Wave 46 First PDSA Cycles

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1 Institute for Healthcare Improvement Improvement Advisor Professional Development Program Wave 46 First PDSA Cycles February 23, 2017

2 Please Check In IA IA IA Brenda Carson James Todd Maxine Gibson Brian McGarvey Jane McMillan Mike Fealey Cathy McCusker Linsey Sheerin Nynn Hui Chang Conor Campbell Louise Hunter Suzanne Pullins David Hamilton Lynne Charlton Tage Jonas Holmqvist Deborah McCord Marco Aurelio Tanja Gyldengren Grace Hamilton Margaret Devaney Tracey Van Wyk Mary Donaghy Turid Lund

3 Where are you?

4 IA Program Faculty and Staff Team for Wave 46 4 Robert Lloyd Lead Faculty Amar Shah Faculty Jane Taylor Faculty WS3 Richard Scoville Faculty Rebecca Steinfield Program Director/ Faculty Dave Williams Faculty Brandon Bennett Faculty Jerry Langley Faculty Lloyd Provost Faculty Sam Wickham IHI Project Coordinator

5 Objectives for this Call Share insights regarding MUSIQ Share experiences running PDSA cycles Move into more testing for our projects

6 Time Agenda Lead 3:00 pm GMT Welcome and Assignments Bob 3:10 MUSIQ-Your results and Reflections Bob 3:25 Review of First PDSAs- Summary Amar 3:40 Presentation of PDSA Cycles 10 min each -learning from each other, questions, insights James Conor Tanja 3:00 Accelerating the Rate of Improvement Amar 4:25 Additional Questions/ Next Steps Bob

7 March Reporting Reports due March 7 th You will be reviewing each other s reports!

8 Paired Leadership Report Review Assignment: Purpose: Strengthen one another s Leadership Reports Time estimate: 45 minutes Due Date: March 30, 2017 Step 1: After the March 7 due date, download your partner s most recent leadership report by going to the following Extranet location: Resource Tab Monthly Reports Folder your partners name folder. Step 2: Review your partner s report and comment on strengths and suggest improvements to their report using the Leadership Report Review feedback form (Resource Tab Forms ). Step 3: Post the feedback form or report with comments to your own team extranet page under: --> Your team resources tab Paired Leadership Report Assignment folder. Send an to your partner that you have completed your review.

9 Paired Leadership Report Feedback Form Some Attributes of a Helpful Leadership Report Aspect Strengths Suggested Improvements Clearly identifies IA, Executive Project Champion, Sponsor, Date of report Aim of Project is clear: what they intend to accomplish Business Case - why do this project? How the project supports the strategic objectives of the organization Identifies changes to be tested or implemented next Identifies barriers and needs from sponsors Key project measures exist (outcome, process and balancing) and data is graphed (at least annotated run chart) for each measure so results are visible Includes a high level system map, linkage of processes, flow chart, or other diagram that describes the system the project is focused on Includes cumulative list of changes proposed, tested, and implemented Form can be found on the Extranet in the Forms Folder on the Resources Tab Includes a PDSA cycle and PDSA Strategy (ramp of PDSA cycles)

10 Wave 46 Leadership Report Review Partners

11 SPC Assignment Choose and load SPC Software Download SPC Assignment 1 file (see SPC Assignment folder) Follow instructions (you will be making a P chart and a Run Chart) Post your graphs to your Action Period Call Assignments folder on YOUR Extranet page by March 8

12 Run Chart

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14 SPC Software Options Excel Macros ( Add-ins ) QI charts - no charge for IAs personal use; no tech support; not always working with 64 bit; some glitches with some versions of Excel; only works on a Windows Operating System QI Macros Others? Professional-grade SPC software (works for Excel, Access, linkable to other data bases) MiniTab PQ Systems Statit Other?

15 What we look for in SPC Software Correct approach with Shewhart charts Formulas, I chart screening (Nelson option), ability to tell software what data to use in limits, full range of types of charts See guidance on Extranet or in Data Guide before purchasing Ease of use Appropriate level of tech support for your needs Please note that faculty will have experience on some software types-but not all You will need to be fluent in your software prior to WS 2 Pages ; The Health Care Data Guide, Jossey Bass, Provost and Murray

16 Instructions for installing QI Charts is on the Extranet There is limited technical support for getting QI Charts loaded on your laptop. We will help as best we can!

17 Using the Model for Understanding Success in Quality (MUSIQ)

18 Purpose of MUSIQ Gives IA s and teams a method to reflect on the set-up and contextual support for your projects at the beginning of the Wave. Opportunity to make adjustments to your project and organizational support system early in the program. Focus on modifiable factors Makes relationships among contextual factors bit more explicit Will re-assess near end of program (Pre-Graduation) Helps research team build predictive evidence for the MUSIQ model. As MUSIQ improves will be made available to you

19 Kaplan et al. BMJ Quality & Safety, 2011

20 MUSIQ Scores (17/23 IAs Posted) Project has serious contextual issues and is not set up for success Project could be successful, but possible contextual barriers Project has a reasonable chance of success 2 0 <

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22 MUSIQ Score 7 Wave 46 MUSIQ Scores By IA (17 of 23) IA

23 MUSIQ Score 7 Wave 46 MUSIQ by Factor Factor

24 Initial MUSIQ Assessments Strongest Components Organization Senior Leader Sponsor Task Strategic Importance to the Organization QI Team Subject Matter Expert Organization QI Culture Microsystem QI Culture Organizational QI Leadership QI Team Leadership QI Team Norms QI Team Tenure External Motivators Components of Concern QI Team Physician Involvement Organization QI Maturity Microsystem Motivation QI Workforce Focus Resource Availability QI Team QI Skill Data Infrastructure Triggering Event External Project Sponsorship QI Team Prior QI Experience Microsystem QI Capability

25 MUSIQ Initial Assessments What are you insights related to MUSIQ? Have you used any of your insights to begin to change anything related to your project context?

26 First PDSA Cycle Sharing! Appreciation of a System Theory of Knowledge Human side of change Understanding Variation Ch. 4, p. 77

27 Wave 46 first PDSA s Wave 46 First PDSA Results (19 of 23) Submitted Complete Collecting Data Testing Change Implementing 2 0

28 Our Observations The PLAN contains the PLAN for testing the change (not just the plan for data collection) Don t forget to describe the objective of the PDSA cycle (which will be different from your project aim); All PDSA cycles require some kind of data collection - to answer your question(s) Collecting data is not testing a change A well-formed question (or questions) helps set up a productive PDSA cycle. What do you want to learn? We are seeing many closed-ended questions - better if not yes/no; how might you reframe these? Predictions should tie directly to your questions. Be specific (requires courage!). Don t complete the DO, STUDY and ACT until you have Done, Studied, and Acted. Do: what happened any surprises? Study: make sure each question/prediction has an answer in the study Act: propose a next cycle, include size of test

29 The PDSA-o-meter! 6 or more How many PDSAs since WS 1?

30 Repeated Use of the PDSA Cycle 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? DVT Prophylaxis Beta Blockade Prop SSI interventions Reduce Per-op harm by 30% Peri-op Harm Rate Changes That Result in Improvement One of SSI Interventions Hunches Theories Ideas A P S D Very Small Scale Test Followup Tests Wide-Scale Tests of Change Implementation of Change

31 Elements of the PDSA Cycle ACT - W hat changes are to be made? - Next cycle? STUDY - Complete the analysis of the data - Compare data to predictions - Summarize what was learned PLAN - Objective - Questions and predictions - Plan to answer the questions (who, what, where, when) DO - Carry out the plan - Collect the data - Begin analysis of the data The activity was planned, including a plan for collecting data. The plan was attempted. Time as set aside to analyze the data and study results. Action was rationally based on what was learned. p. 97

32 PDSA Form: Short form: Act Study Plan Do MODEL FOR IMPROVEMENT Objective for this PDSA Cycle: DATE Is this cycle used to develop, test, or implement a change? What question(s) do we want to answer on this PDSA cycle? Plan: Plan to answer questions: Who, What, When, Where Plan for collection of data: Who, What, When, Where Predictions (for questions above based on plan): Do: Carry out the change or test; Collect data and begin analysis. Study: Complete analysis of data; Compare the data to your predictions and summarize the learning Act: Are we ready to make a change? Plan for the next cycle

33 As we listen to our colleagues-let s add value! What could improve this PDSA cycle? What do you think of the size of test? Complexity? Quality of the questions? Of the predictions? Plan? What did you learn that will help you with your future PDSA cycles?

34 James Todd Lead Social Work Training Consultant for Adult Safeguarding Southern Health and Social Care Trust Project: The project aims to reduce the number of inappropriate Adult in need of protection referrals, and enhance effective interventions for adults who are at risk of harm and require alternative safeguarding responses.

35 cycle 1 James Todd Adult Safeguarding Referrals

36 Question Which referral source produces the largest numbers of inappropriate referrals? Theory That the Learning Disability Teams produce the largest number of referrals to the Adult Gateway Service which are screened out as not appropriate for a protection response.

37 Collect the data available to count the referrals, each week, over the previous 12 weeks. Then use a Pareto Chart to identify which sources produce the largest numbers of inappropriate referrals. Plan for collection of data: Who, What, When, Where Work with the Admin staff within the ASG Gateway service to collate the data. 2 nd week in February

38 Prediction The data will show that the Learning Disability Directorate produces the largest number of inappropriate referrals

39 The data was collected and put into a spread sheet, to calculate the total numbers of referrals by directorate each week. The numbers of inappropriate referrals were then used to develop a Pareto chart.

40 Study

41 Study

42 Study

43 Study

44 The next phase of this cycle is to establish an ongoing mechanism to continue to gather the data and ensure consistent approach is taken to do so. Another PDSA ramp will be established, with team members from the LD directorate, to begin to develop changes to try increase their ability to manage safeguarding concerns at source.

45 Conor Campbell, PGDip Safe and Effective Care Manager (Governance and User Involvement) South Eastern Health and Social Care Trust Project: To develop system / processes that will support delivery of evidenced improved outcomes in user experience across SEHSCT setting.

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54 Tanja Gyldengren, MSc Project Consultant Danish Society for Patient Safety Project: The overall primary program is aimed at reducing pressure ulcers, medication errors, reducing falls, and reducing infections. I will primarily take part in the improvement of medication management and reduction of pressure ulcers.

55 Date: January 31, 2017 PDSA Cycle #: 1 OBJECTIVE OF THIS CYCLE: Collect data Develop a change (or modify a previous change) Description: Introduce the staff to the pressure ulcer calender PLAN QUESTIONS TO BE ANSWERED FROM THE DATA OBTAINED FROM THIS CYCLE: 1. Will awareness of the pressure ulcer calender make the staff fill out the dots Prediction: It will get a higher number of days filled out. The prediction is 2 out of 7 IA Name: Tanja Team: Test a change Implement a change Are historical data available to answer the questions above? YES NO Does the team agree on the predictions? YES for question(s) _x NO for question(s) DEVELOP A PLAN TO ANSWER THE QUESTIONS: Who: Henrik What: Present the PU calender Where: In the lunch room When: During lunch break (11.30) during week 3 The plan considered the following methods: Run Charts Did you assign responsibilities for collection and analysis of data? YES NO Is training needed? YES NO Is the plan consistent with the charter? YES NO Can the plan be carried out on a small scale? YES NO Have you considered people outside the team who will be affected by this plan? YES NO

56 DO OBSERVATIONS IN CARRYING OUT THE PLAN: The staff was informed, but it was not clear who should put the dot on the calendar if there was a pu. Both if there were one and if there were not. The problem if there were one, they were uncertain about if it was registered two times, and if not what if there were other citizens that had one, when would you know that you could put a green dot on. Things observed that were not part of the plan: Things that went wrong during the data collection: Used a Control Chart ANALYSIS OF DATA: 1. Identified special causes as data was collected STUDY Prediction: It will get a higher number of days filled out. The prediction is 2 out of 7 Results: No green dots, only one red. The rest of the days, where not filled out. One of the questions were, who was responsible for filling out and when could you put a green dot, if you actually didn t new if any of the staff had found one. COMPARE THE ANALYSIS OF THE DATA TO THE CURRENT KNOWLEDGE: Do the results of the cycle agree with predictions made in the planning phase? YES NO Under what conditions could the conclusions from this cycle be different? What are the implications of the unplanned observations and problems during the data collection? That the staff won t be responsible for filling out the pu calendar at this stage of the project Do the data help answer the questions posed in the plan? YES NO SUMMARIZE THE NEW KNOWLEDGE GAINED IN THIS CYCLE: Flowcharts reflect what was learned Cause and effect diagrams reflect what was learned What was learned can be applied in another area. Comments:

57 ACT WHAT CHANGES ARE TO BE MADE TO THE PROCESS: One from the team will ask every lunchtime if there have been any pressure ulcers, and then he will fill out the dot. So the responsibility will be on the team and not yet the staff. List other organizations and people that will be affected by the changes: The cause system is sufficiently understood. An appropriate action or changes has been developed or selected. The changes have been tested on a small scale. Change responsibilities for implementation and evaluation completed. Actions or changes will improve performance in the future. Completed an analysis of forces in the organization that will help or hinder the changes. OBJECTIVE OF NEXT CYCLE: Collect data Develop a change Test a change Implement a change Description: We will test if the PU calendar will be filled out if one from the team will ask the staff every day, if there have been any new pus during the last 24 hours.

58 Your Reflections What are your take aways here? What did you learn that will help you with future PDSA cycles?

59 Our Focus: Accelerate the Rate of Improvement To do this we accelerate the rate of testing!

60 Testing/Implementation/Scale-up and Spread Collecting data to develop a change: don t have an idea (theory) to test yet. We are learning about the system, looking for ideas to test. Testing: Trying and adapting existing knowledge on small scale. Learning what works in your system. Implementing: Making this change a part of the day-to-day operation of the system in your pilot population Scaling-up or Spreading: adapting change to areas or populations other than your pilot populations

61 Diagnosing the current process? Teams often spend too much time thinking about all of the possible options, ramifications, and implementation issues before proceeding with a test of a change. Can one learn more by diagnosing the current process or system, or by changing something? Improvement efforts are frequently stuck in the diagnostic journey (analysis paralysis). The alternative is to very quickly run a test. Experience has shown this latter approach leads to accelerated learning and improvement. p. 142

62 We have different PDSA Forms on Extranet: Short form: Act Study Plan Do MODEL FOR IMPROVEMENT Objective for this PDSA Cycle: Is this cycle used to develop, test, or implement a change? DATE What question(s) do we want to answer on this PDSA cycle? Plan: Plan to answer questions: Who, What, When, Where Plan for collection of data: Who, What, When, Where Predictions (for questions above based on plan): Do: Carry out the change or test; Collect data and begin analysis. Study: Complete analysis of data; Compare the data to your predictions and summarize the learning Act: Are we ready to make a change? Plan for the next cycle

63 Forming Questions in a PDSA Plan anybody who has ever tackled a truly tough problem knows that one of the most difficult tasks is finding the right questions to ask and the right order to ask them in The form our questions take opens up some avenues and closes off others, and we don t want to waste time and energy barking up the wrong trees. Breaking the Spell Religion as a Natural Phenomenon By Dr. Daniel C. Dennett (2006, Viking Press, p. 19)

64 We have different PDSA Forms on Extranet: Short form: Act Study Plan Do MODEL FOR IMPROVEMENT Objective for this PDSA Cycle: Is this cycle used to develop, test, or implement a change? DATE What question(s) do we want to answer on this PDSA cycle? Plan: Plan to answer questions: Who, What, When, Where Plan for collection of data: Who, What, When, Where Predictions (for questions above based on plan): Do: Carry out the change or test; Collect data and begin analysis. Study: Complete analysis of data; Compare the data to your predictions and summarize the learning Act: Are we ready to make a change? Plan for the next cycle

65 Yogi Berra on Predictions it is hard to make predictions, especially about the future. "I didn't really say everything I said." Taken from How the Mind Works (1997), by Steven Pinker, p. 343

66 Reference: Mistakes Were Made (but not by me) Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts by Carol Tavris and Elliot Aronson Published by Harcourt, NY, See p. 108 The Need for Scientific Thinking The scientific method consists of the use of procedures designed to show not that our predictions and hypotheses are right, but that they might be wrong. Scientific reasoning is useful to anyone in any job because it makes us face the possibility, even the dire reality, that we were mistaken. It forces us to confront our self-justifications and put them on public display for others to puncture. At its core, therefore, science is a form of arrogance control.

67 Methods to accelerate the learning Use the PDSA Cycle to Accelerate Learning Three principles to guide testing a change: Principle 1: Test on a small scale and build knowledge sequentially Principle 2: Collect data over time Principle 3: Include a wide range of conditions in the sequence of tests p. 145

68 Multiple Cycles to Implement Each Component of the ICIC Chronic Care Model Component: Decision Support Chinatown, Asthma BTS, 2001 A P S D Use of Flow sheet V.4 by all physicians and nurses Cycle 6: Implement use of V.4, do peer review of documentation and use Will a flow sheet be useful for asthma patients? A P S D Cycle 4: Two week trial of V.3, review meetings Cycle 3: Try V.2 by two providers for a few days Cycle 2: Try V.1 with two patients Cycle 1: Gather sample flow sheets. Cycle 5: Trial of V.4 by all providers

69 Use a Concept Design: Multiple PDSA Cycle Ramps Triage Diagnostic Testing Fast Track Patients Capacity / Demanding Flow Change Concepts

70 Cycles Develop Test Progress Snapshot PDSA Cycles Implement TRST Research Research Blaylock Blaylock Blaylock Feb Dec Dec Nov Nov Nov PCC Tool Allied Referral Poster Bed Avail Question Feb 2008 Feb 2008 Jan CCC Rehab Decision Tree Feb 26 to Mar Patient Pamphlet Discharge Package Checklist Discharge Package Checklist Discharge Package Checklist Risk Screening Communication Referral Discharge Source: Paula Raggiunti, Wave 6 IHI IA Program Special Needs Notice Bed Avail. Tool Bed Avail. Tool Jan 28 to Mar Feb 10 to Mar Jan 28 to Feb Jan. 28 to Feb Feb Feb Jan 28 to Feb

71 Hints for planning useful cycles Think a couple of cycles ahead of the initial test (future tests, implementation). Scale down the size and decrease the time required for the initial test. Do not require buy-in or consensus as a prerequisite for the test (for instance, recruit volunteers, or run tests to evaluate conflicting ideas). Use temporary supports to facilitate the change during the test. Be innovative to make the test feasible. p. 143

72 Appropriate Scope for a PDSA Cycle IG-p. 146 Current Situation No Commitment Some Commitment Low Degree of Belief that change idea will lead to Improvement Cost of failure large Cost of failure small Staff/Physician Readiness to Make Change Very Small Scale Test Very Small Scale Test Very Small Scale Test Very Small Scale Test Strong Commitment Very Small Scale Test Small Scale Test High Degree of Belief that change idea will lead to Improvement Cost of failure large Cost of failure small Very Small Scale Test Small Scale Test Small Scale Test Large Scale Test Large Scale Test Implement

73 Measurement and Data Collection During PDSA Cycles Collect useful data, not perfect data - the purpose of the data is learning, not evaluation/judgment Use a pencil and paper until the information system is ready Use sampling as part of the plan to collect the data Use qualitative data (feedback) rather than wait for quantitative Record what went wrong during the data collection

74 Your Questions Can speak them, chat them, raise hand.just please do ask them!!

75 SPC Assignment Choose and load SPC Software Download SPC Assignment 1 file (see SPC Assignment folder) Follow instructions (you will be making a P chart and a Run Chart) Post your graphs to your Action Period Call Assignments folder on YOUR Extranet page by March 8

76 Next Call March 14, 3:00 4:30 pm GMT We will review your practice charts, have bit of tutorial and review of software questions Suggested reading (available on the Extranet: Resources/Articles to Support the Curriculum/PDSA SPC Exercise) Application of SPC in Healthcare Improvement: A systematic review; Thor Controlling Variation in Health Care: A Consultation from Walter Shewhart; Berwick Note: In Workshop 2 we provide file with data and have series of exercises based on this data and using your software

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