The Model for Improvement and PDSA DHCF Nursing Facility Quality - - PowerPoint PPT Presentation

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The Model for Improvement and PDSA

DHCF Nursing Facility Quality Improvement Collaborative March 2019 Selena Bolotin, LICSW

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So Many Choices… Where to Begin?

• Model For Improvement

(MFI) and Plan-Do- Study-Act (PDSA)

• Baldrige
• ISO Quality

Management Systems

• Lean
• Reliability Science
• Human Factors
• Situation-Background-

Assessment- Recommendation (SBAR)

• Six Sigma

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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?

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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

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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

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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

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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

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Example: Annotated Run Chart

Goal: 100.0 Median: 0.0 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 a b c d e

0.0 20.0 40.0 60.0 80.0 100.0 120.0

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Rate Date

Process Measure 1: Documented Pre-trial preference and motivation

Rate Goal Median

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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.)

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Accelerating Improvement: PDSA Cycles Paired with the Model For Improvement

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Act Plan Study Do

The PDSA Cycle Four Steps: Plan, Do, Study, Act

Also known as:

• Shewhart Cycle
• Deming Cycle
• Learning and

Improvement Cycle

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PDSA Cycle for Learning Improvement

Act Plan Study Do

• Adopt, Adapt, or

Abandon?

• What changes are

to be made?

• Next cycle?
• Objective
• Questions and

predictions (Why)

• Who, What, When,

Where

• Complete the analysis
• f the data and compare

to predictions

• Summarize

learning

• Carry out the plan
• Document problems,

unexpected

• bservations
• Begin analysis

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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

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Decrease the Time Frame for a PDSA Test Cycle

• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes

Drop next down two levels to plan test cycle!

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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

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Repeated Use of the PDSA Cycle

Proposals, Theories, Ideas Changes That Result in Improvement

A P S D A P S D

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How will we know that a change is an improvement? What change can we make that will result in improvement? accomplish? What are we trying to

Model for Improvement

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Change Concepts, Theories, Ideas

Concept B Concept C Concept A Concept D Goal

Aligning all the Pieces to Reach the Goal

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Current Situation Resistant Indifferent Ready Low Confidence That change idea will lead to improvement Large Cost of failure Very, very Small Test Very, very Small Test Very, very Small Test Small Cost of failure Very Small Test Very Small Test Small Test High Confidence That change idea will lead to improvement Large Cost of failure Very Small Test Small Test Large Test Small Cost of failure Small Test Large Test Implement

Do you always need to test? It depends…..

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Games for Teaching Quality Improvement to Staff

Airplane game Tabletop football game Tennis ball game Nut-and-bolt game

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Worksheets

• Project planning
• PDSA planning
• Run charts
• Others

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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.

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• 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.

References (cont.)

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Questions and Answers

24 Prepared with assistance from Lloyd Provost, Associates in Process Improvement, and the Institute for Healthcare Improvement