model for improvement mfi
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Model For Improvement MFI. 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. Improvement Guide , Chapter 1, p.24 Appendix C, p. 454. - PowerPoint PPT PresentationTRANSCRIPT
Model For ImprovementMFI
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
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
What are we trying to accomplish
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study DoImprovement Guide, Chapter 1, p.24
Appendix C, p. 454
AIM
Some is not a number, soon is not a time
Recommended elements in an aim statement
What is expected to happen The timeframe for accomplishing the aim The system to be improved The patient population that change
process is going to be applied to How much/by when
Example of Aim statement
Has it met the qualities of a good aim?
• What is expected to happen
• The timeframe for accomplishing the aim
• The system to be improved
• The patient population that change process is going to be applied to
• How much/by when
Example 1
We aim to reduce the average length of stay for >64 year old (and >54 year old Maori and Pacific) hip fracture patients from 22 days to 19 days by the 30th of June 2013.
Example 2
The aim of this project is to keep the people well in community by increasing the number of patients with chronic respiratory condition enrolled into Better Breathing (pulmonary rehabilitation) Programme (BBP) from 60 to 250 per year by June 30th 2013
Breakout – Aim statement
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
MEASURES
Measurement
“Crude measures of the right things are better than precise measures of the wrong things.”
“Improvement strategy: More frequent samples (over time) of ‘good enough’ measures”
Roles of measurement
Key measures are required to assess team’s progress against the aim
Balancing measures are required to ensure that improvement in one part of the system does not cause damage in another area
Data (including from patients and staff) can be used to focus improvement and refine changes
Specific measures can be used doing PDSA cycles to inform future cycles
Methods of Measurement
• Chart review
• Observation of behaviour
• Surveys
• Questionnaires
• Coding data
• Checklists
Measurement guidelines
To answer: “How will we know that a change is an improvement?” usually requires more than one measure:
1. A balanced set of a few (3 – 8) key measures
2. Integrate measurement into the daily routine
3. Think about balancing, process and outcome measures (be careful about overdoing process measures)
4. Plot the data in a time series
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Developing Change
All Improvement requires
change, but not all changes
result in improvement
How do we develop fundamental change that will result in improvement?
What is a Theory?
• A description of our best understanding about why things are the way they are
•What are some theories?
• Biology – Theory of Evolution
• Physics – Theory of General Relativity
• Economics – Game Theory
• Psychology – Maslow’s Theory of the Hierarchy of Needs
Driver Diagram - a tool to visualize our Theory
A driver diagram is an approach to describing our theories of improvement:
• Used to help organize our theories and ideas in an improvement effort.
• The initial driver diagram for an improvement project might lay out the descriptive theory of improved outcomes that can then be tested and enhanced to develop a predictive theory.
•The driver diagram should be updated throughout an improvement effort and used to track progress in theory building.
Improvement Guide, p.429-431
Conceptual Driver DiagramOutcome 1⁰ driver 2⁰ driver Change Concepts Specific Change Ideas
Aim or Outcome
1⁰ driver 1
1⁰ driver 2
2⁰ driver 3
2⁰ driver 2
2⁰ driver 1
2⁰ driver 4
2⁰ driver 5
Concept 1
Concept 2
Concept 4
Concept 3
Concept 5
Concept 6
Ideas:123456789......N
CauseEffectDrivers
To reduce preventable
complications and ALOS
associated with early onset
confusion for patients 65+ on
Ward 4
Identification
Intervention
Assessment
Change Concepts Specific Change Ideas
Measures:CAM completionCAM documentation1. Complications2. ALOS3. Readmission4. Mortality
HOP- Delirium identification / ManagementDriver Diagram-v3.0Date: 11 June2012
Primary Drivers Secondary Drivers
Management
Delirium guidelines
Documentation
Discharge planning
Assessment frequency for
CAM tool
Appropriate use of CAM tool
Timeliness
Resource
Assessment on presentation
Staff awarenessEducate
Pt Watch
Medication
Pt safety interventions
Hand over to GP/Service
Discharge location
Care in place
Delirium as diagnosis in EDSInformation exchange
iPMS flagging
Intervention checklist
Introduce Ward champion
Family involvement
MDT
CAM tool audit
CAM lit search
Review CAM format
standardisation
CAM run one each shift
Educate family
concept
Family questionnaire
Family Feedback
Outlier Pt
Review education package
Educate
Ownership
iPMS flagging at presentation
Move to Home
Usable
Tertiary Drivers
Education Information on admission/Discharge
Symbol for Delirium on patient
Where ideas come from
Outcome 1⁰ driver 2⁰ driver Change Concepts Specific Change Ideas
Aim or Outcome
1⁰ driver 1
1⁰ driver 2
2⁰ driver 3
2⁰ driver 2
2⁰ driver 1
2⁰ driver 4
2⁰ driver 5
Concept 1
Concept 2
Concept 4
Concept 3
Concept 5
Concept 6
Ideas:123456789......N
Where ideas come from:1.Medical Literature2.Websites like www.ihi.org3.Team members who have innovative thoughts about what to do differently4.Structured Creativity Sessions (use of change concepts, provocations, random entry, etc.)5.Other Teams6.Improvement Advisors
Breakout – Developing Change
Outcome 1⁰ driver 2⁰ driver Change Concepts Specific Change Ideas
Aim or Outcome
1⁰ driver 1
1⁰ driver 2
2⁰ driver 3
2⁰ driver 2
2⁰ driver 1
2⁰ driver 4
2⁰ driver 5
Concept 1
Concept 2
Concept 4
Concept 3
Concept 5
Concept 6
Ideas:123456789......N
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study DoTesting
Science behind PDSAHypothesisPredictionExperimentEvaluate/Analysis
Scientific Method Build on previous knowledgeAcquire/generate new knowledge
1939
Step 1- Design, Step 2 – Produce, Step 3 - Sell was converted to a circle with aforth step added: Step 4 - Redesign through marketing research.
1939
Act Plan
Check Do
1951 1986
1993
The Plan-Do-Study-Act Cycle
PlanAct
DoStudy
- Objective- Questions and predictions (Why?)- Plan to carry out the cycle(who, what, where, when)- Plan for Data collection
- Carry out the plan- Document problems and unexpected observations- Begin analysis of the data
- Complete the analysis of the data - Compare data to predictions - Summarize what was learned
- What changes are to be made?
- Next cycle?
Improvement Guide, Chapter 5, p. 97
Most Important Part of a PDSA cycle
Because with out it we don’t have a comparison for the purpose of learning -
Why prediction?
Prediction combined with a learning cycle interrogates our understanding of a system.
It reveals gaps in our knowledge and provides us a starting place for growth.
Without it our learning is accidental at best but with it we are able to direct our efforts toward building a more complete picture of how things work in the system.
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
Improvement Guide, Chapter 7, p. 146
The work of improvement
Primary Driver 1
Change Idea 1
Change Idea 2
Change Idea 3
Primary Driver 2
Change Idea 1
Change Idea 2
Change Idea 3Primary Driver 3
Change Idea 1
Change Idea 2
Change Idea 3
Goal Discharge Date
Establish GDD & Daily Review
Pt awareness on GDD
Staff awareness on GDD
Check consultant aware of GDD in mind
Doc to use care plan to review GDD-Ruth/Michele 5/12
Is the GDD documented on care plan?
GDD mentioned in notes
# of clinical directors believe in establishing GDD
GDD given to surgical pt and any plans documented
Pt awareness on GDD-Surgical
Prediction: GDD will improve the patient experience and efficiency. Also this will reduce the LoS
To have a standardised process to provide each patient with a GDDHow and what is the best way to establish a GDD?
To have a standardised process to share GDDBest way to communicate the GDD to patient and interested parties?
Aim: To improve the number of inpatients having GDD from 0% to 100% alsoTo increase the number of inpatients achieving the GDD for from 0% to 100% by July 2013.
Achieving the GDD
To have the processes in place to achieve the GDDHow can we achieve the GDD as a team
Sharing GDD
Patient & Family
Drs
Staff
Other Services
Update GDD on white board
Update GDD on WiMS
DOC to use care plan for updated GDD info
Nurse to inform Pt-Ruth
Ascertain ref process in ward 6
Delay in x-fer to AT&R
Referral system assessment & documentation from acute to AT&R
Early Dx if Pr referred to NASC earlier
E-referral – Erin 5/12
Timely task referral
GDD in MDT meeting
Nurse setting the GDD
GDD match with actual Dx date
Reasons of Pt waiting on Bed
CAT tool to indentify why Pt waiting
CAT tool usefulness
Post ward round delay in services for Pt > 7 days
Pt less than 48 hour
Repeat PDSA
Active PDSA
Adopt
Adapt
Abandon
What's Happening
Who, How, When?
Transition of CarePDSA TreeDate: 27/11/2012 Reviewed 27/02/2013
PDSA box
Identifying Pt need @ admission in EC(Ajay Kumar/ Fionna W)
Staff to set a GDD based on the top 10 DRGs-Michele 5/12
GDD by Doc post acute ward round – Brian 17/12
Reason of GDD not met-Ruth& Michele 12/12
Cultural Support to inform – Maika/Ian 23/12
Doc reviewing /confirming GDD-Ajay 5/12
What ref system are available in service dir.
Identifying Pt need @ admission in EC 4 pts(Ajay Kumar/ Fionna W) 13/1
Microsoft Word Document
GDD in ward 33Janene & Michele 23/1
Discharge to HHC
Process MapJanene/Michele 23/1
Known patient dx communication to HHC Owner: Prem Kumar
HHC to receive Dx list twice daily
Repeat with interventions 10/5
Transitions of Care
PDSA Tree
Dx ChecklistClivena/Helen10/4
Visual Display of GDD-Surgical
Test the checklist for ref to DN 27/3 Surgical
Add time of DxSurgical-17/4
To attend CN meeting
Dx Summary
??
GDD orientation to HO rotation
17/4
Checklist/Process map in notes 17/4Fionna
GDD assigned in EC-Fionna17/4
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Every morning find the right colour socks with in 5 seconds
* Right Colour Right Socks * Time to find the socks * The mess created * My satisfaction* * After wash placement time
• On your table there is a stack of index cards with numbers written on them
• Give these to 8 people around your table
• Each of you has now been assigned a number – you can find your number by locating the middle number on your card (i.e. if your card says 1-4-8, then you are number 4)
Break out Exercise
• Your current process involves tossing the tennis ball provided from person to person, following the sequence provided on the index cards (i.e. Person 1 tosses to Person 4 who tosses to person 8 and so on, until the ball returns to person 1)
• Assign a time keeper/ball drop counter (preferably not a ball tosser)
• Practice your process one time – Time keeper please time how long the team takes to complete the process and the number of times they drop the tennis ball
Break out Exercise
• Team Aim: We aim to reduce the time taken for every person to touch the ball from X to Y. We also aim to reduce our ball drops from A to B.
• Form a theory, come up with change ideas, use the MFI to test those ideas
•Rules:
• The initial sequence as provided by the cards must be adhered to
• You may only test one change idea at a time
Break out Exercise
Cycle Change Idea Time Ball Drops
1
2
3
4
5
6
7
8
Break out Exercise