ihi expedition: preventing obstetrical adverse events

5/29/2012

1

IHI Expedition: Preventing Obstetrical Adverse Events

Deb Bell-Polson, MSN, RNC-OB

Peter Cherouny, MD

Sue Gullo, RN, BSN, MS

These presenters have nothing to disclose

Expedition Coordinator

2

Kayla DeVincentis, Project Coordinator, has worked at IHI since 2009, starting as an intern in the Event Planning department. Since then, Kayla has contributed to the STAAR Initiative, the IHI Summer Immersion Program, and the IHI Expeditions. Kayla obtained her Bachelor’s in Health Science from Northeastern University and brings her interest in health and wellness to IHI’s Health and Fitness team.

5/29/2012

2

3

WebEx Quick Reference

3

WebEx Quick Reference

• Welcome to today’s session!

• Please use Chat to “All Participants” for questions

• For technology issues only, please Chat to “Host”

• WebEx Technical Support: 866-569-3239

• Dial-in Info: Communicate / Join Teleconference (in menu)

Raise your hand

Select Chat recipient

Enter Text

4

When Chatting…

Please send your message to

All Participants

5/29/2012

3

5

Chat Time!

What is your goal for participating in this Expedition?

5

6

Join Passport to:

• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements.

• Train your middle managers to effectively lead quality improvement initiatives.

. . . and much, much more for $5,000 per year!

• Visit www.IHI.org/passport for details.

• To enroll, call 617-301-4800 or email [email protected].

5/29/2012

4

What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

Where are you joining from?

5/29/2012

5

Our Expedition Director

9

Sue Leavitt Gullo, RN, BSN, MS, Managing Director, Institute for Healthcare Improvement (IHI), brings 30 years of health care experience to her current roles, which include work in IHI's national and international patient safety work, and IHI's faculty for leadership and patient safety. She is the Director of the Perinatal Improvement Community and The Safer Patient Project in Denmark. Prior to joining IHI, Ms. Gullo was the Director of Women's Services at Elliot Hospital in New Hampshire. Her prior nursing roles included experience in the frontline clinical areas of maternal-child health, oncology, and medical-surgical nursing. Ms. Gullo has also been active as national faculty in obstetrical care for the last 15 years. Her involvement with IHI dates back to 1995 as a participant in the IHI Breakthrough Series on Improving Maternal and Neonatal Outcomes and continued as IHI faculty until she joined the IHI staff

in 2005.

Ground Rules

10

• We learn from one another – “All teach, all learn”

• Why reinvent the wheel? - Steal shamelessly

• This is a transparent learning environment

• All ideas/feedback are welcome and encouraged!

5/29/2012

6

Today’s Agenda

11

• Expedition introduction and objectives

• Making the case for an improvement effort

• IHI’s Model for Improvement

• Homework for next session

12

Overall Program Aim

The aim of this Expedition, Preventing Obstetrical Adverse Events, is to…

5/29/2012

7

Expedition Objectives

At the end of the Expedition, participants will be able to:

• Describe two reasons to eliminate elective deliveries prior to 39 weeks confirmed gestation.

• Identify the components of the IHI Perinatal Care Bundles.

• Define reliability and give an example of components that will achieve different levels.

• Describe the Model for Improvement and the need for small scale testing.

13

Schedule of Calls

Session 1 – Introduction to Obstetrical Adverse EventsWednesday, May 30, 1:00 PM – 2:30 PM ET

Session 2 – Structure and Process for System RedesignDate: Wednesday, June 13, 1:30 PM – 2:30 PM ET

Session 3 – Executing Oxytocin BundlesDate: Wednesday, June 27, 1:30 PM – 2:30 PM ET

Session 4 – Designing Reliable ProcessesDate: Wednesday, July 11, 1:30 PM – 2:30 PM

Session 5 – Using the Perinatal Trigger Tool to Identify System HarmDate: Wednesday, July 25, 1:30 PM – 2:30 PM

Session 6 – Results Report-out and Advanced Bundles

Date: Wednesday, August 8, 1:30 PM – 2:30 PM14

5/29/2012

8

Faculty

15

Deb Bell-Polson, MSN, RNC-OB, is a Masters prepared Perinatal Nurse with 22 years of experience. Most recently has worked as a Clinical Nurse Manager leading a multidisciplinary team that has had great success in the IHI Perinatal Community. We had proven results in changing culture for quality and safety and achieving 95% compliance on the Elective Induction and Augmentation bundles as well as the Vacuum Bundle. Also serves on a regional Quality and Safety Network guidelines team that is working to set regional standards for care in the Northern New England region. Is most recently a part of a state wide Committee to review cases of Sudden unexplained infant Deaths and work to prevent them in the future. When not working I keep busy with my family of three sons and a wonderful husband.

Faculty

16

Peter Cherouny, MD, Professor of Obstetrics and Gynecology, University of Vermont College of Medicine, has strong clinical interests in obstetric health care quality improvement and is currently serving as Chair of the Institute for Healthcare Improvement's Perinatal Improvement Community. He was also the lead author of the IHI white paper, "Idealized Design of Perinatal Care." He has been Chair of Quality Assurance and Improvement and Credentialing for the Women's Health Care Service of Fletcher Allen Heathcare for the last 15 years. His recent research and work in obstetric quality improvement is as Chair of the March of Dimes collaborative, "Improving Prenatal Care in Vermont," and as co-investigator of the MedTeams project.

5/29/2012

9

Agenda

• Who are we at the Institute for Healthcare Improvement?

• Why focus on perinatal care? Why is this important now?

• The concept of reliability of care and reliable design

• Understanding our systems; Structure, Process, Outcomes

17

Who We Are

18

5/29/2012

10

1990 1993 1996 1999

2002 2005 2008

2010

IHI’s Global Growth: 1990-2010

IHI Open School Chapters

US Chapters in 46 states

International Chapters in 51 countries

383Chapters

5/29/2012

11

Will, Ideas, and Execution (IHI Style)

• Will….why are you here?

• Ideas….alternatives beyond the

status quo

• Execution….making it real. Best

practice actually reaches the patient.

21

Strategies for Successful Execution

• A clear, defined and executable aim.

• Linked with the overall strategy of the organization

• Tempo-monthly reviews for on track status, quarterly by chief executives

• Transparency- visibility

• Focus- less is more

• Change at the local level

22

5/29/2012

12

• Align Unit Measures Strategies Projects with Org Strategy and Goals (Clinical , Patient, Exp. Financial and Workforce)

• Channel Senior Leadership Attention and Develop Unit Leadership • Engage Physicians • Build Improvement Capacity and Provide Resources for Improvement• Establish a Just Culture• Develop a Competent Trained and Available Workforce• Establish Credentialing of Core Competency and Training for all Providers• Use ACOG/AWHONN Guidelines for Documentation and Staffing• Develop a Consumer Advisory Board

Perinatal Leadership

• Execute care that meets national standards (Implement Bundles, Perinatal Core Processes)

• Develop standard processes and protocols for response to obstetrical emergency • Design care process improvement based on trigger tool analysis, event detection,

sentinel event• Standardize administration of high alert medications – oxytocin, magnesium sulfate,

epidurals• Create an environment that Supports Care and Healing• Consider segments of population and design reliable and appropriate processes for

specific needs and characteristics of this segment of the population

ReliableDesign / Reduce

Variation

• Adopt common language and interpretation of EFM with multi-disciplinary training i.e NICHD criteria

• Implement techniques for effective communication i.e. SBAR• Establish reliable techniques for handoffs• Establish Team Response Protocols• Implement Huddles• Design Simulations

Effective Peer

Teamwork

• Design processes to support partnership in care between provider and patient and family

• Develop with patient a customized interdisciplinary shared care plan• Design care process improvement based on information obtained about patient

experience (interviews, assessments, focus groups, surveys) • Include patients and families on design and improvement teams • Communicate openly and honestly with family and patients at regular intervals • Do what you say, mean what you do

RespectfulPatient

Partnership

Reduce harm to 5 or less per 100 live births

Zero incidence of elective deliveries prior to confirmation of fetal maturity

Augmentation Bundle(s) Composite or Compliance greater than 90%

Improve organizational culture of safety survey scores in Perinatal units by 25%

100% of participating teams will have documentation of Patient & Family Centered Care

Perinatal Community:

Reducing Harm,

Improving Care,

Supporting Healing

1-3 months .. 3-6 months…

Perinatal

Oxytocin Bundles

Perinatal

Trigger Tool

Common EFM

Language and

Training

Reduce

Variation-

Meds, Emergencies

Implement

Techniques

for Effective

Communication

Engage

Patients and

Families

Establish

a multi-

disciplinary team

training program

Establish

Huddles,

Multi-disciplinary

rounds

Design

Interventions

From Trigger

Tool findings

Consistent

(across disciplines)

Credentialing

Standards

Collaborative

And Supportive

Culture

Vacuum Bundle

• Effective Team with Active,

Supportive Perinatal Leadership

• Senior Leaders & Board Support

of Perinatal Leadership &

Improvement Team

3 m

on

ths

to

36

mo

nth

s a

nd

be

yo

nd

….

Deep Dive

Pre-work

3 - 9 months………

12-24 months……..

12-36 months and beyond……

Patients on

Improvement

Teams

Care is

Transparent

Institute for Healthcare Improvement (IHI)

5/29/2012

13

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study DoSource:

Langley, et al. The Improvement Guide, 1996.

The three questions provide the strategy

The PDSA cycle provides the tactical approach to work

Agenda





26

5/29/2012

14

Why focus on perinatal care?

• Good science exists

• Significant variability in process.

─Care is provider driven rather than standardized.

─This autonomous practice focus contributes to the unreliable delivery of care.

Acceptable Variability?

Induction Rate by Physician

Seton Healthcare Network

m8

n11

n4

n8n6

n2 n15

m16

n1

n9

n12

n7

n14n10

m2 m17

m20n3

m22

m7 m9 m15

m1

m10

m3

m23

m12

m4

m18m25

m11

n5

m5

m14

m21n13 m24m19

m13m6

Mean = 30.0%

UCL

LCL

1s

2s

1s

2s

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rate

5/29/2012

15

Acceptable Variability?

Instrumented Delivery Rate By Physician

Seton Healthcare Network

b6m25 n4 m21

m15m7

b5 m1m22 n6m19m20 m4

m5b2 n5 n2

b7 b4

n11s2

s4

n15

n10m9n1n14m23n13

m10

m17

s1b3

m16

m14

m11n3

m8

n9

m13

n12

n7

m3

m18

m12

m24m6 m2

n8s3

b1

Mean = 8.6%

UCL

LCL

1s

2s

1s

2s

0%

5%

10%

15%

20%

25%

Quality Care in ObstetricsWhy is this important now?

0

5

10

15

20

25

30

35

1951 2006

Birth Injury per 1000

P

R

E

V

E

N

T

A

B

L

E

N

O

N

P

R

E

V

E

N

T

A

B

L

E

Morbidity

5/29/2012

16

Quality Care in ObstetricsWhy is this important now?

0

5

10

15

20

25

30

35

1951 2007

Birth Injury per 1000

P

R

E

V

E

N

T

A

B

L

E

N

O

N

P

R

E

V

E

N

T

A

B

L

E

Morbidity

Mazza F, et al. Eliminating birth trauma at Ascension Health. Jt Comm J Qual Patient Saf 33:15-24, Jan. 2007

Why focus on perinatal care?

4,317,119 births in US

Birth trauma 6.3-7.3/1000

estimated 50-90% are preventable

5/29/2012

17

What does that mean for US?

27,000-32,000 injured babies total

13,500-28,000 preventable

• $23.8M award in childbirth lawsuit

• By Scott Allen, Globe StaffBoston Globe

• 2 doctors faulted at Mass. General• In one of the largest malpractice verdicts in state history, a Suffolk

County jury has awarded $23.8 million to the family of a girl born with cerebral palsy after a traumatic delivery at Massachusetts General Hospital. Jurors took less than four hours Monday to find two Mass. General obstetricians negligent in the delivery in 1996

What does that mean for us?

5/29/2012

18

What do we want to do?

Prevent the preventable

Minimize unexplained variability

Defend the unpreventable

Explain necessary variability

Key Documents

• IHI’s Idealized Design of Perinatal Care

White Paper (available at www.IHI.org)

• “Evidence Based Maternity Care: What It

Is and What It Can Achieve”http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf

• Toward Improving the Outcome of

Pregnancy: Enhancing Perinatal Health

Through Quality, Safety and Performance

Initiatives (TIOP III)http://www.marchofdimes.com/TIOPIII_FinalManuscript.pdf

36

5/29/2012

19

Agenda





37

“The First Law of Improvement”

“Every system is perfectly designed to achieve exactly the results it gets.”

Paul Batalden

5/29/2012

20

What is Reliability?

• “Reliability is failure free operation over time.”

David Garvin

Harvard Business School

• “When applied to clinical processes consider the viewpoint of the patient by invoking the all or none measure.”

IHI Innovation Team

Reliable Care

What I need, when I need it. No more, no less.

40

5/29/2012

21

Reasons for the Reliability Gap In Healthcare

• Current Improvement methods in healthcare are highly dependent on vigilance and hard work

• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security

• Often excessive clinical autonomy creates and allows wide performance margins

• The use of deliberate designs to achieve reliability goals seldom occurs

The Reliability Design Strategy

• Prevent initial failure using intent and standardization

• Back-up/contingency function (identify failure and mitigate)

• Measure and then communicate learning from defects back into the design process

5/29/2012

22

Why Standardize?

• Contributes to building an infrastructure (who does what, when, where, how and with what)

• Support training and competency testing to sustain the process

• Achieve front line articulation of key processes by staff

• Allows the appropriate application of Evidence Based Medicine consistently

• Feedback about errors and application of learning to design is possible

Improvement Concepts Associated with Performance Resulting in 80-90% Process Reliability

(Primarily can be described as intent, vigilance, and hard work)

• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures

• Personal check lists

• Feedback of information on compliance

• Suggestions of working harder next time

• Awareness and training

5/29/2012

23

Improvement Concepts Resulting in 95% Process Reliability

(Uses human factors and reliability science to design failure prevention, failure

identification, and mitigation)

• Decision aids and reminders built into the system

• Desired action the default (based on scientific evidence)

• Redundant processes utilized

• Scheduling used in design development

• Habits and patterns know and taken advantage of in the design

• Standardization of process

Your Experience

• Think of a process or service you think is reliable

• How do you know it is reliable?

• What makes it reliable?

5/29/2012

24

Lessons from Human Factors

• Reliance on memory

• Distractions / interruptions

• Fatigue

• Sleep deprivation

• Shift work

• Lack of training and experience

• Overload

• Psychosocial factors

Health Care Processes

Desired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom -variation

Current -Variable, lots of autonomynot owned,poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels

Terry Borman, MD Mayo Health System

5/29/2012

25

Agenda





49

Process/Structure/Outcome

1919-2000

Avedis Donabedian, M.D., M.P.H.

5/29/2012

26

Structure and Process

• Create the sense of urgency─Deep Dive for data

• Define what to measure─Structure and process measures

• Structure─ The “What”

• Process─ The “How”

• Outcome─ The “Results”

Quality Measures in Obstetrics

5/29/2012

27

• Most system problems are not the result of human error

─People are only a part of the system

─Current Improvement methods in healthcare that are highly dependent on vigilance and hard work are not successful

─People are just being vigilant and working hard within the same system


• Fundamental understanding of systems

─We must accept human error as inevitable —

and design around that fact.

-Don Berwick


5/29/2012

28


• What are structure measures?

─The “What” we use to provide care

�The people

�The tools

�The layout of our unit


• What are structure measures?

─The “What” we use to provide care

�Do we provide adequate training for the expected care

�Do we have a single type of fetal monitor

�Do we have a standard regimen for oxytocin

5/29/2012

29


• What are process measures?

─The “How” we do things

�More frequent than the rare bad outcomes

�Look at actual care; not the policy behind the care

�Need to be relative proxies for outcomes to have an improvement effect


• What are process measures?

─The “How” we do things

�How often antibiotics are given preoperatively

�How often we chose the right antibiotics

�How often we give recommended DVT prophylaxis

5/29/2012

30


• The “Deep Dive”

─Oxytocin deep dive

─Labor deep dive

Structure MeasuresOxytocin Deep Dive

Yes/No or N/A

• Interdisciplinary Fetal Monitoring Education

• Documentation tools consistent with NICD terminology

• Weekly fetal monitoring strip and case reviews (or#4)

• Monthly fetal monitoring strip and case reviews

• Standard mixture and policy for oxytocin administration

5/29/2012

31


Yes/No or N/A

• One standard administration order set

• If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed.

• Team definition for tachysystole

• Clinical algorithm for identification and management of tachysystole

• Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)


Yes/No or N/A

• RN empowered to call cesarean team (not to diagnose the need for cesarean, but to activate the team)

• RN empowered to call neonatal team

• Consistent handoff tool {SBAR, etc} specify

• Informed Consent for oxytocin administration

• Individual Provider data published about induction/augmentation rates?

5/29/2012

32

Process Measures

• Based on Failure to Rescue Algorithm

─Careful monitoring

─Timely identification

─Appropriate interventions

─Activation of the team response

Process MeasuresFirst Stage

• Careful monitoring

─Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity while oxytocin administered

─Oxytocin initiated as intended – no delay in administration due to provider or nursing response.

5/29/2012

33


• Timely Identification

─Tachysystole identified and managed according to protocol /algorithm

─Tachysystole identified and managed according to team definition and standing orders

─ Indeterminate/abnormal FHR identified


• Appropriate interventions─Oxytocin dose decreased or discontinued during labor

due to tachysystole─Oxytocin dose decreased or discontinued during labor

due to FHR─Oxytocin resumed after a decrease or stop─ Terbutaline administered─ Interventions needed─Once labor was progressing, was oxytocin

discontinued?

5/29/2012

34


• Activation of Team Response─ Documentation of physician notification of change in

dosage of oxytocin

─ If requested, timely response by OB care provider for bedside evaluation

─ Escalation plan in place if needed and documented

Outcome Measures

• Selected Triggers from Perinatal Trigger Tool

─Neonatal triggers

─Maternal triggers

5/29/2012

35

Outcome Measures

• Neonatal Triggers─ (T1) Apgar <7 at 5 min─ (T2) Admission to NICU or higher level of care─ (T18) Instrumented delivery, vacuum or forceps

(document indication)─ 2 or more late preterm infant (LPI Indicators)─ (T16) Neonatal Injury (e.g. fractured clavicle)

cephalohematoma, facial drooping, documented palsy, hyperbilirubinemia

─ (T20) Cord gas < 7.20─ (T22) Other Shoulder dystocia (document morbidity)

Outcome Measures

• Maternal Triggers─(T7) 3rd or 4th degree laceration─(T9) Blood Transfusion─(T18) Instrumented delivery, vacuum or

forceps (document indication)─(T15) Excessive blood loss, postpartum

hemorrhage─(T22) Other Shoulder dystocia (document

morbidity)─Cesarean section (indication)

5/29/2012

36


• Results of Deep Dive─Unique to each hospital

─Defines focus of improvement efforts

─Allows measurement for improvement work

Oxytocin Diagnostic Tool

• 100% review of oxytocin charts

• Questions

─Structural

─Reflective

5/29/2012

37

Structure Yes No N/A

1. Interdisciplinary Fetal Monitoring Education

2. Documentation tools consistent with NICD terminology(paper or electronic)

3.Weekly fetal monitoring strip and case reviews, or (#4)

4. Monthly fetal monitoring strip and case reviews

5. Standard mixture and policy for oxytocin administration

6. One standard administration provider order set

7. If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed

8. Team definition for tachysystole (add your definition-)

9. Clinical algorithm for identification and management of tachysystole

10. Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)

11. RN empowered to call cesarean team (not to diagnosis the need for cesarean, but to activate the team)

12. RN empowered to call neonatal team

13. Consistent handoff tool {SBAR, etc} specify

14. Informed Consent for oxytocin administration

15. Individual Provider data published about induction/augmentation rates?

Structure Document Directions:

• Interview at least 5 different people on the unit (Nurses, Physicians) to determine if they all share the same yes/no answer on these questions. It will assist you in identifying any gaps from policy/procedure to care delivery at the patient level.

• Example: A nurse on weekends or nights may not have the same answer as a nurse on the day shift during the week.

5/29/2012

38

• Align Unit Measures Strategies Projects with Org Strategy and Goals (Clinical , Patient, Exp. Financial and Workforce)

• Channel Senior Leadership Attention and Develop Unit Leadership • Engage Physicians • Build Improvement Capacity and Provide Resources for Improvement• Establish a Just Culture• Develop a Competent Trained and Available Workforce• Establish Credentialing of Core Competency and Training for all Providers• Use ACOG/AWHONN Guidelines for Documentation and Staffing• Develop a Consumer Advisory Board

Perinatal Leadership

• Execute care that meets national standards (Implement Bundles, Perinatal Core Processes)

• Develop standard processes and protocols for response to obstetrical emergency • Design care process improvement based on trigger tool analysis, event detection,

sentinel event• Standardize administration of high alert medications – oxytocin, magnesium sulfate,

epidurals• Create an environment that Supports Care and Healing• Consider segments of population and design reliable and appropriate processes for

specific needs and characteristics of this segment of the population

ReliableDesign / Reduce

Variation

• Adopt common language and interpretation of EFM with multi-disciplinary training i.e NICHD criteria

• Implement techniques for effective communication i.e. SBAR• Establish reliable techniques for handoffs• Establish Team Response Protocols• Implement Huddles• Design Simulations

Effective Peer

Teamwork

• Design processes to support partnership in care between provider and patient and family

• Develop with patient a customized interdisciplinary shared care plan• Design care process improvement based on information obtained about patient

experience (interviews, assessments, focus groups, surveys) • Include patients and families on design and improvement teams • Communicate openly and honestly with family and patients at regular intervals • Do what you say, mean what you do

RespectfulPatient

Partnership

Reduce harm to 5 or less per 100 live births

Zero incidence of elective deliveries prior to confirmation of fetal maturity

Augmentation Bundle(s) Composite or Compliance greater than 90%

Improve organizational culture of safety survey scores in Perinatal units by 25%

100% of participating teams will have documentation of Patient & Family Centered Care

Perinatal Community:

Reducing Harm,

Improving Care,

Supporting Healing

S

T

R

U

C

T

U

R

E

P

R

O

C

E

S

S

O

U

T

C

O

M

E

The Clinical Bundle as Standardization

5/29/2012

39

Vacuum Bundle

� Alternative labor strategies considered

� Prepared patient

�Informed consent discussed and documented

� High probability of success

�EFW, fetal position and station known

� Maximum application time and number of pop-offs predetermined

� Exit strategy available

�Cesarean and resuscitation team available

5/29/2012

40

Other Clinical Bundles

• VAP, Ventilator Associated Pneumonia

• Central Line Bundle

• Peripheral Catheter Bundle

• Bladder Catheter Bundle

• Pressure Ulcer, SKIN Bundle

79

Ascension Health

Always ask:

What is the real problem we are trying to solve?

80

5/29/2012

41

The Sequence for Improvement

Spreading a change 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 of routine operations

Questions?

82

Raise your hand

Use the Chat

5/29/2012

42

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

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.

83

Plan• Compose aim

•Pose questions/predictions

•Create action plan to carry

out cycle (who, what, when,

where)

•Plan for data collection

DoStudy

Act

• Carry out the test and

collect data

•Document what occurred

•Begin analysis of data

• Complete data analysis

•Compare to predictions

•Summarize learning

• Decide changes to make

•Arrange next cycle

84

5/29/2012

43

Principles & Guidelines 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

• 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

85

Repeated Use of the PDSA Cycle

Hunches Theories Ideas

Changes That Result in Improvement

A P

S D

A P

S D

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

Sequential building of knowledge under a wide range of conditions Spread

86

5/29/2012

44

Aim: Implement Rapid Response Team on non-ICU unit

Improved Communication

A P

S D

A P

S D

Cycle 1: ICU nurse responds to rapid response team calls on one unit,

one shift for one day

Cycle 2: Repeat cycle 1 for three days

Cycle 3: Have Respiratory Therapist attend

rapid response calls with ICU Nurse

Cycle 4: Expand coverage of RRT on unit

to one unit for one shift for five days

Cycle 5: Have Nurse Practitioner

respond to calls in addition to RT and

RN

Cycle 6: Expand rounds to

one unit for one shift seven

days a week

87

Questions?

Raise your hand

Use the Chat

88

5/29/2012

45

Expedition Communications

• If you would like additional people to receive session notifications please send their email addresses to [email protected].

• We have set up a listserv for the Expedition to enable you to share your progress. To use the listserv, address an email to [email protected].

89

Next Session

Wednesday, June 13, 1:30 PM – 2:30 PM ET

Session 2 – Structure and Process for System Redesign

90