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