Model for Improvement

1
Model for Improvement

• Kevin Little, Ph.D., IHI
• Corinna Nyquist, RN, BSN, Indian Health Council
• Marni Kopenski, NP, Gerald Ignace Indian Health
  Center
• Jana Towne, RN, BSN, Whiteriver Service Unit

2
Overview of the Model for Improvement
Kevin Little, IHI 25 June 2008
Based on a presentation developed by Jerry
Langley, IHI Cindy Hupke, IHI for Innovations in
Planned Care for the Indian Health System
2
3
Agenda

• Context for IPC work
• Team example 1
• Theory and Concepts-1
• Team example 2
• Theory and Concepts-2
• Team example 3
• Q and A/Discussion
• Next Steps/Summary

3
4
Blood Pressure PDSAPurpose/Objective of
CycleTo determine/assess our blood pressure
techniques

• Corinna Nyquist
• Indian Health Council

5
PLAN

• The Change
• What are we testing? Taking blood pressures
  after a client has rested for 5 minutes vs. upon
  entry to clinic.
• Who are testing on? The next 5 clients.
• When are we testing? Today.
• Where are we testing? In the medical clinic.
• Our Prediction
• We anticipate that BPs taken 5 minutes after the
  client has rested will be better than those taken
  when clients first arrive.

6
PLAN cont.

• Data
• What data do we need to collect? BPs upon entry
  into the clinic and again 5 minutes after the
  client is roomed.
• Who will collect the data? The team.
• When will the data be collected? Today at 3 pm.
• Where will the data be collected? In the medical
  clinic.

7
DO (carry out the test)

• What was actually tested? Took BPs on 4 clients
  upon entering the clinic and repeated 5 minutes
  later after client had been sitting down.
• What happened? 4 out of 4 BPs were lower after
  resting for 5 minutes.
• Observations? BPs decreased when clients were
  sedentary for 5 minutes.
• Problems? Asked data entry staff what they do if
  there are 2 BPs response was that they enter
  1st BP taken.

8
STUDY

• Blood pressures taken after client was seated for
  5 minutes were substantially lower than those
  taken upon entry to the clinic. Team realized
  that we needed to change our current process and
  complete BPs after client is roomed and has
  rested.

9
ACT

• What changes should we make before the next test
  cycle? Meet with MAs and nurses tomorrow
  morning and ask them to room the client and then
  complete any questionnaires and screens prior to
  doing vitals. Also, we need to write protocol
  for data entry regarding two results for any
  given test.
• When will the next test cycle be? Tomorrow.
• Are we ready to implement the change? Yes by
  11-13-07.

10
Your Observations

• What was effective?

• Opportunities to do better?

11
Theory and Concepts-1
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To Be Successful at Improvement You Need the
Following

• Will - for improvement
• Ideas - for changes that will lead to improvement
• Execution a framework for action to adapt the
  changes to achieve improvement

13
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?
G. Langley et al. (1996), The Improvement Guide
A Practical Approach to Enhancing Organizational
Performance, Jossey-Bass Publishers, San
Francisco.
14
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?

15
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?
16
An Aim Statement

• Whiteriver Service Unit seeks to fundamentally
  redesign its delivery of care for all patients in
  order to promote the health and wellness of the
  community, and to improve the prevention and
  treatment of chronic conditions. We will improve
  health care processes and outcomes for each
  patient across the entire population in a cost
  effective manner. This commitment is reflected
  in our strategic goal to provide compassionate,
  quality health care that is timely and effective,
  that maximizes patient safety and that excels at
  best practices.

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Some Guidance to Support the Aim

• We will actively partner with the White Mountain
  Apache community to collaborate in the design of
  patient-centered care processes in order to have
  the community take ownership of the changes.
• The initiative will develop care processes which
  focus on a positive patient and family members
  health care experience.
• These processes will be developed, tested, and
  packaged in such a manner that they can be spread
  throughout Whiteriver Hospital and Cibecue Health
  Center within the next 3 years.
• The team will define patient care process through
  the use of flowcharts create a list of possible
  changes, and prioritize and implement the
  changes. A specific focus will address how to
  sustain improvements.
• The initial microsystem that will receive
  improvement focus is located in Whiteriver
  Hospitals Outpatient Clinic A. Core staff for
  the care team will include at a minimum, 1.0FTE
  Med Staff coverage (2 physicians and 2 physician
  assistants,) 2 RNs, 2 Certified Nursing
  Assistants, Medical Clerk, Pharmacist, Dietician,
  Lab Tech, Clinical Applications Coordinator and
  Patient Registration representative. A patient
  panel of 1000 patients who represent all ages
  will be created. These patients will participate
  as members of their own care teams.

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Some Goals to Support the Aim (within 12
months evaluated annually thereafter)

• Health improvement for this panel of patients (as
  measured by chronic condition and preventive
  services outcomes) by 100.
• Patient and family experience improvement as
  evidenced by satisfaction scores to gt 95 and
  third next available appointment with the care
  team to lt 1 month.
• Efficiency improvement as measured by decreased
  office visit cycle time to 60 minutes when
  pharmacy is included (40 minutes without
  pharmacy) and increased value-added face time to
  40 min.
• Decrease in Urgent Care and Emergency visits by
  50 per 1000 patients
• Changes will occur within existing funding
  resources.
• Create a process for identifying waste, and then
  reduce it in all forms.
• Patients who indicate that they feel confident
  managing their own conditions will increase to gt
  95.

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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?
20
IPC Measures (Fall 2007)
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(No Transcript)
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Intake Screening Bundle
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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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Some Change Ideas for IPC

• Empanelling
• Care team
• Use data to drive improvement
• Optimize use of HIT
• Remove waste
• Plan for every pt
• Segment care
• Reminders system
• Move work to appropriate licensure
• Reliable follow-up
• Max packing

• Proactive care across spectrum
• Self-Management
• Integration into community
• BH integrated into primary care
• Train workforce
• Transportation for pts
• Integration of traditional medicine
• Guidelines of care
• Advanced access
• Adjusting meds to control

25
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?
26
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
The most effective PDSAs are those that are
linked to your aim, measures, and key change
conceptsthe arrow from the three questions to
the PDSA is not decorative!
What change can we make that
will result in improvement?
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The PDSA Cycle for Learning and Improvement
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 PDSA CycleTestingThe Basics
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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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Testing on a Small Scale

• Have others that have some knowledgeable about
  the change review and comment on its feasibility.
• Test the change on the members of the team that
  helped developed it before introducing the change
  to others.
• Incorporate redundancy in the test by making the
  change side-by-side with the existing system.
• Conduct the test in one facility or office in the
  organization, or with one patient.
• Conduct the test over a short time period.
• Test the change on a small group of volunteers.
• Develop a plan to simulate the change in some way.

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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 access or
  efficiency
• Collect data during the Do Phase of the Cycle to
  help differentiate the these situations.

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Study ? Act

• Compare data to prediction
• Summarize what was learned
• ACT - Take action on the new knowledge

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The Sequential Nature of PDSA Cycles Building
upon what we learn

• Marni Kopenski
• Gerald Ignace Indian Health Center

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PDSA 5

• Purpose/Objective To determine if patients are
  bringing their medications or medication cards to
  their appointments (on each appointment card it
  says to bring in your medications).

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PLAN

• The Change
• What are we testing? To determine if patients
  are bringing in their medication cards or
  medications at their visit.
• Who are testing on? 5 patients of Marni
  Kopenskis (all the diabetic patients on that
  day).
• When are we testing? June 6, 2007.
• Where are we testing? In the clinic.
• Our Prediction
• We predict that at least 3 of the 5 patients will
  bring in either their current med list or the
  actual meds.

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PLAN cont.

• Data
• What data do we need to collect? If patient has
  a medication list or their meds with them at the
  visit.
• Who will collect the data? The MA rooming the
  patient.
• When will the data be collected? Before the
  provider enters the room beginning of visit.
• Where will the data be collected? On a bright
  green recording sheet.

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DO (carry out the test)

• What was actually tested? Measuring the number
  of patients who brought in their meds or med
  list.
• What happened? Of the 5 scheduled diabetic
  patients, only 1 patient showed up.
• Observations? We didnt realize that we have
  many days when scheduled patients dont show up.
• Problems? We couldnt accurately tell how many
  have a med list or actual meds due to only 1
  patient showing up for visit.

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STUDY

• 1 of 5 diabetic patients showed up for their
  scheduled appt. That is a 80 no show rate on
  that day for diabetic patients. The one patient
  that did show up had her medications with her and
  a medication card that she carries with her at
  all times.

39
ACT

• What changes should we make before the next test
  cycle? We have to determine our current no show
  rate and what we can do to decrease it. Reception
  staff has not consistently been calling the day
  before to remind patients of appointments.
• What will the next test cycle be? On Monday,
  June 25, the receptionist will call MKs patients
  that are scheduled for Tuesday appointments
  will remind them of the appt. date and time, to
  bring their meds, and to call and cancel if they
  cant make it.
• Are we ready to implement the change? Yes

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PDSA 6

• Purpose/Objective Our last PDSA showed we had a
  lot of no shows and we wanted to test if calling
  patients before their appointments would help
  decrease no shows. Our no show rate is currently
  18-22 and increases slightly in the summer. Per
  reception, they have not been calling patients
  because so many phone numbers are inaccurate or
  disconnected.

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PLAN

• The Change
• What are we testing? To see if calling the
  patients before their appointment helps decrease
  no show rate.
• Who are testing on? Marni Kopenskis Tuesday
  morning patients (9 total)
• When are we testing? Reception will call the
  patients today (Monday) and chart who shows up
  tomorrow.
• Where are we testing? In the clinic.
• Our Predictions
• We predict that 1/3 or 3 of the 9 phone
  numbers will be accurate, the no show rate will
  be less than 18, the patients that reception
  actually talked to will show up, and that calling
  the patients the day before their appointment
  decreases no shows.

42
PLAN cont.

• Data
• What data do we need to collect? Call patients
  and record if reception
• Talked to patient and patient said they would
  come to the scheduled appointment
• Left a message on a machine or with a family
  member
• Had a wrong phone number or phone was
  disconnected
• Didnt get an answer couldnt talk to anyone
• Talked to patient and they rescheduled or
  cancelled
• On Tuesday, see what patients showed up and if
  there is a correlation between calling and
  showing up
• Who will collect the data? Reception
• When will the data be collected? Tuesday
  afternoon after MKs patients have been seen.

43
DO (carry out the test)

• What was actually tested? If calling patients to
  remind them of their appointments will decrease
  no show rate.
• What happened? Reception called patients and
  were surprised to reach most of them.
• Observations? Didnt take long to call patients.
• Problems? We still have some patients without
  accurate phone numbers or phones.

44
STUDY

• Monday Calling 9 calls made, patients were
  reminded of appointments, and encouraged to
  cancel if unable to come in.
• 1 wrong number
• 2 messages left
• 6 patients were talked to directly and confirmed
  their appointments
• Tuesday Patients
• 2 people cancelled before their scheduled time
• 5 showed up
• 2 no showed 1 was called day before and said
  she would be at appointment. The other no show
  had a disconnected phone.

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STUDY cont.

• Only 2 of the 9 patients had a disconnected phone
  or wrong number. We had predicted 3/9 so we
  overestimated.
• No show rate was 22. This was higher than
  expected but in normal range. We really thought
  this would be lower with the phone calls the
  night before.
• 6 patients were actually talked to and 5 of the 6
  showed up. Therefore, 83 of the people called
  did show up for their appointments.
• Overall, we feel that the night before phone
  calls were helpful patients that cancelled
  actually called before their appointment time.

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ACT

• What changes should we make before the next test
  cycle? We have now implemented calling patients
  the night before their appointments to remind
  them. Some staff think we have more disconnected
  phones or wrong numbers than these results
  indicate. They believe that when we ask patients
  to update the registration form, they just say,
  its all the same to get back into the clinic
  faster.
• What will the next test cycle be? For patients
  that come in tomorrow, Wednesday, June 27th, each
  one will be given a slip of paper to update their
  address and phone number in the room while
  waiting for the provider. At the end of the day,
  reception will compare what the patient filled
  out to the chart to find the number of
  discrepancies.
• Are we ready to implement the change? Yes

47
PDSA 7

• Purpose/Objective To determine if we give
  patients a piece of paper to fill out address and
  phone number while they are waiting in the exam
  room, we will find discrepancies with the
  information in the chart.
• Background We have found that if we call
  patients the night before, they show up for their
  appointments. However, weve had a difficult time
  ensuring we have the correct phone number and
  address. Although we ask patients to update their
  information at check in, this doesnt always
  happen. The last PDSA showed that 22 of patient
  had an incorrect phone number.

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PLAN

• The Change
• What are we testing? The match between address
  and phone in chart vs. what patients put on piece
  of paper.
• Who are testing on? Marni Kopenskis patients.
• When are we testing? Wednesday, June 27.
• Where are we testing? In the clinic.
• Our Prediction
• We predict that 25 of patients will say
  their information is correct/no changes and when
  we compare slip to chart, there will be a
  discrepancy.

49
PLAN cont.

• Data
• What data do we need to collect? Ask patients if
  address or phone has changed since we saw them
  last and have them fill out slip of paper while
  waiting in exam room.
• Who will collect the data? Reception will ask
  about any changes RNs will hand out and collect
  slip of paper reception will compare with chart.
  
• When will the data be collected? On June 27th
  after patients are gone.
• Where will the data be collected? In clinic by
  RNs and reception.

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DO (carry out the test)

• What was actually tested? The accuracy of the
  information in our charts as compared to what
  patients filled out on slip of paper.
• What happened? Reception did not ask if there
  was an address or phone number change before
  handing out slips (every patient got one).
• Problems? Reception stated they were too busy to
  ask about changes before handing patients the
  slips.

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STUDY

• 11 of 17 scheduled patients showed up for their
  appointments and it was found that 8 of the 11
  did not have discrepancies between the
  information they provided on the slip and what
  was in the chart. 3 patients did have a change
  (and these were the 3 we were not able to reach
  the night before). We were close to our
  prediction of 25 discrepancy rate and feel this
  is pretty accurate.

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ACT

• What changes should we make before the next test
  cycle? If we cant reach a patient to confirm
  their appointment, they will be given a sheet to
  fill out their updated information when they come
  in the next day.
• What will the next test cycle be? We will retest
  with the receptionist just handing out the slips
  to the patients who we are unable to reach the
  night before. If anyone else in the clinic learns
  of a change in information, they will have access
  to the slips and can give them to the patient
  (the slips will be in the exam rooms).
• Are we ready to implement the change? Yes

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Your Observations

• What was effective?

• Opportunities to do better?

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Theory and Concepts-2
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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Hunches Theories Ideas
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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
56
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Repeated Use of the Cycle
Changes That Result in Improvement After cycles
have demonstrated that the change CAN work, use
more cycles to help you figure out how the change
WILL work, every day
DATA
Hunches Theories Ideas
Investigation
Demonstration
Implementation
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What we mean by implementation

• You know a change has been implemented when you
  can have 100 staff turnover in your organization
  and the change will remain in place.
• Implementation requires that staff and leaders
  have built the change into formal plans, job
  definitions, training, and intentional reviews.
  Implementation typically requires a process
  perspective, too.

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Aim Improve primary care appointment
availability through reducing and standardizing
appointment types
Improved access
Cycle 5 Staff education in new
standards
Cycle 4 Standardize appointment types
Cycle 3Test the types with 1-3 physicians
Cycle 2Compare requests to the types for one week
Reduction of appointment types will increase
appointment availability
Cycle 1Define a small number of appointment types
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Overall Aim Increase Access
Specific Test Cycles
Standard panel size
Scheduling protocols
Appointment types
Team approach to care
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Principles of Testing a Change

• 1. Build Knowledge Sequentially
• Test on a small scale
• Use multiple cycles
• 2. Increase the Ability to Predict from the
  Results of the Test
• Collect data over time during the test
• Test over a wide range of conditions

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Why predict?

• Explicit prediction of outcomes in uncertain
  situations followed by comparison of outcomes to
  the prediction may enhance our ability to learn.
  
• This effect has been suggested to occur at the
  level of brain chemistry activating dopamine
  neurons by uncertainty mobilizes attention,
  motivates risk-taking, and promotes learning
  about relationships between external stimuli and
  consequential events. (Shizgal and
  Arvanitogiannis (2003), p. 1858 discussing
  Fiorillo et al (2003))
• Forces you to think about test measures
• Can increase staff interest in your tests

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Data for Improvement

• Key measures (to answer question 2)
• Data to support cycles (short term, process
  focus, include qualitative)
• Implementation relies on a combination of the two
  types

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Successful Cycles to Test Changes

• 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
• 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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Questions for Users of the PDSA Cycle

• Is the planning based on theory? Stated?
• Are the predictions made prior to data
  collection?
• Are multiple cycles run?
• Is there documentation of what was learned?
• Does the learning provide a basis for action?

66
Example from On-Line Course Accelerating
Learning and Improvement

• What Cycle can we complete by 3 PM?
• Willing to compromise on scope, size, rigor, and
  sophistication, but the Cycle must be completed,
  recorded, and sent to us by the time that we get
  back together at 3 pm ET.

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Documenting Improvements
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Link changes to your measuresAnnotated Time
Series
69
Family of Measures for Chronic Care BTS
70
Track your PDSA cycles and Key measure(s).
Annotate your graph to reflect whether a change
led to an improvement
NE Team Actual team PDSA cycles and graph
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PDSA WorksheetPlan Do Study Act

• Organization Whiteriver
• Date 11/9/07
• PURPOSE/OBJECTIVE OF CYCLE
• Define patient perception of appointment time
• 4 question survey of Hon-Dah staff regarding
  perceptions regarding appt times

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PLAN the change, data collection and predict

• The Change
• What are we testing?
• When do patients think their appt time starts?
  Do patients perceive that they should meet with
  the provider at their appt time?
• Who are we testing the change on?
• 5 Hon-Dah employees Use extremes
• younger, older
• When are we testing?
• November 7
• Where are we testing?
• Hon-Day conference center. And casino ?

73

• Predictions
• What do we expect to happen?
• People will say that the visit with the
  provider
• begins at their appointment time (vs.
  the visit process
• starting at their appointment time)
• Data
• What data do we need to collect?
• Read questions to them
• If your clinic appointment is at 900, what
  do you
• expect to happen at 900?
• Who will collect the data?
• Emilia and Cindy
• When will the data be collected?
• This afternoon
• Where will the data be collected?
• In the casino area

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DO Carry out the change/test collect data and
begin analysis

• What was actually tested
• 5 persons who asked their perceptions
• What happened?
• 1 the doctor (shed arrive 5 minutes early)
• 1 doctor
• 1 nurse (vital signs)
• 1 doctor (arrives 20 minutes early to get
  everything done and see her doctor at 900)
• 1 not to get seen (if I come early I still
  wait. I expect that Ill see my doctor at
  1000)
• Observations
• Can group perceptions into 3 categories doctor,
  nurse, no one
• 2 said they would come early for appt
• Problems
• No problem with understanding the question.

75
STUDY Complete analysis of data, summarize what
was learned, and compare data to predictions

• 60 said they would see the doctor at 900
• 20 said they would see a nurse at 900
• 20 said theyd wait an hour to be seen
• 80 expect to see a care provider at 900
• Majority of peoples perceptions met our
  prediction.
• If we want to be patient focused, we need to
  adapt to their perceptions
• ACT What changes should we make before the
• next test cycle?
• We know how to ask the question.
• The prediction is good.
• Where test next
• Increase the number of people asked.
• What will the next test cycle be?
• November 8 first thing in the AM for 10
  minutes as many as possible.
• Are we ready to implement the change?
• NOOOOOOOOOOOOOOOO

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Several cycles later.
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PDSA WorksheetPlan Do Study Act

• Organization Whiteriver
• Date May to June 2008
• PURPOSE/OBJECTIVE OF CYCLE
• Decrease interval between patients appt time and
  when provider interaction begins.

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PLAN the change, data collection and predict

• The Change
• What are we testing?
• Moving clinic start times from 820am to 840am
  and 1240pm to 100pm.
• Who are we testing the change on?
• Clinic staff, providers and empanelled
• patients in IPC clinics.
• When are we testing?
• Beginning with June provider schedule
  (5/19-
• 6/22).
• Where are we testing?
• Clinic A

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• Predictions
• What do we expect to happen?
• Staff will be more prepared for clinic
  day and
• patients will be seen nearer to their
  actual appt time.
• Data
• What data do we need to collect?
• Cycle time data and experiences of staff.
• Who will collect the data?
• Clinic A staff.
• When will the data be collected?
• May 19-June 22, 2008
• Where will the data be collected?
• Clinic A

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DO Carry out the change/test collect data and
begin analysis

• What was actually tested
• Shift of appt day 20 minutes later, from
  0820-1040 to 0840-1100 and 1240-1540 to
  1300-1600.
• (Data reported through end of May only).
• What happened?
• Patients saw their providers nearer to their
  actual appt times and overall patient cycle times
  decreased. No negative impact was noted on appt
  times, staff lunches or when the clinic day ended.

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• Observations
• Staff were very positive about being prepared for
  the day, value-added time increased. Staff said
  they didnt even notice when asked about impact
  to lunch times or the end of the clinic day. The
  time between appt and provider interaction has
  previously been decreasing with clerks rooming
  patients.
• Problems
• Staff have become so efficient there is no longer
  time for the patient to complete the paper intake
  self-screen and staff have reverted to doing this
  verbally.

82
STUDY Complete analysis of data, summarize what
was learned, and compare data to predictions

• Times from patient arrival to provider decreased
  from 46 to 33 minutes
• Interval between actual appt time and provider
  interaction decreased from 30 to 27 minutes
• Overall cycle times decreased by 19 minutes.
• Value-added time increased 6.
• Staff more prepared for clinic day so visits and
  day flow more smoothly.

83
STUDY Complete analysis of data, summarize what
was learned, and compare data to predictions

• No negative impact to appts, lunches or the end
  of the clinic day were noted.
• Interval between actual appt time and provider
  interaction had been decreasing with testing of
  clerks rooming patients. Appt time shift appears
  to continue this decrease.
• Predictions were supported

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Cycle time impact to patients
85
Cycle Time Results-Without Pharmacy visit
86
Cycle Time Results-Including Pharmacy visit
87
ACT

• What changes should we make before the next test
  cycle?
• Test cycle needs to be completed as June data
  has not been analyzed.
• What will the next test cycle be?
• Pending completion of this cycle
• Are we ready to implement the change?
• Pending completion of this cycle

88
Your Observations

• What was effective?

• Opportunities to do better?

89
More Questions and Discussion
90
Next Steps
91
How could you begin?

• Think about the following
• What are the current results within the IPC-IHC
  for your organization? Is there anything that
  stands out as needing improvement
• Do you have a team already at work? Ask the team
  about plans for tests in the coming week or so.
• What are some things that you think could go
  better in the clinic flow and communication?
• What are things that the patients and families
  complain about?
• What are things that you are doing well, but not
  doing reliably or regularly at this time?
• Think about timeliness issueshave any?

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Example

• Took a look at the intake screening bundle
  results and found that depression screening is
  not routinely being done and pulls down the
  percentage of screening bundles being completed
  in our organization.
• Identified the current process
• Nurse identifies current status
• Physician does the screen in the room
• Hunch to test We feel that if the 2-question
  screen was done initially by the nurse, followed
  up by nurse administered PHQ when warranted, it
  will streamline the visit and also increase the
  percent of screens being done.

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Another Example

• Physicians are complaining that the review of the
  record for current status is taking too long and
  delaying the clinic flow.
• Hunch If the iCare summary sheet was printed
  off by registration, it could be placed on the
  chart and sent back to the nurse to verify more
  quickly that scanning the chart.
• Can you test this without the patients present?
  Role play, use each other to test the flow

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One more.
Done without patients present!
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Additional notes on the Model for Improvement

• Model for Improvement analogous to behavior in
  other organisms
• Behavior analogous to the Model for Improvement
  is exhibited by cells swimming in a
  mediasomething like the Model for Improvement
  appears to have a long evolutionary history!
•  
• a. cells carry out measurements and
  record them all the time. The bacterium swimming
  upstream in a glucose gradient was my initial
  candidate example of an autonomous agent. The
  bacterium does so by molecular sensors that
  measure glucose, a molecular motor with a stator
  and a rotor that can rotate in either direction,
  and a flagellum that can rotate in two
  directions, causing swimming in one direction
  and tumbling in the other. The cell achieves
  swimming upstream by continuing to swim if the
  glucose concentration is rising and tumbling then
  swimming in a random direction if not. Kaufmann
  (2000), p. 150
• b. Human sperm act in the same way as the
  bacterium. The sperm seek a human egg, navigating
  a chemical gradient with measurements made by an
  olfactory receptor.
• it has been known for some time that
  olfactory receptors (ORs) reside in spermatozoa,
  the function of these ORs is unknown. Here, we
  identified, cloned, and functionally expressed a
  previously undescribed human testicular OR,
  hOR17-4. hOR17-4 functions in human sperm
  chemotaxis and may be a critical component of the
  fertilization process. Spehr et al (2003), p.
  2054
• Explanation of chemotaxis To
  determine the behavioral implications of our
  findings, we investigated the effects of
  bourgeonal on human sperm swimming. An initial
  experiment tested for the accumulation of cells
  in microcapillaries placed within ascending,
  uniform, or descending chemical gradients.
  Results were used to distinguish between
  mechanisms of chemotaxis (directed movement with
  respect to a chemical concentration gradient),
  chemokinesis (change in swim speed), and cell
  trapping (arrest of swimming). In both the
  ascending and uniform gradients, cell
  accumulation within capillaries increased
  significantly as a function of dose) two-way
  analysis of variance (ANOVA) F4, 281
   30.01, P lt 0.0001. Moreover, densities of
  cells in capillaries within an ascending gradient
  were significantly higher than those within a
  uniform or descending gradient (two-way ANOVA
  F2, 281  164.28, P lt 0.0001). Finally, at each
  effective concentration (10-8 to 10-5 M),
  accumulation of cells in capillaries was ranked
  in the following order, according to chemical
  gradient ascendinggtgt uniform gt descending. These
  collective results are consistent only with a
  chemotaxis mechanism--that is, directed movement
  toward a region of locally elevated bourgeonal
  concentration . (Spehr et al. p. 2057)
• In the bacterium example, the aim is
  food in the sperm example, the aim is an egg.
  In each example, there is a need for measurement
  and a requirement that the cell can change
  direction in response to measured performance.
  Then there is a test cycle. We do not claim
  there is a conscious plan by the cells, rather
  simply that after an action is taken (swimming in
  a particular direction), measurements are taken
  and compared with desired behavior of the signal
  (glucose increasing, buorgeonal increasing), and
  change in direction is made if desired behavior
  of the signal is not seen. These steps are
  clearly analogs of Do, Study and Act.