Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
A IMS What are we trying to accomplish?
Aims What is an Aim? Statement of Intention What are we trying to accomplish? Aligned with strategic goals Based on data Stated clearly using numeric goals Involves senior leaders
Aims and Goals Goal: Improve hospital flow by reducing delays within and between departments Aims: Reduce the input delay Reduce the throughput delay Reduce the output delay
The Patient Journey: Inputs; Throughput; Output ER VisitWait for MD Decision to admit Length of stay on unit Decision to Discharge to discharge Length of stay in in nursing home ER Input ER Throughput ER Output Beds Input Beds Throughput Beds Output NH Input NH Throughput
Sample Input Aims Within 12 months, 100% of patients seeking care in the ED will see the MD within 15 minutes of their arrival. Within 12 months, 100% of surgeries will begin at the scheduled time Within 12 months, 100% of lab specimens will be collected within 20 minutes of the order being received within the department Within 12 months, the time from receiving the order for CT to patient receiving the CT will be reduced by 25% from xx minutes to xx minutes.
Sample Throughput Aims Within 12 months, the average cycle time in the ED will be reduced from xx minutes to 45 minutes Within 12 months the average cycle time for surgery will be reduced by 25% from xx minutes to xx minutes Within 12 months, the average process time for a xx (lab) will be reduced from xx minutes to xx minutes Within 12 months, the average length of stay for xx unit will be reduced by xx% from xx hours to xx hours
Sample Output Aim Within 12 months 100% of patients will be admitted to the receiving unit within 30 minutes of notification from ER (or OR, or PACU, or ICU)
M EASURES How will we know that a change is an improvement?
Measures Measures: How will we know a change is an improvement? Baseline measures Plot data over time. Focus on simple measures directly related to aim Sampling Integrate measurement into daily work. Create simple annotated run graphs.
Kinds of Data Judgment Research Performance appraisal do something TO you Improvement Process improvement efforts do something WITH you
Flow Mapping Record each process step on a separate piece of sticky paper Put the steps in the right order Record who is responsible for each step Add forgotten steps Agree to all of above Analyze
Flow Mapping Example Open toothpaste toothpasteWettoothbrush Applypaste to brush to brushBrushteeth Turnofflight Put away pasteandbrush RinsemouthRinsebrush
Changes and Tests What changes can we make that will result in an improvement?
Tests and Changes How will you reach your aim? Testing changes With likelihood of success For re-assurance in environment Adopting successful strategies based on your tests.
Flow of Work Change Principles Balance upstream and downstream demand and supply for all services Eliminate any backlogs of work Reduce the queues from one entity to the other Develop contingency plans to address demand or supply variation
Flow of Work Change Principles Reduce demand Identify and manage each supply constraint Synchronize the work Predict and anticipate needs Optimize environment: equipment, staff and space
Tests and Changes Tests: Cycles for Learning and Improvement Rapid Cycles Multiple tests of multiple changes Testing vs. implementation
How to Implement a Change Belief that change will result in improvement High Low Successful Change Unsuccessful Change Still Needs Further Testing DevelopingTesting Implementing From Lloyd Provost
Repeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow- up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
PDSA Cycles Are Not Plans! Are small in scale Thinking months think weeks; thinking weeks think days; thinking days think hours Thinking facility think unit; thinking unit think teams; thinking teams, think ONE team Thinking all patients think a type of patient; thinking a type of patient, think a sample; thinking sample then 3-5 may be enough
P A SA P D S A P D S A P D S A P A SA P D S A P D S A P D S A P A SA P D S A P D S A P D S A Balance Demand And Supply Decrease Appt. Types Decrease Demand Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
Summary Keep focused on Aim Measure Change Changes are small experiments Experiment wisely PSDA Learn from small changes over wide conditions before implementing widely Get started and keep going
Model for Improvement Aim: What are we trying to accomplish? Measurement :How will we know that a change is an improvement? What Changes can we make that will result in an improvement? Cycle for Learning and Improvement ACT STUD Y PLAN DO Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
Important Questions What is our current team number and composition? Are we clear about our mission and goals? Are we working together as smoothly and efficiently as we could? Are we providing high quality care for our patients? Is working with this team any fun? Do we get the job done well?
What are the Attributes of a Team? Proactive vs. reactive Communicative vs. isolated Accountable to each other, and to the patient Use measures for feedback Delivers safe and high quality care
Attributes continued. Cross-trained versus territorial Integrated versus separated Continuous flow versus flow based on urgency All staff work to highest level of training, experience, and licensure
Role Test and implement changes Measure and record pertinent data Communicate (successes and unintended consequences)
Profile Willing to be involved in the process Interested in the issues Ready to participate in discussion and test changes Possess knowledge related to the process
Membership Senior department leader(s) Clinical team physician leader Day-to-day leadership Technical experts
Senior Dept. Leader Departments sponsor for the Hospital Flow Improvement Initiative Authority to institute change Authority to allocate the time and resources necessary to achieve the teams aim
Physician Leader Good working relationship with colleagues and with the day-to-day leader(s) Interested in driving change in the system/department and will be a champion for the work Opinion leader in the department (individuals sought out for advice who are not afraid to test change)
Day-to Day Leader Critical driving force of the project, assuring that tests of change are implemented and overseeing data collection Understands not only the details of the system, but also the various effects of making change(s) in the system Able to work effectively with the physician champion(s)
Day-to-Day Leader (cont.) Teams key contact for the initiative Responsible for coordinating communications between the department