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Powerpoint TemplatesPage 1
Powerpoint Templates
Rapid Cycle Improvement
Tucson Nurses Week
May 2012
Diana Lopez, RN, MSN & Jennifer Qualls, RN, MSN
Knowledge Management
Carondelet Health Network
Powerpoint TemplatesPage 2
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
Powerpoint TemplatesPage 3
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
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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
Powerpoint TemplatesPage 5
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
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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?
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Ideas• What changes can we make that
will lead to improvement? What will
lead us to accomplishing our goal?
Powerpoint TemplatesPage 8
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.
Powerpoint TemplatesPage 9
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
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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
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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…
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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
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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
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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?
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Barriers & Resistance
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
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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
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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
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Barriers & Resistance
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
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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
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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
Powerpoint TemplatesPage 30
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
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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
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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
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Barriers and Resistance
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
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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
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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
Powerpoint TemplatesPage 39
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.
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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
Powerpoint TemplatesPage 41
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
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
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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
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Barriers and Resistance
• 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
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Barriers and Resistance
• 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
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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%
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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
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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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