Leading Quality Improvement Essentials for Managers Lesson 5: - - PowerPoint PPT Presentation

Leading Quality Improvement

Essentials for Managers Lesson 5: Practice Improvement Essentials

July 20, 2016

These presenters have nothing to disclose

Janet Porter, PhD Kathy Duncan, RN

Rhonda Dickman, RN, MSN, CPHQ

Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association’s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement work, particularly in the area of

• readmissions. She is also the clinical manager of the

Tennessee Center for Patient Safety’s PSO (patient safety organization). Rhonda has worked in the field of hospital quality management since 2006 and has a clinical background in trauma, critical care, oncology, and organ donation.

rdickman@tha.com 615-401-7404

Attendance

Chat name and organization into the chat box Email Rhonda Dickman that you attended

– rdickman@tha.com

Log in to the webinar using your username and password:

– User name: email address used to register – Password: the password you set up when you registered

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Lead Faculty

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Kathy D. Duncan, RN, faculty, Institute for Healthcare Improvement (IHI), directs IHI Expeditions and manages IHI's work in rural settings. Previously, she provided spread expertise to Project JOINTS, co-led the 5 Million Lives Campaign National Field Team, and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She also served as the content lead for the Campaign's Prevention of Pressure Ulcers and Deployment of Rapid Response Teams

• areas. She is a member of the Scientific Advisory Board for the

AHA NRCPR, NQF's Coordination of Care Advisory Panel, and NDNQI's Pressure Ulcer Advisory Committee. Prior to joining IHI,

• Ms. Duncan led initiatives to decrease ICU mortality and morbidity

as the director of critical care for a large community hospital.

Supporting Faculty

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Janet Porter, MBA, PhD, serves as consultant to hospitals and physician practices for Stroudwater

• Associates. She has 35 years of experience as a hospital

administrator, teacher, consultant, and public health leader.

• Dr. Porter served as the Chief Operating Officer of Dana-

Farber Cancer Institute; the Associate Dean of Executive Education at the University of North Carolina’s School of Public Health; the Interim CEO of the Association of University Programs in Health Administration (AUPHA); and the Vice President, and then COO, of Nationwide Children’s Hospital in Columbus, Ohio. Currently teaching strategic management in the Healthcare Executive MBA program at the University of Miami, she is also an active adjunct professor at the University of North Carolina at Chapel Hill and Ohio State University. Dr. Porter received her BS and MHA from Ohio State University, and her MBA and PhD in health care strategy from the University of Minnesota.

Build the skills and capabilities needed to lead quality improvement efforts at the middle manager level of an

• rganization

Manage the Work Manage Improvement Develop Teams

Leading Change/Influencing Others - Session 2 June 8 JP Time Management – Session 3 June 22 JP Leveraging Teams with Partners – Session 9 Sept 14 JP Patient and Family Engagement – Session 1 May 25 JP Practice Improvement Essentials – Session 5 July 20 KD Identify and Spread Improvement - Session 6 August 3 KD Building and Creating Joy in Teams – Session 8 August 31 KD

Tennessee Leading Quality Improvement: Management Essentials Course

Project Management – Session 4 July 6 JP Incorporating Finance in Improvement– Session 7 August 17

Practice Assignment

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For a current project or past project, ask yourself?

– What has gone well?

What could have gone better? What have you learned?

– What would you do differently next time?

Volunteers:

– Paige Barnes, Marshall Medical Center

Today’s Objectives

Apply the Model for Improvement to at least one improvement opportunity. Use a PDSA cycle to test at least one change Identify which team members you need to engage in a specific test of change Demonstrate how to analyze data over time using a run chart and run chart rules

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Reflection

Video: Model For Improvement Part 1 (2:55) and Part 2 (3:00) Video: PDSA Cycles Part 1 (4:45) and PDSA Cycles Part 2 (3:48) IHI Open School: The human side of Quality Improvement

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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?

Model for Improvement

Act Plan Study Do

Aim of I mprovement Measurement

• f

I mprovement Developing a Change Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational

• Performance. San Francisco, CA: Jossey-Bass, 1996.

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4 Components of an Aim Statement

State the aims clearly (What do you want to accomplish? How good, by when?) Define location or population Set stretch goals Include numerical goals/targets

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?

Model for Improvement

Act Plan Study Do

Aim of I mprovement Measurement

• f

I mprovement Developing a Change Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational

• Performance. San Francisco, CA: Jossey-Bass, 1996.

Three Types of Measurement

Outcome Measures

– Voice of the customer or patient. How is the system

performing? What are the results? Process Measures

– Voice of the performance of the process or system. Are the

parts/steps in the system or process performing as planned? Balancing Measures

– Looking at a system from different directions or dimensions.

What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences,

• ther factors influencing outcome). Don’t “rob Peter to

pay Paul”

Key Points of Measurement

• The purpose of measurement in Improvement is for

learning not judgment!

• All measures have limitations, but the limitations do not

negate their value for learning.

• Measures tell a story; goals or targets provide a

reference point to evaluate performance.

• These measures should operationalize the Aim
• Measures should be integrated into the team’s daily

routine

• Data should be plotted over time on annotate graphs
• Focus on the Vital Few

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?

Model for Improvement

Act Plan Study Do

Aim of I mprovement Measurement

• f

I mprovement Developing a Change Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational

• Performance. San Francisco, CA: Jossey-Bass, 1996.

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Where might you find changes?

What Changes Can We Make?

Understanding the System

Primary Drivers Outcome Secondary Drivers Process Changes Aim: An improved system

• P. Driver
• S. Driver 1

Change 1

• P. Driver
• S. Driver 2
• S. Driver 3
• S. Driver 1
• S. Driver 2

Change 2 Change 3

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What can a driver Diagram do for you?

Driver Diagram

A Driver Diagram is an improvement tool used to organize theories and ideas in an improvement effort. It displays visually, our theory about potential areas we can leverage to change the status quo. The driver diagram is often used to scope or size a project and to clarify the plan for reaching the aim. Primary Drivers: major processes, operating rules, or structures that will contribute to moving towards the aim Secondary Drivers: elements or portions of the primary drivers. The secondary drivers are system components necessary in order to impact primary drivers, and thus reach project aim. Specific changes /Change concepts: Specific changes are concrete actionable ideas to take to testing. Change concepts are broad concepts (e.g. move steps in the process closer together) that are not yet specific enough to be actionable but which will be used to generate specific ideas for change.

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D1 D2 D5 D3

D4 Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts

AIM

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Driver Diagram Basics

D1 D2 D5 D3

D4 Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts

AIM

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Driver Diagram Basics

D1 D2 D5 D3

D4 Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts

AIM

A good aim: 1) Identifies the system to be improved (scope, patient population, drivers selected) 2) Has specific numerical goals and 3) Includes timeframe

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Driver Diagram Basics

D1 D2 D5 D3

D4 Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts

AIM

Primary Drivers: Major processes,

• perating rules, or

structures that will contribute to moving towards the aim

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Robin Zudell Queen of the Valley MC

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Driver Diagram Basics

D1 D2 D5 D3

D4 Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts

AIM

Secondary Drivers: Elements

• r portions of the primary
• drivers. The secondary

drivers are system components necessary in

• rder to impact primary

drivers, and thus reach project aim.

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Robin Zudell Queen of the Valley MC

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Driver Diagram Basics

D1 D2 D5 D3

D4 Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts

AIM

Specific changes: Concrete actionable ideas to test. Change concepts: Broad concepts (e.g., move steps in the process closer together) that are not yet specific enough to be actionable but that will be used to generate specific ideas for change.

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Robin Zudell Queen of the Valley MC

How Will We Know We Are Improving?

Understanding the System for Weight Loss with Measures

Primary Drivers Outcome Secondary Drivers Process Changes

AIM: A New ME! Calories In Limit daily intake Track Calories Calories Out Substitute low calorie foods Avoid alcohol Work out 5 days Walk to errands Plan Meals Drink H2O Not Soda

drives drives drives drives drives drives drives drives

• Weight
• BMI
• Body Fat
• Waist size
• Daily calorie

count

• Exercise

calorie count

• Days between

workouts

• Avg drinks/

week

• Running

calorie total

• % of
• pportunities

used

• Sodas/

week

• Meals off-

plan/week

• Avg cal/day

Etc...

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How might you use a driver diagram?

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?

Model for Improvement

Act Plan Study Do

Aim of I mprovement Measurement

• f

I mprovement Developing a Change Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational

• Performance. San Francisco, CA: Jossey-Bass, 1996.

Principles for Testing

A test of change should answer a specific question A test of change requires a theory and prediction

Test on a Small Scale

Incorporate redundancy in the test by making the change side- by-side with the existing system Conduct the test over a short period of time Conduct the test with one member of your team or with one patient

Learn quickly and go BIG, FASTER

Why Test? Why not just implement than spread?

Increase degree of belief Document expectations Build a common understanding Evaluate theories and predictions Test ideas under different conditions Learn and adapt

Guidelines for Testing a Change

Test on a small scale Collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea Include a wide range of conditions in the sequence of tests

Tips for Testing

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Why do we do multiple cycles?

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Now it is your turn!

I am going to give you a case study – and need your to chat in your thoughts AIM Statement Measures Changes Tests Ready, Set, Go! (Chat)

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What is our aim?

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How will we know our change is an improvement?

Measures: Reminder: Data is for learning …not judgment.

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What Changes will we make?

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What is our Plan?

What are the directions? How did mom do it?

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Do

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Study

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Results of Additional PDSA

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Hunches Theories Ideas Changes That Result in Improvement

A P S D A P S D

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?

Model for Improvement

Source: Improvement Guide, p 10

Yes!

Operational Definitions

Statement of the measurement process used Need to come to agreement on two things:

– A method of measurement or test – A set criteria for judgment

• Provost. L. & Murray. (2008, November) The Date Guide: Learning from Data to Improve Health Care. Austin, TX: API.

The Problem

What we look at and how we look at it will drive what we do with it It can also result in missing the essential learning Aggregated data presented in tables, tabular formats or with summary statistics, will not help you measure the impact of process improvement/redesign efforts. Aggregated data can only lead to judgment, not to improvement.

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Average CABG Mortality

Before and After the Implementation of a New Protocol

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Percent Mortality Time 1 Time 2 3.8 5.2

5.0% 4.0%

Average CABG Mortality

Before and After the Implementation of a New Protocol

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Data Display

Label chart Data should take middle third to half Keep it as simple as possible Annotate

75.0% 80.0% 85.0% 90.0% 95.0% 100.0% 1 2 3 4 5 6 7 8 9 10 11 12

Month

Response Time Compliance - Life Threatening Emergency (I Chart)

Annotations of Changes

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160 180 200 220 240 260 280 300 320

LOS (minutes)

Goal

Work-up done on floor

Bed ahead Individual responsible for bed control Quick-look x- rays 2/16/98 3/16 4/13 5/11 6/8 Week

Non-Random Rules for Run Charts

Source: The Data Guide by L. Provost and S. Murray, Austin, Texas, February, 2007: p3-10.

A Shift: 6 or more An astronomical data point Too many or too few runs A Trend 5 or more 54

How do we classify variation?

Common Cause Variation

Is inherent in the design of the process Is due to regular, natural or ordinary causes Affects all the outcomes of a process Results in a “stable” process that is predictable Also known as random or unassignable variation

Special Cause Variation

Is due to irregular or unnatural causes that are not inherent in the design of the process Affect some, but not necessarily all aspects of the process Results in an “unstable” process that is not predictable Also known as non-random or assignable variation

Practice

Complete one PDSA Worksheet Draft a Driver diagram for one of your projects

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Important THA Announcements

August Regional Networking Meetings

– Thursday, August 4 – Memphis – Tuesday, August 9 – Nashville – Thursday, August 11 – Knoxville – More information: http://tha.com/events

Leadership Summit – Call for Presentations

– Applications due by Friday, July 29 – More information: www.tnpatientsafety.com

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