Session Four Foundational Element: Improvement Infrastructure Kelly - - PDF document

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Session Four Foundational Element: Improvement Infrastructure

Kelly McCutcheon Adams, MSW, LICSW, IHI Director Barbara Balik, RN, EdD, IHI Faculty February 22, 2012 2:00 – 3:00pm EST

David Kim

David Kim, Institute for Healthcare Improvement (IHI), is responsible for managing and coordinating a variety of programs based on Key Processes on the IHI Improvement Map. Mr. Kim is a graduate of Boston University. He has been with the IHI for 2 years. He enjoys sports, food, and travel.

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Kelly McCutcheon Adams, MSW, LICSW

Kelly McCutcheon Adams, MSW, LICSW, Director, Institute for Healthcare Improvement (IHI), has served in this capacity for eight years for a variety of IHI Collaboratives and programs, particularly those focused on critical care. She is a medical social worker with experience in hospice, nursing home, sub-acute rehabilitation, emergency department, and ICU settings. She has also served as faculty for the US Department of Health and Human Services Organ Donation Collaborative and for the Gift of Life Institute.

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Barbara Balik, RN, EdD

Barbara Balik, RN, EdD, Principal, Common Fire Healthcare Consulting, is also Senior Faculty at the Institute of Healthcare

• Improvement. Her areas of expertise include

leadership and systems for a culture of quality and safety, including patient- and family- centered care, patient experience, systems to improve transitions in care, and transforming care prior to or with optimization of an electronic health record implementation. She works with leaders to develop adaptive systems to excel and innovate in complex organizations, and to ensure sustained improvement and innovation every day. Ms. Balik's publications include the book, The Heart of Leadership, and the IHI white paper on “Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care,” among others. Previously, she served in senior leadership roles at Allina Hospitals and Clinics, United Hospital, and Minneapolis Children's Medical Center. 6

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Overall Objectives

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At the end of this program, participants would be able to:

• Articulate key foundational elements in support of all

domains of patient experience improvement

• Share specific testable ideas for improving nurse

communication, pain management, and cleanliness

• Plan small tests of change to try during the Expedition

Session Agenda

• Homework – We did you learn?
• Patient Experience Change Package
• Our focus today: Improvement Infrastructure
• Model for Improvement and Run Charts – Joan

Grebe, IHI Improvement Advisor

• Lessons from the Field – Andy Foret, Operations

Director, John Randolph Medical Center

• Time for Q&A
• Homework

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Homework

• Session 3:

─Test one of the Patient Engagement Key Changes ─What did you learn?

Patient Experience Change Package: Overview

Key areas for improving specific domains of patient experience: Nurse Communication, Cleanliness, and Pain Management Staff and Physicians Patient and Family Connection

Leadership

Engagement Improvement/ Infrastructure Foundational Elements for Improving Patient Experience

Today’s Session

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Foundational Elements for Improving Patient Experience

Leaders take ownership of defining purpose of work and modeling desired behaviors. Staff, leaders, and physicians engage patients and families so that efforts to improve patient experience reflect actual patient experience. Improvement teams are solidly grounded in skills to effect reliable change and gain meaningful understanding of data

Leadership Engagement Improvement/ Infrastructure Today’s Session

Improvement Infrastructure

Key Change Ideas:

• Daily Improvement
• Measurement System
• Reliability
• Patient Journey

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Improvement Infrastructure

Key Change Idea Daily Improvement Incorporate improvement methodologies (e.g. the Model for Improvement) into daily work of care

• team. Develop a process to obtain improvement
• ideas. Empower staff to test improvements

rapidly and on a small-scale and develop a process for feedback, revision, and eventual

• spread. Include night and weekend staff.

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Improvement Infrastructure

Key Change Idea Measurement System

Develop a quantitative and qualitative measurement system to provide timely, pertinent patient experience data for all departments. Aid leaders, staff, and physicians to gain meaningful understanding of data variation to ground decision-making. Move beyond daily evaluation of measures that do not have daily meaning (example: discontinue overly-frequent checking of HCAHPS scores with over-reactive responses to normal variation).

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Improvement Infrastructure

Key Change Idea Reliability Use human factors and reliability science to design simple but effective processes that are in use 95% or more of the time. Measure reliability of key processes to guide continued improvement efforts.

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Improvement Infrastructure

Key Change Idea Patient Journey Observe with current and past patients and families their patient experience journey using direct observation and inquiry looking for what is important to them both technically and emotionally.

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Perspectives from an Improvement Advisor

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Joan M. Grebe, MA, OT, AICF, Improvement Advisor (IA), Institute for Healthcare Improvement, currently supports the Improvement Science Professional Development Program in New Zealand and the Community Clinic Innovation Challenge. She was previously the IA for the IHI Sepsis Collaborative, the IHI High-Risk and Critically Ill Patient Community, the Patient Experience Collaborative and the Assistant Director for IHI in the National Vascular Access Improvement Initiative “Fistula First” project. In addition to her work with IHI, she is an independent health care consultant specializing in facilitating quality improvement teams, and educating others about quality improvement tools and

• techniques. Ms. Grebe began her work in health care

more than 20 years ago as an occupational therapist and rehabilitation administrator in a variety of settings.

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 Improvement Measurement

• f

Improvement 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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The Sequence for Improvement

Sustaining improvements and Spreading the changes to other locations Developing a change Implementing a change Testing a change

Act Plan Study Do Theory and Prediction Test under a variety of conditions Make part

• f routine
• perations

10 20 30 40 50 60 70 80 90 100 J a n F e b M a r A p r M a y J u n J u l A u g S e p t O c t N

• v

D e c Wait Time (Minutes)

Change Implemented

10 20 30 40 50 60 70 80 90 100 Wait Time (Minutes)

Wait Times: Pictures of the Process

10 20 30 40 50 60 70 80 Average Before Change Average After Change

Wait time in minutes

Change Implemented

Facility A Facility B

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Data display using a Run Chart

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Point Number Pounds of Red Bag Waste

3.25 3.50 3.75 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00 Median=4.610

Measure Time

The centerline (CL) on a Run Chart is the Median

• r Average

Use four simple run rules to determine if special cause variation is present

(CL)

Slide courtesy of Robert Lloyd, Ph. D.

Run Chart Rules

• 1. Shifts -6 or more points above or

below center line

• 2. Trends- 5 or more consecutive points

all increasing or decreasing

• 3. Too few, too many runs (use a table to

determine)

• 4. Astronomical-a point far away from
• thers in graph

Common cause (random) variation is a Stable process, for improvement you need to Change the whole process

Special cause (non-random) variation is an Unstable process, for improvement you need to Investigate the reason for the special cause and Take corrective action, either to continue or get rid of the special cause variation

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Note: A point exactly on a control limit is not considered outside the limit . When there is not a lower or upper control limit Rule 1 does not apply to the side missing the limit. Note: Ties between two consecutive points do not cancel or add to a trend. When Shewhart Charts have varying limits due to varying numbers of measurements within subgroups, then rule #3 should not be applied. Note: A point exactly on the centerline does not cancel or count towards a shift.

IH: 25-5

When there is not a lower or upper control limit Rule 4 does not apply to the side missing a limit. Hugging the centerline

Shewhart Rules for Special Causes

Slide used with permission from Robert Lloyd, Ph.D. and Sandra Murray

Funnel Experiment

Devised by Dr. W. E. Demings to show:

• a process in control delivers steady and

predictable results if left alone

• the adverse effects of tampering

 the output will be worse than if left alone

http://www.symphonytech.com/dfunnel.htm

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Why is understanding type

• f variation important?

Danger will over-adjust when a process is stable and predictable (common cause/random variation) and make it worse. Danger will not recognize when a change has taken place. (special cause/non-random variation)

• St. Petersburg HCAPHS Top Box

Nurse Communication

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How will you know . . .

if white boards are being used reliably?

• St. Petersburg 2East White

Boards Meeting Minimum Requirement

Case study data questions

• 1. Which hospitals show special cause?
• 2. Which hospitals show common cause?
• 3. Which hospital shows sustained work?
• 4. What would your actions be as a leader

for hospital 2 as opposed to hospital 3?

• 5. What other items of interest do you notice

about the different graphs?

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Hospital 1 Pain Control Hospital 3 Pain Control Hospital 2 Pain Control Hospital 4 Pain Control

Perspectives from a participant

• Andy Foret, Operations Director, John

Randolph Medical Center, Collaborative Participant

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Homework for the next call

• Complete these activities:

─ Assess your organization on one of the 4 Improvement Infrastructure Key Change Ideas from 1 (low) to 5 (high) ─ Use the attached PI assessment tool to complete an assessment

• Share what you learned from the assessment with

team members at your organization

• Be prepared to share one insight gained at the next

Expedition session

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PI System Assessment

Capacity Description

Our Organization’s Performance Improvement (PI) system is ……… What I learned when I put HCAHPS data on a run chart … Percent of leaders who can successfully use small tests of change every day … How do I demonstrate PI skills in my work?

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Next Call

Session 5 – Nursing/Team Communication Date: Wednesday March 7, 2012 2:00 PM - 3:00 PM Eastern US time

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Listserv

• Patient_experience@ls.ihi.org
• Send and receive questions and

comments to/from faculty and participants

• To be added to the listserv please email

dkim@ihi.org

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