rapid cycle improvement tucson nurses week may...

Powerpoint Templates


Rapid Cycle Improvement

Tucson Nurses Week

May 2012

Diana Lopez, RN, MSN & Jennifer Qualls, RN, MSN

Knowledge Management

Carondelet Health Network

http://www.powerpointstyles.com/



Presentation Objectives

• Define RCI (Rapid Cycle Improvement)

Model for Improvement

• Describe Plan, Do, Study, Act

• Discuss how to set up RCI teams

• Review the change process & common

barriers & resistance to change

• Provide 2 examples of RCI Projects &

lessons learned



What is RCI?

• Applying the recurring sequence of

PDSA (Plan, Do, Study, Act) in a

short period of time to solve a

problem or issue facing the team in

order to achieve a breakthrough or

continuous improvement and realize

results more quickly



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

From: Associates in Process Improvement

Goal Statement

Measures

Ideas

Act Plan

Study Do

PDSA Model for Improvement



Setting a Goal

• Answers and clarifies “What do we

want to accomplish?”

• Creates a shared language for

communicating to others about the

project

• Facilitates conversations &

understanding about the project

within your organization



How Do You Know If Your

Changes Result in Improvements?

MEASURES!

Types of Measures:

• Outcome Measures

– Have we improved the outcomes for our

patients?

– Are the patients having a better experience?

• Process Measures

– Is our work improving outcomes?

• Balancing Measures

– What impact is our improvement work having

on the rest of the system?



Ideas• What changes can we make that

will lead to improvement? What will

lead us to accomplishing our goal?



Determining if the Change is an

Improvement

This work focuses on making changes to systems rather than on measurement but measurement plays a critical role.

• Key measures are required to assess progress toward the aim

• Specific measures can be used for learning during PDSA cycles

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



The PDSA Cycle for

Improvement

PlanAct

DoStudy

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

- 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?


REPEATED USE OF THE PDSA CYCLE

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

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 a

change is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Hold the

Gains

Knowledge & Experience

Rapi

d

Cycle

P

R

O

J

E

C

T

D

I

F

F

I

C

Y

U

L

T

Y


Find Your Champion!



12

Assemble Your Team

CompositionTeam Leader/ Champion

Facilitator

Team member(s)

Helpful hintsMultidisciplinary

Assure leadership support

Include hands-on expertise & variety of skills (example: bedside nurses)

Track progress & celebrate small successes

Clarify roles & responsibilities

Handle conflict constructively & quickly

Maintain core group for consistency



Identify a Problem!

1



Where do you start?

• Examples:

– Improve patient

satisfaction

– Improve Core

Measure Outcomes

– Change the work

environment

– Improve work flow

– Manage time

– Decrease variation

– Eliminate wastes

– Improve systems to

eliminate errors

Determine what you want to change…



Tools to Use with

Rapid Cycle Improvement

• Brainstorming – generating a large number of

ideas about factors contributing to the problem

or issue

• Affinity Diagram – organizing the ideas from

brainstorming into categories/groupings

• Cause & Effect Diagram (Fishbone) – graphic

display of ideas related to the problem or issue

– Generally helps in identifying leverage points

• Flowchart – graphic display of the sequence of

events in a process

– Creating an Actual and Desired flowchart may help in

further defining the Rapid Cycle Improvement objective



Fishbone Diagram



Tips for Success

• Improvement occurs in small steps

• Repeated attempts are needed to test and

implement new ideas

• Assess regularly & improve plan as you go

• Start with changes that are easy to test & likely

to be successful

• Collect and study useful data during each test

• Failed changes = learning opportunities

• Test fast, fail fast, adjust fast (Tom Peters)

• Eventually test over a wide range of conditions



Barriers & Resistance

Barrier - Problems with Teams

Is your leader available and

empowered?

Are you meeting weekly?

Does everyone know their role and

responsibilities?

If you have conflicts, who can help to

resolve them?



Address Conflicts Early




Barrier - Problems with Resources

Suggestions:

Keep your team small at first

Use volunteers and champions

Collect just enough data

Set a dedicated meeting time

Huddle if needed (15 minutes is all you

need!)

Involve senior leadership if resources are

a problem



Barriers & ResistanceBarrier - Resistance : “No one thinks there is a problem”

Take the high ground...

“We’re different”

Share information and challenge assumptions...

“It’s too difficult”

Look at others (internally & externally) that have successfully made a change

Break ideas for change into small components

Present changes as a “test” - that can be accepted, refined, or abandoned

Use just enough data

Post results of the small test from the outset as proof that it can happen

Engage senior leadership



Adapting to Change

Innovators – 2.5%

Early Adopters – 13.5%

Early Majority – 34%

Late Majority – 34%

Laggards – 15%

Identify your Early Adopters

& engage their help




Barrier - Problems with Ownership

Be sure to include all affected areas

Collaborate with staff at all levels

Involve the people that DO the work

Find champions in several disciplines

Keep leaders informed and involved



Examples of CHN RCI Projects

• Glycemic Control: Managing blood sugars in the ICU

• CAP: Administering the correct antibiotics to

pneumonia patients in a timely fashion

• SCIP: Giving surgery patients correct antibiotic & VTE

prophylaxis and removing Foley catheters promptly

• CHF: Completing discharge education for heart failure

patients

• Infection Control: Improving environmental cleaning in

the OR

• Palliative Care: Providing comfort care to patients at

end of life

• Falls: Preventing patient falls

• Customer Service: Improving patient satisfaction in

the Emergency Center

• Quality: Decreasing the time it takes to gather Core

Measure data



Glycemic Control in the ICU

Facility A.• Team Members:

– ICU, lab, pharmacy, IT, and physician

members at Facility A.

• Specific Aim:

– Of all ICU blood glucose values, 80%

or more will be in the optimal range of

60 to 180 mg/dL by Sept 15th, 2011.

• Measure:

– % ICU blood glucose values 60-180

mg/dL


Pilot Blood Glucose Range

10 patient trial, 1:1 RN education

D10W removed,

pt criteria

identified

Unit education,

Hyperglycemia

Audit started

Baseline Period Mean:

77.35%

Pilot Approved

as new Hospital

A. order set

Facility A

Nurse Call

Compliance


Barriers and Resistance

Facility A,• Team leader leaving institution

– Identify new team leader before current

team leader is gone

• Physicians (hospitalists) resistant to

using insulin drips

– Encourage use by demonstrating

reduced hypoglycemia with new orders

– Define patient population ideal for insulin

drip use

– Revise subq insulin orders



Sustainability Plan Facility A

• Nursing Education: one-to-one

remediation for noncompliance on

hyperglycemia audit, reminders at safety

briefs before each shift

• Data Monitoring: blood sugar reports

reviewed weekly with team, posted

weekly in ICU, reported monthly to

administration

• Coaching: designated “coaches” on each

shift for assistance and reinforcement of

education



Glycemic Control Facility B• Team Members:

– ICU, infection prevention, and physician

members at Facility B.

• Specific Aim:– For ICU patients undergoing cardiothoracic

surgery, 80% or more of their blood glucose

values will be in the optimal range of 60 to 180

mg/dL by Sept 15th, 2011.

• Measure:– % ICU blood glucose values 60-180 mg/dL for

ICU patients undergoing cardiothoracic surgery


Optimal Blood Glucose Range

Unit education

completed, new

protocol implemented

Auditing

resumed

Facility B

CHVI Blood Glucose Check

Compliance Data

Concurrent,

100% auditing

began

Auditing

stopped for

protocol

revision

Auditing

resumed



Facility B.

• Maintain high level of compliance

while reducing audit frequency

– Continue to engage glycemic coaches

– Continue providing feedback (data) to staff

• Educate new RNs on insulin drip

protocol

– Include in unit orientation before RN’s first

shift

– Glycemic coaches provide guidance during

first few shifts to ensure understanding



Sustainability Plan

Facility B• Nursing Education: one-to-one

remediation for noncompliance on insulin

drip audit, insulin drip education update

quarterly

• Data Monitoring: compliance reports

reviewed monthly with team, posted

biweekly in ICU, reported biweekly to

administration

• Coaching: designated “coaches” on each

shift for assistance and reinforcement of

education



Lessons Learned

• Buy-in from physicians as well as

nurses is key

• Anticipating and planning for

barriers will help with

implementation in the long run

• Obtaining accurate, timely data

can be an unforeseen barrier



Community Acquired Pneumonia

Antibiotic Selection

• Leverage Point: Physician use of pneumonia order

sets

• Test of Change: Improve ease of access to order

sets. Weekly feed back of order set use to CMO &

physician champions. Robust review of charts that

fall out for antibiotic selection by physician peers.

Antibiotic in 6 Hours

• Leverage Point: Delay in identification of pneumonia

patients entering the EC to the administration of

antibiotic

• Test of Change: Weekly feedback to managers &

nursing staff on antibiotic administered within 6

hours. Education & 1:1 counseling to nursing staff as

needed.



Specific Aim & Measures

AIM

- 100% of Community Acquired

Pneumonia patients will have

appropriate selection & timely

administration of antibiotics by

September 15, 2011

Measures

- Percentage of pneumonia patients

with appropriate selection & timely

administration of antibiotics



Team membersFrom Two Facilities

• Infectious disease physician

• Primary care physicians

• Emergency department physicians

• Staff nurses

• Nurse managers

• Pneumonia core measure abstractors

• Pharmacist

• IT representative


Baseline Data Hospital A.

Best Practice = 94.8% (Dec 2011)

Hosp A. Antibiotic

Selection = 100% (Dec 2011)

Hosp A. Antibiotic

in 6 Hours = 100% (Dec 2011)

Baseline Data

Hospital B.

Best Practice = 100% (Dec 2011)

Hosp B. Antibiotic

Selection = 100% (Dec 2011)

Hosp B. Antibiotic

in 6 hr = 100% (Dec 2011)

Hospital A. Percent of Patients in Whom CAP

Order Sets are Used (weekly)Emergency Center Use

Admissions Use

Meaningful Use BeganData not collected after 8/2011

http://ahstusstat01/eqc/ExecNow.asp?macro=HC_ShowPeriodClass&Class=Admission&Indicator=RCI%20Pneumonia%20Order%20Set%20-%20CSJ&Period=08%2F22%2F11&XID=40776&@&Label=Compare Order%20Set%20Use Performance&@&Window=DetailCard&@&Size=350,425



















Hosp B. Percent of Patients in Whom CAP Order

Sets are Used (weekly)Emergency Center Use Admissions Use

Initiated Robust Review

of Fallouts 4/18/11 Meaningful Use Began

7/4/11


Ease of Access to Pneumonia

Order Set for Physicians

• Place ICON on all

hospital computer

desktops for easier

access to order sets(Completed Sept 2011)

• Improve listing of

order sets




• EC Providers & Admitting Physicians

– Barriers: Physicians do not like using pre-

printed “cook book” order sets. They report

there are barriers to locating order sets on

line.

– Solution:

• Provide evidence via data demonstrating the use

of order sets improves patient outcomes

• Provide education & coaching

• Remove barriers for locating electronic orders




• EC Nursing Staff & Unit Nursing Staff

– Barriers: Nurses worry about additional

tasks but value change when they

understand the benefits.

– Solution:

• Improve communication through timely

feedback of information & data

• Provide education & coaching

– Web based training

– CE packet



Sustainability• Education

– For physicians, nurses, & unit clerks on how

to access preprinted order sets &

components of core measures.

• Data Monitoring

– Monthly reporting of physician use of

preprinted order sets. Reported to CMO’s

– Weekly report to nursing departments on

compliance with antibiotics within 6 hours

• Coaching

– 1:1 Coaching for all physician or nurses

involved in fallouts


Pneumonia STATS: How Are We Doing?

Hospital A

For the week of September 26, 2011

Goal is

100%

http://www.google.com/imgres?imgurl=http://www.windstarembroidery.com/cw2/Assets/product_full/3379_250.gif&imgrefurl=http://www.windstarembroidery.com/Details.cfm?ProdID=3379&usg=__RpaRSd1kXMRTvrslaRawQ14X6x4=&h=391&w=300&sz=23&hl=en&start=62&zoom=1&um=1&itbs=1&tbnid=Pq3SLEHn4r9O2M:&tbnh=123&tbnw=94&prev=/search?q=fleur+de+lis&start=60&um=1&hl=en&safe=active&sa=N&rls=com.microsoft:en-us&ndsp=20&tbm=isch&ei=cWsCTqCQEMTViAK7ooX3BA


Lessons Learned

• Getting someone to collect data is a

challenge

• Weekly feedback to all nursing staff

& managers

• 1:1 follow-up for fallouts by

physicians & nursing managers

• Recognizing early adopters &

shining stars

• Celebrating small victories



Questions?



References• Kendrick, K. et al. Implementing projects using the

rapid cycle approach; JONA; 3/2010; 20 (3):135-

139.

• Valente, S. Rapid cycle change projects improve

quality care; Journal of Nursing Care Quality;

4/2010; 26 (1) 54-60.

• ASQ Quality Press; The public health quality

improvement handbook; 2009.

• Berwick DM. A primer on leading the improvement

of systems.BMJ. 1996;312(9):619-622.

• Kotter JP. Leading change. Harvard Business

Review 2007;85(1): 96-103.


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