The Model for Improvement and PDSA DHCF Nursing Facility Quality Improvement Collaborative March 2019 Selena Bolotin, LICSW 1 1
So Many Choices … Where to Begin? • Model For Improvement • Reliability Science (MFI) and Plan-Do- • Human Factors Study-Act (PDSA) • Situation-Background- • Baldrige Assessment- Recommendation • ISO Quality (SBAR) Management Systems • Six Sigma • Lean 2 2
Three Fundamental Questions for Improvement • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement? 3 3
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? 4 4
What Are We Trying to Accomplish? Developing an Aim • State the aim clearly • Use numerical goals • State the time frame and site of the work Example: “By the end of 2019, our NH will decrease the percentage of LS residents with facility acquired pressure ulcers by 25% through the application of the SKIN bundle 5 5
How Will We Know That a Change Is an Improvement? Measurement Basics • Just enough! • Qualitative vs. quantitative • Should not take more time nor effort than the improvements or system • Monthly measures should clarify your aim statement and make it realistic 6 6
Measurement Basics (cont’d) • Integrate measurement into the daily routine • Plot measures monthly • Use a balanced set of five to seven measures to assure that the system is improved 7 7
Example: Annotated Run Chart Goal: 100.0 Median: 0.0 Process Measure 1: Documented Pre-trial Rate preference and motivation 120.0 100.0 e d 80.0 c 60.0 40.0 20.0 b a 0.0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Date Rate Goal Median Annotations: a Inserviced all staff on interview technique b designated "interview specialists" c expanded "interview specialist" to cover all units and weekends d prompted voiding added as option in standing orders for admission e turnover in designated interview specialists 8
What Change Can We Make that Will Result in Improvement? Change Ideas • Everything goes! • Think outside the box! • Borrow from other disciplines, organizations, topics. • Proven change packages (e.g., Vanderbilt, INTERACT , IHI’s Campaigns, literature, etc.) 9 9
Accelerating Improvement: PDSA Cycles Paired with the Model For Improvement 10 10
The PDSA Cycle Four Steps: Plan, Do, Study, Act Also known as: • Shewhart Cycle Act Plan • Deming Cycle • Learning and Study Do Improvement Cycle 11 11
PDSA Cycle for Learning Improvement Act Plan • Adopt, Adapt, or • Objective • Questions and Abandon? • What changes are predictions (Why) • Who, What, When, to be made? • Next cycle? Where Study Do • Carry out the plan • Complete the analysis • Document problems, of the data and compare unexpected to predictions observations • Summarize • Begin analysis learning 12 12
Testing on a Small Scale • Pick the most likely helpers • Use existing knowledge from co-workers • Incorporate redundancy in the test – Side-by-side with the existing care system – Try the change two different ways • “ Cycle of 1” - Conduct the test in one wing, with one person, with one subject, etc. • Develop a plan to simulate the change in some way 13 13
Decrease the Time Frame for a PDSA Test Cycle • Years • Quarters • Months • Weeks • Days Drop next down • Hours two levels to plan • Minutes test cycle! 14 14
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 Plan Study Do 15 15
Repeated Use of the PDSA Cycle Changes That Result in Improvement A P S D A P S D Proposals, Theories, Ideas 16 16
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? 17 17
Aligning all the Pieces to Reach the Goal Goal Concept D Concept C Concept B Concept A Change Concepts, Theories, Ideas 18 18
Do you always need to test? It depends….. Current Situation Resistant Indifferent Ready Low Large Very, very Very, very Very, very Confidence Cost of failure Small Test Small Test Small Test That change idea will lead to Small Very Small Test Very Small Test Small Test improvement Cost of failure High Large Very Small Test Small Test Large Test Confidence Cost of failure That change idea will lead to Small Small Test Large Test Implement improvement Cost of failure 19
Games for Teaching Quality Improvement to Staff Airplane game Tabletop football game Tennis ball game Nut-and-bolt game 20 20
Worksheets • Project planning • PDSA planning • Run charts • Others 21 21
References • The Improvement Guide: A Practical Approach to Enhancing Organizational Performance . G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. • “Eleven Worthy Aims for Clinical Leadership of Health System Reform,” Don M. Berwick, JAMA , September 14, 1994, Vol. 272, #10, p. 797-802. • “The Foundation of Improvement.” Langley, G. J., Nolan, K. M., Nolan, T. W., 1994. Quality Progress , ASQC, June,1994, pp. 81-86. • “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. 22 22
References (cont.) • Quality Improvement Through Planned Experimentation. 2nd Edition R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998. • “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997. • “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990. 23 23
Questions and Answers Prepared with assistance from Lloyd Provost, Associates in Process Improvement, and the Institute for Healthcare Improvement 24 24
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