Transcript Call #3 Measurement For Spread

Western Node Spread Call #3
Feb 19th, 2009
Understand what you need to measure for
spread
1.
◦ 4 categories of measurement
◦ Team examples
Identifying some sampling strategies
2.
◦
3.
Integrating measurement into systems
Understand how to develop feedback loops
for continuous improvement/learning
A Framework for Spread
Leadership
-Topic is a key strategic initiative
-Goals and incentives aligned
-Executive sponsor assigned
-Day-to-day managers identified
Measurement and Feedback
Social System
Set-up
Better Ideas
-Develop the case
-Describe the ideas
-Key messengers
-Communities
-Technical support
-Transition issues
-Target population
-Adopter audiences
-Successful sites
-Key partners
-Initial spread strategy
Knowledge Management
Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread:
The case of patient access in the Veterans Health Administration.
Joint Commission Journal on Quality and Patient Safety. 2005
Jun:31 (6):339-347.
Develop a Spread AIM
 Leadership
 Set-up/ infrastructure
 Communication
 Social System
 Measurement and Feedback

4
Forms part of your measurement
Developing a Spread Aim

Spread What:

Target Level of Performance:

Spread to Whom:

Time frame:
6
Sample Spread Aim: Prevent Surgical Site
Infections by Implementing the SSI Bundle




Spread What: All measures in the SSI Bundle
Target Level of Performance: Zero Cases of
SSI
Spread to Whom: All surgical populations in
our 10 hospital system
Time Frame: By September 2010
7

Set-up/Infrastructure

General Communication
◦
◦
◦
◦
◦
Establishing steering committees
Orienting leadership groups
Organizing data collection
Developing materials
Identifying successful sites
◦ Wide spread dissemination of information about the
initiative
◦ Sending out comparative data
◦ Holding meetings with a broad range of potential
adopters
8
4 Categories to reflect AIM and 4 levels of
spread activity
Awareness of the change
1.
◦
Reflects spread of communication
Adoption of the Change
2.
◦
Reflects the integrity of the adoption
Outcome of the Change
3.
◦
Adoption
Awareness
Outcome
Progress
Reflects the evidence of better ideas
Progress of the Change
4.
◦
Reflects the places and stage of the adoption
Develop Measures in 4 Categories
For the Big picture on Spread
Regina Qu’Appelle Health Region Spread Measures for Med Rec
1. ‘Awareness of the Proposed Change’
• Number of nurses, unit clerks, pharmacists and physicians
attending the group education sessions, individual mentoring
sessions
2. ‘Adoption of the Proposed Change’
• Percentage of charts stamped by the Unit Clerk
• Percentage of PIP forms used by Nurse to record BPMH
• Percentage of PIP forms used by Physicians to order/address home
medications
3. ‘Outcome of the Change’
• Percentage of identified discrepancies that are resolved by the
physicians use of the PIP form
4. ‘Progress of the Change’
• Percentage of units and rural acute care sites reporting on the
above adoption and outcome measures each week
HMIO = Home medication and initial orders
IHI spread tracking model via excel
Measures
using Small
Multiples:
Overall System
and 4 sites
OUR SITE
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
Apr
Jun
Aug
Oct
Dec
Feb
Apr
Jun
Aug
Oct
Dec
Apr
Jun
Aug
Oct
Dec
Feb
Apr
Jun
Aug
Oct
Dec
Jun
Aug
Oct
Dec
SITE4
SITE3
100
Overall Outcome
Measure
SITE2
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
Apr
Jun
Aug
Oct
Dec
Feb
Apr
Jun
Aug
Oct
Dec
Apr
Jun
Aug Oct
Dec
Feb
Apr
These graphs are called small multiples. They are designed for a quick visual
comparisons of the data from each site The graphs are all presented on the same
scale (both x and y axis)
Sampling
Simple Random Sample
1.
◦
Selection of data by use of random numbers
generated by a random number list or mechanical
devise
Systematic Random Sample
2.
◦
Selection of data by choosing a random starting
point and then selecting data at specified
intervals
Judgment Sampling
3.
◦
Select samples based on judgment of those with
process knowledge to learn about impact of
change on specific portions of a process





10-15% monthly volume sufficient for QI
Minimum of 10
Collect same way over time
Retrospective – data must be in formal
charting
Prospective – data collection sheets,
interviews
EG. You are currently collecting discrepancy rates for MED REC monthly
on admissions and you get 30 admissions per month to that unit.
30x15%=5 which is less than min, thus you would collect on min of 10
charts monthly


Consider the # admissions to all units working on MED REC as
the denominator
Thus 10-15% of the total admissions is the number of charts
to review per month. Divide that by the number of units and
you will get the number of charts per unit
EG. You are spreading to 5 additional units. You need to still collect on
the pilot unit. Each unit gets 30 admissions/month.
30x6=180 x15% = 27 charts/6 units =5 charts per unit per month.
Simple random sampling: Generate a list per unit, roll dice and select
chart number as per dice roll up to 5 charts per unit
Systematic random sampling: Generate a list of all admissions per unit
(30, 30, 30). On each list roll a dice for start number, then every 6th
chart(30admissions /5charts required = every 6th chart for total of
5 charts. Repeat for each unit.
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

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Balance enough data with realistic workload
Ensure the data collection sheet identifies
what unit/area
Sampling would most often apply to
adoption measures & outcome measures
Data collection is for answering your
questions about a process. Be clear on what
you want to know
Formalize regular reporting process to leader
tasked with accountability for this work
Who Needs to Know?
Who’s accountable ?
Brandon Regional Health MB
• Set up a regular reporting process
and format
• Use existing committees, structures if
applicable
• A senior leader needs to hold the
accountability for this work
•Have a system where if decline is
evident in the measure, it is
someone’s role to support the spread
work.
Project TITLE
QIC School Participant Name, Participant Sponsor, Project Sponsor
Charter
Aim: (Aim includes your
numeric goals)
Why is this important?:
Changes – Proposed
(P), Tested (T),
Implemented (I)
Graphs of Measures
Make fonts large, title, labels, dates
and notes very simple on graphs prior
to shrinking graphs. Should be able to
fit 6-8readable graphs here. If no graph yet for
Measure either create “empty” graph or list
Name of measure(s) not yet graphed.
Lessons
Learned/Anecdotes
•Type here
Senior
Role/Recommendations
/ Next Steps
•Type here: what do you
need from Project Sponsor,
Participant Sponsor at this
time to move project?
•Recommendations
•Type here: be clear about
what is proposed (P) (to be
tested) vs. testing (T),
vs.implemented (I)
•Next Steps for project
Team Members
Names/Role here
QIC School Participant Contact Info: Add e-mail/phone here
Refining the spread plan and continually
learning
Review
Data
Modify
support
processes
Refining &
executing
the spread
plan
Ask
questions
Check in
with the
people
“When the music
changes, so does the
dance.” African Proverb




Measurement is meant to answer questions
about how spread is going
Collect just enough to balance knowing and
workload
Initial spread plan is less than 20 % of your
time, 80% is refining, adjusting and
supporting the changes
Be flexible, spread is a learning event not a
dictatorial one!

New Generation of Ideas on Spread, Dec 8, 2008 Joe McCannon,
Marie Schall, Lynn Maher, Rashad Moussad, IHI National Forum

Strategies for Spreading Improvements in Health Care, October 14,
2004
Marie W. Schall, Institute for Healthcare Improvement

Holding the Gains and Spread, July 11, 2006
Bruce Harries, Improvement Associates

The Seven ‘Spreadly’ Sins, October 18, 2006
Roger Resar, MD & Carol Haraden, PhD IHI

Sustainability and Spread, August 28, 2006
Diane Jacobsen, MPH, CPHQ, IHI National Director

Continuing the Conversation Holding the Gains and Spreading
Good Ideas: From Local Improvement to System-wide Change
October 4, 2007 Marie Schall, MA Institute for Healthcare
Improvement
National Health Services (NHS) Modernization Agency Improvement - Sustainability and its
relationship with spread and adoption. www.institute.nhs.uk/improvementleadersguides
Hinchey Judge KA. Et al., Factors Contributing to Sustaining and Spreading learning
Collaborative Improvements, Qualitative Research Study Findings by the Primary Care
Development Corporation, Dec 2007.
Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access
in the Veterans Health Administration. Joint Commission Journal on Quality and Patient
Safety. 2005 Jun:31 (6):339-347.
Paul Plsek, Spreading Good Ideas for Better Health Care - A Practical Toolkit Volume 2 Veterans Health Administration 2000 Research Series. VHA, 2000.
Paul E. Plsek, Charles M. Kilo From resistance to attraction: a different approach to change
- Positively Influencing Physicians Physician Executive, Nov-Dec, 1999.
Dr. Lynne Maher, Emerging themes for improvement and innovation, presentation QHN
Fall Forum, November 21, 2007.
Developing your initial spread plan, IHI Boston Spread Workshop Feb. 2007
Barb Saunders, Spread of Improvement Efforts – Guideline for Fraser Health, March 10,
2005

Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of
patient access in the Veterans Health Administration. Joint Commission Journal
on Quality and Patient Safety. 2005 Jun;31(6):339-347

Attewell, P. Technology Diffusion and Organizational Learning, Organizational
Science, February, 1992

Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.:
Prentice Hall, Inc. 1986.

Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business
School Press, 2000.

Cool et al. Diffusion of Information Within Organizations: Electronic Switching
in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September October 1997.

Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000.

Fraser S. Spreading good practice; how to prepare the ground, Health
Management, June 2000.

Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000.
Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood, Il:Irwin

,1978.
References


Langley J, Nolan K, Nolan T, Norman, C, Provost L. The
Improvement Guide. San Francisco: Jossey-Bass 1996.
Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and
Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17);
May 1, 1991, pg. 2202-2207.

Myers, D.G. Social Psychology (3rd ed.) New York: McGraw-Hill,
1990.

Prochaska J., Norcross J., Diclemente C. In Search of How People
Change, American Psychologist, September, 1992.

Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.

Wenger E. Communities of Practice. Cambridge, UK: Cambridge
University Press, 1998.