Mount Auburn Practice Improvement Program MAPIP Community Learning
Mount Auburn Practice Improvement Program (MA-PIP) Community Learning Session #2 Using the Model for Improvement to Improve Reliability of Care Processes Jennifer Lenoci-Edwards, RN, MPH Director, Patient Safety, Institute for Healthcare Improvement (IHI) Yvonne Cheung, MD, MPH, CPPS Chair, Department of Quality and Patient Safety, MAH September 25, 2015
Learning Objectives Learners will be able to: § § § Demonstrate the use of the Model for Improvement and small tests of change to identify and solve problems Describe strategies to improve the reliability of care processes. Identify strategies to effectively engage patients in improvement work Using test results management as our example
Disclosure Statement All Presenters and Content Developers have no significant financial interest/arrangement with any organization(s) that could be perceived as a real or apparent conflict of interest with the subject matter of the presentation.
4 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 Study Aim of Improvement Measurement of Improvement Developing a Change Plan Do Testing a Change Adapted from Langley, G. J. , Nolan, K. M. , Nolan, T. W. , Norman, C. L. , & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.
Repeated Use of the PDSA Cycle Sequential building of knowledge under a wide range of conditions A AT D A S Hunches Theories Ideas P Very Small Scale Test S D Spread Implementation of Change Wide-Scale Tests of Change D A P S D D S P A A P Changes That Result in Improvement Follow-up Tests 5
Plan-Do-Study-Act (PDSA) Cycle Act • Decide changes to make • Arrange next cycle • Adapt, Adopt, or discard Plan • Compose aim • Pose questions/predictions • Create action plan to carry out cycle (who, what, when, where) • Plan for data collection Study Do • Complete data analysis • Compare to predictions • Summarize learning • Carry out the test and collect data • Document what occurred • Begin analysis of data 6
Principles & Guidelines for Testing Changes § § § A test of change should answer a specific question A test of change requires a theory and prediction Test on a small scale Collect data over time Build knowledge sequentially with multiple Plan -Do-Study-Act cycles for each change idea Include a wide range of conditions in the sequence of tests
Getting Started § Select process you want to make more reliable § § § What keeps you up at night? How could a patient be harmed in your practice? Where are the Pain Points for your team? § Select subset or segment of population § Develop a high level flow diagram § Identify defects in each step § Select which defect you will fix first § State your reliability goal § At least 95% reliable 8
Our Test Case: Test Result Management § Delayed Diagnosis § Poor Outcomes to Patients § Medical Malpractice 9
Where do I begin? Let’s break it down § Did patient get the test I requested? § Did the test come back? § Did the team review the test? § Did the Physician interpret the test correctly? § Did the Physician order the correct follow up test or treatment or referral? § Was the test result communicated to the patient? § Did the follow up occur? § Who will watch my test queue when I am on vacation? 10
Back to the Model For Improvement Aim: What is the process we are focused on improving? By what? By when? Measurement: What is a metric that we use to assess our AIM? Tests of Change: What can we test to improve our system? 11
Back to the Model For Improvement Aim: Increase to 80% the number of (Radiology, Echo, High Risk Patients) test results that are communicated to patients within 48 hours of receipt, by the end of September. Measurement: Weekly review of 10 random charts with pending test results to determine if information was communicated to patient (via phone or letter. ) (On Wednesday check the next 10 test results that came starting Monday, to see if they have been communicated to the patient) Tests of Change: How to identify tests of change 12
Working toward your Tests of Change § Select process you want to make more reliable § § § What keeps you up at night? How could a patient be harmed in your practice? Where are the Pain Points for your team? § Select subset or segment of population § Develop a high level flow diagram § Identify defects in each step § Select which defect you will fix first § State your reliability goal § At least 95% reliable 13
Flow Mapping: Visualize the Steps § High level (work) flow diagram § 3 to 5 Steps-keep it simple § Identify defects § Is there a cascade? § Which is the biggest defect? § Identify what you will fix 14
Flow Mapping – Making the Process Visual Rock in my Shoe: We keep missing the bus! Get Up Make Coffee Make Kids Lunches 15 Pack their Back Packs Wake up the kids
Tool: Ask “Why? ” Five Times Curiosity! To help you understand the underlying reasons for the defects Why? Why? 16
Your turn – Flow mapping for Test Result Management § § Pick one process that you want to improve around test result management Work with 3 -4 people near you to develop a flow map for test results management Use “stickies” to identify 4 -5 key steps in the process Identify potential defects/problems in process 17
Discussion 18
Principles & Guidelines for Testing Changes § § § A test of change should answer a specific question A test of change requires a theory and prediction Test on a small scale Collect data over time Build knowledge sequentially with multiple Plan-Do-Study-Act cycles for each change idea Include a wide range of conditions in the sequence of tests
Selecting a Change to Test ----Building Systems for Reliability 20
How Reliable is Your Test Result Process When compared to: § Airline industry § Automobiles § Starbucks 21
Why Are Processes Not Reliable? § Individual Autonomy § Expecting that a policy will result in improved reliability § Focus on benchmark performance § Over-reliance on training, vigilance and hard work 22
QUALITY is Job #1 Lecture at Noon Work harder. Pay more attention. Photo Credit: St. Barb by Matt Mac. Gillivray (CC BY)
Changes that can Improve Reliability § Simplification § § Are there Steps in your processes that can be eliminated? Standardization § Best known process to achieve desired results § But known today-may change with new knowledge or new context 24
Why Standardize? § Makes it easier to fix a defect when one occurs § Reduce variation § Makes it easier to train § Supports care we expect our patients receive § Makes it easier to assess competency § Easier for patients to identify when there is a failure in the system 25
How do I make this Reliable? Rock in my Shoe: We keep missing the bus! Get Up Make Coffee Make Kids Lunches What changes might you test? 26 Pack their Back Packs Wake up the kids
Testing on a Small Scale What can you do by Tuesday? What can you by this afternoon? “The Power of One” – one patient, one clinician, one visit 27
Your Turn – Small Tests of Change § What are some changes that could be tested to improve your process? § Who would the tests entail? § § Do you have a hunch? Do the reliability principles give you ideas to test? How do you make sure you are testing on a small scale?
Discussion 29
What Makes an Effective Change? Human Factors Engineering and “Actions” § § § Warnings and labels (watch out!) Training (don’t do that) Procedure changes (work around that) Interlock, lock-in, , lock-out, etc. (let me design it so you cannot do that – forcing functions) Is there one right action? ? ? Source: NPSF National Patient Safety Foundation www. npsf. org See detailed version in handouts: Action Hierarchy 30 Weaker Stronger
Engaging Patients in Your Improvement Work 31
Engaging Patients How do we engage patients in this work? § Patients’ perspective – identifying defects § Patients’ suggestions for improvements § Patients’ reaction to changes tested § Patients on your improvement team “The greatest asset we have underutilized is all the assets of the patient. ” Maureen Bisognano President and CEO Institute for Healthcare Improvement 32
Your turn Think about your workflow § How could you involve patients in identifying and testing changes? 33
Discussion 34
Learning from Tests of Change: Plan-Do-Study-Act (PDSA) Cycle Act • Decide changes to make • Arrange next cycle • Adapt, Adopt, or discard Plan • Compose aim • Pose questions/predictions • Create action plan to carry out cycle (who, what, when, where) • Plan for data collection Study • Complete data analysis • Compare to predictions • Summarize learning Do • Carry out the test and collect data • Document what occurred • Begin analysis of data 35
Repeated Use of the PDSA Cycle Sequential building of knowledge under a wide range of conditions A AT D A S Hunches Theories Ideas P Very Small Scale Test S D Spread Implementation of Change Wide-Scale Tests of Change D A P S D D S P A A P Changes That Result in Improvement Follow-up Tests 36
Using the PDSA form PDSA Worksheet for a Small Test of Change Practice Name: _________ Cycle start date: _____ Cycle end date: _____ PLAN: Area to work on: Describe the change you are testing and state the question you want this test to answer (If I do x will y happen? ) What do you predict the result will be? What measure will you use to learn if this test is successful or has promise? Plan for change or test: who, what, when, where Data collection plan: who, what, when, where DO: Report what happened when you carried out the test. Describe observations, findings, problems encountered, special circumstances. STUDY: Compare your results to your predictions. What did you learn? Any surprises? ACT: What will you do next? Adopt, adapt, or abandon the change? 37 A P S D
38 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 Study Aim of Improvement Measurement of Improvement Developing a Change Plan Do Testing a Change Adapted from Langley, G. J. , Nolan, K. M. , Nolan, T. W. , Norman, C. L. , & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.
Review: The Key Steps of Improvement Work § § Pull together the team and build the will Set the aim Be sure to engage patients Testing, Testing 1. Select a process you want to improve 2. Develop a high level flow diagram 3. Identify Defects/Select which defect you will fix first 4. State your reliability goal - At least 95% reliable 5. Identify changes to test 6. Test your changes - keep it small 7. Use PDSA cycles to learn from your test change § Measuring, Measuring 39
To Be Successful … § § Leaders insist that teams focus on developing capable processes/making care safe for patients Teams include front line workers – experts in the process Teams engage patients in the improvement work Teams use the Model For Improvement and Reliability Principles rather than training and education, vigilance and hard work § Teams review share improvement data § Improvement projects have a reasonable time line § Teams ask for help – § Mount Auburn Coaches, Practice Manager Meetings and Community Learning Sessions 40
Keep in mind…. “What keeps you awake at night? (How could a patient be harmed in your practice? )” § § § “Not all changes lead to improvement; all improvement requires change. ” “What can you do by Tuesday? What can you by this afternoon? ” § “The Power of One” – “one patient, one nurse, one visit” § “Just enough measurement to support improvement. ” § “See problems, Solve problems. ” 41
Those who lead healthcare in patient safety § § § Do not necessarily have access to some unique or bountiful resource. Do seek to constantly learn and apply what is learned, along with maximizing the effective use of existing resources. Their willingness to learn and creatively use available resources allows them to be successful in changing their safety culture Source: Steve Spear Senior Fellow, Institute for Healthcare Improvement Senior lecturer, Massachusetts Institute of Technology, Sloan School of Management Faculty for the PROMISES
Organizations that are exceptional create this superior learning dynamic by: 1. Incorporating the detection of problems as part of everyone’s job 2. Being prepared to identify and solve problems 3. When something works, planning how to spread it throughout the organization 4. Leadership that ensures that all staff are actively included, motivated, encouraged and given time Source: Steve Spear
Questions/Discussion Thank You! 44
Mount Auburn Practice Improvement Program (MA-PIP) Community Learning Session #2 Wrap up and Next Steps Lora Gross-Kostka, RN, BSN, Ambulatory Risk Manager/Patient Safety Advisor, MAH Paula Griswold, MS Executive Director, Massachusetts Coalition for the Prevention of Medical Errors September 25, 2015
Ambulatory Risk Management and Patient Safety Program (ARMS) § ARMS major goal- facilitate a Culture of Safety and improve quality of care for patient & providers § How? Integration of existing Q &S initiatives within Office Practice setting with the hospital based infrastructure, i. e. : Ø Ambulatory Quality and Patient Safety Committee, Ø Quality Review Committee, Ø On-line r. L Safety Reporting
Mount Auburn-Performance Improvement Project (MA-PIP) How does this work fit into the ARMS program initiative? Empowers the frontline staff at the point of care by: training Coaches and Teams to “see a problem/solve a problem” using the IHI Model for Improvement to standardize systems & processes and shared learning
Next Steps § § Please complete your evaluation and suggestions and turn in at registration table (MAH will process CMEs) Upcoming meetings: § § § October 30 th – Practice Managers December 4 th – Community Learning Session Thank you to teams, coaches, faculty, staff, and to all of you for your focus on safety and improvement
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