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The Improvement The Improvement ModelModel
Chinook Health RegionChinook Health RegionNovember 2, 2005November 2, 2005T. Rollefstad RN BNT. Rollefstad RN BNSafety Improvement AdvisorSafety Improvement AdvisorWestern NodeWestern Node
Purpose of SessionPurpose of Session
– A basic understanding of the A basic understanding of the Improvement ModelImprovement Model
– Templates to use for creating an Templates to use for creating an Improvement Charter and designing Improvement Charter and designing a PDSA Cyclea PDSA Cycle
– A basic understanding of process A basic understanding of process thinkingthinking
– Some new LINGO! (just what you Some new LINGO! (just what you needed)needed)
Why Quality Why Quality Improvement?Improvement?
““Medicine used to be simple, Medicine used to be simple, ineffective & relatively safe. NOW ineffective & relatively safe. NOW medicine is complex, effective & medicine is complex, effective & positively dangerous!”positively dangerous!”
Dr. Syrl 1999Dr. Syrl 1999English PhysicianEnglish Physician
What Quality What Quality Improvement is NOTImprovement is NOT
A work A work harder harder ethicethic
Not a top Not a top down edictdown edict
What is Quality?
Adopted from D. Ballard, Baylor Healthcare Organization
S - SafeT - Timely
E - EfficientE - Effective
E - EquitableP - Patient Centered
It’s a STEEEP Climb to Quality!
What is What is Quality Quality Improvement?Improvement?
It’s about It’s about creating creating smooth smooth effective effective processesprocesses
Problem Solving ProcessProblem Solving Process
Analyze Current Analyze Current Process Process
Improve the Process
Trigger for Improvement
Breakthrough in Knowledge
Breakthrough in Results
Breakthrough in Culture
Maintain Results
Improvement Model
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Plan
Do
Act
Study
Breakthrough in AttitudeAnd Organization
Establish Project
structure
The Improvement The Improvement ModelModel
Three Questions for ImprovementThree Questions for ImprovementAimAimMeasures Measures IdeasIdeas
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act Plan
Study Do
Improvement ModelImprovement Model
What Are We Trying to What Are We Trying to Accomplish?Accomplish? Align aim with strategic goals of the Align aim with strategic goals of the
organizationorganization Write a clear, concise statement of aim Write a clear, concise statement of aim Make the target for improvement bold Make the target for improvement bold
and unambiguousand unambiguous Include deadlineInclude deadline Include what is needed to keep the Include what is needed to keep the
team focused (strategies, patient team focused (strategies, patient populations, scale, scope, constraints)populations, scale, scope, constraints)
Bold Aim, Firm Bold Aim, Firm DeadlinesDeadlines““Some is not a number. Soon is not Some is not a number. Soon is not
a time”a time”
- Donald Berwick, MD- Donald Berwick, MDInstitute for Healthcare ImprovementInstitute for Healthcare Improvement
Components of Aim Components of Aim StatementStatement DirectionDirection
ProcessProcess
MeasureMeasure
TimelineTimeline
Focuses the team Focuses the team on improvementon improvement
Keeps the team Keeps the team on topicon topic
Defines what Defines what success looks likesuccess looks like
Ensures an Ensures an urgency to urgency to continuecontinue
Example of Aim Example of Aim StatementStatement We will endeavour to prevent We will endeavour to prevent
pneumonia in the ICU by implementing pneumonia in the ICU by implementing the VAP protocolthe VAP protocol
Reduce ventilator-associated Reduce ventilator-associated pneumonia (VAP) rate by 50% within pneumonia (VAP) rate by 50% within 12 months. 12 months.
An unclear AIM An unclear AIM statement can lead statement can lead you astray!you astray!
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act Plan
Study Do
Improvement ModelImprovement Model
How Will We Know a How Will We Know a Change Is an Change Is an Improvement?Improvement?
Choose 2-6 measures that are Choose 2-6 measures that are useful and manageable useful and manageable
Include a balanced set of Include a balanced set of measures to avoid sub-measures to avoid sub-optimization optimization
Purpose is for learning not Purpose is for learning not judgmentjudgment
How Will We Know a How Will We Know a Change Is an Change Is an Improvement?Improvement?Include outcome, balancing and Include outcome, balancing and
process measuresprocess measures– Outcome measuresOutcome measures are driven by the are driven by the
specific objectives identified in the AIM specific objectives identified in the AIM statementstatement
– Process measuresProcess measures indicate whether a indicate whether a specific change is having the intended specific change is having the intended effecteffect
– Balancing measuresBalancing measures are related are related measures to understand the impact of measures to understand the impact of changes on the broader systemchanges on the broader system
Example of Example of Measures for VAPMeasures for VAP VAP rateVAP rate Compliance to a bundle Compliance to a bundle Patient/staff satisfactionPatient/staff satisfaction
Balancing MeasuresBalancing Measures One or two of the following:One or two of the following:
– Patient satisfactionPatient satisfaction– Family satisfactionFamily satisfaction– Provider satisfaction Provider satisfaction – Average or median Length of Stay – Average or median Length of Stay –
Hospital, ICUHospital, ICU– Readmission rate within 30 daysReadmission rate within 30 days– Culture of Safety assessments – % of Culture of Safety assessments – % of
staff who report a positive safety climatestaff who report a positive safety climate
What Changes Can We Make What Changes Can We Make That Will Result in That Will Result in Improvement?Improvement? Change packages (starter kits)Change packages (starter kits) Critical thinkingCritical thinking Creative thinkingCreative thinking HunchesHunches Best practicesBest practices Asking process users and subject Asking process users and subject
matter experts for ideasmatter experts for ideas Insight from research and Insight from research and
benchmarkingbenchmarking
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act Plan
Study Do
Improvement ModelImprovement Model
Example of ChangesExample of Changes Care “Bundles” and Care ComponentsCare “Bundles” and Care Components
– Ventilator bundle, Central Line bundle, 7 Ventilator bundle, Central Line bundle, 7 aspects of care for AMI, Medication aspects of care for AMI, Medication Reconciliation, 4 components of SSI preventionReconciliation, 4 components of SSI prevention
Safety huddlesSafety huddles ChecklistsChecklists Order setsOrder sets Daily goal sheetsDaily goal sheets Multidisciplinary roundsMultidisciplinary rounds Protocols/guidelinesProtocols/guidelines Reliable processesReliable processes
What are the 3 What are the 3 questions in the questions in the Improvement Model?Improvement Model?
Your Improvement Your Improvement CharterCharter
Page 1 Improvement Associates Ltd.
Improvement Charter Project Name: Team Members: Team Sponsor:
Purpose of Project
Scope & Boundaries
WHA
T A
RE
WE
TRYI
NG
TO
AC
CO
MPL
ISH
?
Improvement Objectives
H
OW
WIL
L W
E KN
OW
A C
HA
NG
E IS
A
N IM
PRO
VEM
ENT?
Measures
Current Performance 1. 2. 3. 4. 5. 6.
Goals 1. 2. 3. 4. 5. 6.
W
HA
T C
HA
NG
ES C
AN
WE
MA
KE
THA
T W
ILL
RES
ULT
IN
IM
PRO
VEM
ENT?
Change Concepts and Ideas to Test
The Improvement The Improvement Model Model
PDSA Cycles &PDSA Cycles &Principles for Testing a Principles for Testing a ChangeChange
Creating a New SystemCreating a New System
Hold the Gains
Spread
Improvement (test, implement)
Plan:•State objectives•Make predictions•Make conditions explicit•Develop plan
Do:•Carry out the test•Document problems, observations.•Begin analysis
Study:•Complete analysis•Compare data to prediction•What did you learn?
Act:•Adopt, adapt or abandon?•Build knowledge sequentially
Improvement Model - PDSA
3 Principles for Testing 3 Principles for Testing a Change a Change 1.1. Test on a small scaleTest on a small scale2.2. Collect data over timeCollect data over time3.3. Build knowledge sequentially Build knowledge sequentially
and include a wide range of and include a wide range of conditions in the sequence of conditions in the sequence of teststests
Principle 1: Principle 1: Test On a Small ScaleTest On a Small Scale
Small-to-medium Small-to-medium scale testscale test
Very small-Very small-scale testsscale testsMAJORMAJOR
One cycle to One cycle to implementationimplementation
Medium-scale Medium-scale teststestsMINORMINOR
HIGHHIGHLOWLOWCONSEQUENCCONSEQUENCE OF FAILED E OF FAILED
TESTTEST
DEGREE OF BELIEF IN SUCCESS OF DEGREE OF BELIEF IN SUCCESS OF THE CHANGETHE CHANGE
Designing a Small Designing a Small Scale TestScale Test Simulate the changeSimulate the change Have subject matter experts review Have subject matter experts review
the changethe change Test the idea with volunteersTest the idea with volunteers Use 1:1:1 rule – one clinician in one Use 1:1:1 rule – one clinician in one
facility with one patientfacility with one patient Use manual “pencil and paper” data Use manual “pencil and paper” data
collectioncollection Use samplingUse sampling
Designing a Small Designing a Small Scale TestScale Test
If appropriate, test the changes If appropriate, test the changes developed for different parts of a developed for different parts of a system separatelysystem separately
Conduct the test over a short time Conduct the test over a short time period– what COULD we do by next period– what COULD we do by next Tuesday?Tuesday?
Incorporate redundancy in the test by Incorporate redundancy in the test by making the change side-by-side with making the change side-by-side with the existing processthe existing process
ExamplesExamples Educate next 5 patients on importance of Educate next 5 patients on importance of
“medication cards”“medication cards” Incorporate safety huddle with volunteers Incorporate safety huddle with volunteers
on Monday morning at 9:00on Monday morning at 9:00 Borrow a clipper from another unit before Borrow a clipper from another unit before
purchasingpurchasing Ask for feedback from 1 daytime nurse and Ask for feedback from 1 daytime nurse and
1 nighttime nurse on head of bed 1 nighttime nurse on head of bed education materials education materials
Try smoking cessation counseling on next Try smoking cessation counseling on next patient being dischargedpatient being discharged
Principle 2: Principle 2: Collect Data Over TimeCollect Data Over Time
Before & After Tests
0
1
2
3
4
5
6
7
8
9
Week 4 Week 11
Cyc
le T
ime
Make Change
63% Improvement
3
8
Case 1
0
2
4
6
8
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week
Cyc
le T
ime
Make Change
Case 3
0
2
4
6
8
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Weeek
Cycl
e Ti
me
Make Change
Case 5
0
2
4
6
8
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week
Cycl
e Ti
me
Make Change
Example of Annotated Example of Annotated Run ChartRun Chart
0
10
20
30
Jul/02 Aug/02 Sep/02 Oct/02 Nov/02 Dec/02 Jan/03 Feb/03 Mar/03 Apr/03 May/03 Jun/03 Jul/03
Rat
e
%/1000 catheter-days HDM %/1000 catheter-days Ottawa
Coatedcatheter
Tracking sheetongoing
Education, information,expert
Audits &interventions
Catheter Infection Rate
Principle 3:Principle 3:
Build Knowledge Build Knowledge Sequentially Sequentially Include a Wide Range Include a Wide Range of Conditions in the of Conditions in the Sequence Sequence of Testsof Tests
Sequential Building of Sequential Building of KnowledgeKnowledge
BreakthroughResults
Theories, hunches, best practices & Change Concepts
Learning and improvement
A PS D
Evidence & Data
A PS D
A PS D
A PS D
Example of “Ramping Example of “Ramping PDSA ‘s”PDSA ‘s”
P
S D
A
P
S D
A
P
S D
A
P
S D
A
Change Concepts:Institute a Medical Emergency Team
Cycle # 1 – Create awareness of MET concept with ICU Nurses through poster boards posted for 1 week.
Cycle # 3 – Develop draft “roles and responsibilities” for MET nurse and get feedback from front-line nurses
Cycle # 2 – Create awareness of MET with medical unit nurses. Poster on 1 unit for 2 weeks.
Cycle # 4 – Revise “roles and responsibilities” and get feedback from patient care managers and other stakeholders
Cycle # 6 – Send draft list of MET bag contents and equipment for review
Cycles # 7 – Tested bag with new contents and process for updating the contents
Cycle # 8 – Develop daily log to continually update contents. Assign responsibility.
Cycle # 9 – Develop nursing checklist for MET
P
S D
A P
S D
A
P
S D
A P
S D
A
P
S D
A P
S D
A
P
S D
A P
S D
A
Change Concepts:Institute a Medical Emergency Team
Cycle # 1 – Create awareness of MET concept with ICU Nurses through poster boards posted for 1 week.
Cycle # 3 – Develop draft “roles and responsibilities” for MET nurse and get feedback from front-line nurses
Cycle # 2 – Create awareness of MET with medical unit nurses. Poster on 1 unit for 2 weeks.
Cycle # 4 – Revise “roles and responsibilities” and get feedback from patient care managers and other stakeholders
Cycle # 6 – Send draft list of MET bag contents and equipment for review
Cycles # 7 – Tested bag with new contents and process for updating the contents
Cycle # 8 – Develop daily log to continually update contents. Assign responsibility.
Cycle # 9 – Develop nursing checklist for MET
This team has conducted over 30
PDSA Cycles in less than 6 months.
PredictionsPredictions
““It is not enough to determine that It is not enough to determine that a change resulted in improvement a change resulted in improvement during a particular test…you will during a particular test…you will need to predict whether a change need to predict whether a change will be an improvement under will be an improvement under different conditions in the future”different conditions in the future”Langley, et al. Langley, et al. The Improvement GuideThe Improvement Guide
Elements of the PDSA Elements of the PDSA CycleCycle
Plan:•State objectives. •Make predictions•Make conditions explicit.•Develop plan (5 W’s, How)
Do:•Carry out the test.•Document problems, surprises, and observations.•Begin analysis.
Study:•Complete analysis, synthesis•Compare data to predictions.
•Record under what conditions results be could different.
•Summarize what was learned.
Act:•Adopt, adapt or abandon based on what was learned.•Build knowledge into next PDSA Cycle
Your PDSA CycleYour PDSA Cycle
Page 1 Improvement Associates Ltd.
PDSA Cycles Project Name: Cycle #: Objective of this Cycle:
PLAN
What change are we testing? What is our prediction and theory? Details of the plan (who, what, where, when and how).
DO
Carry out the plan. Record data and observations.
STU
DY
Complete analysis and synthesis. Do the results agree with the predictions? Under what conditions could the results be different? Summarize new knowledge.
ACT
What action are we going to take as a result of this cycle (Adopt, Adapt or Abandon)? Are we ready to implement? What other processes or systems might be affected by this change?
Objective of Next Cycle
Why Test?Why Test? Increase belief that a change will result in Increase belief that a change will result in
improvementimprovement Document how much improvement can Document how much improvement can
be expectedbe expected Learn how to adapt changes to local Learn how to adapt changes to local
conditionsconditions Evaluate costs and effects of the changeEvaluate costs and effects of the change Minimize resistance upon implementationMinimize resistance upon implementation
““Failed” TestsFailed” Tests Expected and importantExpected and important Reasons for “failed” tests Reasons for “failed” tests
– Change not executed wellChange not executed well– Support processes inadequate Support processes inadequate – Hypothesis/hunch/theory not useful for conditionsHypothesis/hunch/theory not useful for conditions– Change executed but did not result in local Change executed but did not result in local
improvementimprovement– Local improvement did not impact safety or Local improvement did not impact safety or
specific aims in the Charterspecific aims in the Charter Collect data during the Do Phase of the Cycle to help Collect data during the Do Phase of the Cycle to help
distinguish between these different reasons.distinguish between these different reasons.
Testing and Testing and ImplementationImplementationDifferencesDifferences:: Testing is temporary, implementation Testing is temporary, implementation
is permanentis permanent Support processes Support processes Expectations of failureExpectations of failure Social impacts and resistanceSocial impacts and resistance Balancing measuresBalancing measures
Example ResultsExample Results
CVL Bloodstream Infection Rates-PICU
05
101520253035
Sep Oct Nov Dec Jan Feb Mar
Month
Rat
e pe
r 10
00 C
VL
-day
s
Monthly rateCumulative rate
ResourcesResources
ContactsContactsMarlies van DijkMarlies van DijkWestern Node LeaderWestern Node Leader403.297.8187403.297.8187westernnode@[email protected]
Tanis RollefstadTanis RollefstadSafety Improvement Advisor Safety Improvement Advisor Western NodeWestern Node403.297.8187403.297.8187Tanis.rollefstad@[email protected]
Bruce HarriesBruce HarriesDirector, Canadian ICU CollaborativeDirector, Canadian ICU CollaborativeImprovement Associates LtdImprovement Associates [email protected]@telus.net
AcknowledgementsAcknowledgementsThe Improvement Model was The Improvement Model was developed by developed by Associates in Associates in Process Improvement (API)Process Improvement (API) and has been used by thousands and has been used by thousands of healthcare and industry teams of healthcare and industry teams around the world. around the world.
Team Plan AssignmentTeam Plan Assignment Break out into groups as outlined Break out into groups as outlined
by Lilaby Lila Each group has a case scenarioEach group has a case scenario Develop an AIM statement for the Develop an AIM statement for the
case scenariocase scenario– Direction, process, measure, timelineDirection, process, measure, timeline
Pick a spokesperson to report outPick a spokesperson to report out
PDSA AssignmentPDSA Assignment Remain in your groupsRemain in your groups From your AIM Statement, From your AIM Statement,
develop one test of change develop one test of change Complete the PDSA form to Complete the PDSA form to
ensure all aspects of plan outlinedensure all aspects of plan outlined What are some measures for your What are some measures for your
AIM and PDSA cycle?AIM and PDSA cycle? Pick a spokesperson to report outPick a spokesperson to report out
