www.ChildrensSafetyNetwork.org 1
October 26th, 2016
Learning Session II
Call (866) 835-7973 to join us
www.ChildrensSafetyNetwork.org 2
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www.ChildrensSafetyNetwork.org 3
Welcome!
Day 1Welcome Bethany Miller, Health Resources and
Services Administration
Rod McClure, Centers for Disease Control and Prevention
Where we are as a Collaborative
Jen Leonardo, CS CoIIN Improvement Advisor
Jenny Stern-Carusone, CS CoIIN Manager
Caretakers Learning to Improve Car Seat Knowledge
Lesha Peterson, Missouri, Child Passenger Safety
Carole Guzzetta, National Highway Traffic Safety Administration
Partnerships & Prioritization Susan Pollack, Kentucky, Teen Driver Safety
Katie Ballard, National Highway Traffic Safety Administration
Accelerating Improvement:
Moving from Developing to Testing, Implementing, and Spread
Jane Taylor, CS CoIIN Improvement Advisor
www.ChildrensSafetyNetwork.org 4
Opening Remarks from HRSA
Bethany MillerDirector of Injury and Violence Prevention Programs
HRSA
Working Together to Create a Systems Approach to Preventing Intentional and
Unintentional Injury
Presentation to
CS CoIIN Learning Session 2
October 26, 2016
Roderick McClure
Angela Marr
Sally ThigpenDivision of Analysis, Research, and Practice Integration
National Center for Injury Prevention and Control, CDC
Injury-related deaths are only apart of the problem
Injury Center Mission
To prevent injuries and violence and reduce their
consequences.
Injury Center Vision
To put injury and violence prevention on the map as the
premier public health achievement of the decade
DARPI
Integrating science and practice to prevent injuries and violence.
I N N O V A T I O N P A R T N E R S H I P
C O L L A B O R A T I O N
DARPI Framework for a Systems Approach to IVP
Systemic Approachto Population Level Injury and
Violence Prevention
KNOWScience & Methods
Cooperative Agreement funding
period: 2016-2022
23 BASE Awardees
5 Regional Network Coordinating
Organization (RNCO) Component
Awardees
4 Surveillance Quality Improvement
(SQI) Component Awardees
Focus Areas: motor vehicle crash
injury and death, child abuse and
neglect, intimate partner and sexual
violence and traumatic brain injury
Core State Violence and Injury Prevention Program (Core SVIPP) Overview
Core State Violence and Injury Prevention
Program (Core SVIPP) Overview
Support states in implementation, evaluation
and dissemination for violence and injury prevention activities
Implementation of IVP programs, practice, and
policy
Collect, analyze and use injury data
Support and Evaluate Program
and Policy interventions
Program Evaluation
Core SVIPP States
Base Component
23 funded states
Key activities:
Collect and analyze data
Implementation of injury and violence prevention
programs, practices and policy
Support and evaluate program and policy
interventions
Inform policy
Program evaluation
Funded states include: Arizona, Colorado, Georgia,
Hawaii, Illinois, Kentucky, Louisiana, Maryland,
Massachusetts, Michigan, Minnesota, Nebraska, New
York, North Carolina, Ohio, Oklahoma, Oregon, Rhode
Island, Tennessee, Utah, Virginia, Washington and
Wisconsin
BASE Component
Purpose: To
support funded
states in
implementation,
evaluation and
dissemination of
programs,
practices, and
policies with the
best available
evidence.
Regional Network Coordinating Organization
(RNCO)
• 5 funded states
• Key activities:
Enhance collaboration between state health
departments (SHDs) and Injury Control Research
Centers (ICRCs)
Conduct a basic needs assessment
Provide peer to peer coaching for SHDs
Facilitate regional and national learning
communities
• Funded states include: Colorado, Maryland,
Massachusetts, North Carolina, and Washington
Purpose: To
provide
coordination
across and
between
states(regardless
of funding status)
and collaborate
with injury and
violence
prevention
organizations to
share scientific
evidence and
programmatic
best practices.
Surveillance Quality Improvement (SQI)
Component
• 4 funded states
• Key activities:
Conduct injury data investigations
supportive of promoting and advancing
uniform injury case definitions and
improving data quality
Advance methodology
Explore emerging sources of injury data
• Funded states include: Colorado, Kentucky,
Maryland, and Massachusetts
Purpose: To
conduct injury data
investigations
supportive of
promoting and
advancing uniform
injury case
definitions,
improving data
quality, and
advancing
methodology and
exploring emerging
sources of injury
data.
Core SVIPP CS CoIIN
Integrated Approaches to IVP Prevention
through Partnerships and Collaboration
Data Quality
Addressing Shared Risk and Protective
Factors
Implementation and Evaluation of Evidence
Supported Strategies
Areas of Focus:
Child Abuse and Neglect
SV/IPV
Motor Vehicle Safety
Traumatic Brain Injury/Youth Sports
Concussion
Improve Partnerships Within and Between
States/Jurisdictions
Spread Evidence-Based Practices to
Vulnerable Populations that Are Not Yet
Receiving Services
Improve the Implementation of Evidence-
Based Practices
Boldly Focus on:
Teen Driver Safety
Child Passenger Safety
Suicide and Self-Harm
Interpersonal Violence
Falls
Core SVIPP – CS CoIIN
Alignment of Priorities
Core SVIPP:
www.cdc.gov/injury/stateprograms
CDC Injury Center:
www.cdc.gov/injury
For More Information
www.ChildrensSafetyNetwork.org 18
Where We Are as a Collaborative
Jen Leonardo,
CS CoIIN Improvement Advisor
Jenny Stern-Carusone,
CS CoIIN Technology Director
www.ChildrensSafetyNetwork.org 19
The Challenge
Less
RequiredFormality, documentation, methods, time, coalition
building, communication, measurementStraight Forward Very Difficult
More
Required
Cleaning
Hotel Rooms
On-time
Shipments
small
warehouse
Teaching of
Chemistry
local school
district
Infections in
Surgery
Sales to
global
accounts
Quality,
safety,
productivity
organization
wide
Multinational
Supply chain
optimization
Teaching of
science
nationwide in
elementary
school
Source: The Improvement
Guide pg. 238
www.ChildrensSafetyNetwork.org 20
Working in a Complex System
Project design
Engagement of frontline workers
Strategies for collecting real-
time data
Coping with data lags
Coordination within and
across agencies and
organizations
Outreach to non-traditional
partner
Requires Special Attention to and Strategies for
www.ChildrensSafetyNetwork.org 21
Quality Improvement Skills
The Model for
Improvement
Building
the System
of Improvement
• Aim Statements
• Systems Thinking
• Gathering Information for Improvement
• Driver Diagrams
• Plan-Do-Study-Act Cycles
• Run Charts
www.ChildrensSafetyNetwork.org 22
Content Knowledge & Skills
Teen Driver Safety
• Engaging Parents
• Innovative Data Collection System
Interpersonal Violence Prevention
• Creating & Expanding Partnerships
• Uptake of Evidence Based Programs
Child Passenger Safety
• Cultural Competency
• Technician Engagement & Retention
Suicide and Self-Harm Prevention
• The Power of Prevention
• Emergency Department Protocols
Falls Prevention
• Concussion Reporting Systems
• Training Coaches
ICD-9 & 10 Coding: Master Cross Walk
Finding Data: Outcome Data
Worksheet
State Updates & Sharing on Webinars
Stories of Success: Collecting Real-
Time Outcome Data
www.ChildrensSafetyNetwork.org 23
Progress MadeReal-Time Outcome Data Collection
Massachusetts
Suicide & Self-Harm Prevention
Tennessee
Falls Prevention
Indiana
Child Passenger Safety
Interpersonal Violence Prevention
Kentucky
Child Passenger Safety
Interpersonal Violence Prevention
2%2%2%
4% 9% 9% 7% 7%
14%22%
35% 30%28%
21%
2%2%
2%
2%16% 21%
26%
2%
0%
10%
20%
30%
40%
50%
60%
March April May June July August September
Improvement by the Teams
1: Forming 1.5: Planning 2: Activity
2.5: Testing 3: Modest Improvement 3.5: Improvement
4: Significant Improvement 4.5: Sustainable Improvement 5: Outstanding Sustainable Results
www.ChildrensSafetyNetwork.org 24
In Your Words
“Will share resource information with
providers - there are actually vast
applications beyond just CoIIN programs.” -
Anonymous
“Most individuals
entering the ED with a suicide attempt (70%) never attend
their outpatient appointment -
key to determine ways to link services!” -Anonymous
“Developing and working with
partners is critical to getting work done.” -
Anonymous
“The insights from other
states made the session even
more valuable.” -Anonymous
“In public health you don’t see the reward of your work for years – sometimes 10.
it’s nice to have the gratification of the work you
are doing now and see ‘man, parents really need this
information.’ It’s great that the CoIIN provided evidence
based strategies to help focus on the direction one should go with a particular
topic.” -Jeanne Bietz, Nebraska
“Starting small and that some
data is better than no data.” -
Anonymous
“Will try to retool everything to be smaller and more measurable, still
building a coalition . . . will try to include passionate family, also PTA and others from community. Better
understanding of the CoIIN process- something just clicked
better finally.” -Anonymous
“It's important to
be able to identify and understand
your system.” -Anonymous
“Refine my process
measures and keeping
track of data.” -
Anonymous
“Got me thinking more
about processes and approaches for measuring & changing them.”
-Anonymous
“How powerful the visual
presentation of data can be. It
shows how useful the data can be.
Great!” -Anonymous
25Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Missouri CLICKCaretakers Learning to Improve
Car Seat Knowledge
Team Members:
Martha Smith – Center for Local Public Health, DHSS
Lori Winkler – Safe Kids St. Louis
Carrie Wolken – Missouri Department of Transportation
Ginny VanAusdall – Safe Kids Bootheel
Rebecca Chitima-Matsiga – Office of Epidemiology, DHSS
Julie Lueckenhoff – Missouri Department of Heath and Senior Services
Lesha Peterson – Missouri Department of Health and Senior Services
Pat Simmons –Missouri Department of Health and Senior Services
26Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Aim Statement
By June 2017, we will reduce child (ages 0-8) passenger deaths, hospitalizations, and emergency department (ED)
visits resulting from a motor vehicle crash in which the victim was an occupant of a vehicle.
Our goals are to:
• Decrease the child passenger mortality rate by 2% relative to the state/jurisdiction baseline.
• Decrease the rate of child passenger hospitalizations by 2% relative to the state/jurisdiction baseline.
• Decrease the rate of child passenger emergency department (ED) visits by 2% relative to the state/jurisdiction baseline.
27Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Process Measures & Goals
• Increased access and learning opportunities for caretakers for child safety seat fitting, installation, and distribution.
• Increase the number of Child Passenger Safety Technicians (CPST) with up-to-date certification.
• Increase the number of mobile inspection stations and car seat inspection stations.
• Increase Child Passenger Safety Technicians/educators teaching caretakers how to adjust seat, buckle harness, install, and protect their children.
28Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Process Measures & Goals
Example where some data is availableProcess Measure Goal
Increase the number of Child Passenger Safety
Technicians (CPST) with up-to-date certifications.
Have at least one certified Child
Passenger Safety Technicians (CPST) in
every county in the state.
Tip: Use as many slides as you need
Delete this slide before submitting
.
29Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Process Measures & Goals
Process Measure Goal Progress
Increased access and
learning opportunities
for families for child
safety seat fitting,
installation, and
distribution.
Expanded network of
CPSTs, inspection
stations, and sites for
distributing child
safety seats.
DHSS offering to assist
agencies in covering costs for
one staff member to attend a
nationally certified CPST
training course.
30Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Organizing Your Work
The Missouri CLICK strategy team is comprised of members of different organizations and agencies located throughout the state that have expertise in child passenger safety.
31Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Organizing Your Work
Can you find
all the
“wrongs” in
this picture?
32Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
Lessons Learned
• Have flexibility to change
directions mid-course.
• Multiple barriers for Child
Passenger Safety
Technician(CPST) training such
as funding and availability of
car seats.
33Missouri CLICK
Caretakers Learning to Improve Car Seat Knowledge
We Wonder If Next We Should . . .
• Offer money to purchase car seats and how to accomplish that task.
• Make more direct contact with counties and identify barriers.
◦ Partner with the Maternal Child Health Program staff to do this outreach.
www.ChildrensSafetyNetwork.org 34
Questions & Comments
We’re
listening.
Carole Guzzetta
Highway Safety Specialist
Office of Impaired Driving and Occupant Protection
National Highway Traffic Safety Administration
Kentucky Teen Driver Safety Strategy Team 35
Teen Driving Kentucky
Our team is working to make sure that
every teen comes home safely, through
parent and teen knowledge of graduated
drivers licensing (GDL) and the risks of
inexperience, speed, excessive
passengers, no seat belt, rural roads and
all types of distraction and impairment.
Kentucky Teen Driver Safety Strategy Team 36
Teen Driving KentuckyRuth Ann Shepherd
MCH Director
KY Department for Public Health
MCH Director
(502) 564-4830
Susan Pollack
IVP Director Desginee
Pediatric and Adolescent Injury Prevention
Program
(859) 421-5881
Tammy Barrett
Primary Point of Contact
Contact
KY Department for Public Health, Division of
Maternal and Child Health
Pediatric Section Supervisor
(502) 564-2154 ext 4409
Monica Clouse
KY Department for Public Health,
Epidemiologist
(508) 564-4830 ext 4394
Ty Collins
KY Office of Highway Safety
Program Coordinator
502-782-3996
Louan Cottrell
Kentucky Department for Public Health
Infant Mortality Nurse
502-564-2154 ext 4410
Sherri Hannan
Safe Kids Fayette County
Program Coordinator
859-323-1153
DeShaun Bailey
Office of Highway Safety
502-229-7004
Steve Sparrow
Kentucky Injury Prevention and Research
Center
Program Coordinator
(859) 257-9484
Robert McCool
Prevention and Research Center
Program Manager
(859) 257-4954
Jon Akers
Ky Center for School Safety
Executive Director
877-805-4277
Sharon Rengers
Kosair Children's Hospital
RN, Manager
502-629-7337
Michael Schwendau
Office of Highway Safety
Assistant Director
502-782-3985
Michael Singleton
Child Passenger Safety, Teen Driver Safety
Kentucky Teen Driver Safety Strategy Team 37
Aim Statement
• By June 2017, we will reduce deaths, hospitalizations, and emergency department (ED) visits resulting from a crash in which the victim was a driver or occupant of a motor vehicle and between the ages of 15 and 19. Our goals are to:
• Decrease the teen motor vehicle mortality rate by 13.33% relative to the state/jurisdiction baseline;
• Decrease the rate of teen motor vehicle-related hospitalizations by 13.33% relative to the state/jurisdiction baseline; and
• Decrease the rate of teen motor vehicle-related ED visits by 13.33% relative to state/jurisdiction baseline.
Kentucky Teen Driver Safety Strategy Team 38
Drivers and Change Ideas
Kentucky Teen Driver Safety Strategy Team 39
Drivers and Change Ideas continued
Kentucky Teen Driver Safety Strategy Team 40
Possible Process Measures
• 9. % of teens reporting understanding of GDL requirements
• 10. % of teens reporting compliance with GDL
• 11. % of parents reporting understanding of GDL requirements
• 12. % of parents reporting enforcement of GDL with their teen driver.
• 13. % of signed parent-teen driving agreements among teens participating in an evidence-based teen driver safety program
• 16. % of parents educated on GDL
• 18. % of active stakeholders in the state/jurisdiction teen driver safety coalition
• Add: % of county/District health departments choosing GDL teen driving package for 2016-17 MCH CFR activities.
Kentucky Teen Driver Safety Strategy Team 41
Example 2: Process Measures & Goals
Process Measure Add1 Goal Progress
% of county/District
health departments
choosing GDL teen
driving package for
2016-17 MCH CFR
activities. (There are
120 counties in KY.)
12 counties (10%) of
counties would choose
Teen Driving as one of
their MCH/CFR
packages for the year.
Currently 1 District (5 counties) and
1 county have chosen Teen Driving.
(5%) Another is considering, and at
least one more county has Teen
Driving efforts going on through the
Safe Kids Coalition, and the list is
not yet complete.
Example where no data is available yet
Kentucky Teen Driver Safety Strategy Team 42
Concept 1: Organizing Our Work
• Steps we have taken to:◦ Develop our team/coalition: invited relevant people/agencies to
meet through the state CDC injury planning and implementation process (KSPAN). Met quarterly there and with some additional times through Office of Highway Safety (OHS). Invited all team members to participate on monthly calls, first together and then individually since being at one’s own desk makes it easier to fully participate in both the visual and auditory parts of the call. Conducted informational phone call, visit and letter recruitment of stakeholders we felt were needed to accomplish the aims.
◦ Work with stakeholders individually to ensure leadership knows their contributions/experience and goals for teen driving safety.
◦ Aligned with ongoing work of OHS and the Injury Center (KIPRC) through KSPAN, running each of the 3 CoIIN pieces through an existing KSPAN committee with existing committee Chairs.
Kentucky Teen Driver Safety Strategy Team 43
Lessons Learned
We planned We found We predict. . .
To rapidly gather a
multi-disciplinary,
multiagency group
of partners into a
stable, ongoing
State Teen Driving
Coalition, with all
contributing to
forward progress.
Having long time occupant protection
people involved who know about teen
driving too is a gift. But when those
people are the same people in the
state who are also the major players in
child passenger safety, there are
inadequate resources to move both
parts of CoIIN forward equally. So we
had to first emphasize teen driving to
gather a group, but were then needed
to respond to a large CPS effort, and
that need continues, forcing a revision
of teen driving timelines. Teen driving
/CPS stakeholders are often teaching
CPS classes at the time we had hoped
to meet before monthly CoIIN calls.
With steady, slower work, we
will be able to accomplish this
goal, it will just take longer
than we had originally
planned with great optimism.
Based on what we have heard
on the monthly CoIIN calls, if
we were able to add a half-
time dedicated coordinator to
this effort (shared with CPS
possibly) it would move faster
than if we continue to have
only the current CoIIN
leadership to drive this
process of finding and
maintaining the group.
Kentucky Teen Driver Safety Strategy Team 44
Lessons Learned
We planned We found We predict. . .
That the process would
flow from that state level
out
That the new year (2016-17)
MCHB options for local health
departments including the
choice of teen driving activities,
and our need to support those,
presented new opportunities to
enlarge our partnership with
the addition of some very
enthusiastic local public health
people who already have some
experience with teen driving
programs/activities in their
counties.
Because leadership for CoIIN
came first from our state-level
team, we envisioned a process
that spread out from there, but
after gathering the group from
that direction, our progress will
now be greater if we can both
leverage and strongly support
county/community efforts as
pilots and use the knowledge
and experience learned from
the local level to inform the
state level.
Kentucky Teen Driver Safety Strategy Team 45
Lessons Learned
We planned We found We predict. . .
To reach out to school
administrators during the
early summer months, so we
could implement at least a
pilot educational program for
parents of teen drivers at one
school in August before
school started.
This process can take
much longer than
anticipated, though it may
take less time in counties
where the health
department or OHS
already have a strong
presence in the schools.
If we start the process of
creating relationships and links
with schools now, we should be
in a good position to implement
a teed driving/GDL awareness
class for parents of youth
wanting school parking permits
for next year. In addition, we
might be ready in time to offer
the program to youth whose
birthdays leave them just
becoming independent licensed
drivers during this year.
Kentucky Teen Driver Safety Strategy Team 46
We plan next to . . .
• Brief additional people from Fayette County Safe Kids, the Pennyrile District (District and 5 counties) and Knox County Health Departments on CoINN thus far and ensure that they are invited to become partners in the teen driving team. (Knox County and some of the Fayette County people have already been on one monthly call). These are the 7 Kycounties known thus far that plan to do teen driving as part of their CFR/MCH activities for the 2016-17 year or are already doing teen driving programs. (Any additional counties will be added as we hear of them, this process has already begun with those we know of.) Have new stakeholders brief the existing teen driving partners on what they have done (Pennyrile and Fayette each have experience in schools) and plan to do (Knox). These counties are located in the center, SW and SE of the state, and will serve as pilots from which we hope to expand.
Kentucky Teen Driver Safety Strategy Team 47
We plan next to…
• Resume recruitment of additional partners foreseen but not yet brought to the table or there in an on-going way: School Health (from MCH, already involved in Pennyrile), insurance people (sometimes local and sometimes regional US), high school athletic association representative, Ky State Police, Ky Transportation Center,
• Support school and community safe teen driving events/programs conducted by these partners. Where possible, incorporate evaluation into the planning.
• Participate with Fayette County Safe Kids in their October 2016 Teen Driver Safety week program at Dunbar High School.
• Continue work to create routine access to information on GDL stage of driver in all motor vehicle crash deaths of youth under age 18. (Office of Highway Safety is leading this effort at present.) Work to ensure that local county review of all teen crash deaths includes or seeks this information.
• Work with the Office of Highway Safety and the legislature to provide education and data for any 2016-17 new GDL legislation proposed.
www.ChildrensSafetyNetwork.org 48
Questions & Comments
We’re
listening.
Katie Ballard
Highway Safety Specialist
National Highway Traffic Safety Administration
www.ChildrensSafetyNetwork.org 49
Accelerating Improvement:
Planning for Scale Up and SpreadChild Safety CoIIN
Jane Taylor, Ed.D.
www.ChildrensSafetyNetwork.org 50
Objectives of this Session
• Participants will be able to:
• State a key strategy for accelerating improvement
• State criteria for moving to scale up
• Value need for social systems change in spread
50
www.ChildrensSafetyNetwork.org 51
Topic Teams
Teen Driver Safety
Child Passenger
Safety
Suicide and Self-
Harm
Inter-personal Violence•Child Maltreatment
•Bullying
•Sexual Assault
•Assault
•Homicide
Falls
www.ChildrensSafetyNetwork.org 52
Strategy:
• Test
• Implement and accelerate
• Sustain
• Scale up and spread
www.ChildrensSafetyNetwork.org 53
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
Model
for
Improvement
Charter or Aim
Measures
Changes
API / IHI.org
www.ChildrensSafetyNetwork.org 54
• Consider stakeholders
• Designate leadership and group with oversight responsibility
• Designate a day to day team with clear roles and responsibilities to execute changes
• Communication plan to constituents and publics
• Recognize the lag between cause and effect and moving the outcome measure
• Develop a strategy to engage pilot group(s) and scale up/spread
• Many replicate CoIINs or Learning Networks as spread vehicle
Complex Change Reminder
www.ChildrensSafetyNetwork.org 55
Accelerating Testing to Move to Implementation and Then Scale Up and
Spread Change
Be the change you want to see in the world.
Mohandas Gandhi
www.ChildrensSafetyNetwork.org 56
The Sequence for Improvement
Sustaining and
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
www.ChildrensSafetyNetwork.org 57
Testing v. Implementation
• Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system.
• Implementation – Making this change a part of the day-to-day operation of the system
• Would the change persist even if its champion were to leave?
www.ChildrensSafetyNetwork.org 58
First Focus
- Select ONE focus area
- Use small scale tests
Ideas and Hunches
Study
Act
Do
Plan
Improvement
Courtesy of IHI IMPACT Program
Test in One Process
www.ChildrensSafetyNetwork.org 59
• Key Principles
• Test small to go faster
• Test changes in Parallel
• Staging change with pilot sites and communities
• Considering extremes
• Orchestrating testing
Accelerating Improvement
www.ChildrensSafetyNetwork.org 60
Primary DriverChanges
Courtesy of IHI IMPACT Program
Secondary Drivers
Test multiple ideas simultaneously
Testing in Parallel
www.ChildrensSafetyNetwork.org 61
Primary Drivers or Expanding a Driver
Ramps or Categories of Change: work in parallel
www.ChildrensSafetyNetwork.org 62
• Test with volunteers
• Don’t wait 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
• Think several cycles ahead
• Use simulation
Accelerating Change
Courtesy of IHI IMPACT Program
www.ChildrensSafetyNetwork.org 63
• Do more testing
• Smaller scale tests-but more of them!
• At least 100 cycles per month. What????
• Teams who run more cycles have more success
• Understand the difference between testing and
implementation
• Use measurement and PDSA for learning
Accelerating Change
www.ChildrensSafetyNetwork.org 64
A Word about Moving to Implementation
• Developed a high degree of belief in the change
• Failures in process no longer occur
• WIFM and rationale must be provided
• Expect resistance because more are effected
• Still think PDSA• Many activities need to be done to make a change
permanent• Training, new hire training
• Job descriptions
• Policy and Procedure
• Communication
• Equipment
• Standard work and work flow
www.ChildrensSafetyNetwork.org 65
Implementation Checklist
Continue to use PDSA cycles as you manage the system changes necessary to make your changes permanent.
Element Owner Comments
Buy-in
Think about the people that will need to agree to adopt this change. How will you ensure their support?
Policies and documentation
Does this change requires changes in SOPs, standard policy, or other organizational standards?
Hiring procedures and requirements
Does this change entail changes in job descriptions or skill sets for new employees?
Staff education/training
Existing staff and new hires will need to be trained on the new process
Job descriptions, evaluation, compensation
Will this revised process become the basis for employee evaluations?
Information flow
Does this change require changes in IT systems, reports, or routing of operational information?
Equipment, supplies purchasing
Make sure that items needed to support the change are on hand, and that equipment purchases are compatible witn the new process.
On-going measurement and control
How will you track the performance of the new process over time, in order to sustain improvement?
Other:
www.ChildrensSafetyNetwork.org 66
Current Situation Resistant Indifferent Ready
Low
Confidence that
current change
idea will lead to
Improvement
Cost of
failure
large
Very Small
Scale Test
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
small
Very Small
Scale Test
Very Small
Scale Test Small Scale
Test
High
Confidence that
current change
idea will lead to
Improvement
Cost of
failure
large
Very Small
Scale Test Small Scale
Test
Large Scale
Test
Cost of
failure
smallSmall Scale
Test
Large Scale
TestImplement
Think About the Size and Scope of a Test
www.ChildrensSafetyNetwork.org 67
The Sequence of Improvement
Sustaining and
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
www.ChildrensSafetyNetwork.org 68
Use Measurement
• Measurement• Visible, viewed over time
• Measurement of crucial support processes (early warning system)
• Used for understanding improvement
• Used to verify sustaining change
• Used for Scale up and Spread
IG 2nd ed., p. 182Courtesy of IHI IMPACT Program
www.ChildrensSafetyNetwork.org 69
Collect Data Over Time
0
10
20
30
40
50
60
70
Se
p-0
2
Oct-
02
No
v-0
2
De
c-0
2
Ja
n-0
3
Fe
b-0
3
Mar-
03
Ap
r-0
3
Ma
y-0
3
Ju
n-0
3
Ju
l-0
3
Au
g-0
3
Se
p-0
3
Oct-
03
No
v-0
3
De
c-0
3
Ja
n-0
4
Fe
b-0
4
Mar-
04
Ap
r-0
4
Ma
y-0
4
Ju
n-0
4
Ju
l-0
4
Au
g-0
4
Pe
rce
nt
Baseline
Testing
Successful
Testing
Evidence of improvement
during implementation
Sustaining Gains
Courtesy of IHI IMPACT Program
www.ChildrensSafetyNetwork.org 70
HC Data Guide p. 121
70
www.ChildrensSafetyNetwork.org 71
Teams Who Hold the Gains
• Use data and continue with run charts
• Continue to report and create accountability
• Have leadership’s support
• Meet periodically
• Train and orient, make policy
• Assign responsibility for key tasks
www.ChildrensSafetyNetwork.org 72
A Word about Scale Up and Spread
• After successful implementation – consider scale up and spread or some might say implementation is a type of scale up
• Useful to proceed in increments of 5
1: 5: 25: 125, etc.
• This will allow most system barriers to be uncovered in small enough “bites” that they can be overcome
• If not overcome your spread will be incomplete
www.ChildrensSafetyNetwork.org 73
Scale Up in a Complex System Demand
• Cooperation to achieve a common purpose.
• Time and attention to set up and management of project
• A system designed to learn about how strategies work
www.ChildrensSafetyNetwork.org 74
Diffusion of Innovations
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
www.ChildrensSafetyNetwork.org 75
Characteristics of Ideas the Spread
• Relative Advantage: Does the innovation work better than the status quo?
• Compatibility: Can the innovation be easily adapted to current work patterns?
• Complexity: How difficult is it to understand and apply?
• Trialability: Can you try it out at low risk?
• Observability: Are differential effects of the innovation visible to other potential adopters?
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
www.ChildrensSafetyNetwork.org 76
Spread Criteria from Everett Rogers, Diffusion of Innovation
• Tip: take your change idea, evaluate it compared to these criteria. Shore up weak areas prior to beginning spread
www.ChildrensSafetyNetwork.org 77
Adoption Curve/Tipping Point Illustration
0
10
20
30
40
50
60
70
80
90
100
1950
1952
1954
1956
1958
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
Percent of US Households with TV
www.ChildrensSafetyNetwork.org 78
Adopter Categories
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
‘Traditionalists’
www.ChildrensSafetyNetwork.org 79
How Adopters
Adopt
1. Awareness
2. Persuasion
3. Decision
4. Implementation
5. Confirmation
www.ChildrensSafetyNetwork.org 80
Match Spread Activities to Need
• Awareness - Broad marketing and communication
• Persuasion - Data feedback
• Decision - Case studies, individualized communication
• Implementation - Tools and resources, Access to technical expertise
• Confirmation - Feedback, Leadership
www.ChildrensSafetyNetwork.org 81
Adoption is a SOCIAL thing!
A better
idea…
…communicated through a
social network…
…over
time
www.ChildrensSafetyNetwork.org 82
Set-upSuccess-
ful Sites
Social
SystemBetter Ideas
Knowledge Management
Measurement and Feedback
Leadership
A Framework for Spread
www.ChildrensSafetyNetwork.org 83
Adapted from Ashkenas, 1995
SHARE
INFORMATION
SHAPE
BEHAVIOUR−
General
Publicationsflyers
newsletters
videos
articles
posters
Personal
Touchletters
cards
postcards
Interactive
Activitiestelephone
visits
seminars
learning sets
modeling
Face-to-faceone-to-one
mentoring
seconding
shadowing
The WAY in which we
communicate is important
(C) 2001, Sarah W. Fraser
Public
EventsRoad shows
Fairs
Conferences
Exhibitions
Mass mtgs
www.ChildrensSafetyNetwork.org 84
The Seven Spreadly Sins
Step #1 Start with large pilots
Step #2 Find one person willing to do it all
Step #3 Use vigilance and hard work
Step #4 If a pilot works then spread the pilot unchanged
Step #5 Require the person and team who drove the pilot to be responsible for system-wide spread
Step #6 Look at process and outcome measures on a quarterly basis
Step #7 Early on expect marked improvement in outcomes without attention to process reliability
www.ChildrensSafetyNetwork.org 85
Managing Spread
• Create plan• Completeness vs. coverage
• Set schedule
• Anticipate needed support services• IT
• Case management/community liaison
• Technical expertise
• Eliminate barriers• Accessible knowledge
• Measurement and feedback
www.ChildrensSafetyNetwork.org 86
+
-
- +
$
Level of Ease
Spread Evaluation Matrix
www.ChildrensSafetyNetwork.org 87
Spread Strategy Matrix
County Jan Feb Mar Apr May
Fulton A B C
Troop A B C
Cherokee A B C
Forsyth A B C
Gainsworth A B C
A=teen driver agreements B=Insurers Distribute Cards with Discount
C=Pediatric Anticipatory Guidance at 14, 15, 16, 16, 18
www.ChildrensSafetyNetwork.org 88
Repeated Use of the PDSA Cycle for Testing
Hunches
Theories
Ideas
Changes That
Result in
Improvement
Very Small
Scale Test
Follow-up
Tests
Wide-Scale Tests of Change
Implementation of Change
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
Sequential building of
knowledge under a wide range
of conditions
Spreading
Sustaining the Gains
www.ChildrensSafetyNetwork.org 89
“There is nothing more difficult to plan, more
doubtful of success, nor more dangerous to
manage than the creation of a new order of
things….”
-Nicolo Machiavelli, The Prince
www.ChildrensSafetyNetwork.org 90
Questions & Comments
We’re
listening.
www.ChildrensSafetyNetwork.org 91
See You Tomorrow!
Day 2 Same Place, Same Time
Welcome Back! Jennifer Allison, CSN Director
Developing a Learning Collaborative
Alan Holmlund, Danielle Bolduc, Kimona Cameron Massachusetts, Suicide and Self-Harm Prevention
Kerri Nickerson, Suicide Prevention Resource Center
How to Establish or Connect to an Improvement Partnerships
Wendy Davis, National Improvement Partnership Network (NIPN)
Testing and Spreading Coaching Boys to Men
Shaquallah Shanks, Tennessee, Interpersonal Violence Prevention
Malia Richmond-Crum, Centers for Disease Control and Prevention
Testing and Implementing GDL Communication
Jeanne Bietz, Nebraska, Teen Driver Safety
Jen Leonardo & Jane Taylor, CS CoIIN Improvement Advisors
Where the CS CoIIN is Going Next
Bekah Thomas, CS CoIIN Director