Uptake, Sustaining, and Spread of Quality Improvement

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Uptake, Sustaining, and Spread of Quality
Improvement
OHQC Long Term Care Quality Improvement
Facilitator Training March 16 - 17, 2009
Toronto

• Eileen Patterson MCE
• Director Quality Improvement
• OHQC

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Objectives

• Successful Spread Efforts
• Uptake of your Quality Improvement activities
  within your organization
• Overview of Spread Concepts

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What Matters to You?

• Immediate need or general Interest?
• Biggest question about spread?
• What experience have you had with spreading
  improvements?

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The Sequence of Improvement and Spread
Spreading a change to other locations
Make part of routine operations
Test under a variety of conditions
Implementing a change
Testing a change
Theory and Prediction
Developing a change

Robert Lloyd
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At what point should we plan for spread?
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During TestingBefore We Even Implement!

• Purposefully test the changes under a wide range
  of conditions (robust design)
• Day shift/night shift, experienced/ inexperienced
  staff

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During Implementation

• Successful testing is not enough to assume
  implementation has occurred.
• Implementation is building it into the current
  system.
• Foolproof the new process/procedure
• Look for ways to use constraints, affordances,
  reminders, differentiation
• Use technology where appropriate
• Look for opportunities to use computers, bar
  coding ,etc.
• Think about reliability and change concepts
  related to reliability

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Target Population for Spread
System of Focus for the initial pilot
(defined by Aim)
(Tests to adapt changes, then implementation)
Success
Success
Success
Success
Success
The Total Health Care System

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Spread is really adoption (creation of new
knowledge)

• New knowledge must be created by each team itself
  (adopted) rather than just listened to and
  implemented.
• Adoption implies EFFORT and CHANGE
• The knowledge ONLY EXISTS in the context of a
  team

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Spread
BETTER IDEAS
COMMUNICATED
In a certain way
Happens over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2001, Sarah W. Fraser
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Creating a New System

Improvement
Spread
Hold Gains

Improvement
Hold Gains
Spread
Design Spread

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How Do We Spread?

• Many possible ways
• Natural diffusion
• Breakthrough Series Collaborative model
• Extension agents
• Emergency mobilization
• Grassroots organizing
• Wave sequence
• Campaign model
• Hybrid models

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A Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives
aligned -Executive sponsor assigned -Day-to-day
managers identified
Social System -Key messengers -Communities
-Technical support -Transition issues
Set-up -Target population
-Adopter audiences -Successful sites
-Key partners -Initial spread
strategy
Better Ideas -Develop the case -Describe the
ideas

Communication Strategies (awareness technical)

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An Integrated Approach to Improvement

• Leadership processes
• Aim setting
• Resource allocation
• Review

Top down

• Results
• Cost and productivity improvement
• Design of resident centered services
• Defect removal

• Methods
• Spread of operational systems
• Fundamental redesign
• Local incremental improvements
• Control of quality

Local improvement capability
Bottom up
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Developing a Spread Aim

• Spread What
• Target Goals
• Spread to Whom
• Time Frame

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Sample Spread Aim Pressure Ulcer Prevention

• Spread What Pressure Ulcer Prevention Best
  Practices
• Target Goals Zero Cases Stage II or above
• Spread to Whom All units in our 10 LTC home
  system
• Time Frame By February 2010

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Things to Consider in Developing a Plan for
Spread

• Nature of the Intervention(s)
• Organizational Structure
• Social System
• Ability to reach target sites all at once
• Constraints

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Measurement for Spread

• Outcome measures
• Rate of spread
• Need a communication plan

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Communication Plan

• Building Awareness
• Moving adopters from decision to action
• Supporting and mentoring adopters

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Develop the Messengers

• Choose the right messengers
• Opinion leaders
• Connectors
• Educate the messengers to deliver the message
• Include peer-to-peer communication

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Moving Adopters from Decision to Action

• Information about the changes
• Mentors, coaches or experts to get answers to
  questions
• Connections with peers
• Feedback
• Accountability for results
• Encouragement and support from leaders

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Examples of Spread Efforts

• 100,000 Lives Campaign, 5 Million Lives Campaign
• Iowa Health System QI Facilitator Dev and
  clinical collaboratives
• Kaiser Permanente - Nurse Knowledge Exchange
• NHS (UK) - Modernization Plan
• Jönköping (SWE) - Advanced Access and Chronic
  Care
• Veterans Health Administration (USA) - Improved
  Access and Chronic Care

Resource White Paper on Spread at
www.ihi.org/products/

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Iowa Health SystemAim 50 Reduction in ADEs
System-wide in 2002

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VA Experience MDRC

• 78 Medical Centers
• Interviews, survey (3870 staff), databases for
  wait time patient satisfaction
• Found important predictors were
• Extent of leadership support
• Extent of teams having using performance data
• Extent of knowledge
• Time

Carol VanDusen Lukas, Mark Meterko
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12 Months vs 2 Months For Cataract Care
Decreased Vision
Decreased Vision
Optometrist DX Cataract/Refers to GP
Ophthalmologist Dx Cataract Completes Pre
surgery Form Books Surgery
GP Consults Ophthalmologist
Pre-op PE Questions RN over phone
Ophthalmologist Confirms DX
Nurse does PE Pre-op visit
Surgery
F/U Phone Call
Surgery
Post-op Ophthalmologist Visit
Optimist for glasses
Optimist for glasses
Simplification of the process in healthcare.
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Reflections on Spread

• the QI initiative as a method for front-line
  engagement was as important an intervention as
  those related to patient care (Aims)
• A new relationship developed between pilot units
  and spread units that helped to create a new
  approach to spread (Social System)
• Senior Leaders, Spread Leaders and unit managers
  took action to support dynamic system

Transforming Care at the Bedside How-to Guide
Spreading Innovations to Improve Care on Medical
and Surgical Units (to be posted on ihi.org)

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Ontario Networks support spread

• Safer Healthcare Now! Campaigns
• Collaboratives
• planning to spread across Ontario LTC
• Planning to spread across a LHIN
• Toronto LTC Alliance Satisfaction and Clinical
  Outcomes
• Seniors Health Research Transfer Network -
  Communities of Practice

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Learning Networks That Are Alive Contain

• Crisp aims (and priorities)
• Shared optimism (opportunity to do something
  remarkable)
• Creativity and opportunism
• Simplicity
• Profound respect for logistics (Amateurs discuss
  strategy)

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Networks That Are Alive Contain

• Total openness as the price of admission (take
  everything people bring)
• Focus on value (tacit, practical knowledge)
• Constantly seeking and tapping energy (what
  exhilarates participants?)
• Creating a shared sense of system (a shared map
  and shared narrative)
• Letting go of need to control - an ecosystem,
  not a hierarchy (trust)

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Networks That Are Alive Contain

• The group that asks versus the group that shares
• Knowledge management (at high speed)
• Harvesting
• Distilling
• Redistributing
• Recognition management (recognition economy)
  and affection-seeking
• Celebration

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Managing Complex Change
Vision
Skills
Resources
Incentives
Action Plan
CHANGE
Skills
Incentives
Resources
Action Plan
CONFUSION
Vision
Resources
Action Plan
ANXIETY
Incentives
GRADUAL CHANGE
Vision
Skills
Action Plan
Resources
Vision
Skills
Incentives
Action Plan
FRUSTRATION
Vision
Skills
Incentives
Resources
FALSE STARTS
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Spread Readiness Checklist

• Quality improvement is a key initiative
• Senior Leaders are responsible for, and engaged
  in spreading the quality improvements
• Clear intent to spread the work of the pilot team
• The pilot team is successful and relatively self
  sufficient

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Overall Lessons

• Set the agenda (build will)
• Clearly define your aim for spread
• Develop a Plan
• Utilize or build an infrastructure to support
  spread
• Connect people to peers, experts and resources
• Set targets and timeframe and make progress
  visible

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• The single biggest problem with communication is
  the illusion that it has taken place -
• Bernard Shaw

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Furthermore!

• Insist on regular meetings
• Rely on measurements to improve
• Continually look for improvement opportunities
• Acknowledge and celebrate successes