What are we trying to accomplish? The aim of this meeting: A - - PDF document

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The Collaborative Way: A Framework for Scale and Spread

Presented by Chad Glenn and Dr. Kirk Jensen

2  Chad Glenn, Innovation Group

What are we trying to accomplish?

The aim of this meeting:

• A better understanding of what to expect over the course of the next

9 months as we embark on this national process improvement journey.

• Helping you, your teams and your patients get the most out of the

2017 Envision ED Patient Flow Breakthrough (BTS) Collaborative. Topics of discussion:

• What exactly is a BTS Collaborative?
• What is the focus and purpose of a BTS Collaborative?
• What can it do for you, your team, and your patients….
• The 3 levels of improvement efforts
• Forming an Effective Team
• The Model for Improvement

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3  Chad Glenn, Innovation Group

What’s in it for you…

• Empowering you, the on-site expert in emergency

department patient flow, operational excellence, and change management.

• Providing you, your team, and your Emergency

Department/ Hospital with everything you need – the knowledge, tools and techniques – to successfully execute the changes you want to see happen in your emergency department.

• Giving you access to patient flow tools, content, experts

and colleagues

• Defining and developing the necessary support

structure to rapidly deploy best practices at your site

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Why you are here…Leader of the pack…

• Respected opinion leaders amongst your peers
• Judicious, wise innovative decision makers
• Change agents with a passion for improvement and

strong leadership skills

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What exactly is an Envision Breakthrough Series Collaborative?

An Envision Breakthrough Collaborative is…

• A cross-divisional effort to make rapid, measurable

improvements in a targeted area of focus where

• Interdisciplinary teams can leverage the science of

continuous improvement and a theory of knowledge about Emergency Medicine Operations and flow through

• A series of learning sessions and action periods

designed to allow professionals to design, collaborate, share, and help hold one another accountable for improvement and change…

Charles Kilo, A Framework for Collaborative Improvement

The 2017 Envision Breakthrough Series Collaborative Model and Timeline

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Envision Breakthrough Series Collaborative Model (9 Month Time Frame)

Select Topic (develop mission) Planning Group

Develop Framework & Changes

Participants (25-100 teams) Prework

LS 1

P S A D P S A D

LS 2 Supports

DCM Kaizen Events Office Hours Individual Meetings Monthly Team Reports

A D P S

Expert Meeting

LS 3

Holding the Gains Spread Centers of Excellence

AP1 AP2 AP3

Acronyms: LS – Learning Session AP – Action Period

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LS1 LS2 LS3 Action Period 1 Action Period 2 Action Period 3

Jun 2017 Jul 2017 Oct 2017 Jan 2017 Mar 2017

1 month 3 months 3 months 3 months S T A R T E N D

Prework

Team meetings, aim statement, Intake Tool, and team intro

Execution Testing, Implementation, and Spread

BTS Collaborative Team Project Timeline

(9 Month Time Frame with Series of Learning Sessions and Action Periods)

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Overview of Envision BTS Collaborative

Prework

• Meet with your team and develop an aim statement and focus for team’s

work.

• Fill out and submit Intake Tool.
• Complete “team introduction” PowerPoint template

Learning Session 1

Get ideas for improvement. Refine aim and measures. Develop plans for tests of changes for Action Period 1. Begin collaboration.

Action Period 1

Test changes through PDSA cycles and get feedback from results. Establish monthly reporting.

Learning Session 2

More ideas for change. Deeper understanding of using PDSA cycles for testing and implementation. Overcoming barriers and project fatigue. More collaboration.

Action Period 2

Test changes in all areas of change package. Collaborate with colleagues. “Become faculty.” Begin discussing plans beyond pilot project

Learning Session 3

Celebrate results. Develop detailed plan for holding the gains and spreading improvements.

Action Period 3

Continue testing and implementation remaining changes. Monitor measures to sustain results. Participate in spread.

The Three Levels of BTS Collaborative Improvement Effort Mission, Aims, Objectives

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Levels of Breakthrough Collaborative Series Improvement Effort

Collaborative MISSION Individual Team AIMS PDSA Cycle OBJECTIVES

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Levels of Breakthrough Collaborative Series Improvement Effort

Collaborative MISSION Individual Team AIMS PDSA Cycle OBJECTIVES

Reducing wait times and delays in your emergency department Example

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Levels of Breakthrough Collaborative Series Improvement Effort

Collaborative MISSION Individual Team AIMS PDSA Cycle OBJECTIVES

Reducing wait times and delays in your emergency department

Decrease Median “Door-to-doc” time from 45 min to 15 min by March 1st 2017

Example

14  Chad Glenn, Innovation Group

Levels of Breakthrough Collaborative Series Improvement Effort

Collaborative MISSION Individual Team AIMS PDSA Cycle OBJECTIVES

Reducing wait times and delays in your emergency department

Decrease Median “Door-to-doc” time from 45 min to 15 min by March 1st 2017

Week 1: PDSA #1 – Process Map Front End Processes Week 2-3: PDSA #2 - Test Immediate Bedding

Example

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Collaborative MISSION

The MISSION of the Envision ED BTS collaborative is to provide key staff and teams from each division with the tactics, tools and implementation skills necessary to

• ptimize flow and staffing within their respective

Emergency Departments. Envisions’ OBJECTIVE is action leading to improvement. This will be an undertaking focused on results. Participants should be able to achieve results for their sites and patients such as:

• Improve patient flow in the Emergency Department to reduce operational

cycle times.

• Reduce the clinical cycle time while reliably delivering proper care.
• Improve patient satisfaction by reducing waits and delays to improve service

times and by managing perceptions and expectations.

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Individual Site/ Team AIMS

 Each team’s AIMS will be aligned to the MISSION of the Envision BTS Collaborative, which is to enhance emergency department patient flow, optimize staffing, increase patient safety, and boost patient and staff satisfaction.  Each team will develop their own aim statement/ project plan based on their individual site’s objectives,

• pportunities and targets.

 Teams will collaborate with other teams to problem solve, share success stories and harvest ideas

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Forming an Effective Team Three different kinds of expertise

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Forming an Effective Team The three different kinds of expertise

Clinical Leader Technical Expertise Day-to- Day Leader

Effective teams include members representing three different kinds of expertise

• 1. Clinical Leadership,
• 2. Technical (Subject Matter)

Expertise, and

• 3. Day-to-Day Leadership

*There may be one or more individuals on the team with each kind of expertise, or one individual may have expertise in more than one area, but all three areas should be represented in order to drive improvement successfully

Courtesy of IHI

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The Model for Improvement A framework for accelerating improvements

20  Chad Glenn, Innovation Group

• 1. Will. One must have

the will to improve

• 2. Ideas. One must have

ideas about alternatives to the status quo

• 3. Execution.

Then one must make it real. Essential elements for systems improvement

Courtesy of IHI

Essential elements of systems improvement

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21  Chad Glenn, Innovation Group

Essential elements of systems improvement

• 1. Will. You must have

the will to improve

• 2. Ideas. You must have

ideas about alternatives to the status quo

• 3. Execution.

Then you must make it real. Essential elements for systems improvement

Courtesy of IHI

22  Chad Glenn, Innovation Group

The Model for Improvement (MFI), serves as a tool/ framework for:  Developing  Testing  Implementing and  Spreading changes

Execution - a Focus on The Model for Improvement

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Model for Continuous 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? Courtesy of IHI

AIMS MEASURES CHANGES

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1 2 3 Test and adapt

Developing Your Teams Project Plan

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 Chad Glenn, Innovation Group

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Model for Continuous 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?

Courtesy of IHI

AIMS MEASURES CHANGES

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1 2 3 Test and adapt

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1 Fundamental Question #1: What are we trying to accomplish?

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How much? By when?

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Aim statement/ Project Charter checklist:

 The system to be improved  The setting or population of focus  Targets represent a significant change from current performance  Clear numerical goals – “How much?”  Timeframe – “By when?”  Be clear on the boundaries/ scope  Recommended strategies for the improvement effort

What are we trying to accomplish?

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31  Chad Glenn, Innovation Group

What are we trying to accomplish?

Improve the pain management system for all general surgical inpatients so that in seven months:

• Patients’ experience of severe pain (as measured by a

pain intensity score of 7 to 10) is reduced by 25%

• 100% of patients will have their pain assessed

Example #1 of an Aim Statement

Courtesy of IHI

32  Chad Glenn, Innovation Group

What are we trying to accomplish?

Improve the pain management system for all general surgical inpatients so that in seven months:

• Patients’ experience of severe pain (as measured by a

pain intensity score of 7 to 10) is reduced by 25%

• 100% of patients will have their pain assessed

Example #1 of an Aim Statement

Courtesy of IHI

System to be improved System to be improved

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33  Chad Glenn, Innovation Group

What are we trying to accomplish?

Improve the pain management system for all general surgical inpatients so that in seven months:

• Patients’ experience of severe pain (as measured by a

pain intensity score of 7 to 10) is reduced by 25%

• 100% of patients will have their pain assessed

Example #1 of an Aim Statement

Courtesy of IHI

Setting/ Population Setting/ Population System to be improved System to be improved

34  Chad Glenn, Innovation Group

What are we trying to accomplish?

Improve the pain management system for all general surgical inpatients so that in seven months:

• Patients’ experience of severe pain (as measured by a

pain intensity score of 7 to 10) is reduced by 25%

• 100% of patients will have their pain assessed

Example #1 of an Aim Statement

Courtesy of IHI

Setting/ Population Setting/ Population System to be improved System to be improved How much? How much?

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35  Chad Glenn, Innovation Group

What are we trying to accomplish?

Improve the pain management system for all general surgical inpatients so that in seven months:

• Patients’ experience of severe pain (as measured by a

pain intensity score of 7 to 10) is reduced by 25%

• 100% of patients will have their pain assessed

Example #1 of an Aim Statement

Courtesy of IHI

Setting/ Population Setting/ Population System to be improved System to be improved How much? How much? By when? By when?

36  Chad Glenn, Innovation Group

What are we trying to accomplish?

Improve the pain management system for all general surgical inpatients so that in seven months:

• Patients’ experience of severe pain (as measured by a

pain intensity score of 7 to 10) is reduced by 25%

• 100% of patients will have their pain assessed

Example #1 of an Aim Statement

Courtesy of IHI

Setting/ Population Setting/ Population System to be improved System to be improved How much? How much? By when? By when? Boundaries / Scope? Boundaries / Scope?

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What are we trying to accomplish?

To fully integrate, by Dec 31, 2007, office redesign, alternative visit

• ptions and advanced access strategies in order to maximize the

provisions of planned care. We will pilot and implement one of these strategies at each of our three clinics and then spread the successful changes from each to all three clinics. We will achieve the following results:

• Reduce third next available appointments to less than 1 day
• Increase continuity of patient’s seeing their Care Team to 90%
• Decrease no shows to under 10%
• Increase immunization rates by 20% for children <2 years of age

Example #2 of an Aim Statement

Courtesy of IHI

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2 Fundamental Question #2: How will we know that a change is an improvement?

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Quality Care Listening to the Voice of the Customer (VOC) Listening to the Voice of the Process (VOP) Statistical Thinking (Run Charts, Control Charts)

The fundamental activities of continuous improvement

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How will we know that a change is an improvement?

Mindset/ Approach

• The purpose of measurement is for learning not

judgment

• All measures have limitations, but the limitations do not

negate their value

• Measures are one voice of the system.
• Hearing the voice of the system gives us information on

how to act within the system

• Measures tell a story; goals give a reference point

Courtesy of IHI

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41  Chad Glenn, Innovation Group

How will we know that a change is an improvement?

Measurement Guidelines

 Need a balanced set of 3 to 10 measures reported each month to assure that the system is improved.  These measures should reflect your aim statement & make it specific  Measures are used to guide improvement and test changes  Integrate measurement into daily routine  Plot data for the measures over time and annotate graph with changes

Courtesy of IHI

42  Chad Glenn, Innovation Group

How will we know that a change is an improvement?

Family of Measures:

1. Outcome Measures

• Results - system level performance

2. Process Measures

• Inform changes to the system

3. Balancing Measures

• Signal “robbing Peter to pay Paul”

Courtesy of IHI

Select 3 – 10 Measures

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Potential Set of Measures for Emergency Department Improvement

Topic Outcome Measures Process Measures Balancing Measures

Improve waiting time and patient satisfaction in the Emergency Department Total Length of Stay(LOS) Average # of patients seen by MD per hour Average # of patients seen by APP per hour LWBS% Patient Satisfaction Scores (Voice of customer) “In Bed” to “Physician Greet” “Physician Greet” to “Disposition, Admissions” “Physician Greet” to “Disposition, Departs” (Voice of the process) Staffing cost per patient Staff satisfaction %Non-billables (Voice of the process) To ensure positive change in one area does not negatively affect another

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How will we know that change is an improvement?

Annotated Run Chart

Time (e.g., Month) Observed Data Value Change 1 tested Change 2 tested

Courtesy of IHI

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3 Test and adapt Fundamental Question #3: What changes can we make that will result in an improvement?

46  Chad Glenn, Innovation Group

What changes can we make that will result in an improvement?

• The collaborative “change package” contains

the key elements of high performing system

• Change concepts – a general notion or approach to

change that has been found to be useful in developing specific ideas for changes that lead to an improvement

• Specific changes – well-defined, actionable change that

can be tested and measured

• Use the change package to identify the changes

you want to make to your system to achieve your aim

Courtesy of IHI

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What changes can we make that will result in an improvement?

Change concept – a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to an improvement

Thought Process Specific Idea A Specific Idea B

Concept

An opportunity to create a new connection

Courtesy of IHI

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What changes can we make that will result in an improvement?

Specific Idea– a clear, concise change action that can be tested and measured (qualitative or quantitative) through the use of PDSA cycles

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1 2 3 Test and adapt

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References…

 Chad Glenn, Innovation Group

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The Improvement Guide. G. Langley et al., Jossey-Bass Publishers., San Francisco, 1996.

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The Health Care Data Guide. L. Provost, S. Murray. Jossey-Bass Publishers., San Francisco, 2011.

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Quality Improvement Through Planned Experimentation. 2nd ed. R. Moen, et al., McGraw-Hill, NY, 1998.