western node spread call #3 feb 19th, 2009. 1. understand what you need to measure for spread ◦ 4...
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Western Node Spread Call #3Feb 19th, 2009
1. Understand what you need to measure for spread
◦ 4 categories of measurement◦ Team examples
2. Identifying some sampling strategies◦ Integrating measurement into systems
3. Understand how to develop feedback loops for continuous improvement/learning
Set-up-Target population -Adopter audiences -Successful sites -Key partners-Initial spread strategy
A Framework for Spread
Social System-Key messengers -Communities -Technical support-Transition issues
Communication Strategies (awareness & technical)
Knowledge Management
Measurement and Feedback
Leadership-Topic is a key strategic initiative
-Goals and incentives aligned-Executive sponsor assigned
-Day-to-day managers identified
Better Ideas-Develop the case -Describe the ideas
Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun:31 (6):339-347.
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Develop a Spread AIM Leadership Set-up/ infrastructure Communication Social System Measurement and Feedback
Forms part of your measurement
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Spread What:
Target Level of Performance:
Spread to Whom:
Time frame:
Developing a Spread Aim
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Spread What: All measures in the SSI Bundle
Target Level of Performance: Zero Cases of SSI
Spread to Whom: All surgical populations in our 10 hospital system
Time Frame: By September 2010
Sample Spread Aim: Prevent Surgical Site Infections by Implementing the SSI
Bundle
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Set-up/Infrastructure◦ Establishing steering committees◦ Orienting leadership groups◦ Organizing data collection◦ Developing materials◦ Identifying successful sites
General Communication◦ Wide spread dissemination of information about
the initiative◦ Sending out comparative data◦ Holding meetings with a broad range of potential
adopters
4 Categories to reflect AIM and 4 levels of spread activity
1. Awareness of the change◦ Reflects spread of communication
2. Adoption of the Change◦ Reflects the integrity of the adoption
3. Outcome of the Change◦ Reflects the evidence of better ideas
4. Progress of the Change◦ Reflects the places and stage of the adoption
For the Big picture on Spread
Awareness
Adoption
Outcome Progress
Regina Qu’Appelle Health Region Spread Measures for Med Rec
1.‘Awareness of the Proposed Change’• Number of nurses, unit clerks, pharmacists and physicians attending the group education sessions, individual mentoring sessions
2.‘Adoption of the Proposed Change’• Percentage of charts stamped by the Unit Clerk• Percentage of PIP forms used by Nurse to record BPMH• Percentage of PIP forms used by Physicians to order/address home medications
3.‘Outcome of the Change’• Percentage of identified discrepancies that are resolved by the physicians use of the PIP form
4.‘Progress of the Change’• Percentage of units and rural acute care sites reporting on the above adoption and outcome measures each week
HMIO = Home medication and initial orders
IHI spread tracking model via excel
Average Waiting Times: All Primary Care
Clinics in VHA System
0
20
40
60
80
100
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June Jul Aug Sep Oct Nov Dec Jan
2 0
0 0
2 0
0 1
2
0
Overall Outcome Measure
Measures using Small Multiples:
Overall System and 4 sites
0
10
20
30
40
50
60
70
80
90
100
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec
OUR SITE
0
10
20
30
40
50
60
70
80
90
100
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec
SITE2
0
10
20
30
40
50
60
70
80
90
100
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec
SITE3
0
10
20
30
40
50
60
70
80
90
100
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec
SITE4
These graphs are called small multiples. They are designed for a quick visual comparisons of the data from each site The graphs are all presented on the same scale (both x and y axis)
Sampling
1. Simple Random Sample◦ Selection of data by use of random numbers generated by a random
number list or mechanical devise
2. Systematic Random Sample◦ Selection of data by choosing a random starting point and then
selecting data at specified intervals
3. Judgment Sampling◦ Select samples based on judgment of those with process knowledge
to learn about impact of change on specific portions of a process
Lloyd Provost, API & Sandy Murray CTC, The Data Guide, Learning from Data to improve Health Care, pg 2-16, 2-17.
10-15% monthly volume sufficient for QI Minimum of 10 Collect same way over time Retrospective – data must be in formal
charting Prospective – data collection sheets,
interviews
EG. You are currently collecting discrepancy rates for MED REC monthly on admissions and you get 30 admissions per month to that unit.
30x15%=5 which is less than min, thus you would collect on min of 10 charts monthly
Consider the # admissions to all units working on MED REC as the denominator
Thus 10-15% of the total admissions is the number of charts to review per month. Divide that by the number of units and you will get the number of charts per unit
EG. You are spreading to 5 additional units. You need to still collect on the pilot unit. Each unit gets 30 admissions/month.
30x6=180 x15% = 27 charts/6 units =5 charts per unit per month.Simple random sampling: Generate a list per unit, roll dice and
select chart number as per dice roll up to 5 charts per unitSystematic random sampling: Generate a list of all admissions
per unit (30, 30, 30). On each list roll a dice for start number, then every 6th chart(30admissions /5charts required = every 6th chart for total of 5 charts. Repeat for each unit.
Balance enough data with realistic workload
Ensure the data collection sheet identifies what unit/area
Sampling would most often apply to adoption measures & outcome measures
Data collection is for answering your questions about a process. Be clear on what you want to know
Formalize regular reporting process to leader tasked with accountability for this
work
Brandon Regional Health MB
Who Needs to Know?Who’s accountable ?
• Set up a regular reporting process and format• Use existing committees, structures if applicable• A senior leader needs to hold the accountability for this work•Have a system where if decline is evident in the measure, it is someone’s role to support the spread work.
Aim: (Aim includes your numeric goals)
Why is this important?:
CharterCharter
Changes – Proposed Changes – Proposed (P), Tested (T), (P), Tested (T), Implemented (I)Implemented (I)
Senior Senior Role/Recommendations Role/Recommendations
/ Next Steps/ Next Steps
Lessons Lessons Learned/AnecdotesLearned/Anecdotes
Graphs of MeasuresGraphs of Measures
•Type here: be clear about what is proposed (P) (to be tested) vs. testing (T), vs.implemented (I)
•Type here
•Type here: what do you need from Project Sponsor, Participant Sponsor at this time to move project?
•Recommendations
•Next Steps for project
Project TITLEQIC School Participant Name, Participant Sponsor, Project Sponsor
QIC School Participant Contact Info: Add e-mail/phone here
Team MembersTeam Members
Names/Role here
Make fonts large, title, labels, datesand notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8readable graphs here. If no graph yet forMeasure either create “empty” graph or listName of measure(s) not yet graphed.
Refining the spread plan and continually learning
“When the music changes, so does the
dance.” African Proverb
Measurement is meant to answer questions about how spread is going
Collect just enough to balance knowing and workload
Initial spread plan is less than 20 % of your time, 80% is refining, adjusting and supporting the changes
Be flexible, spread is a learning event not a dictatorial one!
New Generation of Ideas on Spread, Dec 8, 2008 Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad, IHI National Forum
Strategies for Spreading Improvements in Health Care, October 14, 2004 Marie W. Schall, Institute for Healthcare Improvement
Holding the Gains and Spread, July 11, 2006Bruce Harries, Improvement Associates
The Seven ‘Spreadly’ Sins, October 18, 2006 Roger Resar, MD & Carol Haraden, PhD IHI
Sustainability and Spread, August 28, 2006Diane Jacobsen, MPH, CPHQ, IHI National Director
Continuing the Conversation Holding the Gains and Spreading Good Ideas: From Local Improvement to System-wide Change October 4, 2007 Marie Schall, MA Institute for Healthcare Improvement
National Health Services (NHS) Modernization Agency Improvement - Sustainability and its relationship with spread and adoption. www.institute.nhs.uk/improvementleadersguides
Hinchey Judge KA. Et al., Factors Contributing to Sustaining and Spreading learning Collaborative Improvements, Qualitative Research Study Findings by the Primary Care Development Corporation, Dec 2007.
Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun:31 (6):339-347.
Paul Plsek, Spreading Good Ideas for Better Health Care - A Practical Toolkit Volume 2 - Veterans Health Administration 2000 Research Series. VHA, 2000.
Paul E. Plsek, Charles M. Kilo From resistance to attraction: a different approach to change - Positively Influencing Physicians Physician Executive, Nov-Dec, 1999.
Dr. Lynne Maher, Emerging themes for improvement and innovation, presentation QHN Fall Forum, November 21, 2007.
Developing your initial spread plan, IHI Boston Spread Workshop Feb. 2007
Barb Saunders, Spread of Improvement Efforts – Guideline for Fraser Health, March 10, 2005
Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun;31(6):339-347
Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992
Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.
Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press, 2000.
Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October 1997.
Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000.
Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000.
Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood,
Il:Irwin ,1978.
Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996.
Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207.
Myers, D.G. Social Psychology (3rd ed.) New York: McGraw-Hill, 1990.
Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992.
Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.
Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998.
References
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