Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
5/29/2012
1
IHI Expedition: Preventing Obstetrical Adverse Events
Deb Bell-Polson, MSN, RNC-OB
Peter Cherouny, MD
Sue Gullo, RN, BSN, MS
These presenters have nothing to disclose
Expedition Coordinator
2
Kayla DeVincentis, Project Coordinator, has worked at IHI since 2009, starting as an intern in the Event Planning department. Since then, Kayla has contributed to the STAAR Initiative, the IHI Summer Immersion Program, and the IHI Expeditions. Kayla obtained her Bachelor’s in Health Science from Northeastern University and brings her interest in health and wellness to IHI’s Health and Fitness team.
5/29/2012
2
3
WebEx Quick Reference
3
WebEx Quick Reference
• Welcome to today’s session!
• Please use Chat to “All Participants” for questions
• For technology issues only, please Chat to “Host”
• WebEx Technical Support: 866-569-3239
• Dial-in Info: Communicate / Join Teleconference (in menu)
Raise your hand
Select Chat recipient
Enter Text
4
When Chatting…
Please send your message to
All Participants
5/29/2012
3
5
Chat Time!
What is your goal for participating in this Expedition?
5
6
Join Passport to:
• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements.
• Train your middle managers to effectively lead quality improvement initiatives.
. . . and much, much more for $5,000 per year!
• Visit www.IHI.org/passport for details.
• To enroll, call 617-301-4800 or email [email protected].
5/29/2012
4
What is an Expedition?
ex•pe•di•tion (noun)
1. an excursion, journey, or voyage made for some specific purpose
2. the group of persons engaged in such an activity
3. promptness or speed in accomplishing something
Where are you joining from?
5/29/2012
5
Our Expedition Director
9
Sue Leavitt Gullo, RN, BSN, MS, Managing Director, Institute for Healthcare Improvement (IHI), brings 30 years of health care experience to her current roles, which include work in IHI's national and international patient safety work, and IHI's faculty for leadership and patient safety. She is the Director of the Perinatal Improvement Community and The Safer Patient Project in Denmark. Prior to joining IHI, Ms. Gullo was the Director of Women's Services at Elliot Hospital in New Hampshire. Her prior nursing roles included experience in the frontline clinical areas of maternal-child health, oncology, and medical-surgical nursing. Ms. Gullo has also been active as national faculty in obstetrical care for the last 15 years. Her involvement with IHI dates back to 1995 as a participant in the IHI Breakthrough Series on Improving Maternal and Neonatal Outcomes and continued as IHI faculty until she joined the IHI staff
in 2005.
Ground Rules
10
• We learn from one another – “All teach, all learn”
• Why reinvent the wheel? - Steal shamelessly
• This is a transparent learning environment
• All ideas/feedback are welcome and encouraged!
5/29/2012
6
Today’s Agenda
11
• Expedition introduction and objectives
• Making the case for an improvement effort
• IHI’s Model for Improvement
• Homework for next session
12
Overall Program Aim
The aim of this Expedition, Preventing Obstetrical Adverse Events, is to…
5/29/2012
7
Expedition Objectives
At the end of the Expedition, participants will be able to:
• Describe two reasons to eliminate elective deliveries prior to 39 weeks confirmed gestation.
• Identify the components of the IHI Perinatal Care Bundles.
• Define reliability and give an example of components that will achieve different levels.
• Describe the Model for Improvement and the need for small scale testing.
13
Schedule of Calls
Session 1 – Introduction to Obstetrical Adverse EventsWednesday, May 30, 1:00 PM – 2:30 PM ET
Session 2 – Structure and Process for System RedesignDate: Wednesday, June 13, 1:30 PM – 2:30 PM ET
Session 3 – Executing Oxytocin BundlesDate: Wednesday, June 27, 1:30 PM – 2:30 PM ET
Session 4 – Designing Reliable ProcessesDate: Wednesday, July 11, 1:30 PM – 2:30 PM
Session 5 – Using the Perinatal Trigger Tool to Identify System HarmDate: Wednesday, July 25, 1:30 PM – 2:30 PM
Session 6 – Results Report-out and Advanced Bundles
Date: Wednesday, August 8, 1:30 PM – 2:30 PM14
5/29/2012
8
Faculty
15
Deb Bell-Polson, MSN, RNC-OB, is a Masters prepared Perinatal Nurse with 22 years of experience. Most recently has worked as a Clinical Nurse Manager leading a multidisciplinary team that has had great success in the IHI Perinatal Community. We had proven results in changing culture for quality and safety and achieving 95% compliance on the Elective Induction and Augmentation bundles as well as the Vacuum Bundle. Also serves on a regional Quality and Safety Network guidelines team that is working to set regional standards for care in the Northern New England region. Is most recently a part of a state wide Committee to review cases of Sudden unexplained infant Deaths and work to prevent them in the future. When not working I keep busy with my family of three sons and a wonderful husband.
Faculty
16
Peter Cherouny, MD, Professor of Obstetrics and Gynecology, University of Vermont College of Medicine, has strong clinical interests in obstetric health care quality improvement and is currently serving as Chair of the Institute for Healthcare Improvement's Perinatal Improvement Community. He was also the lead author of the IHI white paper, "Idealized Design of Perinatal Care." He has been Chair of Quality Assurance and Improvement and Credentialing for the Women's Health Care Service of Fletcher Allen Heathcare for the last 15 years. His recent research and work in obstetric quality improvement is as Chair of the March of Dimes collaborative, "Improving Prenatal Care in Vermont," and as co-investigator of the MedTeams project.
5/29/2012
9
Agenda
• Who are we at the Institute for Healthcare Improvement?
• Why focus on perinatal care? Why is this important now?
• The concept of reliability of care and reliable design
• Understanding our systems; Structure, Process, Outcomes
17
Who We Are
18
5/29/2012
10
1990 1993 1996 1999
2002 2005 2008
2010
IHI’s Global Growth: 1990-2010
IHI Open School Chapters
US Chapters in 46 states
International Chapters in 51 countries
383Chapters
5/29/2012
11
Will, Ideas, and Execution (IHI Style)
• Will….why are you here?
• Ideas….alternatives beyond the
status quo
• Execution….making it real. Best
practice actually reaches the patient.
21
Strategies for Successful Execution
• A clear, defined and executable aim.
• Linked with the overall strategy of the organization
• Tempo-monthly reviews for on track status, quarterly by chief executives
• Transparency- visibility
• Focus- less is more
• Change at the local level
22
5/29/2012
12
• Align Unit Measures Strategies Projects with Org Strategy and Goals (Clinical , Patient, Exp. Financial and Workforce)
• Channel Senior Leadership Attention and Develop Unit Leadership • Engage Physicians • Build Improvement Capacity and Provide Resources for Improvement• Establish a Just Culture• Develop a Competent Trained and Available Workforce• Establish Credentialing of Core Competency and Training for all Providers• Use ACOG/AWHONN Guidelines for Documentation and Staffing• Develop a Consumer Advisory Board
Perinatal Leadership
• Execute care that meets national standards (Implement Bundles, Perinatal Core Processes)
• Develop standard processes and protocols for response to obstetrical emergency • Design care process improvement based on trigger tool analysis, event detection,
sentinel event• Standardize administration of high alert medications – oxytocin, magnesium sulfate,
epidurals• Create an environment that Supports Care and Healing• Consider segments of population and design reliable and appropriate processes for
specific needs and characteristics of this segment of the population
ReliableDesign / Reduce
Variation
• Adopt common language and interpretation of EFM with multi-disciplinary training i.e NICHD criteria
• Implement techniques for effective communication i.e. SBAR• Establish reliable techniques for handoffs• Establish Team Response Protocols• Implement Huddles• Design Simulations
Effective Peer
Teamwork
• Design processes to support partnership in care between provider and patient and family
• Develop with patient a customized interdisciplinary shared care plan• Design care process improvement based on information obtained about patient
experience (interviews, assessments, focus groups, surveys) • Include patients and families on design and improvement teams • Communicate openly and honestly with family and patients at regular intervals • Do what you say, mean what you do
RespectfulPatient
Partnership
Reduce harm to 5 or less per 100 live births
Zero incidence of elective deliveries prior to confirmation of fetal maturity
Augmentation Bundle(s) Composite or Compliance greater than 90%
Improve organizational culture of safety survey scores in Perinatal units by 25%
100% of participating teams will have documentation of Patient & Family Centered Care
Perinatal Community:
Reducing Harm,
Improving Care,
Supporting Healing
1-3 months .. 3-6 months…
Perinatal
Oxytocin Bundles
Perinatal
Trigger Tool
Common EFM
Language and
Training
Reduce
Variation-
Meds, Emergencies
Implement
Techniques
for Effective
Communication
Engage
Patients and
Families
Establish
a multi-
disciplinary team
training program
Establish
Huddles,
Multi-disciplinary
rounds
Design
Interventions
From Trigger
Tool findings
Consistent
(across disciplines)
Credentialing
Standards
Collaborative
And Supportive
Culture
Vacuum Bundle
• Effective Team with Active,
Supportive Perinatal Leadership
• Senior Leaders & Board Support
of Perinatal Leadership &
Improvement Team
3 m
on
ths
to
36
mo
nth
s a
nd
be
yo
nd
….
Deep Dive
Pre-work
3 - 9 months………
12-24 months……..
12-36 months and beyond……
Patients on
Improvement
Teams
Care is
Transparent
Institute for Healthcare Improvement (IHI)
5/29/2012
13
What are we trying toAccomplish?
How will we know that achange is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Act Plan
Study DoSource:
Langley, et al. The Improvement Guide, 1996.
The three questions provide the strategy
The PDSA cycle provides the tactical approach to work
Agenda
• Who are we at the Institute for Healthcare Improvement?
• Why focus on perinatal care? Why is this important now?
• The concept of reliability of care and reliable design
• Understanding our systems; Structure, Process, Outcomes
26
5/29/2012
14
Why focus on perinatal care?
• Good science exists
• Significant variability in process.
─Care is provider driven rather than standardized.
─This autonomous practice focus contributes to the unreliable delivery of care.
Acceptable Variability?
Induction Rate by Physician
Seton Healthcare Network
m8
n11
n4
n8n6
n2 n15
m16
n1
n9
n12
n7
n14n10
m2 m17
m20n3
m22
m7 m9 m15
m1
m10
m3
m23
m12
m4
m18m25
m11
n5
m5
m14
m21n13 m24m19
m13m6
Mean = 30.0%
UCL
LCL
1s
2s
1s
2s
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rate
5/29/2012
15
Acceptable Variability?
Instrumented Delivery Rate By Physician
Seton Healthcare Network
b6m25 n4 m21
m15m7
b5 m1m22 n6m19m20 m4
m5b2 n5 n2
b7 b4
n11s2
s4
n15
n10m9n1n14m23n13
m10
m17
s1b3
m16
m14
m11n3
m8
n9
m13
n12
n7
m3
m18
m12
m24m6 m2
n8s3
b1
Mean = 8.6%
UCL
LCL
1s
2s
1s
2s
0%
5%
10%
15%
20%
25%
Quality Care in ObstetricsWhy is this important now?
0
5
10
15
20
25
30
35
1951 2006
Birth Injury per 1000
P
R
E
V
E
N
T
A
B
L
E
N
O
N
P
R
E
V
E
N
T
A
B
L
E
Morbidity
5/29/2012
16
Quality Care in ObstetricsWhy is this important now?
0
5
10
15
20
25
30
35
1951 2007
Birth Injury per 1000
P
R
E
V
E
N
T
A
B
L
E
N
O
N
P
R
E
V
E
N
T
A
B
L
E
Morbidity
Mazza F, et al. Eliminating birth trauma at Ascension Health. Jt Comm J Qual Patient Saf 33:15-24, Jan. 2007
Why focus on perinatal care?
4,317,119 births in US
Birth trauma 6.3-7.3/1000
estimated 50-90% are preventable
5/29/2012
17
What does that mean for US?
27,000-32,000 injured babies total
13,500-28,000 preventable
• $23.8M award in childbirth lawsuit
• By Scott Allen, Globe StaffBoston Globe
• 2 doctors faulted at Mass. General• In one of the largest malpractice verdicts in state history, a Suffolk
County jury has awarded $23.8 million to the family of a girl born with cerebral palsy after a traumatic delivery at Massachusetts General Hospital. Jurors took less than four hours Monday to find two Mass. General obstetricians negligent in the delivery in 1996
What does that mean for us?
5/29/2012
18
What do we want to do?
Prevent the preventable
Minimize unexplained variability
Defend the unpreventable
Explain necessary variability
Key Documents
• IHI’s Idealized Design of Perinatal Care
White Paper (available at www.IHI.org)
• “Evidence Based Maternity Care: What It
Is and What It Can Achieve”http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf
• Toward Improving the Outcome of
Pregnancy: Enhancing Perinatal Health
Through Quality, Safety and Performance
Initiatives (TIOP III)http://www.marchofdimes.com/TIOPIII_FinalManuscript.pdf
36
5/29/2012
19
Agenda
• Who are we at the Institute for Healthcare Improvement?
• Why focus on perinatal care? Why is this important now?
• The concept of reliability of care and reliable design
• Understanding our systems; Structure, Process, Outcomes
37
“The First Law of Improvement”
“Every system is perfectly designed to achieve exactly the results it gets.”
Paul Batalden
5/29/2012
20
What is Reliability?
• “Reliability is failure free operation over time.”
David Garvin
Harvard Business School
• “When applied to clinical processes consider the viewpoint of the patient by invoking the all or none measure.”
IHI Innovation Team
Reliable Care
What I need, when I need it. No more, no less.
40
5/29/2012
21
Reasons for the Reliability Gap In Healthcare
• Current Improvement methods in healthcare are highly dependent on vigilance and hard work
• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security
• Often excessive clinical autonomy creates and allows wide performance margins
• The use of deliberate designs to achieve reliability goals seldom occurs
The Reliability Design Strategy
• Prevent initial failure using intent and standardization
• Back-up/contingency function (identify failure and mitigate)
• Measure and then communicate learning from defects back into the design process
5/29/2012
22
Why Standardize?
• Contributes to building an infrastructure (who does what, when, where, how and with what)
• Support training and competency testing to sustain the process
• Achieve front line articulation of key processes by staff
• Allows the appropriate application of Evidence Based Medicine consistently
• Feedback about errors and application of learning to design is possible
Improvement Concepts Associated with Performance Resulting in 80-90% Process Reliability
(Primarily can be described as intent, vigilance, and hard work)
• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures
• Personal check lists
• Feedback of information on compliance
• Suggestions of working harder next time
• Awareness and training
5/29/2012
23
Improvement Concepts Resulting in 95% Process Reliability
(Uses human factors and reliability science to design failure prevention, failure
identification, and mitigation)
• Decision aids and reminders built into the system
• Desired action the default (based on scientific evidence)
• Redundant processes utilized
• Scheduling used in design development
• Habits and patterns know and taken advantage of in the design
• Standardization of process
Your Experience
• Think of a process or service you think is reliable
• How do you know it is reliable?
• What makes it reliable?
5/29/2012
24
Lessons from Human Factors
• Reliance on memory
• Distractions / interruptions
• Fatigue
• Sleep deprivation
• Shift work
• Lack of training and experience
• Overload
• Psychosocial factors
Health Care Processes
Desired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom -variation
Current -Variable, lots of autonomynot owned,poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels
Terry Borman, MD Mayo Health System
5/29/2012
25
Agenda
• Who are we at the Institute for Healthcare Improvement?
• Why focus on perinatal care? Why is this important now?
• The concept of reliability of care and reliable design
• Understanding our systems; Structure, Process, Outcomes
49
Process/Structure/Outcome
1919-2000
Avedis Donabedian, M.D., M.P.H.
5/29/2012
26
Structure and Process
• Create the sense of urgency─Deep Dive for data
• Define what to measure─Structure and process measures
• Structure─ The “What”
• Process─ The “How”
• Outcome─ The “Results”
Quality Measures in Obstetrics
5/29/2012
27
• Most system problems are not the result of human error
─People are only a part of the system
─Current Improvement methods in healthcare that are highly dependent on vigilance and hard work are not successful
─People are just being vigilant and working hard within the same system
Quality Measures in Obstetrics
• Fundamental understanding of systems
─We must accept human error as inevitable —
and design around that fact.
-Don Berwick
Quality Measures in Obstetrics
5/29/2012
28
Structure and Process
• What are structure measures?
─The “What” we use to provide care
�The people
�The tools
�The layout of our unit
Structure and Process
• What are structure measures?
─The “What” we use to provide care
�Do we provide adequate training for the expected care
�Do we have a single type of fetal monitor
�Do we have a standard regimen for oxytocin
5/29/2012
29
Structure and Process
• What are process measures?
─The “How” we do things
�More frequent than the rare bad outcomes
�Look at actual care; not the policy behind the care
�Need to be relative proxies for outcomes to have an improvement effect
Structure and Process
• What are process measures?
─The “How” we do things
�How often antibiotics are given preoperatively
�How often we chose the right antibiotics
�How often we give recommended DVT prophylaxis
5/29/2012
30
Structure and Process
• The “Deep Dive”
─Oxytocin deep dive
─Labor deep dive
Structure MeasuresOxytocin Deep Dive
Yes/No or N/A
• Interdisciplinary Fetal Monitoring Education
• Documentation tools consistent with NICD terminology
• Weekly fetal monitoring strip and case reviews (or#4)
• Monthly fetal monitoring strip and case reviews
• Standard mixture and policy for oxytocin administration
5/29/2012
31
Structure MeasuresOxytocin Deep Dive
Yes/No or N/A
• One standard administration order set
• If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed.
• Team definition for tachysystole
• Clinical algorithm for identification and management of tachysystole
• Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)
Structure MeasuresOxytocin Deep Dive
Yes/No or N/A
• RN empowered to call cesarean team (not to diagnose the need for cesarean, but to activate the team)
• RN empowered to call neonatal team
• Consistent handoff tool {SBAR, etc} specify
• Informed Consent for oxytocin administration
• Individual Provider data published about induction/augmentation rates?
5/29/2012
32
Process Measures
• Based on Failure to Rescue Algorithm
─Careful monitoring
─Timely identification
─Appropriate interventions
─Activation of the team response
Process MeasuresFirst Stage
• Careful monitoring
─Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity while oxytocin administered
─Oxytocin initiated as intended – no delay in administration due to provider or nursing response.
5/29/2012
33
Process MeasuresFirst Stage
• Timely Identification
─Tachysystole identified and managed according to protocol /algorithm
─Tachysystole identified and managed according to team definition and standing orders
─ Indeterminate/abnormal FHR identified
Process MeasuresFirst Stage
• Appropriate interventions─Oxytocin dose decreased or discontinued during labor
due to tachysystole─Oxytocin dose decreased or discontinued during labor
due to FHR─Oxytocin resumed after a decrease or stop─ Terbutaline administered─ Interventions needed─Once labor was progressing, was oxytocin
discontinued?
5/29/2012
34
Process MeasuresFirst Stage
• Activation of Team Response─ Documentation of physician notification of change in
dosage of oxytocin
─ If requested, timely response by OB care provider for bedside evaluation
─ Escalation plan in place if needed and documented
Outcome Measures
• Selected Triggers from Perinatal Trigger Tool
─Neonatal triggers
─Maternal triggers
5/29/2012
35
Outcome Measures
• Neonatal Triggers─ (T1) Apgar <7 at 5 min─ (T2) Admission to NICU or higher level of care─ (T18) Instrumented delivery, vacuum or forceps
(document indication)─ 2 or more late preterm infant (LPI Indicators)─ (T16) Neonatal Injury (e.g. fractured clavicle)
cephalohematoma, facial drooping, documented palsy, hyperbilirubinemia
─ (T20) Cord gas < 7.20─ (T22) Other Shoulder dystocia (document morbidity)
Outcome Measures
• Maternal Triggers─(T7) 3rd or 4th degree laceration─(T9) Blood Transfusion─(T18) Instrumented delivery, vacuum or
forceps (document indication)─(T15) Excessive blood loss, postpartum
hemorrhage─(T22) Other Shoulder dystocia (document
morbidity)─Cesarean section (indication)
5/29/2012
36
Structure and Process
• Results of Deep Dive─Unique to each hospital
─Defines focus of improvement efforts
─Allows measurement for improvement work
Oxytocin Diagnostic Tool
• 100% review of oxytocin charts
• Questions
─Structural
─Reflective
5/29/2012
37
Structure Yes No N/A
1. Interdisciplinary Fetal Monitoring Education
2. Documentation tools consistent with NICD terminology(paper or electronic)
3.Weekly fetal monitoring strip and case reviews, or (#4)
4. Monthly fetal monitoring strip and case reviews
5. Standard mixture and policy for oxytocin administration
6. One standard administration provider order set
7. If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed
8. Team definition for tachysystole (add your definition-)
9. Clinical algorithm for identification and management of tachysystole
10. Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)
11. RN empowered to call cesarean team (not to diagnosis the need for cesarean, but to activate the team)
12. RN empowered to call neonatal team
13. Consistent handoff tool {SBAR, etc} specify
14. Informed Consent for oxytocin administration
15. Individual Provider data published about induction/augmentation rates?
Structure Document Directions:
• Interview at least 5 different people on the unit (Nurses, Physicians) to determine if they all share the same yes/no answer on these questions. It will assist you in identifying any gaps from policy/procedure to care delivery at the patient level.
• Example: A nurse on weekends or nights may not have the same answer as a nurse on the day shift during the week.
5/29/2012
38
• Align Unit Measures Strategies Projects with Org Strategy and Goals (Clinical , Patient, Exp. Financial and Workforce)
• Channel Senior Leadership Attention and Develop Unit Leadership • Engage Physicians • Build Improvement Capacity and Provide Resources for Improvement• Establish a Just Culture• Develop a Competent Trained and Available Workforce• Establish Credentialing of Core Competency and Training for all Providers• Use ACOG/AWHONN Guidelines for Documentation and Staffing• Develop a Consumer Advisory Board
Perinatal Leadership
• Execute care that meets national standards (Implement Bundles, Perinatal Core Processes)
• Develop standard processes and protocols for response to obstetrical emergency • Design care process improvement based on trigger tool analysis, event detection,
sentinel event• Standardize administration of high alert medications – oxytocin, magnesium sulfate,
epidurals• Create an environment that Supports Care and Healing• Consider segments of population and design reliable and appropriate processes for
specific needs and characteristics of this segment of the population
ReliableDesign / Reduce
Variation
• Adopt common language and interpretation of EFM with multi-disciplinary training i.e NICHD criteria
• Implement techniques for effective communication i.e. SBAR• Establish reliable techniques for handoffs• Establish Team Response Protocols• Implement Huddles• Design Simulations
Effective Peer
Teamwork
• Design processes to support partnership in care between provider and patient and family
• Develop with patient a customized interdisciplinary shared care plan• Design care process improvement based on information obtained about patient
experience (interviews, assessments, focus groups, surveys) • Include patients and families on design and improvement teams • Communicate openly and honestly with family and patients at regular intervals • Do what you say, mean what you do
RespectfulPatient
Partnership
Reduce harm to 5 or less per 100 live births
Zero incidence of elective deliveries prior to confirmation of fetal maturity
Augmentation Bundle(s) Composite or Compliance greater than 90%
Improve organizational culture of safety survey scores in Perinatal units by 25%
100% of participating teams will have documentation of Patient & Family Centered Care
Perinatal Community:
Reducing Harm,
Improving Care,
Supporting Healing
S
T
R
U
C
T
U
R
E
P
R
O
C
E
S
S
O
U
T
C
O
M
E
The Clinical Bundle as Standardization
5/29/2012
39
Vacuum Bundle
� Alternative labor strategies considered
� Prepared patient
�Informed consent discussed and documented
� High probability of success
�EFW, fetal position and station known
� Maximum application time and number of pop-offs predetermined
� Exit strategy available
�Cesarean and resuscitation team available
5/29/2012
40
Other Clinical Bundles
• VAP, Ventilator Associated Pneumonia
• Central Line Bundle
• Peripheral Catheter Bundle
• Bladder Catheter Bundle
• Pressure Ulcer, SKIN Bundle
79
Ascension Health
Always ask:
What is the real problem we are trying to solve?
80
5/29/2012
41
The Sequence for Improvement
Spreading a change to other
locations
Developing a change
Implementing a change
Testing a change
Act Plan
Study Do
Theory and Prediction
Test under a variety of conditions
Make part of routine operations
Questions?
82
Raise your hand
Use the Chat
5/29/2012
42
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
Act Plan
Study Do
Aim of Improvement
Measurement of
Improvement
Developing a Change
Testing a Change
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.
83
Plan• Compose aim
•Pose questions/predictions
•Create action plan to carry
out cycle (who, what, when,
where)
•Plan for data collection
DoStudy
Act
• Carry out the test and
collect data
•Document what occurred
•Begin analysis of data
• Complete data analysis
•Compare to predictions
•Summarize learning
• Decide changes to make
•Arrange next cycle
84
5/29/2012
43
Principles & Guidelines for Testing
• A test of change should answer a specific question
• A test of change requires a theory and prediction
• Test on a small scale
• Collect data over time
• Build knowledge sequentially with multiple PDSA cycles for each change idea
• Include a wide range of conditions in the sequence of tests
85
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
Sequential building of knowledge under a wide range of conditions Spread
86
5/29/2012
44
Aim: Implement Rapid Response Team on non-ICU unit
Improved Communication
A P
S D
A P
S D
Cycle 1: ICU nurse responds to rapid response team calls on one unit,
one shift for one day
Cycle 2: Repeat cycle 1 for three days
Cycle 3: Have Respiratory Therapist attend
rapid response calls with ICU Nurse
Cycle 4: Expand coverage of RRT on unit
to one unit for one shift for five days
Cycle 5: Have Nurse Practitioner
respond to calls in addition to RT and
RN
Cycle 6: Expand rounds to
one unit for one shift seven
days a week
87
Questions?
Raise your hand
Use the Chat
88
5/29/2012
45
Expedition Communications
• If you would like additional people to receive session notifications please send their email addresses to [email protected].
• We have set up a listserv for the Expedition to enable you to share your progress. To use the listserv, address an email to [email protected].
89
Next Session
Wednesday, June 13, 1:30 PM – 2:30 PM ET
Session 2 – Structure and Process for System Redesign
90