The Model for Improvement

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The Model for Improvement

• Connie Davis
• Judy Huska

With many thanks to Jerry Langley, Lloyd Provost,
IHI
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What are we trying to accomplish?

• Understand the Model for Improvement
• Experience running PDSA cycles
• Start an improvement charter

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Reference The Improvement Guide A Practical
Approach to Enhancing Organizational Performance

• Langley GJ, Nolan KM, Nolan TW, Norman CL,
  Provost LP. San Francisco Jossey-Bass 1996.

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Prerequisites of breakthrough improvement

• Will to do what it takes to change to a new
  system
• Ideas on which to base the design of the new
  system
• Execution of the ideas

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Three fundamental questions for improvement

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an
  improvement?

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What are we trying to accomplish?

• Develop an aim statement

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Establishing the aim

• Involve senior leaders Align aim with strategic
  goals of the organization
• Focus on issues that are important to your
  organization choose appropriate goals

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Establishing the aim, cont.

• Write a clear statement of aim with numerical
  goals make the target for improvement
  unambiguous
• Guidance Include anything to keep the effort
  focused (location, strategies, client
  populations, office, spread plans, etc.)

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Example aim statement

• Improve the patient partnership in our office so
  that in one year
• Decrease no-show rate by 50
• 80 of patients have a self-management goal
• 40 of patients have improved self-confidence
• 75 say they would recommend us to a friend
• Guidance
• Budget, personnel
• Pilot size

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How do we know that a change is an improvement?
This effort is about changing our organizations
approach to providing care (or doing a
process) However
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If you aim at nothing. you hit it every time!
Measurement tells us whether or not we are
hitting our target!
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Measurement guidelines

• Need a balanced set of 4 to 7 measures reported
  each month (or week) to assure that the system is
  improved
• These measures should reflect your aim statement
  make it specific
• Measures are used to guide improvement and test
  changes
• Integrate measurement into daily routine
• Plot data for the measures over time and annotate
  graph with changes

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Some measurement assumptions

• The purpose of measurement in the collaborative
  is for learning not judgment
• All measures have limitations, but the
  limitations do not negate their value
• Measures are one voice of the system. Hearing the
  voice of the system gives us information on how
  to act within the system
• Measures tell a story goals give a reference
  point

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Types of measures

• Outcome measures
• Results - system level performance
• Process measures
• Inform changes to the system
• Balancing measures
• Signal robbing Peter to pay Paul
• Unintended consequences
• What you are afraid might happen to another
  part of the system

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The Triple Aim

• Care experience
• Population health outcomes
• Cost

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Annotated run chart

• Plot small samples frequently over time

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Make measurement work for you

• Entire improvement program Use a simple data
  collection form which captures items for a sample
  of patients seen each month
• One Thursday each month, have staff answer 2
  questions about their engagement with work
• This week, look at charts of 5 patients on unit
  and check one measure

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Measurement example
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Measurement tips

• Carefully define your routine measures so that
  you know exactly what to do each time you
  measure
• Begin reporting measures immediately
• Do tests on measurement as needed
• Display as run charts in a place others can see
• Update at least monthly (weekly for some measures)

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The improvement charter

• One or 2 page document
• Aim Statement (answers question 1)
• Guidance
• Measures (answers question 2)
• Who is on the team leader, content experts,
  front line staff
• Can include run charts and be a record of what
  was accomplished

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What changes can we make that will result in
improvement?

• The clinical ideas for excellent care
• Ideas about processes
• Models

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Using a concept to create an idea to test
Specific idea to test A
Principle or concept
Thought process
Specific idea to test B
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The PDSA cyclefour steps Plan, Do, Study, Act
Act
Plan

• Also known as
• Shewhart Cycle
• Deming Cycle
• Learning and Improvement Cycle

Study
Do
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Use the PDSA cycle for

• Answer first two questions
• Developing a change
• Testing a change
• Implementing a change
• Spreading a change

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Testing versus implementation

• Testing - trying and adapting alternatives
• Implementation - making a change part of the day
  to day operation of the system

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The PDSA cycle
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Why test?

• Increase the belief that the change will result
  in improvement
• Predict how much improvement can be expected from
  the change
• Learn how to adapt the change to conditions in
  the local environment
• Evaluate costs and side-effects of the change
• Minimize resistance upon implementation

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The PDSA cycle
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The PPPP cycle
Plan
Panic
Plan
Plan
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The PDSA cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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The peg game
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To be considered a PDSA cycle

• The test or observation was planned (including a
  plan for collecting data)
• The plan was attempted
• Time was set aside to analyze the data and study
  the results
• Action was rationally based on what was learned

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Repeated use of the PDSA cycle
Changes that result in improvement
DATA
Implementation of change
Wide-scale tests of change
Hunches theories ideas
Follow-up tests
Very small scale test
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Do Study

• Reasons for failed tests
• 1. Change not executed well
• 2. Support processes inadequate
• 3. Hypothesis/hunch wrong
• Change executed but did not result in local
  improvement
• Local improvement did not impact our measures
• Collect data during the Do phase of the cycle to
  help differentiate these situations.

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Health care may not be rocket science

• Excerpt from October Sky
• Describes PDSAs by young men in West Virginia in
  the 1950s for a science fair
• See them collecting resources, interacting with
  experts and performing PDSAs
• See their science teacher

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Measurement and data collection during PDSA
cycles

• Collect useful data, not perfect data - the
  purpose of the data is learning, not evaluation
• Use sampling as part of the plan to collect the
  data
• Use qualitative data rather than wait for
  quantitative
• Record what went wrong during the data
  collection
• Use paper and pencil until the information system
  is ready

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Successful cycles to test changes

• Plan multiple cycles for a test of a change
• Think a couple of cycles ahead
• Scale down size of test ( of patients,
  location)
• Test with volunteers

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Successful tests - cont.

• Do not try to get buy-in, consensus, etc.
• Be innovative to make test feasible
• Collect useful data during each test
• Test over a wide range of conditions
• Simulate the test

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Form for planning a PDSA cycle
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Aim Decrease undocumented intentional
discrepancies and unintentional discrepancies by
75 of baselineIncrease the success index to 90
Reduced Adverse Drug Events
Adapted from The Institute for Healthcare
Improvement
DATA
Cycle 10 Patient/Family complete form _at_ bedside
if on 3 or gt meds
Cycle 9 Patient/Family complete form _at_ bedside
Cycle 8 Patient/Family complete form _at_ triage if
on 3 or gt meds
Cycle 7 Patient/Family complete form _at_ triage
Cycle 6 Bedside nurse using the form on admitted
patients on 3 or more meds
Cycle 5 Bedside nurse using the form on admitted
patients on meds
Forms and processes to support Med Rec
Cycle 4 Bedside nurse using the form on all
admitted patients
Cycle 3 BPMH form at triage for patients on 3 or
gt medications
Cycle 2 BPMH form at triage for patients only if
on medications
Cycle 1 BPMH form at triage for all patients
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Kelownas Aim Reduce use of foley catheters
following joint arthroplasty surgery
Standing orders do not include catheters
Idea Dont insert at all or else remove
catheters Day 1
DATA
Cycle 4 All surgeons to trial same order.
Surgeons encouraging pts to tx urinary
retention problems prior to surgery.
Cycle3 Second surgeon trials no foley and in
and out PRN
Cycle 2 Dr. OC trials no foley insertion on
pt. with no hx of urinary problems. In and out
catheter if unable to void
Cycle 1 On male pt. of Dr. OCs, with no hx of
urinary problems, foley is d/cd POD1 with order
to perform in and out catheter if unable to void
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Personal Aim become a fearless knitter
Goal Not afraid To try any lace pattern
DATA
Idea Learn to knit lace
Cycle 5 Knitting a lace cardigan with 4
different lace patterns
Cycle 4 Knitted lace edging for a momento for my
daughters wedding using thread.
Cycle 3 Created a diamond-pattern lace hat with
friends help.
Cycle 2 Learned to make a triangle shawl,
followed written pattern using worsted weight
yarn.
Cycle 1 Friend demonstrated an easy scarf
pattern for me. Made it for my mom.
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Screening frail elderly population
Implement Screening and assessment tools
How do we Implement Screening for Frailty
DATA
Cycle 5 Care plan data Leads to registry
development
Cycle 4 GP review
Cycle 3 Adding in contact assessment
Cycle 2 RN before discharge
Cycle 1 MOA handout flu clinie
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Kelowna using the patient perspective to guide
PDSA cycles

• Physio interviewed 2 patients with previous joint
  replacements (no revisions) to check patient
  perspective
• One patient reported increased satisfaction with
  new protocols, esp. significantly less pain, less
  nausea and no catheter
• Chart review LOS surgery L TKR (2000) and R TKR
  - (2000) 6 days each R THR (2005) 4 days, this
  surgery L THR (2006) - 3 days
• Other patient reported main difference was
  catheter following first surgery (L THR 2005),
  and no catheter second surgery (R THR). LOS 3
  days both surgeries
• Summary We are on the right track!

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Overall aim improve chronic care
Specific Test Cycles
Clinical Information System
Decision Support
Community Engagement
Delivery System design
Self-management
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Overall aim improve patient partnership
Specific Test Cycles
Respect Dignity
Information
Participation
Collaboration
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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?
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Drafting a charter

• Time to give it a try!

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References

• The Improvement Guide A Practical Approach to
  Enhancing Organizational Performance Langley GJ,
  Nolan KM, Nolan TW, Norman CL, Provost LP. San
  Francisco Jossey-Bass 1996.
• www.ihi.org, search for Model for Improvement
• Quality Improvement Through Planned
  Experimentation. 2nd edition. R. Moen, T. Nolan,
  L. Provost, McGraw-Hill, NY, 1998.
• Understanding Variation, Quality Progress, Vol.
  13, No. 5, T. W. Nolan and L. P. Provost, May,
  1990.
• A Primer on Leading the Improvement of Systems,
  Don M. Berwick, BMJ, 312 pp 619-622, 1996.
• Accelerating the Pace of Improvement - An
  Interview with Thomas Nolan, Journal of Quality
  Improvement, Volume 23, No. 4, The Joint
  Commission, April, 1997.