Learning Collaborative: Learning Session 1

Transcription

1 Learning Collaborative: Learning Session 1 November 12, 2014

2 Collaborative Learning Objectives Explore the fundamental theories underlying improvement science. Understand and apply fundamental principles, methods and tools for designing and implementing a quality improvement project in a simulated environment. Apply the methods and tools to a quality improvement project in your organization.

3 Exercise Write your name on a piece of paper. De-brief

4 Collaborative Overview

5 Objectives for the Collaborative To support organizations in operationalizing one quality priority known to the organization that will directly improve service for clients; To enhance capability for quality improvement in the community sector at the staff and executive sponsor levels; and, To support teams in achieving early improvements in process measures related to their project aim.

6 Timeline for the Collaborative and Beyond Pre-work: October Scope Project, Form Team Ensure Time/Resources Allocated Mid-March: End of Coaching Support Oct 2015 Sharing Results At Annual OCSA Conference Learning Session 1 Nov 12 Learning Session 2 Dec 16 5 wks 5 wks Learning Session 3 Jan 21 7 wks Action Period 1 Action Period 2 Action Period 3 30 wks: Independent Continuous Improvement Spread & Sustain Executive Sponsor Session Oct 24th Virtual Coaching: 1-2 Webinars, Document Submission, 1 Phone Call, Support Virtual Coaching: 1-2 Webinars, Document Submission, 1 Phone Call, Support Virtual Coaching: 1-2 Webinars, Document Submission, 1 Phone Call, Support

7 Project Set-up: Roles and Responsibilities Executive Sponsor Project Lead Note that QI Teams often also identify an Improvement Advisor

8 Collaborative Expectations Capability for Improvement: Enhance the skills of Executive Sponsors in: scoping and designing a project articulating a project aim forming a team supported by sufficient resources understanding contextual factors that enable success supporting/coaching a team Enhance the skills of Staff in: Understanding the phases of project design, planning and implementation Learning the Model for Improvement and applying tools for project planning and management, diagnosing root cause, generating change ideas, testing ideas using small, rapid cycle change, and measuring change Engage and build the motivation for all participating staff to engage in continuous improvement, on an ongoing basis

9 Program Content & Collaborative Expectations Project Charter & Work Plan Problem Statement Aim Statement Family of Measures Diagnostic Tools Reinforce Learning from Nov 12 Creative Thinking & Change Ideas PDSA Measurement using Run Charts Change Management Leadership Communication Tools Micro-System Sustainability Coaching Focus on areas requiring reinforcement Team presentations Session 1 Nov 12 ACTION PERIOD 1 Session 2 Dec 16 ACTION PERIOD 2 Session 3 Jan 21 ACTION PERIOD 3 OCSA Conference FALL 2015 Webinar & Individual Team Call/ feedback) Submit: Partial Project Charter Fishbone & Pareto Webinar & Individual Team Call/ feedback) Submit: Updated Project Charter PDSA worksheet Leadership Report Template for Session 3 Team Presentation Webinar & Individual Team Call/ feedback) Submit: Leadership Report NHS Sustainability Tool PDSA Worksheet PDSA Ramp Form Team Storyboard Potentially 1-2 presentations

10 Subject matter knowledge Increased Capability to Make Improvements Profound Knowledge

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12 Deming s System of Profound Knowledge 1. Systems Thinking What is the whole system? And how do the different parts interact and depend on each other? 2. Variation What is the variation in results telling us about the system? 3. Knowledge What are the predictions about the system s performance? And what theories inform the predictions? 4. Psychology How do the people in the system react to change? What are the important interactions? What motivates them?

13 The Model for Improvement Specify and set the aim Establish measures Change concepts & change ideas PDSA Cycle A P S D Langley, Nolan, Nolan, Norman, Provost; The Improvement Guide, 1996.

14 Project Design What are we trying to accomplish? Design/ Preparation What changes can we make that will result in improvement? Diagnostic Solution Generation How will we know that a change is an improvement? Testing/ Implementation Spread & Sustainability Context: Design in Factors for Success QI Methods (Lean, Six Sigma, Model for Improvement) Project Charter Problem Identification Change Concepts/ Change Ideas Driver Diagrams with Measures Rapid Cycle Improvement: PDSA Cycles PDSA Ramps Team Composition & Roles Process Mapping Aim Statement Family of Measures Root Cause Analysis (Affinity, Ishakawa, 5 Why s) Pareto Chart Complex Adaptive Systems Source: Paula Blackstien-Hirsch

15 You ve all come today with the first few parts of your project plan BATTLE PLAN You flank from the left. I ll grab the cookies.

16 Sharing of Projects (1.5 min per Team): Organization Names and Roles on Team Project

17 Family of Measures Outcome, Process, Balancing

18 What is an Outcome Measure? Outcome Measures /[Big Dots] Answer so what? (Why are we delivering service?) Voice of the Client; what payers care about Some will be organization-specific (within the control of a single organization); others will be cross-sector (contributed to by more than one sector) Example: Organization-specific: Access: Wait Time for Service Client-centred: Client Satisfaction with Care Coordination Cross-sector: Repeat Visits to the Emergency Department 18

19 What is a Process Measure? And when are these defined? Process Measures Provide information about the extent to which a practice/intervention has been implemented; voice of the process Example 1: Outcome Measure: Wait Time from Referral to Service Initiation Change Idea: Standard Work Intake Staff prioritize client appointments for assessment within 48 hours of referral Process Measure: % Client Calls Made Within 48 Hours of Referral Example 2: Outcome Measure: Client Satisfaction with Care Coordination Change Idea: Assign a Care Coordinator to clients assessed as high risk/complex condition Process Measure: % of Complex Clients Assigned a Care Coordinator 19

20 Examples of Linked Outcome and Process Measures Outcome Measures Process Measures Weight Loss # Calories per Day Minutes of Exercise per Week Experience with Continuity of Service Provision % Clients who have the same PSW throughout service delivery 20

21 Outcome Measures Functional Improvement on a Standardized Scale/Instrument Process Measures % Clients assessed at regular intervals with a standardized tool % Clients provided with an exercise regimen to practice between visits Readmissions to Hospital % Clients with complex needs receiving a risk assessment within hours of service initiation % Clients with a service plan that focuses on key ADL and IADL activities linked to risk assessment

22 What is a Balancing Measure? Balancing Measures Measure unintended consequences that could result from implementing the idea(s) for change. Example 1: Outcome Measure: Decreased length of service delivery Idea for Change: Provide education on self-management and provide fewer weeks of service delivery Balancing Measure: % Clients on service with a CTAS 4 or 5 ED Visit within 30 days of service delivery termination Example 2: Outcome Measure: Overall Client Experience Idea for Change: Ask clients prior to leaving their house if there is anything else you can do for them today Balancing Measure: Decreased Staff Satisfaction related to Workload

23 Measurement Exercise: For each of the project scenarios, sort the indicators into categories of Outcome, Process or Balancing

24 BREAK

25 Diagnostic Tools

26 Improvement Process Hardwire Ongoing Monitoring Of Measures Project Aim Project Team Annotated Run Charts or SPC Charts Implementation Phase 4 Sustainability Phase 5 Intervention/ Testing Phase 3 Project Phase 1 Diagnostic Phase 2 Understand Process/ Identify Root Causes. Process Mapping. Fishbone/5 Whys. Pareto Chart. EBD P S D A P S D A P S D A P S D A Plan the change Do a small test/run/spc Chart Study the effects Act on the results Adapted from Patient Safety Education Program: Canada

27 What happens when you test solutions that don t address the root cause?

28 What Contributes to Our Problem? Tools for Identifying Root Cause EFFECT / PROBLEM

29 Fishbone Diagram (Ishikawa/Cause & Effect)

30 Fishbone Diagram Is a structured brainstorming tool; Allows us to gather many perspectives around causes of a specific problem, and to go deeper around the reasons why things happen; Assists in getting us out of tunnel thinking and allow all staff to contribute to problem solving.

31 There are many different combinations of headers for the spines of the fish

32 Benefits of Building a Fishbone Diagram Keeps everyone focused on the same problem; Everyone gets a chance to contribute, see that their ideas are captured and won t be lost; Expands brainstorming to include different types of causes; Allows for thorough exploration of a problem; Can guide teams to a change idea that will have an impact.

33 The 5 Whys It is a tool to get to the root cause of a problem area you have identified by allowing you to dig deeper; It involves progressively asking Why?, Why is it happening or Why is that? until you get to the root of the problem; While it is called the 5 Whys you can ask Why? as many or as few times as needed to get to the root of a problem; The 5 Whys requires intimate knowledge of the system or processes where the problem occurs; Avoid getting caught up on blame, stay focused on the system causes and identify where a proactive approach is available.

34 Asking Powerful Questions 5 Whys Worksheet Caution: If your last answer is something you cannot control, go back up to the previous answer. Cannot be because of a person. Action:

35 An Example Got caught speeding WHY? Late for work WHY? Got up late WHY? Alarm clock did not work WHY? Batteries were flat WHY? Buy an alarm clock that plugs into an outlet or replace batteries at set intervals before they run out. Forgot to replace them

36 Pareto Analysis

37 The Pareto Principle Vilfredo Pareto ( ) Italian Economist, Sociologist and Philosopher In 1906: Pareto found using his formula that 80% of the wealth in Italy belonged to 20% of the population Joseph Juran: A Quality Management Pioneer The vital few and the useful many 80/20 rule

38 Pareto Chart Defects in care identified as contributors to decreased satisfaction

39 Linking the tools in a logical sequence. Standard Categories Select a reasonable Number Possibly using multi-voting

40 How to Build a Fishbone Decide on your rib bone categories for the causes PEOPLE POLICIES Problem Statement PROCESSES EQUIPMENT

41 How to Build a Fishbone Brainstorms causes and add to ribs PEOPLE POLICIES Problem Statement EQUIPMENT PROCESSES

42 An Example Cause: Cause: Cause: Policies Provider/Staff Person/Resident The policy is not clear on who should document Policy does not include Residents with RB No policy for documenting RB We do not have enough space to do our documentation Not my resident Don t know where to document Not enough time Do not know what to document New Resident to home Duplication of documentation Not a new behavior for Resident Every resident has a behavioural issue Problem / Effect Why are there so many challenges documenting responsive behaviours? Our electronic documentation tool does not allow for the different types of behaviours Not sure where to document the behaviour in the notes Not sure when to document Place/Equipment Cause: Procedures Cause:

43 Depicting a root cause People Not enough time Interruptions by family members Problem Statement

44 Let s Give it a Try! Step 2: Cause and Effect Diagram Put your Problem at head of fish Use the following categories (or come up with your own): People, Equipment, Policies, Processes Write one cause per post-it note and place it under the appropriate category; For today s exercise, identify at least causes across your 3-4 categories.

45 The 5 Why Analysis

46 Let s Give it a Try! Step 1: The 5 Why Analysis By consensus, decide on two causes that you will try the 5 Whys on; Work through the 5 Why Analysis to ensure you have identified the real root causes.

47 Transitioning from Cause and Effect to a Pareto Need to identify the most likely root causes from the Cause and Effect Diagram (many do multi-voting with the Team); then use the 5 why s to ensure you ve got the root causes - pick no more than 8-10 Rationale: Need to collect data to identify which of these potential root causes occurs most of the time, and you can t burden the team with measurement of 40 or more variables

48 Where Do We Focus to Achieve the Greatest Improvement? DEFECT OR DEFECT CAUSE Frequency Count % Frequency % Cumulative Frequency TOTAL 100% 100%

49 Manual Data Collection Cause Count Total Percentage of Total No label put on ///// ///// ///// / 16 32% 32% Staff cannot use label 13 26% 58% ///// ///// /// machine Put with Outsourced 12 24% 82% ///// ///// // Linen Hoarding Behavior //// 4 8% 90% Taken home by family // 2 4% 94% Cumulative Percentage Label machine broken / 1 2% 96% Delivery to wrong room / 1 2% 98% Thrown out / 1 2% 100%

50 Pareto Chart Defects in care identified as contributors to decreased satisfaction

51 Let s Give it a Try! Step 3: Pareto Analysis Go back to your fishbone; Each member of your group has 5 dots; Place your votes (dots) on the post it notes/causes that you think are key causes underlying the problem; Build your pareto chart.

52 Exercise: Building the Pareto Chart Select the post-it notes that have the most to least dots and place them in order from left to right along the x axis Label the left side y-axis as Frequency Count Draw a bar reflecting the frequency (# of votes in this case) for each post-it note Using the data collection sheet, label the right side y-axis as Cumulative Frequency & calculate your cumulative frequency for each bar Draw the cumulative frequency curve Identify the causes that account for 80% of the effect

53 Building a Pareto Chart during routine morning huddle

54 Process Mapping

55 Process Map A tool to understand a process: who is doing what, when (sequence of events) and for how long (waits/delays), decisions that are made. Tool is used to: Create collaborative awareness of current process. Develop a common understanding cycle times, roles and responsibilities. Identify specific opportunities for improvement. Develop/visualize an improved future state process.

56 Guiding principles Include level of detail necessary to support improvement activities Involve individuals from a variety of disciplines who have knowledge of the day-to-day workings of the process There has probably never been a process map developed where someone has not said: I didn t realize that happened. Why are we doing it that way? Why does that happen there? Do we still do that?

57 Symbols BUILDING A PROCESS MAP Boundaries start & stop Direction/Flow Decision Point Yes Action steps No

58 Building a Process Map 1. Establish the start and the end of the process. Use the oval terminal symbol. Start Stop

59 Building a Process Map 2. Outline the high level steps in the process (generally greater than 2-3 steps but less than 9-10; generally about 5-8 steps) A B C D E F D E

60 Building a Process Map 3. Outline a more detailed set of steps under each of the high level steps Use the 8 x 8 Technique until you get to the level of detail required A B C D E F

61 Depicting steps in the process Serial Tasks Parallel Tasks Time

62 2 Example: Testing a blood sample Current state map STEP 5: Determine initial areas of opportunity Value-add: ~15 min Non value add ~ 5 hrs Customer order Customer request Lab results need to be accurate Urgent need for results asap Potential areas of focus Results available Blood sample taken Label & register sample Store sample CT = 1 min CT = 2 min CT= 1.5 hr 80% < 2 hrs Test sample CT = 30 min Very variable (single test takes 10 min) Capture results CT = 2 min Value-add Non valueadd 1 min 2 min 10 min 2 min 1 hrs 10 sec 30 sec 1.5 hr 30 sec 20 min (transport) (walking) 15 min (waiting) 1.5 hrs 62

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64 Process Map with Swim Lanes

65 Identifying Opportunities for Improvement Look for opportunities to: Reduce Bottlenecks Reduce Delays Remove Duplication and/or Unnecessary Steps Eliminate Rework Link steps to remove gaps in flow (tight connections) Standardize practice to reduce variation in practice Reorganize to improve efficiency & effectiveness (eg re-order steps, do steps in parallel) Improve steps that are prone to error

66 The Seven Wastes ( Muda ) Type Definition Example Defects Not meeting specified requirements Medication errors; incomplete forms; any type of rework Overproduction Waiting Ties up more resources than necessary Paper waiting to be processed; Customers waiting services when not indicated; antibiotics for viruses; adding forms to a chart prior to knowing what s needed/faxing Waiting for appointments, waiting for transport, forms waiting to be processed

67 Type Definition Example Over-processing Inventory Duplication of effort with no benefit to the customers Applies to anything that is in a queue. Ties up capital risking obsolescence or damage & creates additional work. Reassessments if just completed by another similar agency, duplicate paperwork, duplicate questions, questions you won t address Supplies; equipment; referrals Motion Transportation Unnecessary movement by workers creating inefficiencies Unnecessary movement of clients or materials adding time and consuming space Long hallways, long travel distances in the community, searching for supplies, non-proximal workstations Moving clients between depts or sites;

68 Video: Making Toast Cut Bread Toast Bread Spread Butter/Peanut Butter Serve/Eat Toast

69 Cut Bread Toast Bread Spread Butter/Peanut Butter Serve/Eat Toast Get bread from container Cut Bread Toast Bread Throw out bread Spread butter Toast Bread Cut bread Adjust toaster setting Spread peanut butter Put toast on plate Serve & eat toast Where in this process were there quality issues that need to be addressed?

70 Debrief on Exercise 1: Redesign Making Toast Type Definition Defects Not meeting specified requirements? Overproduction Ties up more resources than necessary? Waiting Over-processing Inventory Motion Transportation Paper waiting to be processed; Customers waiting Duplication of effort with no benefit to the customers Applies to anything that is in a queue. Ties up capital risking obsolescence or damage & creates additional work. Unnecessary movement by workers creating inefficiencies Unnecessary movement of patients or materials adding time and consuming space?????

71 Exercise 1 What would you do to redesign the process? Process??????

72 LUNCH