d16 e16 presentation - ihiidentify a key figurehead to launch the work align the will by using...
TRANSCRIPT
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Best Practices and Learningsfrom IHI’s Spread and Network Methodology: How to Develop and Enhance Networks to Further Process ImprovementKathyDuncan,RN,Faculty,IHIKateO’Rourke,NetworkManager,IHIChristinaGunther‐Murphy,Director,IHI
D16/E16
These presenters have nothing to disclose
December12,2012
Objectives
Identify several strategies to develop and support a network
Describe practical tools used for spread of clinical elements throughout a network
Describe several key network theories
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Ground to Cover
Spread and disseminations definition and boundariesFramework overview
– Motivation– Foundation– Aim– Nature of the intervention– Nature of the social system– Network building
Deep dive into each element:– What to do– Examples– Hard-won lessons– Ideas to try
Summary and questions
Collective Experience
IMPACT Collaboratives
Hospital Quality Work
100,000 Lives Campaign
5 Million Lives Campaign
1,000 Lives Campaign
100,000 Homes Campaign
Advancing Excellence Campaign
Project JOINTS
Healthier Hospitals Initiative
Patient Safety First Campaign
Partnership for Patients
The Conversation Project
Surgical Safety Sprint
IHI Open School
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What Are We Talking About When We Say “Spread” or “Dissemination?”
The science of taking a local improvement (intervention, idea, process) and actively disseminating it across an existing system
There are many possible definitions for “a system” (e.g., a hospital, a group of hospitals, a region, a country)
Core Elements
Aim: What are you trying to accomplish by when?
Nature of the Social System: How are you accounting for the environment in which you are trying to spread?
Nature of the Intervention: What are you asking people to adopt?
Motivation: Why would anyone participate?
Foundation: Who else has adopted the intervention?
Network Building: What is the infrastructure for connection between participants?
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“All models are wrong, some are useful.” – George Box, Industrial Statistician
Who? What? Where? When? Why?
Effective Large Scale Change
Foundation
Aim
NetworkBuilding
Motivation
Nature of the Social
System
Nature of the
Intervention
AimWhatareyoutryingtoaccomplishbywhen?
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Aim
“Some is not a number, soon is not a time.”
Inspirational and aspirational
Back of the envelope calculations to develop strategy
Group process to generate number and gain buy-in
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What are we trying to accomplish?
Developing the Aim Statement
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Create an Aim That Is:
Aligned with the strategic priorities of the organization– Involve senior leaders in its creation and approval.
Consider:– What investments are we willing to make?
– What activities should we de-emphasize?
– What conflicts are we willing to resolve?
– What risks are we willing to take?
– How much disruption in the organization are we willing to support to make the transition to a better performing system?
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Tips for Creating Aim Statements
State the aims clearly – What do you want to accomplish
– How much?
– By when?
Define location or population
Set stretch goals
Include numerical goals/targets
Who is responsible for this aim? How are they held accountable?
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© 2005 Institute for Healthcare Improvement
Some Is Not a Number… Soon Is Not a Time
THE NUMBER:
100,000 LivesTHE TIME:
June 14, 2006 – 9 a.m. ET
Aim
The 100,000 Homes Campaign is a national movement of communities working together to find permanent homes for 100,000 of the country’s most vulnerable and chronically homeless individuals and families by July 2014.IHI asked hospitals participating in the Campaign to prevent 5 million incidents of medical harm over a period of two years (December 12, 2006-December 9, 2008).Save 100,000 lives by adopting six evidence-based interventions by June 14, 2006 at 9:00 am ET10 million conversations about what individuals want at the end of their life by 2015
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Sample Aim StatementOur organization intends to optimize a culture that promotes patient/family centered care, prevents harm and improves patient outcomes by providing safe, efficient, evidence-based care.
Specific goals to achieve by December 31, 2008: Reduce ICU mortality rate to < 8% a) Reduce ventilator associated pneumonia (VAP) by 30% b) Decrease vent LOS by 20%c) Maintain greater than 95% compliance with all 5 components of
the ventilator bundleReduce overall sepsis mortality rate by 20% a) Ensure sepsis resuscitation bundle use on at least 95% of all
appropriate patients b) Ensure sepsis management bundle use on a least 95% of all
appropriate patients
Back of the Envelope
The IHI Open School: “Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational institutions train about 1 million new doctors, nurses, midwives, and public health professionals every year.”
In order to achieve the goal, what numbers would we need in terms of: – students enrolled on IHI.org?– students taking courses? Certifications?– In-person chapters?
Frenk, Julio, Lincoln Chen, Zulfiqar A. Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, et al. 2010. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet376(9756): 1923‐1958.
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Aim – Hard Won Lessons
What not to do:
Avoid a time and a number
Ignore the heart of the work
What to do:
Ensure it aligns with the larger organizational goals, but still has an edge to it
Goldilocks
Ideas to Try
Getting Started:• Set a “what by when” goal• Have team create back of the envelope calculations; discuss
similarities and differences• Use thumbs up, neutral, or down to come to number agreement• Ask yourself: How is the heart of this work reflected in the aim?Accelerating Good Work:• Re-evaluate your aim. Will you reach it? If not, do not be afraid to
extend the time. How will you change your work to reach the aim?• Identify three of four stories that support your overall aim and bring a
face to the work• Set milestones along the way; what’s the trajectory of the work?
Where do you expect to be at interim periods?
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Nature of the Social SystemHowareyouaccountingfortheenvironmentinwhichyouaretryingtospread?
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Nature of the Social System –What to Do
Understand and account for subcultures:– Physicians vs. nurses vs. community workers
– ICU vs. Med/Surg
– Georgia vs. California
– US vs. UK
Think about who leads the charge and who brings up the back
Understand the ups and downs of regulations
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Reflection
Think about the social system you are trying to change.
What makes the system special?
What particular challenges does the system face?
How is your work taking these unique attributions and particular challenges into account?
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“Follow Us on Twitter”24
Letter Text:
“Requesting hard copy of Conversation Starter KitPlease mail to:…”
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Nature of the Social System – Hard Won Lessons
Take a second look. Are you being true to the environment or what you want it to be?
How are you accounting for a changing environment? (What works once won’t always work twice…)
Are there additional relationships you need to cultivate before getting started?
Is there more research needed about regarding the history of group dynamics?
Ideas to Try
Getting Started:
• Base recruitment strategies off what you know about the environment
• Build on success from other leaders or projects
Accelerating Good Work:
• Evaluate what has changed in the environment. How have you adjusted your work to account for the changes?
• Allow organizations to tailor content to specific needs. Create templates that organizations can alter.
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Nature of the InterventionWhatareyouaskingpeopletoadopt?
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Nature of the Intervention –What to Do
Once you think an intervention is simple enough, simplify againHelp participants sequence workAppeal to the nature of all types of facilities and use varied examples.Business case, how-to guide, annotated bibliographyMake tacit knowledge explicitStart with the willingPortfolio of interventions
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Attributes of Innovation
Relative advantage
Compatibility
Complexity
Trialability
Observability
(Hard core, soft periphery)
from E. Rogers, 1995
JOINTS Graph30
0
10
20
30
40
50
60
70
Resource usefulness
Not at all useful
Somewhat useful
Useful
Very useful
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Sequencing Methods
Identify the high leverage skills or capabilities;
Use data to identify problem areas;
Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates;
Start with units with improvement capability or champions;
Start in areas where you are likely to see early success.
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Complexity
CLABSI SSI CA‐UTI VAP VTE
PU CA‐UTI Falls
OB
VTE CA‐UTI
ADE
Reliability and Teamwork
Rounding and Prevention
Risk Assessment
Monitoring & Titration
Working Across Microsystems
Care Transitions
TimeSept’ 10 Sept’ 13
Improving Outcomes for High-Risk and Critically Ill Patients Community: Institute for Healthcare Improvement
A Three to Thirty‐Six Month Initiative (series of projects)
Sepsis Resuscitation
Bundle
Sepsis Management
Bundle
Ventilator Bundle
Central Line
Bundle
Multi‐disciplinary Rounds and Daily Goals
Rapid Response Team
Early Warning System
Glucose Control
End ofLife Care
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Nature of the Intervention – Hard Won Lessons
The Medication Reconciliation lesson
Put lots of time and energy into the resources you find helpful
Don’t focus on the exceptions (Pareto rule)
Simple to complex
Make sure it really is the right thing to do
Ideas to Try
Getting Started:
If you can’t count the steps on one hand, go back to the drawing board
Put asterisks by the most low resource places to start, but remind people they will have to do all the work eventually
Don’t make it too hard. (Pareto principle)
Accelerating Good Work:
Supplemental materials for specific types of organizations (e.g., pediatric)
Develop a gap assessment or tool to help people know where to start
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MotivationWhywouldanyoneparticipate?
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Motivation – What to Do
Align with local priorities AND push the envelope
Find figureheads to champion the work
Make sure there is a linkage to higher priorities
How does this solve someone else’s problem?
Develop a plan to engage leaders
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100,000 Lives Launch39
Motivation – Hard Won Lessons
Even if your paycheck depends on the work, don’t make it seem like it
Do too much too quickly
Overuse figureheads
Figureheads need to have more friends than enemies
Not letting figureheads slow down your pace
Three step registration process for Project JOINTS. Technology our enemy. Don’t want to waste any will
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Motivation – Ideas to Try
Just Getting Started:Identify a key figurehead to launch the workAlign the will by using relatable examples (patients, teams, families, time savings, etc)Make it really easy to sign up – low barrier to join. Don’t want to turn anyone away.
Accelerate Good Work:Build relationships beyond the figureheadUpdate often – data, cases, successesPut yourselves on a board/all staff/executive team meeting agenda for 90 days from now to report out on your work and results
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FoundationWhoelsehasadoptedtheintervention?
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Foundation – What to Do
Include letters of support
Kick off calls with high ranking leaders
Pull examples from other units, organizations
Tell the story of the testing (pilot unit to third floor)
Find people that look like intended adopters (“We are not Boston.”) Testing with local stuff and similar facilities
Use recognized brands
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Foundation – What Not to Do
Depend on these leaders too frequently
Make sure you are using people with a good reputation
Shouldn’t be about the person. What do they represent?
Ideas to Try
Getting Started:
Record the story of testing
Identify well-liked peers
Accelerate Good Work:
Develop an alignment grid
Name drop
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Network BuildingWhatistheinfrastructureforconnectionbetweenparticipants?
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Network Building – What to Do
Highlight others on callsCall for examples from the field Listservs for participants to ask/answer questionsPeople want to be connected to othersUnderstand what type of network you are trying to createStart with the end in mind The network is a living thing that must be tended and shaped and loved (it is a deliberate, managed process)The value of celebration and recognition (economy)The value of affection
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Networks
A network is a collection of nodes (people, organizations) with a specific set of ties (connections, relationships) between them.
Network research is important because it allows one to better understand, or even visualize, the invisible structures underlying all human interactions.
These structures influence the way people behave, make decisions, and share information.
Whole Network Concepts
Purpose (the reason for its existence)
Role (how the network promotes value among members)
Function (what the network actually does e.g., community building, sharing knowledge, convening stakeholders)
Form (the structural and organization characteristics of the network)
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Value of Recognition
“Not sure if you had anything to do with this recognition, but you have no idea how much it has impacted our hospital. It has given us the jolt of energy around quality that we needed. We have focused all week on celebrating and refocusing around quality. Thanks for all you do. You really make the fight worthwhile!”
-Hospital Quality Manager
Campaign Field Operations Structure
FACILITIES (2000‐plus)
NODES (approx. 75)
*Each Node Chairs 1 Network
*30 to 60 Facilities per Network
Introduction, expert support/science, ongoing orientation, learning network development, national environment for
change
Ongoing communication
IHI and Campaign Leadership
Local recruitment and support of a smaller network through communication/collaboratives
Implementation (with roles for each stakeholder in
hospital and use of existing spread strategies)
Mentor Hospitals
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Network Building – Hard Won Lessons
Have every answer come from you
If you build it, they will come
Technology as a barrier to what people want to be doing
Depending on one relationship
Know your audience
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Ideas to Try
Getting Started:
Think about where you want to be at the end of the work; imagine an infrastructure to accomplish it
Who would be the first two people you’d want to include and with what frequency and format would you like to connect?
Create a node structure
Accelerating Good Work:
Test a new strategy for the type of network you are creating
Identify additional contacts
Identify opportunities for recognition and celebration
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Core Elements - Summary
Aim: What are you trying to accomplish by when?
Nature of the Social System: How are you accounting for the environment in which you are trying to spread?
Nature of the Intervention: What are you asking people to adopt?
Motivation: Why would anyone participate?
Foundation: Who else has adopted the intervention?
Network Building: What is the infrastructure for connection between participants?