Peer Coaching Unit 3C Quality Improvement Methodology- Part 3: Plan-Do-Study-Act ~ A Tool for Testing Changes
Objectives Review of SMART goals and measures Review of the Model for Improvement Importance of Testing Changes Using the Plan-Do-Study-Act (PDSA) cycle Don Berwick s personal PDSA story Practice session using PDSA tool PDSA a part of the QAPI process 3
What Do You Want to Learn Today? 4
Setting the stage developing SMART Goals Specific Measurable Attainable Relevant Time-bound 5
Three Fundamental Questions From the Model for Improvement From the Model for Improvement Goal statement Measure Change 6
A balanced set of measures shows if you are improving? Outcome Measures Process Measures Balancing Measures 7
Reminders as you begin your improvement plan Gather information to provide focus for the project. Seek input from staff about what might improve the process. What are the specific issues to be investigated? What would be the impact on the organization? What resources will be required? 8
The Benefits of Testing the Changes Increase your belief that the change will result in improvement Document how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation 9
The PDSA Cycle for Learning and Improvement What changes are to be made? Next Cycle? Act Plan Objective Predictions Plan to carry out the cycle (who what, where, when) Plan for data collection Analyze data Compare results to predictions Summarize what was learned Study Do Carry out the plan Document observations Record data 10
Goal: Reduce the number of residents developing in-house acquired pressure ulcers by 20% in 3 months In-house acquired PU rate reduced Cycle 5: Implement protocol for all residents Cycle 4: Pilot for 1 month Implement pressure ulcer prevention protocols as best practice Cycle 3: Train/educate pilot group staff Cycle 2: Establish protocol for reporting and documentation Cycle 1: Develop skin care protocols to be used 11
Keys to Successful Cycles to Test Changes Plan multiple cycles for testing a change (think a couple of cycles ahead.) Scale down size of test (# of residents, sites) Do not try to get consensus or ownership at this time Collect useful data during each test Test over a wide range of conditions 12
Keys to Successful Data Collection During PDSA Cycles Collect useful, not perfect data. The purpose is learning, not evaluation 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 rather than wait for quantitative Record what went wrong during the data collection 13
Number of Residents Use your graphs to tell your QI story Number of Residents with Nosocomial Pressure Ulcers Educate pilot Team Unit wide implementation Begin Pilot Implement Facility-wide Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 Months 14
Fourth Grade Girl s Soccer 15
Don Berwick s PDSA Story 16
What was missing in Berwick s PDSA story? Q: What was missing in his process of testing? A: He did not gather any information or input from his team on how to improve the process. You need to involve the people impacted by the change. Q: Did he learn from each failed attempt? A: No His hunches were wrong due to insufficient information before running his test. 17
Let s plan the first PDSA cycle for this scenario 18
Setting the stage to begin the testing Step 1 Develop a goal Identify your goal statement. What do you want to improve? What change do you want to make? Step 2 Develop 1 outcome measure and process measure Write 1 outcome and process measure. How will you know your change is an improvement? Step 3 Develop first test Develop the first test cycle for your plan. What change can you make that will result in improvement? 19
Dissecting Your Data to get to the Root Cause Date Admitted Acquired Census Admitted Acquired # stage I # stage II # stage III # stage IV # unstageable # sdti Total # PU Jan-12 2 4 248 0.81% 1.61% 0 4 0 0 0 0 4 Feb-12 3 6 245 1.22% 2.45% 1 5 0 0 0 0 6 Mar-12 2 4 243 0.82% 1.65% 0 3 1 0 0 0 4 Apr-12 2 2 245 0.82% 0.82% 1 3 0 0 0 1 5 May-12 2 6 245 0.82% 2.45% 0 6 1 0 0 1 8 Jun-12 4 5 246 1.63% 2.03% 0 4 1 0 0 0 5 Jul-12 5 8 245 2.04% 3.26% 2 5 0 0 1 0 8 Aug-12 4 4 243 1.65% 1.65% 0 3 0 0 0 1 4 Sep-12 5 5 245 2.04% 2.04% 1 4 0 0 0 0 5 Oct-12 4 4 243 1.65% 1.65% 0 5 0 0 0 0 5 Nov-12 3 4 246 1.22% 1.63% 1 3 0 0 0 0 4 Dec-12 4 5 248 1.61% 2.02% 0 3 2 0 0 0 5 Jan-13 2 4 245 0.82% 1.63% 0 3 1 0 0 0 4 Feb-13 1 6 243 0.41% 2.47% 0 4 2 0 0 0 6 Mar-13 # Residents with new PU Monthly % of Residents with Pressure Ulcers # of Newly acquired PU by Stage 20
Your Observations and Questions Observation Question Stage 2 consistently developing. Stage 1 being missed Occurring on a specific unit, team? Is it a specific type of resident? 21
Let s look at an example. Step 1 Develop a goal To reduce number of residents with an in-house acquired PU by 4 in 2 months. Step 2 Develop 1 outcome measure and process measure Outcome- Percent of residents with newly acquired pressure ulcer. Process Percent of newly admitted residents that have a pressure ulcer risk assessment within 24 hours of admission. Step 3 Develop first test 1st cycle- Review and update skin care prevention procedures. 22
Rocking Horse Nursing Home- A Falls Investigation 23
Rocking Horse NH PIP Team Challenge Issue- Number of residents falling are increasing. During the monthly QAPI steering committee meeting at Rocking Horse NH a trend over the last 2 months was observed. QAPI steering committee chartered a performance improvement project (PIP) team to further investigate these trends and develop an initial plan to address the issue. 24
Rocking Horse NH PIP Team Challenge Instructions Look at the numbers in the data table for the falls measure. After reviewing the data table: What patterns do you see? What questions do you need to ask and who? What actions will the team need to do? 25
What does the data show us? Facility Name: Rocking Horse Unit B wing Falls Tracking Tool- 1/2013 -- 3/2014 Date # of Falls this month # of Falls with injury this month Monthly Census % of Falls this month % of Falls w/ injury this month # of falls in or tranf. to the bathroom # of falls out of bed # of falls from chair/wc # of falls while walking # of falls occuring on Week End # of falls occuring on 3-11 or night shift Jan-13 49 3 241 20.3% 1.2% 2 35 0 11 9 24 0 Feb-13 32 0 251 12.7% 0.0% 4 22 0 6 5 18 0 Mar-13 32 3 249 12.9% 1.2% 0 17 0 12 11 19 0 Apr-13 36 0 248 14.5% 0.0% 6 22 5 4 5 28 0 May-13 43 0 250 17.2% 0.0% 4 19 17 4 10 27 0 Jun-13 42 1 238 17.6% 0.4% 2 22 13 3 12 24 0 Jul-13 43 2 250 17.2% 0.8% 7 25 5 6 6 19 0 Aug-13 49 2 250 19.6% 0.8% 6 20 6 5 8 20 0 Sept-13 50 3 249 20.1% 1.2% 5 22 7 7 7 24 0 Oct-13 51 1 249 20.5% 0.0% 6 23 5 6 10 26 0 Nov-13 51 0 251 20.3% 0.0% 7 22 4 4 9 28 0 Dec -13 52 1 250 20.8% 0.4% 8 24 6 6 8 26 0 Jan -14 53 4 249 21.3% 1.6% 6 25 5 7 7 28 0 Feb -14 54 2 248 21.8% 0.8% 4 22 6 7 8 30 0 Mar -14 55 1 251 21.9% 0.4% 5 23 5 6 9 29 0 Other 26
What does your P-D-S-A plan look like? 27
What did the data tell you? Observation Questions Number of falls increasing past 5 months. What are residents trying to do before falling OOB? More than half of the falls are on the off shifts (eve and nights). What are the times of the falls on eve and nights? 20% of the falls on this unit are residents getting OOB. What is staff s routine at the time of the falls? 28
For Example Step 1 Develop a goal B wing has an increasing number of falls per month. Reduce the number of falls on B wing by 12 over the next 6 months. This will be done through implementing our falls prevention protocol as written. Step 2 Develop 1 outcome measure and process measure Outcome- Percent of residents who experience a fall. Process 100% of residents will receive a fall risk screening upon admission. Step 3 Develop first test 1st cycle- Revisit and revise fall prevention protocol. 29
Possible PDSA Cycles for Scenario 1st Cycle 2nd Cycle 3rd Cycle 4th Cycle 5th Cycle Revisit and revise fall prevention protocol. Train pilot staff on B wing on revised fall prevention protocol. Pilot revised falls protocol for 2 weeks (Size: 1 resident, team, or unit). Expand pilot group to 1 team/ 1 shift and test for 2 weeks. Expand pilot group to entire team/ 3 shifts and test for 2 weeks. 30
Successful Change Requires A Plan Identify where implementation will take place Engage management structures to make the change permanent Change must be turnover proof 31
QAPI Strategic Element #3 Feedback, Data, Systems and Monitoring Systems to monitor care and services, drawing data from multiple sources. Feedback systems to actively incorporate input from staff, residents, families, and others as appropriate. Performance Indicators to monitor a wide range of care processes and outcomes. Review findings against benchmarks and/or targets the facility has established for performance. Tracking, investigating, and monitoring adverse events must be investigated every time they occur. Action plans implemented to prevent recurrences. 32
How Does QAPI fit into QI Process QAPI committee collects and evaluates data from a variety of sources, e.g., Quality Measures, Customer Satisfaction, Performance Improvement Tool, etc. QAPI committee meets monthly to identify opportunities for improvement based on the evaluation of the data QAPI Committee assigns a Performance Improvement Project (PIP) and a PIP Team to evaluate a process using a small- scale rapid cycle for improvement 33
How Does QAPI fit into QI Process (cont d) PIP Team meets as often as necessary between monthly QAPI committee meeting. PIP TEAM RUNS THE PDSA Cycles. PIP Team reports findings to QAPI Committee QAPI Committee evaluates ongoing effectiveness of PIP Team QAPI Committee sets timetable for follow-up of PIP, if necessary 34
In Summary We practiced writing a SMART goal and measures Used the Model for Improvement questions to develop a QI plan. Practiced using the Plan-Do-Study-Act (PDSA) cycle tool to set up a QI plan. Looked at how the PDSA testing tool is a part of strategic element # 3 in the QAPI process. 35
Questions & Suggestions alliantquality.org Nancy Fendler, Task Lead, Acute & Post-Acute Care 678-527-3679 nancy.fendler@alliantquality.org 36
This material was prepared by GMCF, for Alliant Quality, the Medicare Quality Innovation Network Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 11SOW-GMCFQIN-NC-C2-15-05 37