Barb Boushon,Barb Boushon,
Mike Davies, MDMike Davies, MD
Mark Murray and AssociatesMark Murray and Associates
The Process Improvement Model: Aims, Measures, Tests/Changes and Teams
Why Change Strategies Often Don’t
Work
• Lots of planning then lots of implementing– Analysis paralysis– Lack of consensus on problem and
solution– Implemention vs. test– Risky change process
Why Change Strategies Often Don’t Work
• Pushing one solution/idea– One person’s perspective– How do we know it works?– Lack of agreement– Ignores context/circumstances
Improvement Involves “Experimentation”
• Setting aims/goals• Generating ideas • Testing • Measuring progress• Reflection
Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
AAIMSIMSAAIMSIMS
What are we trying to What are we trying to accomplish?accomplish?
AimsWhat 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 Visit Wait for MD
Decision to admitto admit
Length of stayon unit
Decision toDischarge todischarge
Length of stay inin nursinghome
ER Input ER Throughput
ER Output
Beds InputBedsThroughput
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)
MMEASURESEASURESMMEASURESEASURES
How will we know that a How will we know that a change is an improvement?change is an improvement?
MeasuresMeasures: 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.
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3rd Next Avail. Appt. for Non-Emergent CT Scan
Measures• Delay
– Input– Throughput– Output
• Demand (and variation)
• Supply• Activity• Satisfaction• Defects
– No-shows– Internal and external diversions– Readmission rate
“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
OpenOpen toothpastetoothpaste
Wet Wet toothbrushtoothbrush
Apply Apply pastepaste
to brushto brush
Brush Brush teethteeth
Turn Turn off off lightlight
Put awayPut awaypaste paste and and
brushbrush
Rinse Rinse mouthmouth
Rinse Rinse brushbrush
Changes and TestsChanges and TestsChanges and TestsChanges and Tests
What What changes changes can we make can we make that will result in an that will result in an
improvement?improvement?
Tests and ChangesHow 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 ChangesTests: Cycles for Learning and
Improvement
• Rapid Cycles
• Multiple tests of multiple changes
• Testing vs. implementation
How to Implement a Change
Belief thatchange willresult inimprovement
High
Low
SuccessfulChange
Unsuccessful Change
Still Needs Further Testing
Developing Testing Implementing
From Lloyd Provost
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
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 achange is an improvement?
What change can we make thatwill 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
PA
S A
P
DS
A
P
DS
A
P
DS
A
PA
S A
P
DS
A
P
DS
A
P
DS
A
PA
S A
P
DS
A
P
DS
A
P
DS
A
BalanceDemandAnd Supply
DecreaseAppt. 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 ImprovementAim: 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
STUDY
PLAN
DO
Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
TeamsTeamsTeamsTeams
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• Department’s sponsor for the Hospital
Flow Improvement Initiative • Authority to institute change • Authority to allocate the time and
resources necessary to achieve the team’s 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.)
• Team’s “key contact” for the initiative • Responsible for coordinating
communications between the department team and the Steering Team
• Organize team meetings, assist with completion of agreed-upon tasks, assure follow-thru with assignments, and facilitate communication
Technical Expert(s)• Knows the department well and
understands the various processes and tasks of care – Understands the processes/tasks of entry
into the department– Understands the care processes within the
department– Understands the processes/task of how the
patient leaves the department
Meetings
• Schedules• Tasks• Effective meetings
Effective Meetings
• Develop a plan or purpose ahead of time
• Use agendas• Start and end on time• Review aim at each meeting• Take minutes• Review progress
Effective Meetings (cont.)
• Manage discussion• Deal with difficult meetings or
individuals• Celebrate• Close the meeting• Address environmental issues
Teamwork!
Outsid
e
Diagn
ostic
s
Beds
OR
ED
ICU
Teams
Team Meeting 1Objective 1: To refine and finalize your aims
for this collaborative.Objective 2: To refine team membershipProcess: • Select a recorder and a reporter.• Refine and record your aims
– Input delay– Throughput delay– Output delay
• Refine your team• Prepare to report back.
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