Creating Adoptable & Sustainable Improvement

Transcription

1 December 4, 2016 Creating Adoptable & Sustainable Improvement Chris Hayes, MD, Chief Medical Information Officer, St. Joseph s Healthcare Hamilton Frank Federico, Vice President, Senior Expert, Patient Safety, IHI IHI National Forum Presenters have nothing to disclose

2 Objectives Analyze why some QI strategies lead to more sustained improvement Utilize tools to develop more sustainably adoptable improvement strategies Use exercises learned in this session to engage others in their organization in initiatives to create sustainable improvement

3 Agenda 1:00-1:10 Session introduction 1:10-1:25 Why do some improvement initiatives fail? 1:25-2:05 Exercise #1 To Fail or Not to Fail 2:05-2:30 Highly Adoptable Improvement 2:30-3:00 Break 3:00-3:30 Exercise #2 Assessing adoptability 3:30-4:15 Exercise #3 Assessing and addressing workload 4:15-4:30 Open discussion and closing remarks

4 Why Do Some Improvement Efforts Fail Poor implementation planning and overly aggressive timelines Failing to create buy-in/ownership of the initiative Ineffective leadership and lack of trust in upper management Failing to create a realistic plan or improvement process Ineffective and top-down communications A weak case for change, unclear focus, and unclear desired outcomes Little or no teamwork or cooperation Failing to provide ongoing measurement, feedback, and accountability Unclear roles, goals, and performance expectations Lack of time, resources, and upper-management support

5 Why Do Some Improvement Efforts Fail We do not get to the root of the problem We fail to engage those that do the work We do not understand human factors and engineer systems to deal with the human condition We do not simplify We add steps to the processes that result in increased complexity We do not consider a system approach

6 Change Concepts Simplification Are there Steps in your processes that can be eliminated? Standardization Best known process to achieve desired results But known today-may change with new knowledge or new context

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11 Error Reduction Overview: Hierarchy of Controls Facilitate Mitigate Policies, Training, Inspection Minimize consequences of errors Make errors visible Make it easy to do the right thing Human Factors Make it hard to do the wrong thing Eliminate Eliminate the opportunity for error Standardization & Simplification Bonacum, KP

12 Five Main Factors That Influence Adoption of an Innovation Relative Advantage - The degree to which an innovation is seen as better than the idea, program, or product it replaces. Compatibility - How consistent the innovation is with the values, experiences, and needs of the potential adopters. Complexity - How difficult the innovation is to understand and/or use. Triability - The extent to which the innovation can be tested or experimented with before a commitment to adopt is made. Observability - The extent to which the innovation provides tangible results.

13 To Fail or Not to Fail that is your task Exercise #1 Work with the people at your table to design a QI project Groups A you will work to design for high adoptability and success of the QI intervention Groups B you will work to design for low adoptability and failure of the QI intervention Your QI task is design falls prevention intervention(s) to reduce the falls rate of admitted patients/ residents over age of 65. List attributes of the design on flipchart paper

14 To Fail or Not to Fail that is your task For each group underline the strategies that are similar to your existing falls prevention strategy (be honest) Report back What are the main features of your design plan? What are the key differences between the groups plans?

15 15 HIGHLY ADOPTABLE IMPROVEMENT A model and tool to address workloadcapacity balance and perceived value amongst quality improvement projects

16 16 Have you ever experienced this? We don t have time for this Too much change happening We don't understand why we have to do this This doesn t make sense This doesn t match our workflow OR Works for a while but not sustained Need to implement reminders Provide compliance data on unit s/ areas performance

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19 In an effort to Improve healthcare are we making it Harder to provide care

20 Impact of Change on Workload/ Capacity Ventilator associated pneumonia bundle (VAP) ~2hrs/day direct nursing time - affected other activities Branch-Elliman. BMJQS 2013 Intensive blood glucose monitoring in ICU (GC) ~2hrs/ day direct nursing time Aragon. AJCC 2006 Electronic medical record / Health IT (HIT) Surgical safety checklist (SSC) Central line infection bundle (CLB) Longer workdays, see fewer patients, disrupted workflows ~90-120sec/case - 31% reduction in delays Cart was instrumental everything available averted delays Miller. Health Affairs 2004 Nundy. Arch Surg 2008 Dixon-Woods. Mil Quart 2011

21 Impact of Change on Workload/ Capacity Zone of change VAP, GC, HIT Workload Baseline More workload/ less capacity Unchanged Less workload/ more capacity Post implementation of change CLB, SSC Time

22 Cumulative Impact of Change Unsustainable Workload Acceptable Ideal Time

23 Impact of Change on Perceived Value People are not passive recipients of change; they evaluate, seek meaning and develop feeling towards change Perceived Value the willingness or readiness of individuals to adopt change when they believe the outcome of the change will be of value to them (or things of importance to them.) Emotional = That will save lives! Practical Logical = I can see myself doing that new practice = That new process makes sense

24 24 Hypothesis Change initiatives that do not add additional workload and have high perceived value are more likely to be adopted, cause less workplace burden and, achieve the intended outcomes Perceived value More adoptable Design For Here! Less adoptable Reduced Same Workload Increased

25 Highly Adoptable Improvement Implementation Strategy How we are asking people to do it WORKLOAD VALUE - CAPACITY Intended outcomes NOT Burnout, change achieved fatigue, cynicism, error, workarounds Intervention Design What we are asking people to do + Sustainably adopt improvement intervention Intended outcomes achieved * The person icon represents the collective recipients of the change; those individuals required to carry out the tasks associated with the intervention

26 Now for a Highly Needed Break! Please be back for 3:00!!

27 Highly Adoptable Improvement Implementation Strategy How we are asking people to do it WORKLOAD VALUE - CAPACITY Intended outcomes NOT Burnout, change achieved fatigue, cynicism, error, workarounds Intervention Design What we are asking people to do + Sustainably adopt improvement intervention Intended outcomes achieved * The person icon represents the collective recipients of the change; those individuals required to carry out the tasks associated with the intervention

28 How do you assess adoptability?

29 29 Highly Adoptable Improvement Selected Factors End-user participation Alignment and planning Resource availability Workload Complexity Efficacy Associated Questions Are end-user staff/ physicians involved in the change? Does the change initiative align with the organization s and/or team s goals and has the rollout been planned effectively? Are the required resources (training, equipment, time, personnel) for the implementation of the change initiative known and will they be made available? How much workload (cognitive, physical, time) is associated with the intervention? How complex is the change intervention? What degree of evidence and belief is there that this intervention will lead to the intended outcome?

30 30 Highly Adoptable Improvement End-user participation Are end-user staff/ physicians involved in the change? Active participation of end-users in the design, testing, revising and implementation of change interventions increases the likelihood of higher perceived value and is more likely to produce a less workload intensive intervention, thus increases the chance of sustained adoption. High risk Moderate risk Some risk Highly adoptable The intervention has not been designed with or tested with endusers. Workload End-user staff/ physicians were invited to participate in the initial planning meetings where their input was sought. End-user staff/ physicians played an initial role in the design and testing of the intervention. Their feedback will be sought after implementation. End-user staff/ physicians play a continuous role in the change initiative, including designing, piloting and revising the intervention and, during the implementation phase. Their feedback is continuously sought and addressed. How much workload (cognitive, physical, time) is associated with the intervention? Interventions that have less workload or make the current workflow easier to perform are more likely to be sustainably adopted and reliably performed. High risk Moderate risk Some risk Highly adoptable We have not estimated how much workload is associated with the intervention. We have attempted to estimate the additional workload associated with the intervention and believe the additional workload should be adoptable by end-users. We have piloted the intervention and worked with end-users to assess the workload demands and have determined that the intervention adds additional workload. We are looking to see if the intervention can be further simplified, other work removed, or additional resources added. We have piloted the intervention and worked with end-users to assess the workload demands and have determined that the new work can be implemented and reduce workload and make their current work easier.

31 How did your strategies fair? Exercise 2 Look back at your fall prevention strategies. Using the Highly Adoptable Improvement Assessment Guide review each set of statements Mark an X in the column that best matches to the strategy you used in your falls prevention plan.

32 How does this relate to your work? Discuss with members of your table current or past QI projects/ initiatives. For those that were a success discuss some of the strategies you felt led to success Discuss the same for projects that were less successful or weren t sustained Would the Assessment Guide have helped at the onset and during the project/ initiative?

33 How do you Assess & Address workload?

34 Highly Adoptable Improvement 34 How much mental activity is required to perform your job (thinking, deciding, calculating, remembering, looking, searching, etc ), Do you find that your work is physically strenuous? How much physical activity is required to perform your job (e.g., pushing, pulling, turning, controlling, activating, etc How much time pressure do you feel due to the rate or pace at which the tasks or task elements occurred?), How hard do you have to work (mentally and physically) to accomplish your level of performance? How hard do you have to work (mentally and physically) to accomplish your level of performance? How insecure, discouraged, irritated, stressed and annoyed versus secure, gratified, content, relaxed and complacent do you feel about your job?

35 Assessing and addressing workload? Exercise 3 Your organization is having an upcoming accreditation survey visit You will be introducing a new process aimed at meeting a gap in an accreditation requirement The new process has not been assessed from a workload perspective Your table will simulate the new process and then assess workload using the NASA TLX score Groups A two volunteers from each table go with Frank Groups B two volunteers from each table go with Chris

36 36 Highly Adoptable Improvement Timing the steps and processes involved in the intervention can give you an estimate of the additional workload. You can then reflect on the complexity of the intervention and ask: 1) Does it need all the proposed steps/processes? 2) Could steps/ processes be simplified? 3) Could necessary equipment and technology be provided to reduce the workload associated with the steps? 4) Could other staff, providers or patient/families be involved to distribute the workload? Using LEAN tools can help identify other workflow steps that may have associated waste (or non-value added time), or could be modified to better incorporate the new work

37 37 A practical example Knowing estimated date of discharge (EDD) on admission for surgical patients increases likelihood of on-time discharge Surgeons EDD completion rate 30% surgeon completion to 75% Checklist, Reminders, Feedback Surgeons EDD completion rate 30% knowledge of EDD to 75% Use usual LOS data as EDD

38 Take home messages Efforts to improve healthcare can increase workload and often fail Choosing the right change interventions is essential The Highly Adoptable Improvement model and guide supports focusing on the impact of change on care providers and staff and seems useful and usable Ongoing work in this area will continue to provide guidance on effectively implementing improvement initiatives and programs Change is hard.let s avoid making it harder!!

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