Transcript Slide 1

August 21st Track One Virtual Meeting
Prepared and Presented by
Institute for Healthcare Improvement Faculty
Sue Gullo, Director
Jane Taylor, Improvement Advisor
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Session Objectives
Objectives:
1. Describe in-depth the Lens of Profound Knowledge
2. Identify change concepts
3. Develop a plan for testing changes
4. Discuss change concepts and testing in the context of
Falls and HAPU’s
5. Use the Lens of Profound Knowledge to identify what is
working and what needs improvement from a system
perspective
6. Work with faculty to develop organizational PDSA’s
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For real change to be designed..
• Complete Pre-work- Open School Modules and Video “Building
Skills in Data Collection and Understanding Variation”
– QI 102 Lesson 4:Developing Changes
– QI 102 Lesson 5: Testing Changes
• Print plenary session slides- we will refer to them during our track.
• Have data on hand that relates to Immobility- HAPU and Falls
specifically.
• Improvement Fellows-bring a Clinical Buddy to the sessions. This
would be a person who you can partner with from a clinical unit to
test, collect and post data, and drive change.
• Have handouts printed and ready to use
• Be ready to change your world!
• Homework will be described at the end of the session and it will be
in collaboration with a clinical buddy you have identified.
A Model for Learning and Change
Source: Langley, J. et
al, The Improvement
Guide, Jossey-Bass
Publishers, 2nd edition,
2009
Change Concepts
The Improvement Guide
contains an Appendix
(Appendix A: A Resource
Guide to Change Concepts)
that describes in detail how
72 change concepts can be
used to create ideas for
testing.
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Useful Ways to Develop Changes- OS
Critical thinking about the current system1
Sometimes, simply reflecting on problems within a system can generate some good ideas for
change. If you make a flow chart of your current process, it may be possible to identify parts
of the system that aren’t working or are needlessly complex. Another way to go about critical
thinking is to gather and analyze data on the way your system currently works—for example,
how you are communicating with people about the meeting—which can then help you
identify problems and develop changes to address them.
Benchmarking
Comparing your own process to “best practice” can help you identify where your own system
falls short.
Take the patient’s perspective
When you see the care system from a patient’s perspective, you’ll see opportunities for
improvement that might not be apparent as a caregiver. Is it too loud when you’re trying to
sleep? Do bright lights give you a headache? Do you have to wait too long to get your test
results? Patient shadowing and interviewing are useful techniques when coming up with
good ideas to change.
Useful Ways to Develop Changes- OS
Creative thinking1
Where do new ideas come from? You can spark creative thinking in
various ways, including simply taking the time to do this sort of
thinking; exposing yourself to situations (such as taking the role of a
patient) that can spark new ideas; identifying the boundaries that
limit the changes you can make and then finding ways to dismantle
those boundaries; and temporarily considering unrealistic goals that
can prompt you to break out of your old way of thinking.
Using Change Concepts
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Using Change Concepts to Come Up with IdeasOS
• A change concept is a general notion or approach to change
that has been found to be useful in developing specific ideas
for changes that lead to improvement. Creatively combining
these change concepts with knowledge about specific
subjects can help generate ideas for tests of change.
• After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to
test a change or group of changes on a small scale to see if
they result in improvement. If they do, expand the tests and
gradually incorporate larger and larger samples until you are
confident that the changes should be adopted more widely.
Guidance for Testing a Change
Concept
•
A test of change should answer a specific question!
•
A test of change requires a theory and a prediction!
•
Test on a small scale and 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.
•
Don’t confuse a task with a test!
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To Be Considered a Real Test
• Test was planned, including a plan for
collecting data
• Plan was carried out and data were
collected
• Time was set aside to analyze data and
study the results
• Action was based on what was learned
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The PDSA Cycle For Learning And
Improvement
What’s
next?
Act
• Ready to
implement?
• Try something
else?
• Next cycle
Plan
What will
• Objective
happen if we
• Questions &
try something
predictions
• Plan to carry out: different?
Who?When?
How? Where?
Study Do
Did it
work?
• Complete data • Carry out plan
analysis • Document
• Compare to
problems
predictions • Begin data
• Summarize
analysis
Let’s try it!
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Linking PDSA Cycles - Tips for
Doing It Right
•
Linking small tests of change helps ensure buy-in from all the people involved.
Think Ahead
You already know you’ll want to do multiple tests. So make your life easier by
planning for it. Think a couple of cycles ahead, testing over a wide range of
conditions and collecting useful data from each test to guide the next one.
Start Small
Keep it simple at the beginning. Scale down the size of the test (for instance, start
with just a few patients in one location). Test with volunteers and don’t try to get
consensus from everyone in the organization before starting.
Get Started
Don’t wait around! Ask, “What change can we test by next Tuesday?”
Repeated Use of the PDSA Cycle for
Testing
P
P
S
A
D
S
P
D
A
P
D
Implementation of Change
P
D
A
S
P
P
A
Hunches
Theories
Ideas
A
Sustaining the gains
D
S
Spreading
S
A
A
D
What change can we make that
will result in improvement?
Changes That
Result in
Improvement
S
How will we know that a
change is an improvement?
S
What are we trying to
accomplish?
D
Model for Improvement
Wide-Scale Tests of Change
Follow-up
Tests
Very Small
Scale Test
15
Sequential building of
knowledge under a wide range
of conditions
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PDSA Tests- Falls
Hunch/
Theory
Very Small
Scale Test
Operational
definition of a
round is not
standard
Ask 5 people
to define the
process for
hourly
rounding
If we do hourly
rounding, we
will prevent
falls
One patient,
one day
(manage variationCC; eliminate waste,
doing tasks in
Follow Up
Tests
Wide-Scale
Tests of
Change
Implementation
1-3-5; 2-4-6
All patients for
one week
After I have
identified
barriers and
tested my way
through the
barriers
All patients one
day
Documentation
, prompting,
tools
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Appropriate Scope for next PDSA Cycle
Current Situation
Low
Confidence
that current
change idea
will lead to
Improvement
High
Confidence
that current
change idea
will lead to
Improvement
Resistant
Indifferent
Cost of
failure
large
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
small
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
large
Very Small
Scale Test
Cost of
failure
small
Small Scale
Test
Ready
Very Small
Scale Test
Small Scale
Test
Small Scale
Test
Large Scale
Test
Large Scale
Test
Implement
Repeated Use of the PDSA Cycle for
Testing- Falls
P
P
S
A
D
S
P
D
A
P
D
Implementation of Change
P
D
A
S
P
P
A
Hunches
Theories
Ideas
A
Sustaining the gains
D
S
Spreading
S
A
A
D
What change can we make that
will result in improvement?
S
How will we know that a
change is an improvement?
Changes That
Result in
Improvement
S
What are we trying to
accomplish?
D
Model for Improvement
Wide-Scale Tests of Change
Follow-up
Tests
Very Small
Scale Test
19
Sequential building of
knowledge under a wide range
of conditions
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PDSA Tests- HAPU
Hunch/
Theory
If we hourly
round, we can
reposition.
Very Small
Scale Test
One patient
one day
Follow Up
Tests
Wide-Scale
Tests of
Change
Implementation
1-3-5; 2-4-6
All patients for
one week
After I have
identified
barriers and
tested my way
through the
barriers
All patients one
day
Documentation
, prompting,
tools
What data will
you collect?
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Appropriate Scope for next PDSA Cycle
Current Situation
Low
Confidence
that current
change idea
will lead to
Improvement
High
Confidence
that current
change idea
will lead to
Improvement
Resistant
Indifferent
Cost of
failure
large
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
small
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
large
Very Small
Scale Test
Cost of
failure
small
Small Scale
Test
Ready
Very Small
Scale Test
Small Scale
Test
Small Scale
Test
Large Scale
Test
Large Scale
Test
Implement
Repeated Use of the PDSA Cycle for
Testing- HAPU
P
P
S
A
D
S
P
D
A
P
D
Implementation of Change
P
D
A
S
P
P
A
Hunches
Theories
Ideas
A
Sustaining the gains
D
S
Spreading
S
A
A
D
What change can we make that
will result in improvement?
Changes That
Result in
Improvement
S
How will we know that a
change is an improvement?
S
What are we trying to
accomplish?
D
Model for Improvement
Wide-Scale Tests of Change
Follow-up
Tests
Very Small
Scale Test
23
Sequential building of
knowledge under a wide range
of conditions
Failed Test…Now What?
• Be sure to distinguish the reason:
– Change was not executed
– Change was executed, but not effective
• If the prediction was wrong – not a failure!
– Change was executed but did not result in improvement
– Local improvement did not impact the secondary driver or
outcome
– In either case, we’ve improved our understanding of the system!
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Worksheet- AIM Statement
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Exercise: Aim Statement
• Our focus will be on Pressure Ulcers and Falls.
• So, take a few minutes and evaluate your current Aim
Statements. Review them for clarity, performance
expectations, and completion date.
• If you have started work on a new HAC or are revising
your work plan, take this opportunity to create new
Aim Statements or modify existing ones.
• Use the Aim Statement Worksheet to create or revisit
your an Aim Statement.
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Aim Statement Worksheet
HAC name:
Aim statement
(What’s the problem? Why is it important? What are we going to do about it?)
How good?
By when?
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Exercise
Plan Your First (next) PDSA
• Use your Aim Statement, Driver Diagram,
Measurement Plan Worksheet and your Developing
Ideas for Change Worksheet as reference materials for
this exercise.
• Select one idea from your Developing Ideas for
Change Worksheet as an initial test of change.
• Complete the Plan section of the PDSA Worksheet
• Get feedback on your work from others at your table
and be prepared to report your plan to the class.
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MODEL FOR IMPROVEMENT
A P
S D
CYCLE:____DATE:____
Objective for this PDSA Cycle
PLAN:
QUESTIONS:
PDSA Worksheet
PREDICTIONS:
PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE
• Use this to
document individual
tests.
• Remember: It’s not
a test if you don’t
actually change
some aspect of the
process!
PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE
DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.
STUDY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.
ACT:
ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
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The Lens of Profound Knowledge
Appreciation
of a system
“The system of profound
knowledge provides a lens.
It provides a new map of
theory by which to
understand and optimize our
organizations.”
(Deming, Out of the Crisis)
Theory
of
Knowledge
QI
It provides an opportunity
for dialogue and learning!
Understanding
Variation
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Human
Behavior
What insights might be obtained by looking
through the Lens of Profound Knowledge?
Appreciation for a System
•
•
•
•
•
Interdependence, dynamism
World is not deterministic
Optimization, interactions
System must have an aim
Whole is greater than sum of the parts
Human Behavior
Theory of Knowledge
• Prediction
• Learning from theory, experience
• Operational definitions
• PDSA for learning and
improvement
• Interaction between people
• Intrinsic motivation,
movement
• Beliefs, assumptions
• Will to change
Understanding Variation
•
•
•
•
Variation is to be expected
Common or special causes
Ranking, tampering
Potential mistakes
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Profound Knowledge Worksheet
Appreciation for a System
•
•
•
•
Human Behavior
•
•
•
Theory of Knowledge
•
•
•
•
Understanding Variation
•
•
•
•
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Prep for September 11th
• What process measures tell you where you
need to go?
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Project Name:
Project Manager:
Description of change:
Implementation dates: From
to
.
Predicted impact of change on key measures:
Measure
Current Level of
Performance
1
2
3
4
5
6
7
8
Processes or Products affected by the change:
Processes or Process or Product
Number of
Change in
Products
Owner
People
Standard?
Affected
Affected
Yes/No
1
2
3
4
5
6
7
8
Documentation of change:
Materials/forms defined. Comments:
Procedure defined. Comments:
Equipment defined. Comments:
Change request procedure. Comments:
Changes in job descriptions or role statements. Comments:
Impact on training:
Training procedure defined for implementation. Comments:
Training resources allocated. Comments:
Training schedule complete. Comments:
New employee training procedure complete. Comments:
Measurements required:
New measurements defined. Comments:
Measurement procedures defined. Comments:
Measurement responsibilities defined. Comments:
Measurement review scheduled with responsibilities. Comments:
Analysis of data responsibility assigned. Comments:
Predicted Level
after Change
Predicted
Acceptance
High/Med/Low
Implementation
Checklist
(Source: Langley, J.
et. al. The
Improvement
Guide, page 136)
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Collect daily process measures
on a run chart
• Quality Buddy and Clinical Buddy meet daily
to plot and discuss the data.
• Process measures
– Percentage of patients assessed on admission
(locally defined)
• Your choice- falls or pressure ulcers
– Percentage of patients at risk re-assessed daily
• Continue on your pressure ulcer or fall choice above
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For September 11th
• Participants are expected to complete the
following IHI Open School Modules prior to
the September 11th session:
• QI 103 Lesson 1: Measurement Fundamentals
• QI 103 Lesson 2: Displaying Data
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