Marie W. Schall

This presenter has no

conflicts to disclose

November 5, 2013

Sustaining and Leveraging your Improvements

By the end of this session, you should be able to:

Identify key strategies for sustaining improvements (holding the gains)

Apply reliability science to strengthen implementation and ability to sustain improvements

Manage a portfolio of initiatives to leverage improvements across hospitals and systems

Sustaining Improvements

Our information system makes it easy for us to monitor how we are

doing!

The new way is much easier than the old

way…I would never go back!

We started this new process with a few patients

but now we do it for all!

Creating a New System

Part One: Make improvements

Part Two: Sustaining Improvement (Holding the gains)

Part Three: Spread the improvements to others

The Sequence for Getting (and Sustaining!) Results at Scale

Scaling up and Spreading a

change

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

Testing - Try and adapt ideas to learn what works in your system

Implementation - Make a change a permanent part of the day to day operation of the system

Spread: Have individuals outside the pilot adopt (and adapt) the changes

Scale-up: Identify and overcome the infrastructure issues that arise during spread

Some Common Language…..

Improvement

Hold GainsTest Implement

I. During testing

II. During implementation

III. After implementation

Taking Action to Hold the Gains

Improvement

Hold GainsTest Implement

I. During testing

II. During implementation

III. After implementation

Taking Action to Hold the Gains

Improving Likelihood that We Will Hold Gains: During Testing

Purposefully test the changes under a wide range of conditions (robust design) – Day shift/night shift, experienced/ inexperienced staff

Foolproof the new process/procedure– Look for ways to use constraints, affordances, reminders,

differentiation

Use technology where appropriate– Look for opportunities to use computers, bar coding ,etc.

Acknowledgement: Sandy Murray

During Implementation: Exercise

Think of a time in your experience when an improvement was implemented. Are the gains from that change still there?─ If yes, what was done that resulted in the gains being held?─ If no, why did the gains fail to be held? What got in the way?

Implementation

The change is a specified part of daily work - need to develop all support infrastructure to maintain change

High expectation to see improvement (no failures; but eagerness to continue testing if needed)

Increased scope will lead to increased resistance (value of evidence from successful tests)

To Implement . . .

Use PDSA cycles to test implementation steps

Establish buy–in, build consensus

Create an infrastructure and support

Build communication channels

Create education and training

Review policies & procedure

Assign accountability

Cultivate leadership

Testing Vs. Implementation PDSA Cycles

Cycle 1: Recruit one volunteer for one shift, draft duties

Cycle 2: Recruit two volunteers for one week (day shift) revise duties as needed

Cycle 3: Recruit another volunteer, one day two shifts

Cycle 4: Two volunteers for one week of day and evening shift.

Cycle 5: Three volunteers for one day, all shifts.

Cycle 1: Create job descriptions or alter other job descriptions as needed

Cycle 2: Conduct market salary study

Cycle 3: Post and hire positions

Cycle 4: Training for current employees

Cycle 5: Orientation and training for new employees

Cycle 6: Formalize measures and required reports

Improvement

Hold GainsTest Implement

I. During testing

II. During implementation

III. After implementation

Taking Action to Hold the Gains

After Implementation: Key Components of Strategy

Continue Communication– Publicize benefits, document improvement, keep contact w/ team after initial

improvement effort

Continue to Build Infrastructure– Job descriptions, policies, hiring, orientation, supply stream, etc.– Assign ownership for improvement and maintenance work of the new process– Senior leaders held responsible for efforts to sustain

Design an Effective Control System– Use your internal QA/I resources and integrate activities into hospital-wide

control system– Plan to standardize new process and verify conformance to the standard– Graphically monitor data for performance/outcomes

Example of Continuing use of Run Chart to Hold the Gains From Safety BTS (Quantum Leaps)

Holding the Gains

Collaborative

John Whittington OSF Healthcare

Cycle No.

Change Tested or Implemented Lead June July August September October November 24 1 8 15 22 29 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25

Policies

Documentation

Hiring Procedures

Staff education/training

Job descriptions

Information Flow

Equipment Purchases

PROJECT TEAM WORKSHEET: Redesign of Support Processes for Implementation of Change Change Implemented: ________________________

Date:

Improvement

Hold GainsTest Implement

I. During testing

II. During implementation

III. After implementation

Taking Action to Hold the Gains

Holding the Gains

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Reliability Science Can Help

Our EMR includes information about the process and what the patient understands

We use data to check for “failures” so we can find the problems and

make adjustments

We can all define the steps in the Teach Back process

Levels of Reliability

Chaotic process: Failure in greater than 20% of opportunities (5 front line users cannot describe the process)

80% or 90% success: 1 or 2 failures out of 10 opportunities (5 front line users cannot describe the process)

95% success: 5 failures or less out of 100 opportunities (5 front line users CAN ALL describe the process)

The IHI Three-Step Model

Prevent Failure: Design the system to prevent a breakdown in operations or functions

Identify & Mitigate Failure: Identify failure when it occurs and intercede before harm is caused or mitigate the harm caused by failures that are not detected and intercepted

Redesign: Take steps to redesign the process on the critical failures identified

Source: Nolan, T., Resar, R., Haraden, C., Griffin, F. Improving the Reliability of Health Care. Institute for Healthcare Improvement, Innovation Series, 2004, page 1.

Intent, Vigilance and Hard Work(will generate performance with < 95% reliability)

Process Design to Prevent Basic Failures:

• Common equipment, standard orders

• Personal check lists

• Working harder next time

• Feedback of information on compliance

• Awareness and training

Use of Human Factors and Reliability Science (will generate performance with > 95% reliability)

Process Design to Identify and Mitigate Failures• Standardize work processes• Build job aides and reminders • Take advantage of preexisting work and

habits• Make the desired the default rather than the

exception• Create redundancy• Bundle related tasks

Build Job Aides and Reminders

Some examples…Reminder in EMR to ask patients how they learn bestPatient-friendly teaching materialsAuto reminder to record who is learner besides patientWhite board to notes re: discharge date and what needs to be done before thenEasy access lists of who to call for scheduling at the physicians’ offices

Bronson: Standard Work Product

Supervisor assigns bed: pages clerks in ED & unit & monitoring tech

5 min lapsed time - ED unit clerk prints SBAR report to admit unit

Admit unit clerk assures charge RN got SBAR

10 min lapsed time - charge RN on unit gets SBAR to assigned nurse

15 min lapsed time – assigned RN reviews SBAR and calls ED RN with questions

25 min lapsed time – ED PCA prepares patient for transport, calls unit, “we’re on the way”

30 min lapsed time – patient transported to unit bed

Bronson Hospital, Battle Creek Michigan

Take Advantage of Pre-existing Work and HabitsSome examples:

Multidisciplinary rounds have standard discussion around going home preparations

Change of shift reports include patients and key hand over elements

Teach Back is built into patient and family education documentation

Medication reconciliation offers going home patient-friendly medication list

How Standard is your Work?

On a scale of 1 - 5 with 5 being the highest level of confidence: How confident are you that a process you select occurs the same way every time? Share with your partner…..– What accounts for the variation?– What steps might you do to reduce variation

and improve the reliability of your process so that the process is done the same way every time?

Small sample – “Go Ask 5”

Pick a process you want reliable that has been taught to frontline staff

Review what was taught

Ask 5 people who do the process to describe – Why the process is important

– How they do the process

How many of 5 got it right? – 4 of 5 means only 80% reliability is possible

Observe the Actual Process

Go see (don’t just talk about it in meeting rooms)

Check assumptions

Learn what really happens compared to what is described− Observe and ask “why?” five times − Get to the root causes of current performance

Identify what gets in the way of reliability

Discuss changes that your team would like to test

Specify the Existing Work

Precisely specify the work YOU SEE:Who does it?

What do they do?

When do they do it (and for which patients)?

Where do they do it?

How do they do it? (include tools that are used)

How often do they do it?

Why do they do it?

Specify Improvements to Tackle

Select a process to work on

Specify the changes in the documented existing work the team would like to test‒ who, what, when, where, how

Use iterative PDSA cycles (tests of change) to try the changes

Use process measures to assess progress over time (aim to achieve > 90% reliability)

Example: Observing the Current State of Patient Teaching

Identify a staff member to observe while teaching a patient

Get permission from the patient

Observe 1) staff teaching, 2) from the patient and family caregivers perspective

Consider what went well and what could be improved?

Reliable Use of Teach-back

www.teachbacktraining.com

ToolkitA. Involve all

learners in patient education

B. Always Use Teach-back! throughout the hospital stay

Provide Effective Teaching and Facilitate Learning

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www.teachbacktraining.com

Help Mid-level Managers Coach

Honor the current work through observation

Understand that change is hard and uncomfortable

Resistance to change is natural; comes from fear of change

Promote new skill development

Build confidence to integrate the new habit into work patterns

Build reliability

Manage relapses

www.teachbacktraining.com

Teaching New Processes

NEW WAY (TWI)Test to reliable processSpecify the processDesign education Include help aidsTeach test group in workplaceStick around to see if they can do it as taughtIf needed, redesign education, process or bothTeach the next group; can they do it as taught?

OLD WAYTeach & leave

Death by slides

During busy staff meetings

Teach in remote conference rooms

Gail A Nielsen 2012

Using Process Measures to Evaluate the Reliability of Processes

Process measures tell us whether the specific changes we are making are working as planned.

When displayed in annotated run charts, the data gives us feedback on the relationship between our theory (the changes we are making) and the outcomes for our patients (readmissions and overall experience).

Example of an Annotated Run Chart: Process Measure for Using Teach Back

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Outcome Measures: Readmission Data

Reliability vs. Sustainability

Sustainable

The process never deteriorates over time regardless of the participants

Reliable

The process provides the best care for every patient every time

Managing a Portfolio of Projects

Our leaders have assigned clear responsibility for

leading the work

We don’t try and do everything at

once….but have a plan for building our work

We understand how each of our improvement

initiatives fits together

Sequencing Methods

Identify the high leverage skills or capabilities;

Use data to identify problem areas;

Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates;

Start with units with improvement capability or champions;

Start in areas where you are likely to see early success.

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Com

plex

ity

CLABSI SSI CA-UTI VAP VTE

PU CA-UTI Falls

OB

VTE CA-UTI

ADE

Reliability and Teamwork

Rounding and Prevention

Risk Assessment

Monitoring & Titration

Working Across Microsystems

Care Transitions

TimeSept’ 10 Sept’ 13

Work Area Aim Progress

Care Transitions

Just started

25% progress

50% progress

100% progress

Sustaining

CLABSI Just started

25% progress

50% progress

100% progress

Sustaining

SSI Just started

25% progress

50% progress

100% progress

Sustaining

CA-UTI Just started

25% progress

50% progress

100% progress

Sustaining

VAP Just started

25% progress

50% progress

100% progress

Sustaining

VTE Just started

25% progress

50% progress

100% progress

Sustaining

OB Just started

25% progress

50% progress

100% progress

Sustaining

PU Just started

25% progress

50% progress

100% progress

Sustaining

Falls Just started

25% progress

50% progress

100% progress

Sustaining

ADE Just started

25% progress

50% progress

100% progress

Sustaining

Portfolio of ProjectsProject Areas of Focus

Cardiac Care Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF)

Med. Safety High Alert Meds., Med. Reconciliation

Med/Surg Unit Spread

Pressure ulcers, Med. Rec., High Alert Meds. AMI, CHF, Infection Control

Infection Control

Methicillin-Resistant Staphylococcus Aureus (MRSA)

ICU Safety Rapid Response Teams (RRT), Ventilator-Acquired Pneumonia (VAP), Central Line Infections (CLI)

Surgery Safety Surgical Site Infections (SSI), Surgical Care Improvement Project (SCIP)

Portfolio of Projects & Skills NeededProject Resources and Responsibilities

Lead Sponsor Driver Skills

Cardiac Care Senior cardiologist

Director of cardiac service line

Nurse manager

Reliability and Flow ImprovementDC planning

Med. Safety Director of pharmacy

COO PharmD MeasurementADE Triggers ImprovementMD Engagement

Med/Surg Unit Safety

VP Nursing COO Nurse Manager

Spread Improvement

Infection Control

Manager infection control

CMO Senior infection control RN

Behavioral changeHuman factors Improvement

ICU Safety Med. Director ICU

CMO Nurse manager

ReliabilityCooperation Improvement

Surgery Safety

High Volume Surgeon

Director of surgery

RN managersurgery

Coordination Cooperation Improvement

Objectives - Reflection

Identify key strategies for sustaining improvements (holding the gains)

Apply reliability science to strengthen implementation and ability to sustain improvements

Manage a portfolio of initiatives to leverage improvements across hospitals and systems

Reflections

What ideas did you hear that you might apply?

What may have been confusing?

What might you need more information about….?

Resources

Improving the Reliability of Health Care (IHI White Paper)

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ImprovingtheReliabilityofHealthCare.aspx

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996.

Execution of Strategic Improvement Initiatives (IHI White Paper)

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ExecutionofStrategicImprovementInitiativesWhitePaper.aspx.

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