on the Vital Few

15 Model for Improvement 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? Aim of Improvement Measurement of Improvement Developing a Change Act Study Plan Do 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.

16 Where might you find changes? 16

17 What Changes Can We Make? Understanding the System Outcome Primary Drivers Secondary Drivers Process Changes S. Driver 1 Change 1 P. Driver Change 2 S. Driver 2 Aim: An improved system S. Driver 3 Change 3 P. Driver S. Driver 1 S. Driver 2

18 What can a driver Diagram do for you? 18

19 Driver Diagram 19 A Driver Diagram is an improvement tool used to organize theories and ideas in an improvement effort. It displays visually, our theory about potential areas we can leverage to change the status quo. The driver diagram is often used to scope or size a project and to clarify the plan for reaching the aim. Primary Drivers: major processes, operating rules, or structures that will contribute to moving towards the aim Secondary Drivers: elements or portions of the primary drivers. The secondary drivers are system components necessary in order to impact primary drivers, and thus reach project aim. Specific changes /Change concepts: Specific changes are concrete actionable ideas to take to testing. Change concepts are broad concepts (e.g. move steps in the process closer together) that are not yet specific enough to be actionable but which will be used to generate specific ideas for change. AIM Primary Drivers D1 D2 D3 D4 Secondary Drivers Specific Ideas to Test or Change Concepts D5

20 Driver Diagram Basics Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 D3 D4 D5 20

21 Driver Diagram Basics Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 A good aim: 1) Identifies the system to be D3 improved (scope, patient population, drivers selected) 2) D4 Has specific numerical goals and D5 3) Includes timeframe 21

22 22

23 Driver Diagram Basics Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 D3 Primary Drivers: Major processes, operating rules, or structures that will contribute to moving towards the aim D4 D5 23

24 Robin Zudell Queen of the Valley MC 24

25 Driver Diagram Basics Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 D3 D4 D5 Secondary Drivers: Elements or portions of the primary drivers. The secondary drivers are system components necessary in order to impact primary drivers, and thus reach project aim. 25

26 Robin Zudell Queen of the Valley MC 26

27 Driver Diagram Basics Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 D3 D4 D5 Specific changes: Concrete actionable ideas to test. Change concepts: Broad concepts (e.g., move steps in the process closer together) that are not yet specific enough to be actionable but that will be used to generate specific ideas for change. 27

28 Robin Zudell Queen of the Valley MC 28

29 How Will We Know We Are Improving? Understanding the System for Weight Loss with Measures Outcome Primary Drivers Secondary Drivers Process Changes drives Calories In Daily calorie count drives drives drives Avg cal/day Limit daily intake % of Substitute opportunities used low calorie foods Track Calories Running calorie total Plan Meals offplan/week AIM: A New ME! Weight BMI Body Fat Waist size drives Calories Out Exercise calorie count drives drives drives Avoid alcohol Work out 5 days Avg drinks/ week Days between workouts Drink H2O Not Soda Sodas/ week Walk to errands Etc...

30 How might you use a driver diagram? 30

31 Model for Improvement 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? Aim of Improvement Measurement of Improvement Developing a Change Act Study Plan Do 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.

32 Principles for Testing A test of change should answer a specific question A test of change requires a theory and prediction

33 Test on a Small Scale Incorporate redundancy in the test by making the change sideby-side with the existing system Conduct the test over a short period of time Conduct the test with one member of your team or with one patient Learn quickly and go BIG, FASTER

34 Why Test? Why not just implement than spread? Increase degree of belief Document expectations Build a common understanding Evaluate theories and predictions Test ideas under different conditions Learn and adapt

35 Guidelines for Testing a Change Test on a small scale Collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea Include a wide range of conditions in the sequence of tests

36 Tips for Testing 36

37 Why do we do multiple cycles? 37

38 Now it is your turn! P38 I am going to give you a case study and need your to chat in your thoughts AIM Statement Measures Changes Tests Ready, Set, Go! (Chat)

39 What is our aim? 39

40 40 How will we know our change is an improvement? Measures: Reminder: Data is for learning not judgment.

41 What Changes will we make? 41

42 42 What is our Plan? What are the directions? How did mom do it?

43 Do 43

44 Study 44

45 Results of Additional PDSA 45

46 Model for Improvement 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? A P S D Changes That Result in Improvement Hunches Theories Ideas A P S D Source: Improvement Guide, p 10

47 Yes!

48 Operational Definitions Statement of the measurement process used Need to come to agreement on two things: A method of measurement or test A set criteria for judgment Provost. L. & Murray. (2008, November) The Date Guide: Learning from Data to Improve Health Care. Austin, TX: API.

49 The Problem 49 What we look at and how we look at it will drive what we do with it It can also result in missing the essential learning Aggregated data presented in tables, tabular formats or with summary statistics, will not help you measure the impact of process improvement/redesign efforts. Aggregated data can only lead to judgment, not to improvement.

50 Average CABG Mortality Before and After the Implementation of a New Protocol Percent Mortality % 4.0% Time 1 Time 2

51 Average CABG Mortality Before and After the Implementation of a New Protocol 51

52 Data Display 100.0% Response Time Compliance - Life Threatening Emergency (I Chart) 95.0% 90.0% 85.0% 80.0% 75.0% Month Label chart Data should take middle third to half Keep it as simple as possible Annotate

53 Annotations of Changes Quick-look x- rays Work-up done on floor Bed ahead LOS (minutes) Goal Individual responsible for bed control /16/98 3/16 4/13 5/11 6/8 Week

54 Non-Random Rules for Run Charts A Shift: 6 or more A Trend 5 or more Too many or too few runs An astronomical data point Source: The Data Guide by L. Provost and S. Murray, Austin, Texas, February, 2007: p

55 How do we classify variation? Special Cause Variation Is due to irregular or unnatural causes that are not inherent in the design of the process Affect some, but not necessarily all aspects of the process Results in an unstable process that is not predictable Also known as non-random or assignable variation Common Cause Variation Is inherent in the design of the process Is due to regular, natural or ordinary causes Affects all the outcomes of a process Results in a stable process that is predictable Also known as random or unassignable variation

56 Practice 56 Complete one PDSA Worksheet Draft a Driver diagram for one of your projects

57 Important THA Announcements 57 August Regional Networking Meetings Thursday, August 4 Memphis Tuesday, August 9 Nashville Thursday, August 11 Knoxville More information: Leadership Summit Call for Presentations Applications due by Friday, July 29 More information: