Transcript 20,000 Days

Model For Improvement
MFI
Model for Improvement
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
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
Act
Plan
Study
Do
Model for Improvement
AIM
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
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
Some is not a number, soon is not a time
Recommended elements
in an aim statement




What is expected to happen
The timeframe for accomplishing the aim
The system to be improved
The patient population that change
process is going to be applied to
 How much/by when
Example of Aim statement
Example 1
We aim to reduce the average
length of stay for >64 year old (and
>54 year old Maori and Pacific) hip
fracture patients from 22 days to
19 days by the 30th of June 2013.
Example 2
The aim of this project is to keep
the people well in community by
increasing the number of patients
with chronic respiratory condition
enrolled into Better Breathing
(pulmonary rehabilitation)
Programme (BBP) from 60 to 250
per year by June 30th 2013
Has it met the qualities of a
good aim?
• What is expected to happen

• The timeframe for
accomplishing the aim

• The system to be improved

• The patient population that
change process is going to
be applied to

• How much/by when

Breakout –
Aim statement
Model for Improvement
What are we trying to
accomplish?
MEASURES
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
Act
Plan
Study
Do
Measurement
“Crude measures of the right things are
better than precise measures of the wrong
things.”
“Improvement strategy: More frequent
samples (over time) of ‘good enough’
measures”
Roles of measurement
 Key measures are required to assess team’s progress
against the aim
 Balancing measures are required to ensure that
improvement in one part of the system does not cause
damage in another area
 Data (including from patients and staff) can be used to
focus improvement and refine changes
 Specific measures can be used doing PDSA cycles to
inform future cycles
Methods of Measurement
•
•
•
•
•
•
Chart review
Observation of behaviour
Surveys
Questionnaires
Coding data
Checklists
Measurement guidelines
To answer: “How will we know that a change is an
improvement?” usually requires more than one
measure:
1. A balanced set of a few (3 – 8) key measures
2. Integrate measurement into the daily routine
3. Think about balancing, process and outcome
measures (be careful about overdoing process
measures)
4. Plot the data in a time series
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
Developing
Change
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
What change can we make that
will result in improvement?
Act
Plan
Study
Do
All Improvement requires
change, but not all changes
result in improvement
How do we develop fundamental change
that will result in improvement?
What is a Theory?
• A description of our best understanding about why things
are the way they are
•What are some theories?
• Biology – Theory of Evolution
• Physics – Theory of General Relativity
• Economics – Game Theory
• Psychology – Maslow’s Theory of the Hierarchy of
Needs
Driver Diagram - a tool to visualize
our Theory
A driver diagram is an approach
to describing our theories of
improvement:
• Used to help organize our theories
and ideas in an improvement effort.
• The initial driver diagram for an
improvement project might lay out
the descriptive theory of improved
outcomes that can then be tested
and enhanced to develop a predictive
theory.
•The driver diagram should be
updated throughout an improvement
effort and used to track progress in
theory building.
Improvement Guide, p.429-431
Conceptual Driver Diagram
Outcome
1⁰ driver
2⁰ driver
2⁰ driver
1
1⁰ driver
1
Change Concepts
Concept 1
Concept 2
2⁰ driver
2
Concept 3
Aim or
Outcome
2⁰ driver
3
1⁰ driver
2
Effect
2⁰ driver
4
Drivers
2⁰ driver
5
Concept 4
Concept 5
Concept 6
Specific Change Ideas
Ideas:
1
2
3
4
5
6
7
8
9
.
.
.
.
.
.
N
Cause
HOP- Delirium identification /
Management
Driver Diagram-v3.0
Primary Drivers
Secondary Drivers
Tertiary Drivers
Change Concepts
Specific Change Ideas
Outlier Pt
Date: 11 June2012
Assessment
frequency for
CAM tool
concept
CAM run one each shift
CAM tool audit
Identification
Assessment
Appropriate use
of CAM tool
standardisation
CAM lit search
Timeliness
Usable
Review CAM format
Resource
To reduce
preventable
complications
and ALOS
associated with
early onset
confusion for
patients 65+ on
Ward 4
Assessment on
presentation
Family Feedback
Staff awareness
Pt Watch
Intervention
Measures:
CAM completion
CAM documentation
1. Complications
2. ALOS
3. Readmission
4. Mortality
iPMS flagging at
presentation
Educate
Family questionnaire
Educate
Review education
package
Ownership
Introduce Ward
champion
Pt safety interventions
Management
Medication
Documentation
MDT
Symbol for Delirium
on patient
Delirium guidelines
Intervention checklist
Family involvement
Education
Care in place
Move to
Home
Discharge
planning
Educate family
Information on
admission/Discharge
iPMS flagging
Discharge location
Hand over to
GP/Service
Information exchange
Delirium as diagnosis
in EDS
Where ideas come from
Outcome
1⁰ driver
2⁰ driver
2⁰ driver
1
1⁰ driver
1
Aim or
Outcome
2⁰ driver
2
2⁰ driver
3
1⁰ driver
2
2⁰ driver
4
2⁰ driver
5
Change Concepts
Specific Change Ideas
Where ideas come
Ideas: from:
1
1. Medical Literature
2
2.
Websites
like
Concept 2
3
www.ihi.org 4
3. Team members
5 who
6
Concept 3 have innovative
7
thoughts about
what to
8
do differently 9
.
Concept 4.
4 Structured Creativity
Sessions (use. of
.
change concepts,
.
provocations, .random
Concept 5
entry, etc.) .
5. Other Teams N
Concept 6.
6 Improvement Advisors
Concept 1
Breakout –
Developing Change
Outcome
1⁰ driver
2⁰ driver
2⁰ driver
1
1⁰ driver
1
Change Concepts
Concept 1
Concept 2
2⁰ driver
2
Concept 3
Aim or
Outcome
2⁰ driver
3
1⁰ driver
2
2⁰ driver
4
2⁰ driver
5
Concept 4
Concept 5
Concept 6
Specific Change Ideas
Ideas:
1
2
3
4
5
6
7
8
9
.
.
.
.
.
.
N
Model for Improvement
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
Testing
Improvement Guide, Chapter 1, p.24
Appendix C, p. 454
Science behind PDSA
Scientific Method
Hypothesis
Prediction
Experiment
Evaluate/Analysis
Build on previous knowledge
Acquire/generate new knowledge
Act
Check
1939
1939
Plan
Do
1951
Step 1- Design,
Step 2 – Produce,
Step 3 - Sell was converted to a circle with a
forth step added:
Step 4 - Redesign through marketing research.
1986
1993
The Plan-Do-Study-Act Cycle
Act
- What changes
are to be
made?
- Next cycle?
Study
- Complete the analysis
of the data
- Compare data to
predictions
- Summarize what
was learned
Improvement Guide, Chapter 5, p. 97
Plan
- Objective
- Questions and
predictions (Why?)
- Plan to carry out
the cycle
(who, what, where, when)
- Plan for Data collection
Do
- Carry out the plan
- Document problems
and unexpected
observations
- Begin analysis
of the data
Most
Important
Part of a
PDSA cycle
Because
with out it
we don’t
have a
comparison
for the
purpose of
learning -
Why prediction?
 Prediction combined with a learning cycle interrogates
our understanding of a system.
 It reveals gaps in our knowledge and provides us a
starting place for growth.
 Without it our learning is accidental at best but with it we
are able to direct our efforts toward building a more
complete picture of how things work in the system.
Repeated Use of
the PDSA Cycle
A P
Changes That
Result in
Improvement
S D
Implementation
of Change
Wide-Scale
Tests of Change
A P
Hunches
Theories
Ideas
S D
Follow-up
Tests
Very Small
Scale Test
Improvement Guide, Chapter 7, p. 146
The work of improvement
Primary Driver 1
Primary Driver 2
Change Idea 1
Change Idea 3
Change Idea 2
Change Idea 1
Change Idea 3
Primary Driver 3
Change Idea 2
Change Idea 1
Change Idea 3
Change Idea 2
Transition of Care
Date: 27/11/2012
Reviewed 27/02/2013
Who, How, When?
Establish GDD &
Daily Review
To have a standardised
process to provide each
patient with a GDD
How and what is the best
way to establish a GDD?
Staff awareness
on GDD
# of clinical
directors believe in
establishing GDD
Check consultant
aware of GDD in mind
GDD in ward 33
Janene & Michele 23/1
GDD mentioned in
notes
CAT tool to indentify
why Pt waiting
Post ward round delay in
services for Pt > 7 days
CAT tool
usefulness
To have a
standardised
process to share
GDD
Best way to
communicate the
GDD to patient and
interested parties?
Nurse to inform PtRuth
DOC to use care plan for
updated GDD info
Doc reviewing /confirming
GDD-Ajay 5/12
PDSA Tree
Update GDD on white board
Staff
Update GDD on WiMS
Other
Services
Ascertain ref
process in ward 6
E-referral –
Erin 5/12
PDSA box
Timely task referral
Prediction:
GDD will
improve the
patient
experience and
efficiency. Also
this will reduce
the LoS
Transitions of
Care
Cultural Support to inform
– Maika/Ian 23/12
Drs
Achieving the
GDD
To have the
processes in
place to achieve
the GDD
How can we
achieve the GDD
as a team
Process Map
Janene/Michele 23/1
Add time of Dx
Surgical-17/4
Visual Display of
GDD-Surgical
Patient &
Family
GDD by Doc post acute
ward round – Brian 17/12
Is the GDD documented
on care plan?
Pt less than 48 hour
Sharing
GDD
Reason of GDD not metRuth& Michele 12/12
Doc to use care plan to review
GDD-Ruth/Michele 5/12
Pt awareness on
GDD-Surgical
Reasons of Pt
waiting on Bed
Aim: To improve
the number of
inpatients having
GDD from 0% to
100% also
To increase the
number of
inpatients
achieving the GDD
for from 0% to
100% by July
2013.
GDD match with
actual Dx date
GDD in MDT
meeting
GDD given to surgical pt and
any plans documented
Goal
Discharge
Date
Staff to set a GDD based on
the top 10 DRGs-Michele 5/12
Nurse setting
the GDD
Pt awareness
on GDD
PDSA Tree
Dx Checklist
Clivena/Helen
10/4
What ref system are
available in service dir.
Repeat PDSA
Active PDSA
Identifying Pt need @
admission in EC
(Ajay Kumar/ Fionna W)
Identifying Pt need @
admission in EC 4 pts
(Ajay Kumar/ Fionna W) 13/1
Repeat with
interventions
10/5
GDD assigned in
EC-Fionna
17/4
Early Dx if Pr referred
to NASC earlier
Delay in x-fer to AT&R
Referral system assessment &
documentation from acute to AT&R
Discharge
to HHC
Checklist/Process
map in notes 17/4
Fionna
Known patient dx
communication to HHC
Dx
Summary
HHC to receive
Dx list twice
daily
GDD
orientation to
HO rotation
17/4
Adopt
Adapt
Abandon
??
Test the checklist for
ref to DN 27/3
Surgical
To attend CN
meeting
What's
Happening
Owner: Prem Kumar
Model for Improvement
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
Every morning find the right colour
socks with in 5 seconds
* Right Colour Right Socks * Time to find the socks
* The mess created * My satisfaction*
* After wash placement time
Break out Exercise
• On your table there is a stack of index cards with numbers
written on them
• Give these to 8 people around your table
• Each of you has now been assigned a number – you can
find your number by locating the middle number on your card
(i.e. if your card says 1-4-8, then you are number 4)
Break out Exercise
• Your current process involves tossing the tennis ball
provided from person to person, following the sequence
provided on the index cards (i.e. Person 1 tosses to Person 4
who tosses to person 8 and so on, until the ball returns to
person 1)
• Assign a time keeper/ball drop counter (preferably not a ball
tosser)
• Practice your process one time – Time keeper please time
how long the team takes to complete the process and the
number of times they drop the tennis ball
Break out Exercise
• Team Aim: We aim to reduce the time taken for every
person to touch the ball from X to Y. We also aim to reduce
our ball drops from A to B.
• Form a theory, come up with change ideas, use the MFI to
test those ideas
•Rules:
• The initial sequence as provided by the cards must be
adhered to
• You may only test one change idea at a time
Break out Exercise
Performance (Time to complete the
cycle)
1
Change Idea
Time
Ball
Drops
20
Time in sec
Cycle
2
16
12
8
4
0
1
2
3
3
4
5
Cycle
6
7
8
4
Performance (Times Ball is dropped)
10
6
8
7
8
Ball Drops
5
6
4
2
0
1
2
3
4
5
Cycle
6
7
8