finishing what we started carol haraden, phd this presenter has nothing to disclose. april 11, 2014
TRANSCRIPT
Finishing What We StartedCarol Haraden, PhD
This presenter has nothing to disclose.
April 11, 2014
Coverage and Completeness
Coverage: the improvement has been implemented in every clinical setting that will benefit patients
Completeness: the improvement creates the same superior results in every clinical setting that will benefit patients
How are we doing with this?
What are the barriers?
What helps?
3
4
Think of a change you have implemented.
Have you been able to spread this change everywhere you want? (coverage)
Were you able to sustain the initial improvements at all spread locations? (completeness)
If you answered no to the second or third question, why didn’t your
efforts succeed?
Dialogue #1- 3 minutes
Improvement Hold Gains Spread
Creating a New System
Design Spread
Improvement
Hold Gains
Spread
Old Way
New Way
The Sequence of Improvement
Sustaining improvements and Spreading changes to other locations= coverage and completeness
Developing a change
Implementing a change: spread
Testing a change: prototype, pilot
Act Plan
Study Do
Theory and Prediction
Test under a variety of conditions
Make part of routine operations
How Can We Foster the Adoption of Successful Change Ideas?
The Traditional Approaches
PolicyManual
EmailDate: February 2014
To: All Staff
From: Management
Starting next Monday, all staff will be
expected to implement the new
procedure we just tested in the 3 West
med/surg unit.
It worked there so in order to save time,
everyone will now start doing the new
procedure like 3 West.
Thank you for your
cooperation.
An Early Adopter
Will this be one of your team members?
SEPSIS
Bundle
Clarify “Where” We Spread
What is your level of our ambition?
– Every unit or ward in a hospital?
– Every service line (clinical & operations)?
– Every hospital in a system or region?
– All primary care clinics?
– All inpatient and outpatient mental health?
– All levels of care across a population?
1. Consider the change you discussed in Dialogue #1 OR a change you plan to make in the near future.
2. Identify all of the locations and/or people who will need to make that change. For example: all ORs, primary care practices, med-surgical units
3. Do you have a robust prototype that serves as an example of success? How do you know? If not, STOP HERE!
11Dialogue #2 - 3 minutes
Sustaining improvements and Spreading changes to other locations= coverage and completeness
Developing a change
Implementing a change: spread
Testing a change: prototype, pilot
Act Plan
Study Do
Teams test and improve
Spread planned and executed by senior leaders
Results tracked by front
line and leadership
Improvement
strategic
Focus at Each Step
Sustaining improvements and Spreading changes to other locations= coverage and completeness
Developing a change
Implementing a change fully one clinical area
Testing a change: prototype, pilot
Act Plan
Study Do
Focus: Stabilize process reliability, frontline notice and improve variation: measure outcomes
Focus: spread to new and sustain at previous; frontline notice and improve variation
Focus: Improve process reliability; reduce common cause variation; measure and reflect daily; outcomes when process
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Focus Variation Measure
Testing in prototype and pilot
Process Reliability Frontline notice and manage
-Process daily and reflect daily-Outcomes: unlikely to see change until greater coverage
Implement in one clinical area
-Process reliability under varying conditions-Improved outcomes in clinical area
Frontline notice and manage
-Process daily and reflect daily-Outcomes unlikely to see change until greater coverage
Spread to all relevant areas
-process reliability sustained in previous areas-outcomes improving at scale
-Leadership notice and manage across system-Frontline notice and manage in area
See next slide
How long do we measure?
• Daily till stable• Weekly x 6; if stable then: • Biweekly x 4; if stable then:• Monthly x 4; if stable then • Quarterly, no less
Variation within clinical area? Manage in area
Variation across clinical areas? Leadership investigates and manages
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The Seven Spreadly Sins(If you do these things, spread efforts will fail!)
Step #1 Start with large pilots
Step #2 Find one person willing to do it all
Step #3 Expect vigilance and hard work to solve the problem
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
Consider an example where a change has spread poorly.
Did you commit any of the 7 Spreadly Sins? (see previous
slide)
Which one(s)?
Dialogue #3 - 4 minutes
Maturity Model of Improvement(under development) Steven J. Spear – High Velocity Edge
Level Characteristics
5Leaders lead Leaders actively engaged in leading changes
4Leaders cheer
Systems change organically creating value as they do
3Spectator x3
Systems stabilized; episodic process improvement
2Spectator
Adopting tools and systems
1Buffers
Some standard work
0Chaos
“Winging it”
Maturity Model of Improvement(under development) Steven J. Spear – High Velocity EdgeLevel Characteristics Description “Results”
5Leaders
lead
Leaders actively engaged in leading changes
Leaders work with teams to create improvement in the work areas . Leaders as coaches.
Continuous improvement system throughout organizationNew levels of performance. Breakthroughs attained
4Leaders
cheer
Systems change organically creating value as they do
Local microsystems complete the work and solve problems and improve processes daily. Continuous PDSA cycles.
Pockets of continuous improvementLeaders showcase work of top performersIslands of excellence
3Spectator
x3
Systems stabilized; episodic process improvement
Repeated process re-build “Experts return
Improvement occurs. Staff maintains, but does not continueSporadic good results, many sustained
2Spectator
Adopting tools and systems
Chartered teams, Kaizen’s, redesigns as organizational initiatives. “PI team leaves, project ends”
No improvement beyond initial levelSame projects repeated again and again
1Buffers
Some standard work People in roles standardize their individual work (ex. Charge nurses, chief residents, managers)
Local order, system chaos; People and systems act as buffers. Small improvements –not replicable or sustained“Positive Deviants” lead small workgroups and units
0Chaos
“Winging it” Daily work, daily problems No processes, random variationNo improvement
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• Adopters may need to “reinvent” the interventions.
• Key strategy to get early adopters from decision to
action? Identify issues that are barriers to adoption
and remove
• Goal: coverage AND completeness
• The spread process needs to be managedLangley J. Nolan K. et al. Improvement Guide. Jossey Bass, 2009.
Some Thoughts on Spread
Develop the Measurement and Feedback System
Key Contacts Bill NichollLiz ArmourSG&R - Fiona Gibson
Activity Hand Hygiene Safety Briefings SBARMedicines
ReconciliationAnti Coag
ManagementTrigger Tool Daily Goals SEWS PVC Bundle
Month November November November November November November November November
Clinical/Practice AreaTay Ward PRIEarn Ward PRIRehab Stroke UnitSimpson Day Hospital
Legend ( more than one legend can be entered to display progress eg. Testing & implementing within one month)
Testing TFully Implemented FSpreading SNot yet Measuring NMNot Yet in Place NPNot Applicable NA
Tests Carried Out
Challenges
Successes
Plans for Spread
Perth & Kinross CHP- Spread Plan
Date: November 07Completed by:
Tracking the Spread of Specific Ideas Across Multiple Sites
Pilot 1
Pilot 2
Spread 1
Spread 2
Spread 3
Progress Score 3.5 3.0 2.0 3.0 1.5
A B C D A B C D A B C D A B C D A B C D
VTE Prophylaxis x x x x x
Sepsis x x x x x
Unit Briefings x x x x x
VAP x x x x 0
Hazard Drug/Area # 1 x x x x x
Early Warning System x x 0 0 0
Reconciliation x x x x x
Pressure ulcers x x x x x
Central lines x x x x x
Patient Involvement x x x x x
Simulation x NA
NA
NA
NA
Legend: A= Planning B= Start C= In Progress D= Fully Implemented
Don’t be a slave to the plan!
You will learn a lot that may require a change to your plan
Don’t be frustrated by having to back up and reevaluate - just don’t take forever!
– Change takes longer than you thought!– Some units want the change NOW!– Some never want it!
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Good luck with your journey!
Spreadland