Beginners

Improvement Skills WorkshopJanuary 17th 2012

Objectives

By then end of the session.........• You will be familiar with the Model for Improvement and the

Plan Do Study Act methodology

• You will have completed your own PDSA

• You will have a plan to begin your improvement work

SEPSIS /SEVERE SEPSIS FACTS

• >37000 DEATH PER YEAR

• KILLS MORE PATIENTS EACH YEAR THAN MYOCARDIAL INFARCTIONS, AND LUNG,+BREAST+ COLON CANCER

STAG Sepsis Management in Scotland

• Signs of sepsis < 2 days• 2% of emergency

admissions (~5000)• 73% had a EWS• 34% had severe sepsis• 21% blood cultures• 32% IV Antibiotics• 70% IV fluids

Scottish Defect Rate was 18-74%

VTE – the facts

• Up to 25,000 deaths each year in England & Wales

• No reason to believe that Scotland is any better

• Significant gap in delivery of evidence based interventions

The First Law of Improvement

Every system is perfectly designed to achieve exactly

the results it gets.

Peter Senge The Fifth Dimension

How do we build a bridge from the science of improvement to the practice of improvement?

The Model for Improvement

‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’

Dr Donald M. BerwickFormer CEO, Institute for Healthcare Improvement

A Model for learning and Change

When you combine

the 3 questions with the…

PDSA cycle, you get……

……the Model for

Improvement.

The Improvement Guide, API, 1996

• What are we trying to achieve? – Know exactly what you are trying to do – Have clear aims and objectives

• How will we know that change is an improvement?– Measuring processes and outcomes

• What changes can we make that will result in an improvement?– What do we want to test? What can we learn as we go

along?

3 Key Questions - the thinking part

Plan Do Study Act - the doing part

• A simple tool – used to test out ideas that will improve systems and processes

• A structured approach for making small incremental changes to systems

• A full cycle for planning, implementing, testing and identifying further changes

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Developing the team’s Aim Statement

Question 1: What are We Trying to Accomplish?

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Check Points in Developing anAim Statement

AIM Content • Explicit over arching description• Specific actions or focus• Goals

AIM Characteristics• Measurable (How good?)• Time specific (By when?)• Define participants and

customers

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Aim Statement Exercise: You Make the Call!

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Aim Statement Good Bad Ugly

We aim to reduce harm and improve patient safety for all of our internal and external customers.

By June of 2011 we will reduce the incidence of pressure ulcers in the critical care unit by 50%.

Our outpatient testing and therapy patient satisfaction scores are in the bottom 10% of the national comparative database we use. As directed by senior management, we need to get the score above the 50 th percentile by the end of the 2ndQ of 2011.

We will reduce all types of hospital acquired infections.

According to the consultant we hired to evaluate our home health services, we need to improve the effectiveness and reliability of home visit assessments and reduce rehospitalisation rates. The board agrees, so we will work on these issues this year.

Our most recent data reveal that on the average we only reconcile the medications of 35% of our discharged inpatients. We intend to increase this average to 50% by 4/1/11 and to 75% by 8/31/11.

Question 2: How Do We Know that a Change is an Improvement?

“When you can measure what you are speaking about and express it in numbers, you know

something about it; but when you cannot measure it, when you cannot express it in numbers, your

knowledge is of a meager and unsatisfactory kind.”

Lord Kelvin, May 3, 1883

“In God we trust.All others bring data.”

W. E. Deming

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Improvement is NOT just about measurement However… without measurement you will never be able to answer the Question

D D

How Do We Know if a Change is an Improvement????

Traditionally why have we measured……?

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Improvement?

Judgment?Research?

“The Three Faces of Performance Measurement: Improvement, Accountability and Research”

“We are increasingly realizing not only how critical measurement is to the quality improvement we

seek but also how counterproductive it can be to mix measurement for accountability or research

with measurement for improvement.”

Improvement vs. ResearchContrast of Complementary Methods

ImprovementAim: • Improve practice of health care

Methods:• Test observable• Just enough data• Adaptation of the changes• Many sequential tests……

Clinical ResearchAim: • Create New clinical knowledge

Methods:• Test blinded• Just in case data• Fixed hypotheses• One fixed test

Three types of measures

Outcome Measures – Directly relates to the overall aim Voice of the customer or patient How is the system performing? What is the result?

Process Measures - Voice of the workings of the system. Are the processes that contribute to the aim performing as planned?

Balancing Measures – Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)?

Balloon Buldge

• Process measures will start to move first

• Outcome measures will most likely lag behind process measures

• Balancing measures – just monitoring – not looking for movement (pay attention if there is movement)

Expectations for Improvement

When will my data start to move?

• % patient receiving discharge materials• Patient volume…increase or decrease • Total Length of Stay…including wait time

• Time to registration• Staff satisfaction• Patient Satisfaction• Availability of antibiotics• “Left without being seen” (LWBS)• Costs…increase or decrease

Measure

P

B

OP

B

O

P

Topic: Reduce waiting time and

increase patient satisfaction in A&E

Perspective (O, P, B)

BB

Stages of Facing Reality:

• “The data are wrong”• “The data are right, but it’s not a problem”• “The data are right; it is a problem; but it is not my

problem.”• “This is my data and I accept the burden of

improvement”

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10

20

30

40

50

60

70

80

90

100

Com

plia

nce

Month

5th element

High % of agency/bank

04/02/05 - 17/02/05 tests of change x 6 to implement sedation vacation

4 element bundle on

New intake of anaesthetists, high usage of bank/agency

Engage with the data and Tell the Story!

Question 3: What changes can we make that will result in Improvement?

• Sepsis– Improve screening

• EWS + SIRS

– Improve timely treatment

– Reliable escalation

The Sepsis Six

• VTE– Risk assessment

– Appropriate treatment

– Timely reassessment

– Patient involvement

SIGN 122

Source: The Improvement Guide, API

Model for Improvement

Now, let’s focus on the PDSA

part of the MFI and tests of

change

Why Test Changes?

• To increase the belief that the change will result in improvements in your setting

• To learn how to adapt the change to conditions in your setting

• To evaluate the costs and “side-effects” of changes

• To minimise resistance when spreading the change throughout the organisation

Plan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

What will happen if we try something

different?

Did it work?

What’s next?

The PDSA Cycle for Learning & Improvement

Do It !!!

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Guidance for Testing a Change Concept

• A test of change should answer a specific question!

• A test of change requires a theory and a prediction!

• Test on a small scale and 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.

• Don’t confuse a task with a test!

• 1 patient

• 1 day

• 1 admission

• 1 clinician

Start Small ~ 1:3:5:All

Move Quickly to Testing Changes

• Year• Quarter• Month• Week• Day• Hour

“What tests can we completed by next Tuesday?”

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

Key Points to Remember!

• PDSA’s cannot be too small• One PDSA will almost always lead to another• You can achieve rapid results• They help you to be thorough & systematic• They help you learn from your work• Anyone can use them in any area

PDSA Worksheet

Worksheet for Testing Change

Aim: Every goal will require multiple smaller tests of change

Describe your first (or next) test of change: Person responsible

When to be done

Where to be done

Plan List the tasks needed to set up this test of change Person

responsible When to be done

Where to be done

.

Predict what will happen when the test is carried out

Measures to determine if prediction succeeds

Do Describe what actually happened when you ran the test

Study Describe the measured results and how they compared to the predictions

Act Describe what modifications to the plan will be made for the next cycle from what you learned

Your 1st test of change

The Value of “Failed” Tests

“I did not fail one thousand times; I found one thousand ways how not to make a light bulb.”

Thomas Edison

PDSA Testing

Over to you !!