so now you have to lead your team through the model for improvement

1

So Now You Have To Lead Your Team Through the Model for Improvement

Debbie Barnard, SHN PM, CPSI Dannie Currie, SIA Atlantic Node

October / November 2007

2Atlantic NodeAtlantic Node

Objectives

Each participant will be able to:

• Coach others on the Model for Improvement structure

• Evaluate and critique aim statements

• Evaluate and critique a team’s measurement strategy

• Coach teams on the use of the PDSA cycle

• Help teams design small scale PDSA cycles for initial tests of change

• Help teams design a series of PDSA cycles to implement a change idea

Source: Daniel, Donna, “Teaching the Model for Improvement” Collaborative Sponsor Training


Introduction



Model for Improvement*

• A simple yet powerful tool for accelerating improvement

• The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes

and outcomes

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming


Model for Improvement*

• The model has two parts:

- Three fundamental questions, which can be addressed in any order.

- The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement.

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming


Key Concepts

Three Basic Questions



• Does the aim statement include recommended elements?– What is expected to happen

– The system to be improved

– The setting or sub-population of patients

– Specific numerical goals

– Guidance for the activities such as strategies for the effort and limitations

• Is the aim specific enough to be accomplished in the Collaborative time frame?

• Does the team match the aim?

• Are the goals and population consistent with the mission for the Collaborative?

Evaluating Aim Statements


The SHN campaign is about making changes to systems, not measurement. But measurement plays a key role role:

• Key measures are required to assess progress on team’s aim

• Specific measures can be used for learning during PDSA cycles

• Balancing measures are needed to assess that other parts of the system are not being negatively impacted.

How Do We Know That a Change Is an Improvement?


An aim statement should include:

• What is expected to happen

• The system to be improved

• The setting or sub-population of patients

• Goals

• Guidance for the activities such as strategies for the effort and limitations

What Are We Trying to Accomplish?


ConceptAn opportunity to create

a new connection

Thoughtprocess

Specificidea B

Specificidea A

What Changes Can We Make That Will Lead to 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 improvement.


Types of MeasuresType of measure Examples

Outcome measures

Process measures

Balancing measures

RatesFailuresRe-admitsMortality, LOS

% use order set, guideline, etc% treated in required time% receiving 100% of ‘bundle’Times, durationsEtc

CostsDelaysResources% detected by redundant processEtc


• Clinical measures of patients health

• Documentation of behaviors

• Questionnaires

• Assessments

• Summary of databases

• Chart audits

• Observations

Methods of Measurement


Measurement Guidelines

• The Vital Few: a few key measures that clarify a team’s aim and make it tangible

• Balanced set of measures

• Process, Outcome, Balancing

• Integrate measurement into the daily routine

How will we know that a change is an improvement?


Outcome vs. Process Measures

Outcome = Represents the customer / patient: • How is the system performing?

• What is the result?

• How is the health of the patient affected?

What the CEO/Administrator/Director ultimately wants to know

Process = Represents the workings of the system: • Are the parts / steps in the system performing as planned?

• Are key changes being implemented in the system?


• Conceptual, Vague, Strategic

• Specific Ideas, Actionable

• Improve

• Redesign process

• Move steps in the process closer together

• Move order receipt and warehouse closer together

• Move the fax that receives orders into the warehouse

• Write a work order to have the fax moved on Monday

Concepts to Ideas


Compete List of Change Concepts

A. Eliminate Waste E. Enhance the Producer/Customer Relationship

1. Eliminate Things That Are Not Used 2. Eliminate Multiple Entry 3. Reduce or Eliminate Overkill 4. Reduce Controls on the System 5. Recycle or Reuse 6. Use Substitution 7. Reduce Classifications 8. Remove Intermediaries 9. Match the Amount to the Need 10. Use Sampling 11. Change Targets or Set Points

38. Listen to Customers 39. Coach Customers to Use Product/Service 40. Focus on the Outcome to a Customer 41. Use a Coordinator 42. Reach Agreement on Expectations 43. Outsource for “Free” 44. Optimize Level of Inspection 45 Work with Suppliers

F. Manage Time 46. Reduce Setup or Startup Time 47. Set up Timing to Use Discounts

B. Improve Work Flow 48. Optimize Maintenance 12. Synchronize 13. Schedule into Multiple Processes 14. Minimize Handoffs 15. Move Steps in the Process Close

Together 16. Find and Remove Bottlenecks 17. Use Automation 18. Smooth Work Flow 19. Do Tasks in Parallel 20. consider People as in the Same System 21. Use Multiple Processing Units 22. Adjust to Peak Demand

49. Extend Specialist’s Time 50. Reduce Wait Time

G. Manage Variation 51. Standardization (Create a Formal Process) 52. Stop Tampering 53. Develop Operational Definitions 54. Improve Predictions 55. Develop Contingency Plans 56. Sort Product into Grades 57. Desensitize 58. Exploit Variation

C. Optimize Inventory H. Design System to Avoid Mistakes 23. Match Inventory to Predicted Demand 24. Use Pull Systems 25. Reduce Choice of Features 26. Reduce Multiple Brands of Same Item

59. Use Reminders 60. Use Differentiation 61. Use Constraints 62. Use Affordances

D. Change the Work Environment I. Focus on the Product or Service 27. Give People Access to the Information 28. Use Proper Measurements 29. Take Care of Basics 30. Reduce Demotivating Aspects of Pay

System 31. Conduct Training 32. Implement Cross-Training 33. Invest More Resources in Improvement 34. Forcus on Core Processes and Purpose 35. Share Risks 36. Emphasize Natural and Logical

Consequences 37. Develop Alliance/Cooperative

Relationships

63. Mass Customize 64. Offer Product/Service Anytime 65. Offer Product/Service Anyplace 66. Emphasize Intangibles 67. Influence or Take Advantage of Fashion

Trends 68. Reduce the Number of Components 69. Disguise Defects or Problems 70. Differentiate Product Using Quality

Dimensions

Reference: The Improvement Guide, Langley, Nolan, Nolan, Norman, Provost, Jossey-Bass, San Francisco, CA, 1995, Appendix pages 293-359.


Key Concepts

Plan, Do, Study, Act



What are we trying toWhat are we trying toaccomplish?accomplish?

How will we know that aHow will we know that achange is an improvement?change is an improvement?

What changes can we make that willWhat changes can we make that willresult in the improvements we seek ?result in the improvements we seek ?

Act Plan

Study Do

Model for improvement

Aims

Measurement

Thethree

fundamentalquestions forimprovement

The fourthquestion:

how to make changes

Langley, Nolan et al 1996

Ideas, evidence, hunches,Other people etc.


Cycles for Testing

• Increase your belief that the change will result in improvement

• Document how much improvement can be expected from the change

• Learn how to adapt the change to conditions in the local environment

• Evaluate costs and side-effects of the change

• Minimize resistance upon implementation


To Be Considered a PDSA Cycle:

The test or observation was planned (including a plan for collecting data)

The plan was attempted (do the plan)

Time was set aside to analyze the data and study the results

Action was rationally based on what was learned


Attributes of Changes That Are Readily Adopted*

• The change has a clear advantage over the current system

• The change is compatible with current system and values

• The change is easy to try and reverse

• Understanding and adapting the change requires minimum complexity

• The change and its impact can be observed

*From Everett Rogers “Diffusion of Innovations”

22

What is the PDSA Cycle?

Act

• What changes are to be made?

• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data


Tasks at Each Station

Act PlanPlan a test (change, theory, prediction)

Record plan on planning sheet

Study DoModify your plane to Incorporate your changes; fly 3 times; record data, unusual events

Plot data, interpret results. Compare data to predictions

Keep changes, modify, abandon?


Testing on a Small Scale• Have others that have some knowledge

about the change review and comment on its feasibility

• Test the new product or the new process on the members of the team that developed the change before introducing it to others

• Incorporate redundancy in the test by making the change side-by-side with the existing process or product

25

What is the PDSA Cycle?

Act

• What changes are to be made?

• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data


Tasks at Each Station

Act PlanPlan a test (change, theory, prediction)

Record plan on planning sheet

Study DoModify your plane to Incorporate your changes; fly 3 times; record data, unusual events

Plot data, interpret results. Compare data to predictions

Keep changes, modify, abandon?


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


Repeated Use of the PDSA Cycle to Improve

LOS for ED patients with X-rays

Theories Ideas

Changes That Result

in Improvement

A P

S D

APS

D

A P

S DD S

P A

DATA

Cycle 1a: Pilot quick-look for extremity x-rays on one shift. Monitor LOS for patients with x-rays and error rate. Review results with Radiology

Cycle 1b: Revise documentation process and try quick-look for two days

Cycle 1c: Redesign viewing area and continue quick-look for two weeks

Cycle 1d: Make quick-look standard practice and monitor

EXAMPLE


Decrease the Time Frame for a PDSA Test Cycle

• Years

• Quarters

• Months

• Weeks

• Days

• Hours

• Minutes

Drop down next “two levels” to plan test cycle!


Successful Cycles to Test Changes

• Plan multiple cycles for a test of a change

• Think a couple of cycles ahead

• Scale down size of test (# of patients, location)

• Test with volunteers

• Do not try to get buy-in, consensus, etc.

• Be innovative to make test feasible

• Collect useful data during each test

• Test over a wide range of conditions


Testing on a Small Scale Cont.

• Conduct the test in one facility or office in the organization, or with one customer

• Conduct the test over a short time period

• Test the change on a small group of volunteers

• Develop a plan to simulate the change in some way


Reasons for Failed Tests

1. Change not executed well

2. Support processes inadequate

3. Hypothesis / hunch wrong:• Successful change did not result in local

improvement

• Local improvement did not impact global measure

Collect data during the “Do” phase of the cycle to help differentiate these situations.


Cycles for Implementation

• The change is permanent - need to develop all support processes to maintain change

• High expectation to see improvement (no failures)

• Increased scope will lead to increased resistance

• Generally takes more time than tests


EXERCISE

Building Planes and Flying in the

Alaska Bush

Original Work Developed by IHI.org

35

Key Activities

• Review baseline data

• Study change ideas

• Learn about Model for Improvement


What the Experts Know “Change Package”

Problem• Short flight

distances

• Nose dives

• Wanders off-target

Changes• Use heavier paper• Change launch

angle

• Add tape weight to rear

• Reinforce plane body with clips


Debbie Barnard, MS, CPHQProject Manager Safer Healthcare Now!

Canadian Patient Safety Institute

Suite 1414, 10235 101 Street

Edmonton, Alberta T5J3G1

Phone: 780-498-7259 or 1-866-421-6933

Fax: 780-409-8098

Email: [email protected]

Website: www.patientsafetyinstitute.ca

Questions/Comments

The Canadian Patient Safety Institute would like to acknowledge funding support from Health Canada. The views expressed here do not necessarily represent the views of Health Canada

so now you have to lead your team through the model for improvement

Documents

accelerating improvement

improvement structureevaluate

aim specific

pdsa cyclehelp teams

studyact pdsa cycle

change concept

pdsa cyclesbalancing

studyact cycle