Download - Rapid Cycle Improvement 2009
Learning ObjectivesLearning Objectives• This will be a fun, interactive session
designed to:– Review what it takes to accelerate
improvement-some key components– Show how the Model for Improvement and
PDSA (Plan-Do-Study-Act) can be practically and quickly applied
– Illustrate how testing things on a small scale can result in faster and sustainable changes and improvements
• This will be a fun, interactive session designed to:– Review what it takes to accelerate
improvement-some key components– Show how the Model for Improvement and
PDSA (Plan-Do-Study-Act) can be practically and quickly applied
– Illustrate how testing things on a small scale can result in faster and sustainable changes and improvements
A SimulationA Simulation
• Set Up:– Work in groups of ??
– ?? people represent key steps in the core process of an Emergency Department patient having a lab test performed
– 1 person is the quality officer and data collector
• Set Up:– Work in groups of ??
– ?? people represent key steps in the core process of an Emergency Department patient having a lab test performed
– 1 person is the quality officer and data collector
A SimulationA Simulation• Equipment
– 1 tennis ball (representing the test itself from the time it is ordered until results received)
– 1 stop watch– Paper to write down
times
• Equipment– 1 tennis ball
(representing the test itself from the time it is ordered until results received)
– 1 stop watch– Paper to write down
times
• Organization– Group forms a
circle representing the steps in the process
– 1 (quality officer) stands aside and observes/ records data
• Organization– Group forms a
circle representing the steps in the process
– 1 (quality officer) stands aside and observes/ records data
Process Process
• One person passes the ball to the person across from him/her in the circle, remembering who you threw it to. Then the receiver passes it to another person, remembering who each time. The last person passes it to the person that started.– Maintain the same sequence – Start over if execution is done incorrectly or
someone “drops the ball”.
• One person passes the ball to the person across from him/her in the circle, remembering who you threw it to. Then the receiver passes it to another person, remembering who each time. The last person passes it to the person that started.– Maintain the same sequence – Start over if execution is done incorrectly or
someone “drops the ball”.
Process Process • The quality officer:
– Records time from beginning to end– Enforces all rules:
• Sequence violated–start over
• Ball dropped–start over
• Execution done incorrectly any other manner
–start over
• The quality officer: – Records time from beginning to end– Enforces all rules:
• Sequence violated–start over
• Ball dropped–start over
• Execution done incorrectly any other manner
–start over
AIM and Quality AIM and Quality
• AIM: – Improve Turnaround
Time for all Labs – No mistakes/harm (no
dropping the ball!!)
• Basic Quality Criteria– Ball must be touched by
each person in sequence
– Start and end with the same person
– Speed
• AIM: – Improve Turnaround
Time for all Labs – No mistakes/harm (no
dropping the ball!!)
• Basic Quality Criteria– Ball must be touched by
each person in sequence
– Start and end with the same person
– Speed
• Quality Officer – Starts the process
by saying “go”– Start process over
if ball is dropped or order is not maintained (time does not stop)
– Baseline data• Trial run
• Quality Officer – Starts the process
by saying “go”– Start process over
if ball is dropped or order is not maintained (time does not stop)
– Baseline data• Trial run
Not good enough! Patients are waiting and getting angry
Need to cut the time in half!
Not good enough! Patients are waiting and getting angry
Need to cut the time in half!
What changes can we make that will lead to improvement?
What changes can we make that will lead to improvement?
Debrief: What did we learn?
Debrief: What did we learn?
TeamnessAim, Goals & Measures
PDSA Cycles
TeamnessAim, Goals & Measures
PDSA Cycles
Teamness Teamness
• Multiple views– which
challenge and surface multiple inferences
• Generative – Build
• Multiple views– which
challenge and surface multiple inferences
• Generative – Build
Measures & GoalsMeasures & Goals
• Measures– Overall time
• Stretch goal –Others
achieved
• Measures– Overall time
• Stretch goal –Others
achieved
Improvement Approaches Improvement Approaches
• Standardization
• Incremental
• Innovation
• Standardization
• Incremental
• Innovation
Source: W. Edwards Deming
Cycles Have Been Going on for YearsCycles Have Been Going on for Years
“Negative results on the fish…Let’s try rubbing two sticks together.”
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 The PDSA cycle provides
the means to apply, adaptand implement the changesAnd ideas.
Rapid Cycle ChangeRepeated Use ofThe Cycle
Rapid Cycle ChangeRepeated Use ofThe Cycle
PA D S
HunchesTheories
Ideas
Changes which result
in Improvement After cycles
have demonstrated
that the change CAN work,
use more cycles to help you figure out
how the change WILL work, every
day
Use of Multiple PDSA cyclesAdapted from The Improvement Guide
PA D S
PA D S P
A D S
Aim: Improve HCAHPS score “% of patients who reported their nurses always communicated well”.
Aim: Improve HCAHPS score “% of patients who reported their nurses always communicated well”.
Use of scripting
Improved
Score
APS D
APS
D
A PS DD S
P A
DATADSP A
Cycle 1A:Develop a script and have one nurse test with one patient.
Cycle 1B:Revise script and test with three more patients.
Cycle 1C: Revise and have nurses on one shift test script with all patients for one week
Cycle 1E: Implement and monitor the feedback
Do
The D cycle The D cycle
Plan
Study Do
The PDSA cycle The PDSA cycle
The PDSA Cycle
Why Test?
The PDSA Cycle
Why Test?
Act Plan
Study Do
Why Test?Why Test?
• Increase the belief that the change will result in improvement in your environment
• Predict 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
• Increase the belief that the change will result in improvement in your environment
• Predict 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
Change and InformationChange and Information
change
denial
anger
bargaining
depression
acceptance
renewal
FACTS
SUPPORT
ENCOURAGEMENT
Source: E. Kubler Ross
How to Test on a Small ScaleHow to Test on a Small Scale
• Test the change on the members of the team that helped developed it before introducing the change to others
• Conduct the test in one facility or office in the organization, or with one patient
• 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
• Test the change on the members of the team that helped developed it before introducing the change to others
• Conduct the test in one facility or office in the organization, or with one patient
• 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
Accelerating Learning and Improvement
Accelerating Learning and Improvement
What can we complete by “next Tuesday”?
You may compromise scope, size, rigor, and sophistication, but the Cycle must be completed by “next Tuesday.”
What can we complete by “next Tuesday”?
You may compromise scope, size, rigor, and sophistication, but the Cycle must be completed by “next Tuesday.”
Act Plan
Study Do
Source: Donald Berwick, MD, IHI
When do we implement?When do we implement?
Current Current SituationSituation
ResistantResistant IndifferenIndifferentt
ReadyReady
Low Low Confidence Confidence that current that current change idea change idea will lead to will lead to ImprovemeImprovementnt
Cost of Cost of failure failure largelarge
Very Small Very Small Scale TestScale Test
Very Very Small Small Scale Scale TestTest
Very Very Small Small Scale Scale TestTest
Cost of Cost of failure failure smallsmall
Very Small Very Small Scale TestScale Test
Very Very Small Small Scale Scale TestTest
Small Small Scale Scale TestTest
High High Confidence Confidence that current that current change idea change idea will lead to will lead to ImprovemeImprovementnt
Cost of Cost of failure failure largelarge
Very Small Very Small Scale TestScale Test Small Small
Scale Scale TestTest
Large Large Scale Scale TestTest
Cost of Cost of failure failure smallsmall
Small Small Scale TestScale Test
Large Large Scale Scale TestTest
ImplemenImplementt
Staff/Physician Readiness to Make Change
Copyright 2008 Institute for Healthcare Improvement and R.C. Lloyd & Associates
Rapid Cycle Improvement Planner
Let’s Try It….Let’s Try It….
• Ask the patient if they have any questions or concerns prior to leaving him/her.
• Offer the patient a blanket, pillow or some other comfort-maker. If medically appropriate, perhaps a drink or snack.
• Have a volunteer specifically trained in customer service round in the waiting room as a patient liaison—running small errands, meeting comfort needs, explaining ED routines (i.e., delays, why others are seen first).
• Hourly rounding by nurses.• Senior leader rounding for outcomes.
• Ask the patient if they have any questions or concerns prior to leaving him/her.
• Offer the patient a blanket, pillow or some other comfort-maker. If medically appropriate, perhaps a drink or snack.
• Have a volunteer specifically trained in customer service round in the waiting room as a patient liaison—running small errands, meeting comfort needs, explaining ED routines (i.e., delays, why others are seen first).
• Hourly rounding by nurses.• Senior leader rounding for outcomes.
If you always do
what you have always done;
You always will get
what you always got!!!
If you always do
what you have always done;
You always will get
what you always got!!!
For more infoFor more info
• Custom Learning Systems
• 1800.667.7325
• www.customlearning.com
• Custom Learning Systems
• 1800.667.7325
• www.customlearning.com