Model For ImprovementMFI

Improvement Guide, Chapter 1, p.24

Appendix C, p. 454

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

Model for Improvement

Act Plan

Study Do

What are we trying to accomplish

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study DoImprovement Guide, Chapter 1, p.24

Appendix C, p. 454

AIM

Some is not a number, soon is not a time

Recommended elements in an aim statement

What is expected to happen The timeframe for accomplishing the aim The system to be improved The patient population that change

process is going to be applied to How much/by when

Example of Aim statement

Has it met the qualities of a good aim?

• What is expected to happen

• The timeframe for accomplishing the aim

• The system to be improved

• The patient population that change process is going to be applied to

• How much/by when

Example 1

We aim to reduce the average length of stay for >64 year old (and >54 year old Maori and Pacific) hip fracture patients from 22 days to 19 days by the 30th of June 2013.

Example 2

The aim of this project is to keep the people well in community by increasing the number of patients with chronic respiratory condition enrolled into Better Breathing (pulmonary rehabilitation) Programme (BBP) from 60 to 250 per year by June 30th 2013

Breakout – Aim statement

Improvement Guide, Chapter 1, p.24

Appendix C, p. 454

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

Act Plan

Study Do

MEASURES

Measurement

“Crude measures of the right things are better than precise measures of the wrong things.”

“Improvement strategy: More frequent samples (over time) of ‘good enough’ measures”

Roles of measurement

Key measures are required to assess team’s progress against the aim

Balancing measures are required to ensure that improvement in one part of the system does not cause damage in another area

Data (including from patients and staff) can be used to focus improvement and refine changes

Specific measures can be used doing PDSA cycles to inform future cycles

Methods of Measurement

• Chart review

• Observation of behaviour

• Surveys

• Questionnaires

• Coding data

• Checklists

Measurement guidelines

To answer: “How will we know that a change is an improvement?” usually requires more than one measure:

1. A balanced set of a few (3 – 8) key measures

2. Integrate measurement into the daily routine

3. Think about balancing, process and outcome measures (be careful about overdoing process measures)

4. Plot the data in a time series

Improvement Guide, Chapter 1, p.24

Appendix C, p. 454

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

Act Plan

Study Do

Developing Change

All Improvement requires

change, but not all changes

result in improvement

How do we develop fundamental change that will result in improvement?

What is a Theory?

• A description of our best understanding about why things are the way they are

•What are some theories?

• Biology – Theory of Evolution

• Physics – Theory of General Relativity

• Economics – Game Theory

• Psychology – Maslow’s Theory of the Hierarchy of Needs

Driver Diagram - a tool to visualize our Theory

A driver diagram is an approach to describing our theories of improvement:

• Used to help organize our theories and ideas in an improvement effort.

• The initial driver diagram for an improvement project might lay out the descriptive theory of improved outcomes that can then be tested and enhanced to develop a predictive theory.

•The driver diagram should be updated throughout an improvement effort and used to track progress in theory building.

Improvement Guide, p.429-431

Conceptual Driver DiagramOutcome 1⁰ driver 2⁰ driver Change Concepts Specific Change Ideas

Aim or Outcome

1⁰ driver 1

1⁰ driver 2

2⁰ driver 3

2⁰ driver 2

2⁰ driver 1

2⁰ driver 4

2⁰ driver 5

Concept 1

Concept 2

Concept 4

Concept 3

Concept 5

Concept 6

Ideas:123456789......N

CauseEffectDrivers

To reduce preventable

complications and ALOS

associated with early onset

confusion for patients 65+ on

Ward 4

Identification

Intervention

Assessment

Change Concepts Specific Change Ideas

Measures:CAM completionCAM documentation1. Complications2. ALOS3. Readmission4. Mortality

HOP- Delirium identification / ManagementDriver Diagram-v3.0Date: 11 June2012

Primary Drivers Secondary Drivers

Management

Delirium guidelines

Documentation

Discharge planning

Assessment frequency for

CAM tool

Appropriate use of CAM tool

Timeliness

Resource

Assessment on presentation

Staff awarenessEducate

Pt Watch

Medication

Pt safety interventions

Hand over to GP/Service

Discharge location

Care in place

Delirium as diagnosis in EDSInformation exchange

iPMS flagging

Intervention checklist

Introduce Ward champion

Family involvement

MDT

CAM tool audit

CAM lit search

Review CAM format

standardisation

CAM run one each shift

Educate family

concept

Family questionnaire

Family Feedback

Outlier Pt

Review education package

Educate

Ownership

iPMS flagging at presentation

Move to Home

Usable

Tertiary Drivers

Education Information on admission/Discharge

Symbol for Delirium on patient

Where ideas come from

Outcome 1⁰ driver 2⁰ driver Change Concepts Specific Change Ideas

Aim or Outcome

1⁰ driver 1

1⁰ driver 2

2⁰ driver 3

2⁰ driver 2

2⁰ driver 1

2⁰ driver 4

2⁰ driver 5

Concept 1

Concept 2

Concept 4

Concept 3

Concept 5

Concept 6

Ideas:123456789......N

Where ideas come from:1.Medical Literature2.Websites like www.ihi.org3.Team members who have innovative thoughts about what to do differently4.Structured Creativity Sessions (use of change concepts, provocations, random entry, etc.)5.Other Teams6.Improvement Advisors

Breakout – Developing Change

Outcome 1⁰ driver 2⁰ driver Change Concepts Specific Change Ideas

Aim or Outcome

1⁰ driver 1

1⁰ driver 2

2⁰ driver 3

2⁰ driver 2

2⁰ driver 1

2⁰ driver 4

2⁰ driver 5

Concept 1

Concept 2

Concept 4

Concept 3

Concept 5

Concept 6

Ideas:123456789......N

Improvement Guide, Chapter 1, p.24

Appendix C, p. 454

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

Act Plan

Study DoTesting

Science behind PDSAHypothesisPredictionExperimentEvaluate/Analysis

Scientific Method Build on previous knowledgeAcquire/generate new knowledge

1939

Step 1- Design, Step 2 – Produce, Step 3 - Sell was converted to a circle with aforth step added: Step 4 - Redesign through marketing research.

1939

Act Plan

Check Do

1951 1986

1993

The Plan-Do-Study-Act Cycle

PlanAct

DoStudy

- Objective- Questions and predictions (Why?)- Plan to carry out the cycle(who, what, where, when)- Plan for Data collection

- Carry out the plan- Document problems and unexpected observations- Begin analysis of the data

- Complete the analysis of the data - Compare data to predictions - Summarize what was learned

- What changes are to be made?

- Next cycle?

Improvement Guide, Chapter 5, p. 97

Most Important Part of a PDSA cycle

Because with out it we don’t have a comparison for the purpose of learning -

Why prediction?

Prediction combined with a learning cycle interrogates our understanding of a system.

It reveals gaps in our knowledge and provides us a starting place for growth.

Without it our learning is accidental at best but with it we are able to direct our efforts toward building a more complete picture of how things work in the system.

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

Improvement Guide, Chapter 7, p. 146

The work of improvement

Primary Driver 1

Change Idea 1

Change Idea 2

Change Idea 3

Primary Driver 2

Change Idea 1

Change Idea 2

Change Idea 3Primary Driver 3

Change Idea 1

Change Idea 2

Change Idea 3

Goal Discharge Date

Establish GDD & Daily Review

Pt awareness on GDD

Staff awareness on GDD

Check consultant aware of GDD in mind

Doc to use care plan to review GDD-Ruth/Michele 5/12

Is the GDD documented on care plan?

GDD mentioned in notes

# of clinical directors believe in establishing GDD

GDD given to surgical pt and any plans documented

Pt awareness on GDD-Surgical

Prediction: GDD will improve the patient experience and efficiency. Also this will reduce the LoS

To have a standardised process to provide each patient with a GDDHow and what is the best way to establish a GDD?

To have a standardised process to share GDDBest way to communicate the GDD to patient and interested parties?

Aim: To improve the number of inpatients having GDD from 0% to 100% alsoTo increase the number of inpatients achieving the GDD for from 0% to 100% by July 2013.

Achieving the GDD

To have the processes in place to achieve the GDDHow can we achieve the GDD as a team

Sharing GDD

Patient & Family

Drs

Staff

Other Services

Update GDD on white board

Update GDD on WiMS

DOC to use care plan for updated GDD info

Nurse to inform Pt-Ruth

Ascertain ref process in ward 6

Delay in x-fer to AT&R

Referral system assessment & documentation from acute to AT&R

Early Dx if Pr referred to NASC earlier

E-referral – Erin 5/12

Timely task referral

GDD in MDT meeting

Nurse setting the GDD

GDD match with actual Dx date

Reasons of Pt waiting on Bed

CAT tool to indentify why Pt waiting

CAT tool usefulness

Post ward round delay in services for Pt > 7 days

Pt less than 48 hour

Repeat PDSA

Active PDSA

Adopt

Adapt

Abandon

What's Happening

Who, How, When?

Transition of CarePDSA TreeDate: 27/11/2012 Reviewed 27/02/2013

PDSA box

Identifying Pt need @ admission in EC(Ajay Kumar/ Fionna W)

Staff to set a GDD based on the top 10 DRGs-Michele 5/12

GDD by Doc post acute ward round – Brian 17/12

Reason of GDD not met-Ruth& Michele 12/12

Cultural Support to inform – Maika/Ian 23/12

Doc reviewing /confirming GDD-Ajay 5/12

What ref system are available in service dir.

Identifying Pt need @ admission in EC 4 pts(Ajay Kumar/ Fionna W) 13/1

Microsoft Word Document

GDD in ward 33Janene & Michele 23/1

Discharge to HHC

Process MapJanene/Michele 23/1

Known patient dx communication to HHC Owner: Prem Kumar

HHC to receive Dx list twice daily

Repeat with interventions 10/5

Transitions of Care

PDSA Tree

Dx ChecklistClivena/Helen10/4

Visual Display of GDD-Surgical

Test the checklist for ref to DN 27/3 Surgical

Add time of DxSurgical-17/4

To attend CN meeting

Dx Summary

??

GDD orientation to HO rotation

17/4

Checklist/Process map in notes 17/4Fionna

GDD assigned in EC-Fionna17/4

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

Act Plan

Study Do

Every morning find the right colour socks with in 5 seconds

* Right Colour Right Socks * Time to find the socks * The mess created * My satisfaction* * After wash placement time

• On your table there is a stack of index cards with numbers written on them

• Give these to 8 people around your table

• Each of you has now been assigned a number – you can find your number by locating the middle number on your card (i.e. if your card says 1-4-8, then you are number 4)

Break out Exercise

• Your current process involves tossing the tennis ball provided from person to person, following the sequence provided on the index cards (i.e. Person 1 tosses to Person 4 who tosses to person 8 and so on, until the ball returns to person 1)

• Assign a time keeper/ball drop counter (preferably not a ball tosser)

• Practice your process one time – Time keeper please time how long the team takes to complete the process and the number of times they drop the tennis ball

Break out Exercise

• Team Aim: We aim to reduce the time taken for every person to touch the ball from X to Y. We also aim to reduce our ball drops from A to B.

• Form a theory, come up with change ideas, use the MFI to test those ideas

•Rules:

• The initial sequence as provided by the cards must be adhered to

• You may only test one change idea at a time

Break out Exercise

Cycle Change Idea Time Ball Drops

1

2

3

4

5

6

7

8

Break out Exercise