learning by doing€¦ · 11.07-11.26 assisted transport to the nursing home time line – the day...
TRANSCRIPT
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Learning by Doing: Linking Quality Improvement Theory and
PracticeBoel Andersson Gäre, MD, PhD, Professor
Johan Thor MD, MPH, PhD, Director
The Jönköping Academy for Improvement of Health and Welfare
Jönköping University, Sweden
Who are you?
• Health professionals
• Researchers and teachers
• Students
• Managers
• Policy makers
• Quality professionals
• Others
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Better systemperformance
(quality, safety, value)
Everyone
Batalden P, Davidoff F. What is ”quality improvement” and how can it transform healthcare?Qual.Saf.Health Care 2007;16;2-3
Better outcomes(individual, population)
Better professional
development(competence, values,
pride, joy)
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Batalden & Stoltz, 1993, after Deming.
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Multiple knowledge systems are involved…
Generalizable
scientific
evidence
+Particular
context
Measured
performance
improvement
control for
contextinquire into
particular
identity
balanced
measures
over time
choosing
best
plan
executing
locally
Batalden & Davidoff, 2007
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A Model for Improvement
1. What are we trying to accomplish? (Aim)
2. How will we know if a change is an improvement? (Measurement)
3. What changes can we make that will result in improvement?
P
S D
A
Plan-Do-Study-Act
Langley GJ, et al. The Improvement
Guide: a Practical Approach to
Enhancing Organizational
Performance. 2nd ed. San
Francisco: Jossey-Bass; 2009.
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Case: what do they need to know?
Two clinical managers – a head nurse and a physiotherapist – work with hip and knee arthroplasty care Helena Sundquist, RN Sofia Persson, PT
Värnamo
Hospital
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Case: what do they need to know?
• The managers wish to reduce the (unusually long) Length of Stay (LOS) for these patients* – to enhance efficiency and reduce the risk of complications – while maintaining the good clinical outcomes and high patient satisfaction at their hospital
• How should they go about achieving that?
* Hip replacement LOS 7.9 days (national average 6 days, range 3-9 days);
knee replacement LOS 8.4 days (national average 5 days, range 3-9 days)
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The Jönköping Master’s Program on Quality Improvement and Leadership in Health and
Welfare Services
The purpose of the program is to contribute to improvement in health, healthcare and social care.
The Master’s program is intended to strengthen participants’ ability to lead and achieve improvement of health and social care leading to gains in health and welfare as well as good economizing of resources.
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1. Health care
as process,
system.
2. Variation and
measurement.
3. Customer /
Beneficiary
knowledge.
4. Leading,
following and
making changes
in health care.
5. Collaboration.
6. Social
context &
accountability.
7. Developing
new locally
useful
knowledge.
8. Professional
subject matter.
Institute for Healthcare Improvement, IHI, (www.ihi.org), 1998
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Magister- masterprogrammet
Improvement Knowledge I
(5 ECTS)
Drivers &
Sources of
Inspiration for
QI (5 ECTS)
Perspective of
the Patient/
Client
(5 ECTS)
Systems thinking; Organizing,
Leadership and Management
(10 ECTS)
Spring (January-June)Fall (August-January)Ye
ar
1Ye
ar
2Ye
ar
3 Practicum (30 ECTS)
Completion of 2-year Master’s Thesis (30 ECTS)
Project planning
(7,5 ECTS)
1-year Master’s thesis
(15 ECTS)Quality,
Measurement,
and Learning
(7,5 ECTS)
Care Logistics
& Informatics
(7,5 ECTS)
1-year Master students
Improvement Knowledge II
(5 ECTS)
Electives
(7,5 ECTS)
�1-year Master’s Degree
2-year Master students
�2-year Master’s Degree
2-year Master students
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Design Principles for the Master’s Program
• Action learning
• Interprofessional interaction
• ”Blended” learning
• Reflection
• Writing
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Action and Learning
“If you want truly to understand something, try to change it”
Kurt Lewin (1890-1947)
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Concrete experience
Observations and
reflections
Notice
Formation of abstract
concepts and generalizations
Make
senseImplications
for setting,
context
Testing implications
of concepts in new
situations
Anticipate
requisite
assessment
David Kolb
Action Learning
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Design Principles for the Master’s Program
• Action learning – linking theory and practice
• Interprofessional collaboration
• ”Blended” learning
• Reflection
• Writing
Nurses
Physiotherapists
Occupational
therapists
Physicians
Biomedical analysts
Social workers
Finance people
Web designer
Engineers
Psychologists
Dentist
Managers
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Working Groups
Self-selected based on the following criteria:
• 5-7 members/group
• Both sexes
• At least 2 professions represented
• Members born in at least two different decades
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Blended Learning
• Campus sessions: 2 days every 5 weeks
• Synchronous sessions over the web
• Asynchronous distance learning: readings and assignments carried out ”at home”
• Combine with regular work in health or social care
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The value of reflection
“Reflection is the process of stepping back from experience to process what the experience means, with a view to planning further action [ref.s]. It is the critical link between concrete experience, the interpretation and taking new action.”
Coghlan D, Brannick T. Doing action research in your own organization. London:
SAGE; 2001, p. 31.
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Design Principles for the Master’s Program
• Action learning – linking theory and practice
• Interprofessional collaboration
• ”Blended” learning
• Reflection
• Writing
Nurses
Physiotherapists
Occupational
therapists
Physicians
Social workers
Finance people
Web designer
Engineers
Psychologists
Dentist
Managers
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EXEMPLARY CARE AND LEARNING SITES (ECLS)
Starting early to introduce improvement knowledge in health professional education and training
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can both be excellent?
if we deliver better care, are we delivering better education?
if we deliver excellent education, does care improve?
how are these concepts linked?
complementary concepts?
learning care delivery
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An ECLS produces patient-centered care in a way that continuously improves patient outcomes, system performance,& professional developmentHeadrick LA, Shalaby M, Baum KD, Fitzsimmons AB, Hoffman KG, Höglund PJ, Ogrinc G, Thörne K. Acad Med. 2011 Nov;86(11):e6-7.
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Futurum – the Academy for Health and Care
Jönköping County Council hosts:• Students from 14 different professions• from 5 different universities• providing 8000 ”student weeks” yearly of
practice based learning
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Exploration, improvement and learning!
- Students in improvement work
Pilot project, Geriatric ward, Jönköping, Jönköping County Council, Sweden
Pär Höglund, MD, PhDDaniel Gustafsson, MD (resident), Student supervisor, Geriatric ward
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Intended goals
• To help 5th year medical students to gain knowledge of the logistics and the situation outside the hospital for senior patients.
• To present at least three improvement suggestion to the ward.
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The Geriatric project
-documentation and reflection around the discharge of Roy
Maria Lorentz and Jakob Ström, Med School Year 5, Linköping, Sweden
Photo
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Who is Roy?
• Previously a well-functioning individual • Fall injury four months ago, head/neck
injury• Been hospitalized since his injury• Roy feels constant pain, primarily in his
neck
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Discharge planning the day before
• 13.30-13.40: Nurse to Nurse phone report from Geriatric ward to a short term nursing home
• 13.45-13.48: A nurse visits Roy and his wife to inform about a transfer tomorrow to the nursing home
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11.0
7-11
.26
Assisted transport to the nursing home
Time line – the day of discharge10
.30-
10.4
5
Packing his belongings, the RN does som last-minute checking
11.2
7-12
.05
Introduction to the nursing home by CNA
12.1
4-12
.20
RN talks to wife about medications, and nurse student talks with Roy
12.2
0-12
.26
RN chitchats with Roy.
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The students’ presentation at the doctors’ morning meeting
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The Good Parts
• Nurse to Nurse phone report. The template seems ok (but could be more structured)
• RN preparations the day before• RN checklist with admission paper that
should be sent to the nursing home• Friendly reception at the nursing home
and short waiting time for the RN
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Improvements suggestions
• Template for the RN final discharge meeting and/or discharge meeting with the physician– Additional information to the patient and their family,
about for instance future planning
• Short written notice from the doctor to the patient about what the patient has been treated for, follow up etc.– Information useful for the family.– Information may increase adherence?– Time requirement 3 minutes
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How did the clinic benefit from the project?
• Illuminates the students’ capacity• Additional knowledge about nursing
homes• Specific improvements areas and project
were discussed (also during coffee breaks the following week)
• Suggestion from the doctors about other areas to explore and improve.
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What was in it for the student(s)?
• Had a purpose – will be used in the clinic• Expectations from the doctors• A great deal of positive feedback – both on
the content and on the presentation.• Will be remembered after medical school • Knowledge about the logistics and
cooperation between the county and muncipality.
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Integration?
Based on these examples and models, what are your thoughts about how to integrate* research, quality improvement, and implementation of evidence-based practice, student involvement and cultural change?
*Integration: the combining and coordinating of separate parts or elements into a unified whole (Merriam-Webster, Medical Definition of ~)
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MAKING IMPROVEMENT AND STUDYING IMPROVEMENT
Improvement Science in Practice
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Improvement Science
• Making improvement is not the same as studying improvement, but they have a generative relationship
• Improvement science is an emerging field
• Learn more about the evolution of this field at the Health Foundation: http://www.health.org.uk/areas-of-work/improvement-science/
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Improvement Knowledge I
(5 ECTS)
Drivers &
Sources of
Inspiration for
QI (5 ECTS)
Perspective of
the Patient/
Client
(5 ECTS)
Systems thinking; Organizing,
Leadership and Management
(10 ECTS)
Spring (January-June)Fall (August-January)Ye
ar
1Ye
ar
2Ye
ar
3 Practicum (30 ECTS)
Completion of 2-year Master’s Thesis (30 ECTS)
Project planning
(7,5 ECTS)
1-year Master’s thesis
(15 ECTS)Quality,
Measurement,
and Learning
(7,5 ECTS)
Care Logistics
& Informatics
(7,5 ECTS)
1-year Master students
Improvement Knowledge II
(5 ECTS)
Electives
(7,5 ECTS)
�1-year Master’s Degree
2-year Master students
�2-year Master’s Degree
2-year Master students
The Jönköping Master’s Program
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Improving and Studying
• How did you improve what you improved?
• How did you study (inquire into, reflect upon, measure) the improvement process, outcomes?
Paul Batalden, 2012
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SQUIRE Guidelines(Standards for QUality Improvement Reporting Excellence)
A. Clear and accurate information for finding, indexing, and scanning your paper?1) Title2) Abstract
B. Why did you start? (I)3) Background knowledge4) Local problem5) Intended improvement6) Study question
C. What did you do? (M)7) Ethical issues8) Setting9) Planning the intervention
C. What did you do? (cont’d)10) Planning the study of the intervention11) Methods of evaluation12) Analysis
D. What did you find? (R)13) Outcomes
E. What do the findings mean? (D)14) Summary15) Relation to other evidence16) Limitations17) Interpretation18) Conclusions
F. Were other factors relevant to conduct and interpretation of the study?
19) Funding
See: www.squire-statement.orgDavidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S. Publication guidelines for
quality improvement in health care: evolution of the SQUIRE project. Quality &
Safety in Health Care. 2008 Oct;17 Suppl 1:i3-9.
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The improvement project and the study of the project
IMPROVEMENT
PROJECT
Improvementleader/author
•planning•organizing
Patients•interviews•feedback
•touch points
Staff•interviews•feedback
•touch points
Co-designgroup•meeting
•touch points•planning
improvements
Co-designteam
•follow-upmeetings
Co-designteam
follow-upmeetings
Co-designgroup•reunion
•reporting•celebration
The
STUDY
ofthe
IMPROVEMENT
Experiencequestionnaires
Experiencequestionnaires
Experiencequestionnaires
Experiencequestionnaires
Experiencequestionnaires
Focus group interview
Concludingquestionnaire
Bergerum C, 2012
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Back to the Athroplasty ProjectProportion
of patients
who got up
on their legs
on the day
of surgery
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Better systemperformance
(quality, safety, value)
Everyone
Batalden P, Davidoff F. What is ”quality improvement” and how can it transform healthcare?Qual.Saf.Health Care 2007;16;2-3
Better outcomes(individual, population)
Better professional
development(competence, values,
pride, joy)
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Name, occupation/job, location
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The Mission of Jönköping Academy
To promote health and welfare by providing and helping put to good use knowledge on improvement and leadership within health and social care. The Jönköping Academy undertakes education and research through collaboration between university, health and social care partners. Decision-makers and staff in health and social care constitute the Academy's primary audience.
www.jonkopingacademy.se