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Copyright © Institute for Healthcare Improvement
First PDSA CyclesImprovement
Advisor ProgramNES IA Wave 33
Wednesday,26th March 2014
2:00 – 3:30 pm, GMT
Call time amended due to US daylight savings time start.
Copyright © Institute for Healthcare ImprovementSlide 2
Please Check In IA Wave 33:
IA IA IA
April MassonEYC – East Ayrshire CPP
Gavin RussellEYC – East Renfrewshire CPP
Michelle AffleckEYC -NHS Greater Glasgow and Clyde
David MaxwellHealthcare Improvement Scotland
Graham MacKenzieEYC – NHS Lothian
Michelle CochlanEYC - Perth
Dawn MossEYC – NHS Borders
Hamish FraserEYC – Midlothian CPP
Penny BondHealthcare Improvement Scotland
Derek KildayScottish Government
Judith CainEYC – North Lanarkshire Council
Sacha WillEYC – Aberdeen City Council
Diana BeveridgeScottish Government
Kerstin JornaEYC – Dundee City Council
Sally HallNHS Scotland
Donna MurrayEYC – City of Edinburgh Council
Kirsty EllisHealthcare Improvement Scotland
Shalani RaghavanScottish Government
Eileen McGinleyNHS Lanarkshire
Marie-Claire StallardEYC – East Dunbartonshire CPP
Stephanie FrearsonNHS Ayrshire & Arran
Emma LevyNHS Education Scotland
Marsha ScottEYC – West Lothian Council
Stephanie MottramNHS Dunfries and Galloway Royal Infirmary
Gareth AdkinsHealthcare Improvement Scotland
Michele DowlingEYC – South Lanarkshire Council
Wendy TonerEYC – NHS Greater Glasgow and Clyde D
Copyright © Institute for Healthcare Improvement
N
1. NHS Ayrshire & Arran
2. NHS Borders
3. NHS Dumfries & Galloway
4. NHS Fife
10. NHS Lothian
9. NHS Lanarkshire
8. NHS Highland
7. NHS Greater Glasgow & Clyde
6. NHS Grampian
5. NHS Forth Valley
14. NHS Western Isles
13. NHS Tayside
11. NHS Shetland
12. NHS Orkney
12
3
45
6
7
8
9
10
11
13
14
12
15. Golden Jubilee National Hospital
D
Copyright © Institute for Healthcare ImprovementSlide 4
IA Program Faculty and Staff Team: NES Wave 33
Lloyd ProvostFaculty WS3
NHS Education for Scotland
Dr. Robert LloydLead Faculty
Brandon BennettFaculty WS1
IHI Faculty and Staff
Beth O’DonnellProgram Mgr.
B
Sandy MurrayFaculty WS2
Debbie RayFaculty/Director
Dr. Lesley Anne SmithQI Programme Director
Dr. Elaine PacittiEducational Projects Mgr.
Louise CavanaghQI Project Officer
Samantha SmithQI Administrator
Copyright © Institute for Healthcare ImprovementSlide 5
IHI Support Staff for Wave 33
Brian Sanderson,
Project Assistant
bsanderson@ihi.
org
Tom Charlton,
Project Assistant
tcharlton@ihi.org
Copyright © Institute for Healthcare ImprovementSlide 6
IA Graduates and Their Role during the Program
Bernadette McCullochScottish Patient Safety Programme
Maternity & Children Quality
Improvement Collaborative
IA Wave 28
Laura AllisonDG Health and Social Care
Scottish Government
IA Wave 15
Assist your professional development by serving as teacher, coach,
and fellow learner.
B
Copyright © Institute for Healthcare ImprovementSlide 7
Agenda – 26th March 2014 – “PDSAs
Time Agenda Lead
2:00 pm GMT Welcome and Check-In Debbie
2:10 pm GMT Paired Charter Reviews – Assignment Revisited and Insights from the Exercise
Debbie
2:15 pm GMT Paired PDSA Review AssignmentPreparation for SPC Assignment and upcoming WebEx on SPC 23rd April 2014
Debbie
2:25 pm GMT Presentation of PDSA Cycles 10 min each-learning from each other, questions, insights: Michelle Cochlin, Marie-Claire Stallard, Penny Bond
Bob
3:00 pm ET Accelerating the Rate of ImprovementCascading Driver DiagramsDriver Diagram Priority Setting
Bob
3:25 pm ET Additional Questions/ Next Steps Debbie
Copyright © Institute for Healthcare ImprovementSlide 8
Reminder: Paired Charter Review Due Friday, 21st March 2014
The purpose is to review a colleague’s Project charter offering feedback for improvement and to receive feedback or improvement on your Project Charter.
1. Post your updated Project Charter to your Extranet homepage under Newest Resources tab.
2. Send an email to your partner letting them know that you have posted your Charter.
3. Use the Charter Feedback form as a guide and the skills learned during IA Workshop 1 to offer feedback for improvement to your partner. You can send your feedback in an email or make edits to the Posted Charter making sure to save it as a separate document, leaving your partner’s original Charter intact.
Copyright © Institute for Healthcare ImprovementSlide 9
Charter Review Pairings
April Masson David Maxwell
Dawn Moss Derek Kilday
Diana Beveridge Donna Murray
Eileen McGinley Emma Levy
Gareth Adkins Gavin Russell
Graham MacKenzie Hamish Fraser
Judith Cain Kerstin Jorna
Kirsty Ellis Marie-Claire Stallard
Marsha Scott Michele Dowling
Michelle (Shelly) Afflect Michelle Cochlan
Penny Bond Sacha Will
Sally Hall Shalani Raghavan
Stephanie Frearson Stephanie Mottram
Wendy Toner
Copyright © Institute for Healthcare ImprovementSlide 10
Insights Conducting the Charter Review
1. How did you give feedback to your partner – email, notes on
their charter, completed the Charter Feedback Form?
Email Notes on Charter Feedback Form
2. What did you find useful about the Charter Feedback Form?
3. What did you learn about your own project as the result of
reviewing your partner’s charter?
4. If you did not conduct your Paired Charter Review, what was
the barrier – partner didn’t have a Charter posted, I didn’t
understand the assignment, I couldn’t find time to do the
assignment?
No Charter Posted Didn’t Understand No Time
Copyright © Institute for Healthcare ImprovementSlide 11
IA ---PDSA Review Assignment
Purpose: Learn about, and provide
feedback related to PDSA cycles Time estimate: 20 minutes & 4 Easy Steps!
1. Make sure you have your next PDSA cycle posted to your
Extranet team page.
2. Check to see who you are paired with (next slide).
3. Review your colleague’s most recent PDSA cycle using PDSA Cycle Feedback Form by making comments right on the Feedback Form (Extranet –> Resources –> Forms –> PDSA Cycles).
4. Send an email to your colleague with the Feedback Form attached and copy Brian Sanderson at bsanderson@ihi.orgby Thursday, 3rd April 2014.
Copyright © Institute for Healthcare ImprovementSlide 12
Paired PDSA Review Assignment
Wendy Toner David Maxwell
Stephanie Mottram April Masson
Derek Kilday Stephanie Frearson
Shalani Raghavan Dawn Moss
Diana Beveridge Sacha Will
Sally Hall Donna Murray
Michelle Cochlan Eileen McGinley
Penny Bond Emma Levy
Michelle Dowling Gareth Adkins
Graham MacKenzie Marie-Claire Stallard
Michelle (Shelly) Afflect Gavin Russell
Kirsty Ellis Hamish Fraser
Judith Cain Kerstin Jorna
Marsha Scott
Copyright © Institute for Healthcare ImprovementSlide 13
SPC Software Call: Set Up
Next WebEx: Wednesday, 23rd April 2014, 3:00 –5:00 pm GMT (Note this call is 2 hours)
Prior to this call: Email Brian Sanderson bsanderson@ihi.org
to let us know which SPC software you have decided to use. We need this information from each of you. We’re assuming QI Charts but need to verify successful installation.
We will send a prompting email to which you can reply with this information.
Copyright © Institute for Healthcare ImprovementSlide 14
SPC Software Call: Set Up (cont.)
We will post to the Extranet (Resources-Action Period Materials-SPC Assignment):
An Excel database with data and an assignment to build:− a run chart and− a Shewhart control chart using your software and this
data− You do not need to know Control Chart theory to
complete this assignment. You’ll be getting familiar with the Excel macro QI Charts.
Please post your completed run and Shewhart control chart to your home page (chart imported to PowerPoint or Word) No later than Wednesday, 16th April 2014. Please title your document with your name Wave 33 SPC Assignment Run or Shewhart Chart& date.
Copyright © Institute for Healthcare ImprovementSlide 15
Appreciation
of a System
Understanding
Variation
Building
KnowledgeHuman
side of
change
First PDSA Cycle Sharing!
IG Ch. 4, p. 77
Copyright © Institute for Healthcare Improvement
CHAPTER 7 TESTING A CHANGE
“Testing changes builds knowledge about the causal mechanisms at work in a system. A process of building knowledge emphasizes the importance of rational prediction. If during testing a prediction is incorrect, the theory that was used to generate the prediction must be modified.”
p. 140
Copyright © Institute for Healthcare ImprovementSlide 17
Our Observations
Confusion about purpose of the cycle versus overall Aim
Test is a small change to the system
All PDSA cycles collect data—that doesn’t make it the purpose of the cycle
Qualitative data may be all you can get at first
What questions are you trying to answer?
Theory & Predictions required
Scale-sometimes a test is too big! 1: 3: 5: All
Record what happened (documentation)
Study-many didn’t go back and make sure each question/prediction had an answer in the study
Act-plan the next cycles
Test under different conditions
Copyright © Institute for Healthcare ImprovementSlide 18
The PDSA-o-meter!How Many PDSAs since WS 1?
0
1
4
3
2
5
6 or more
Copyright © Institute for Healthcare ImprovementSlide 19
IG page 24
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
Used with permission: Associates in Process Improvement
The activity was planned, including a plan for collecting data.
The plan was attempted.
Time as set aside to analyze the data and study results.
Action was rationally based on what was learned.
IG page 97
Copyright © Institute for Healthcare ImprovementSlide 20
Repeated Use of the PDSA Cycle
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
Very Small
Scale Test
Follow-
up Tests
Wide-Scale
Tests of
Change
Implementation
of Change
How will we know that a
What change can we make that
What are we trying toaccomplish?
change is an improvement?
will result in improvement?
Model for ImprovementReduce Per-op harm by 30%
Peri-op Harm Rate
DVT Prophylaxis
Beta Blockade Prop
SSI interventions
Use clippers
Instead of
Shaving site
Copyright © Institute for Healthcare ImprovementSlide 21
Successful Cycles to Test Changes
Plan multiple cycles for a test of a change:
Think a couple of cycles ahead
Initially, scale down size of test (# of patients, clinicians, locations)
Do not try to get buy-in or consensus for test cycles
Test with volunteers
Use temporary supports to facilitate the change during the test
Be innovative to make test feasible
Collect useful data during each test
In latter cycles, test over a wide range of conditions
IG-p.143
Copyright © Institute for Healthcare ImprovementSlide 22
Use a Concept Design:Multiple PDSA Cycle Ramps
Triage Diagnostic
TestingFast Track
Patients
Capacity /
Demanding
Flow Change Concepts
Copyright © Institute for Healthcare ImprovementSlide 23
Act Plan
Study Do
Act Plan
Study Do
MODEL FOR IMPROVEMENT DATE __________
Objective for this PDSA Cycle:
Is this cycle used to develop, test, or implement a change?
What question(s) do we want to answer on this PDSA cycle?
Plan:
Plan to answer questions: Who, What, When, Where
Plan for collection of data: Who, What, When, Where
Predictions (for questions above based on plan):
Do:
Carry out the change or test; Collect data and begin analysis.
Study:
Complete analysis of data; Compare the data to your predictions and summarize the learning
Act:
Are we ready to make a change? Plan for the next cycle
Short
form:
We have different PDSA Forms on Extranet:
Copyright © Institute for Healthcare ImprovementSlide 24
Long
form:
Copyright © Institute for Healthcare ImprovementSlide 25
Wave
28
Tested
Form:
Copyright © Institute for Healthcare ImprovementSlide 26
As we listen to our colleagues-let’s add value!
What could improve this PDSA cycle?
Size? Complexity? Questions? Predictions? Plan?
What did you learn that will help you with your future PDSA cycles?
Copyright © Institute for Healthcare ImprovementSlide 27
Michelle C., Marie-Claire, and Penny
Marie-Claire
Stallard
East Dunbartonshire
Council
Preschool Referrals
Michelle Cochlin
Perth and Kinross
Council
Bedtime Reading
Enrichment for
Vulnerable Children
Penny Bond
Health Improvement
Scotland
Identification and
Management of
Delirium
Copyright © Institute for Healthcare ImprovementSlide 28
28
Cascade
of
Building a
Learning
What system are you trying
to improve?
The key question, however, is do you fully
understand the complexity of these
systems and which aspects of the system
you want to improve?
You need to start drilling down from the…
Macro
Meso
Micro levels and build a cascade.
Most
cascades
start at the
top!
And,
trickle
downward…
A typical top-down cascade
Board &
CEO
Sr VPS &
VPs
Departments/Staff/Patients
Departments/Units/Wards/Service
Lines
The Big Dots
Mesosystem
Macrosystem
Microsystem
Which way does (should) your
cascade flow?
Top Down?
Bottom Up?
Spread from
the Middle?
IOM Chasm Report Chain of Effect
(it all starts with the patient)
1. Patient (start here)
2. Physician
3. Clinical Unit/Microsystem
4. Clinical Service Line/Mesosystem
5. Health System/Macrosystem
Information System Design Principle: Capture data at lowest level and
aggregate up to higher levels for cascading metrics throughout system.
Think about reversing the
cascade!
Inverted
Pyramids
Traditional
Pyramids
Adapted from the work of Dr. Gene Nelson, Dr. Paul Batalden and Marjorie Godfrey
Quality By Design: A Clinical Microsystems Approach, Jossey-Bass, 2007.
So, think about building an inverted pyramid
Micro: Patient & the provider of
care
Meso: Clinical Units,
Departments and Service
Lines
Macro
Level 1
Level 2
Level 3
Adapted from R. Lloyd & G. Nelson, 2007
Micro Level
Macro Level
Start with the Little Dots
36
Building a Cascading Set of Driver Diagrams
• Review the Driver Diagram you just
made to improve a particular outcome.
• Review the Secondary Drivers you
identified on this initial Driver Diagram.
• Select one of the Secondary Drivers
and make it the Outcome of your new
Driver Diagram.
• Identify the Primary and Secondary
Drivers of this new outcome.
Mesosystem
Macrosystem
Microsystem
Nursing
Services
Nursing
Divisions
Frontline
Nursing Units
Jönköping's System Level Cascade
Source: G. Henriks & Bojestig, Jonkoping County Council, Sweden, 2008
A Cascading Approach to Improvement
Percent compliance
with “bundles”
Hand washing
bundle
Pressure
ulcer bundle
CL bundleVAP bundle
Hospital Acquired
Infection rates
+ ++
Percent inpatient
mortality
Prevent VTE
Hamad Medical Corporation Best Care Always Change
Package: Critical Care Driver Diagram
2014-03-26
Improving Care for Colon Cancer Patients
You begin the adequate treatment
within four weeks
The diagnosis and treatment with ’best
method’ is offered
The best possible health promotion
measures and efficient screening
program is offered
Equally good palliative care is provided
no matter of the place of residence
Prevention
Early detection
Investigation/Treatment
Investigation/Treatment
Patient’s Involvment
Multi-disciplinary Collaboration
Palliation
Our promise to
patients with colon
cancer
Good health care
Regional cancer center should
prioritize patient-oriented research in
oncology
Interactive research approach in
several parts of the project
You are well informed / involved in the
entire healthcare chainPatient’s involvment
The primary effect
"What?
Secondary effect
"How?’’
Goal/
objectives
Patient
Involvement
Dialogue
Cascading Systems Does your organization approach improvement as an
interrelated cascading system or as a bunch of singular
events that are unrelated and fragmented?
Do senior managers and the Board or Governance (Non-
Execs) regularly discuss how your systems of care are driven
by many interrelated factors? Or, do they approach issues of
quality and safety as if one solution will produce better results?
Does your organization have dashboards of measures that
cascade from the macro, through the meso and down to the
micro levels?
Do your measures cascade down from the top or percolate up
from the places where patient care is actually delivered (the
inverted pyramid)?
Prioritizing the Drivers
© Richard Scoville & I.H.I.
Limitations of resources, attention, and will
usually mean we cannot work on everything.
• Which drivers do we believe will deliver the biggest
impact?
• Which ones will be easiest to work on?
(Factors include personnel, culture, resources)
• What is our current level of performance on these
drivers?
Scope
Co
mp
lexity
Pilot Unit Department Intitution System
Multiple
Primary
Drivers
One
Secondary
Driver
Significant system level
• Priority
• Sponsor
• Resources
Department-level
• Priority
• Sponsor
• Resources
What is your level of ambition?
What level of
ambition do you have
for your project?
Institution
44
Oral Health
Clinic Project
Source: Richard Scoville, Ph.D.
At OHC over 16 months, we will
1) increase the % of pts completingcaries control within 2 month by
X% and
2) decrease the % of “riskmanagement” pts who need
treatment for new caries by Y%
(active pt = 18+ w/ >=1 visit in past 2years, not withdrawn)
Risk Management
(no active caries)
Timely Scheduling ofAppointments
Caries Control
(all active cariesrestored)
Treatment Planning & Execution
Patient Education & Support
Risk assessment, communicationof risk status
Patient Self Management (hygiene& preven. Products)
Patient Sense of Urgency,Acceptance of Protocol
Ability/Willingness to Pay
Population Management
Patient Diet
Risk-based preventive care(cleaning, etc)
Timely restorative care for newcaries
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLower
Impact
Process WELL
defined
Process NOT
defined
Oral Health Care Prioritization
46
What’s The Status of This Driver/Process?
LEVEL DEFINITIONAPPROXIMATE
RELIABILITY
0Driver is not defined or status is unknown
1
There is an informal understanding about the driver
by some of the people who do the work. No widely
recognized or formal written description of the driver.50%
2
Driver is documented. driver description includes allrequired participants (including families where
appropriate). The driver is understood by all.80%
3
The driver is well-defined, and enacted reliably.
Quality measures are identified to monitor outcomes of
the driver and may be in use by few/some.90%
4
Ongoing measures of the driver are monitored
routinely by key stakeholders and used to improve the
driver. Documentation is revised as the driver is
improved.
95%
5
driver outcomes are predictable. driveres are fully
embedded in operational systems. The driver
consistently meets the needs and expectations of all
families and/or providers.
99%
DRIVER STATUS
.
D
Driver outcomes are predictable. Drivers are fully
embedded in operational systems. The driver consistently
meets the needs and expectations of all families and/or
providers.
Driver is documented. Driver description includes all
required participants (including families where
appropriate). The driver is understood by all.
47
What Is It’s Predicted Impact?
LEVEL DEFINITION
0This driver has no impact or does not apply to our system
of care
1
This driver has only minimal or indirect impact on patient
services and outcomes
2
This driver will improve services for our patients, but
other driveres are more important
3
This driver has significant impact on outcomes for our
patients
4
This driver is necessary for delivering patient services It
has a major, direct impact on the outcomes.
5
This driver is absolutely essential for achieving results.
Improvement in this driver alone will have a direct,
immediate impact on outcomes
PREDICTED IMPACT
This driver has no impact or does not apply to our system of
care.
This driver has only minimal or indirect impact on patient
services and outcomes.
This driver will improve services for our patients, but other
drivers are more important.
This driver has significant impact on outcomes for our patients.
This is necessary for delivering patient services. It has a
major, direct impact on the outcomes.
This driver is absolutely essential for achieving results.
Improvement in this driver alone will have a direct,
immediate impact on outcomes.
Results of OHC Prioritization
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLower
Impact
Process WELL
defined
Process NOT
defined
Results of OHC Prioritization
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLower
Impact
Process
WELL
defined
Process NOT
defined
High impact, not well defined
processes are key targets for improvement!
Exercise
Prioritizing Drivers
• Use the Prioritizing Drivers Worksheet.
• Plot your secondary drivers on the grid based on
your assessment of: (1) how well the process is
defined, and (2) the level of impact that the drive
can have.
• Discuss and select the drivers that are most
important for improving your system of care.
Prioritizing Drivers Worksheet
Timely
Resore
Prev
CareRisk
Assess
Pt Ed
Diet
Self
Mgmt
Popn
Mgmt
Ability
PayPt
Involved
TxScheduling
0
0.5
1
1.5
2
2.5
3
3.5
4
2.5 3 3.5 4 4.5 5
Impact
Sta
tus
High ImpactLower
Impact
Process WELL
defined
Process NOT
defined
Copyright © Institute for Healthcare ImprovementSlide 52
Churchill on LearningMaking predictions slows up the “hurry”
“Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing has happened.” --Winston Churchill
Taken from: http://home.att.net/~quotesexchange/sirwinstonchurchill.html
Copyright © Institute for Healthcare ImprovementSlide 53
Your Questions & Comments
Can speak them, “chat” them, raise hand….just please do ask them!!
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