This presenter has nothing to disclose. We ve got aims and changes How do we make them work for us? Kevin Little, PhD The Patient Experience: Improving Safety, Efficiency, and CAHPS April 23, 2013 This presenter has nothing to disclose. Objectives At the conclusion of this session, participants will be able to: Describe the components of the Model for Improvement and PDSA cycles Describe the efficacy of and rationale for testing changes on a small scale
Session Agenda 3 Challenge: What can you do by next Tuesday? What it takes to change the system Preview of tomorrow s taking it home session Introduction to Model for Improvement Our Standard Challenge 4 What can you do by next Tuesday?
How far by Tuesday? 5 What it take to change a system: 6 Will to Change Making the changes Ideas for Change
Seminars Help 7 Will to Change! Making the changes Ideas for Change! Change 8 But to change your system, you have to change the way you and your colleagues do the work. We have to get to Making the Changes to make a difference.
Six Basic Change Ideas--Preview 9 Functional Element Leadership Engagement Improvement/ Infrastructure Patient and Family Connection Staff and Physicians Change Idea Establish and clearly articulate the link between organizational strategy and tactics to support patient experience. Involve patients and families in the development of new services and improvement activities. Use run charts to interpret HCAHPS, CG-CAHPS, and other patient experience data. Assure family presence is defined by the patient. Develop shared care plans (care team and patients/families) All In. Deploy 2-3 core behaviors for everyone, everywhere. Questions for any change planning to increase odds of success Aim? (what are you trying to achieve?) How will you measure success or failure of the change? What is your prediction (degree of success)? The usual: What? Who? When? Where? Data Collection: What? Who? When? Where? (to track performance)
Source: Langley et al. (2009), The Improvement Guide, Jossey-Bass: San Francisco, 2 nd ed. 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? Act Study Plan Do Model for Improvement helps you plan and do a change testing is a key perspective. Helpful no matter what the dominant improvement methodology (e.g. Lean, Six Sigma, etc.) Does a change need testing? Source: Table 7.1 from G. Langley et al. (2009), Associates in Process Improvement
Questions for any test plan first Aim? (the question you want to answer) How will you measure success or failure of the test? What is your prediction? (how much, by when?) Change: What? Who? When? Where? Data Collection: What? Who? When? Where? Features of small-scale test Can be done in a day or less. Involves just one staff member or one patient or one event. Data collection can be direct observation (no elaborate checklists or data forms needed).
Your turn tomorrow 1. Take an idea you d like to begin to apply in your system. 2. Start your planning so you are ready to test. 3. If you didn t bring your favorite PDSA form, we have one. 4. New to PDSA? We ll work together on one change idea, to plan a small test! A basic PDSA form
Resources for Self-study 17 D. M. Berwick (1996), A Primer on Leading the Improvement of Systems, BMJ, 312: pp. 619-622. G. Langley et al. (2009), The Improvement Guide, 2nd edition, Jossey-Bass, San Francisco. T. W. Nolan and L. P. Provost (1990), Understanding Variation, Quality Progress, 13, No. 5. Accelerating the Pace of Improvement - An Interview with Thomas Nolan, Journal of Quality Improvement, 23, No. 4, The Joint Commission, April, 1997. Resources on the www.ihi.org site: Search for PDSA Appendix
Roots in W.E. Deming s Contributions 19 Plan-Do-Study-Act cycle (Walter Shewhart 1939 and Deming s courses in Japan, 1950) Theory of Profound Knowledge (1992) Appreciation for a system Knowledge about Variation Theory of Knowledge Psychology 1900 1993 API Consultants developed the Model for Improvement in the late 1980 s and early 1990 s Model for Improving Quality Source: R.D. Moen, T.W. Nolan, L.P. Provost (1991), Improving Quality Through Planned Experimentation, New York: McGraw-Hill, p. 11 Source: 1992 API The Foundation for Improvement technical report by Gerry Langley, Kevin Nolan, and Tom Nolan Wide improvement experience in the1980 s Motivated by Deming s theories Pushed by Deming get to the core of improvement thinking Worked with Don Berwick from the start of the Institute for Healthcare Improvement (IHI) The Improvement Guide (1996), (2 nd edition, 2009) 20
Design Criteria used to create the Model for Improvement 21 1. It works 2. Applies to products and processes, from simple to complex 3. Quick to apply 4. Success by a variety of users, in all environments 5. Fun to use 6. Promotes learning G. Langley, K. Nolan, T. Nolan (1992), The Foundation of Improvement, API, p. 1 Method for change used by IHI in Breakthrough Series Collaboratives starting 1995 Breakthrough Series College IMPACT Communities, e.g. Improving Flow through Acute Care Settings Improving Outcomes for High-Risk and Critically Ill Patients 100,000 Lives campaign 5,000,000 Lives campaign System interventions (VA, Community Health Centers, U.K. National Health Service, Indian Health Service) 22
A General Method! 23 Any improvement effort Individuals, teams and whole organizations Formality and structure vary, not concepts Three Uses of the Model 24 1. Develop new knowledge 2. Test (adapt) ideas* 3. Implement (deploy) ideas* *Typical uses in improvement collaboratives
Use the PDSA Cycle for: 25 Testing or adapting a change idea Implementing a change Spreading a change Risk Reduction methods 26 Feasibility review by local experts Team as guinea pigs Parallel trial: regular way and test way Short test time Rule of ONE to start (one cycle, one patient, one shift change.) Use volunteers Simulate the change
Scope of Improvement Projects 27 small Large Improve regularity of personal exercise Test of shift hand-off methods Deploy care rounding on Med/Surg units Reduce Readmissions for CHF in your hospital Improve discharge planning across a set of hospitals Improve value in care to Medicare patients (CMS national projects) Advantages of the Model 28 Applies to all levels of an organization well-defined, high volume processes to informal, lowvolume processes Executives, providers, support staff Minimally prescriptive, maximally adaptive Formality can vary Stresses user empowerment, learning and growth of knowledge Advanced skills not a requirement for use See The Improvement Guide, 2nd edition, p. 455
Disadvantages? 29 No cookbook Expect and manage some failures in testing can you handle this? Data-driven Need to adapt if you have another standard system in your health system that drives improvement Model for Improvement and Lean, examples Lean concepts are Change Ideas (Question 3) e.g. Make work visible in a department or business unit Iterative changes to Daily Work: align with 3 questions and test cycle Leaders improving Strategy Deployment can use 3 questions and test cycle Apply Model for Improvement to interventions (e.g. Kaizen blasts, Value Stream Mapping activities, 5S work) 30
Model for Improvement and Six Sigma 31 Incorporate 3 questions and test cycles in the Improve and Control steps of DMAIC project path Apply 3 questions and test cycles in deployment of DMAIC projects (improve performance over time of DMAIC projects, viewed as a system).