Rapid Improvement Concepts in Health Care Tammera D' Caine, MS, CPHQ Ohio KePRO Acute Care Services

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Rapid Improvement Conceptsin Health
CareTammera D. Caine, MS, CPHQOhio
KePROAcute Care Services
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Model for Improvement
Three fundamental questions for achieving
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 improvement?
Framework for developing and implementing
successful changes
Act
Plan
Study
Do
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AIM

• Describes the general goal
• Clearly stated measures
• Numerical
• Represent a challenge for your organization.
• Improve left ventricular assessment of heart
  failure patients so that by December 2003, gt90
  of heart failure patients will be discharged on
  ACE inhibitors or their medical records indicate
  a reason why ACE inhibitors were not used.

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AIM Statement

• Direction of change
• Area of change
• Degree of change
• Time frame

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Examples

• Improve the completion of resident care plans so
  that by December 2003 gt75 of heart failure
  patients are discharged on ACE inhibitors or
  their medical records indicate a reason why ACE
  inhibitors were not used.
• Improve left ventricular assessment of heart
  failure patients so that by December 2003 gt85 of
  all heart failure admissions with left
  ventricular systolic dysfunction have a notation
  in their medical record that they are potential
  candidates for ACE inhibitors.

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Examples

• Reduce surgical site infections in hip/knee
  replacement patients so that by December 2003,
  100 of patients given prophylactic antibiotics
  will have those antibiotics discontinued within
  24 hours after surgery.
• Reduce all surgical site infections so that by
  December 2003, 95 of patients receive
  prophylactic antibiotics within one hour prior to
  incision.

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Model for Improvement
Three fundamental questions for achieving
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 improvement?
Framework for developing and implementing
successful changes
Act
Plan
Study
Do
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How will we know a change is an improvement?
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Measure

• Select the measure(s) to be used
• Establish baseline
• Identify a process for obtaining the data and
  person to coordinate
• Ongoing data collection
• Record your measures and document progress

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AIM (where we want to be)
Gap opportunity for tests/change strategies
Baseline (where we are)
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Suggestions

• Align measures with your aim
• Collect useful data, not perfect data (the
  purpose of data is learning, not evaluation)
• Choose measurement tools that
• Already exist or are easy to construct
• Are easy to interpret
• Plot data over time on a run chart
• Keep measurement tool visible
• Record what went well / what didnt

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Run Chart - A Graphical Record of a Measure
Plotted Over Time
Unit 1
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Instead of plotting the number of incidences each
month, plot the time (or number of cases,
patients, visits, etc.) between incidences.
Time Since Last Incidence
200
180
160
140
120
Number of days
100
80
60
40
20
0
Jul-01
Jul-02
Mar-01
May-01
Nov-01
Mar-02
May-02
Nov-02
Mar-03
Jan-01
Jan-02
Jan-03
Sep-01
Sep-02
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Model 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 improvement?
Act
Plan
Do
Study
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What Changes Can We Make That Will Lead to
Improvement?
Change Concept a general notion or approach to
change that has been found to be useful in
developing specific ideas for changes that lead
to improvement.
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Identify Possible Changes

• Review your selected aim
• Identify process changes that relate to the
  selected aim
• Brainstorm hunches / theories
• Record your selected changes

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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?
• Adopt-Adapt-
• Abandon

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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Test Cycle

• Plan Review routine order forms and progress
  notes for heart failure admissions with cardiac
  nurse supervisor within one week.
• Do Completed June 1, 2003
• Study Unable to find routine order forms. The
  progress notes varied in the type of
  information recorded. Left ventricular function
  was not included.
• Act Created a template for progress notes
  for heart failure admissions which included boxes
  for left ventricular function determination.

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Test Cycle

• Plan Recruit MD who is not on the project team
  to pilot the use of the progress notes template
  on new heart failure admissions. Review pilot
  within 3 weeks.
• Do Completed June 14, 2003.
• Study The form seemed effective, but there were
  problems in making it available for all heart
  failure admissions.
• Act Describe process of how template
  progress notes were made available for the pilot
  physician.

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Test Cycle

• Plan Schedule brainstorming session with staff
  involved in all phases of HF admission to
  identify areas where template progress notes
  would be needed to increase inclusion in HF
  medical records.
• Do Completed July 7, 2003.
• Study Having forms available in ER and cardiac
  nursing stations would be advisable.
• Act Continue pilot of progress notes
  template for another 3 weeks with the template
  made available in the identified areas.

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To Be Considered a PDSA Cycle

• The test or observation is planned (including a
  plan for collecting data)
• The plan is attempted
• Data is analyzed and learning connections made
• New actions are rationally based on what was
  learned

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Why Test?

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

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Tips for Testing Change Ideas

• Plan multiple PDSA cycles
• Test ideas side by side with the existing process
• Scale down size of test ( of radiologists,
  units, physicians, drugs, procedures)
• Test with volunteers
• Do not try to get buy-in, consensus, etc.
• Collect useful data during each test
• Spread test over a wide range of conditions

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Repeated use of the Cycle
Changes That Result in Improvement
DATA
Test --- Reflect --- Learn
Test --- Reflect --- Learn
Hunches Theories Ideas
Test ---- Reflect ---- Learn
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Repeated Use of the PDSA 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
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Repeated use of the Cycle
Improve timeliness of antibiotics
Trial with 2 new anesthesiologists for 1 week
DATA
Trial protocol for delivering antibiotics to OR
with patient for one week
1 anesthesiologist accountable for timely
administration for one week
1 preoperative nurse accountable for timely
administration for one week
Develop approaches to improve timeliness of
antibiotics
MD Champion conducts provider education for 1
surgeon and 1 anesthesiologist
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Repeated use of the Cycle
Integrate clippers into system
Implement clipper usage in all ORs
DATA
Identify staff to maintain clippers
Email all surgical staff and remove all razors
Send e-mail to 3 pre-op nurses and 1 surgeon re
advantages of clippers over razors
Develop approaches to decrease use of razors
Remove razors from one OR for two days
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Reduce Surgical Infection Rate for
Detail Design
Use Antibiotic Appropriately
Avoid shaving site
Maintain normal Blood glucose
Maintain Normal body temperature
Concept Design Ramping Cycles
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AIM
Concept D
Concept C
Concept B
Concept A
Change Concepts, Theories, Ideas
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Reduce Medication Errors
Concept Design Ramping Cycles
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Reduce Adverse Drug Effects
Concept Design Ramping Cycles
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Cycles for Testing Changes

• Cycle 1 - Use preprinted order forms
• Cycle 2 - Specify single or daily dose
• Cycle 3 - Include both mg dose and the
  calculated dose
• Cycle 4 - Allow only oncology certified nurses
  to administer

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Reduce Adverse Drug Effects
Concept Design Ramping Cycles
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Cycles for Testing Changes

• Cycle 1 - Use preprinted order forms
• Cycle 2 - Prohibit verbal orders except in
  emergencies
• Cycle 3 - Perform blood glucose monitoring on
  patient care units
• Cycle 4 - Use blood glucose flow sheets and
  maintain them with patient MAR

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Reduce Adverse Drug Effects
Concept Design Ramping Cycles
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Cycles for Testing Changes

• Cycle 1 - Implement a weight based heparin
  protocol
• Cycle 2 - Provide patient care units with
  prefilled heparin syringes for flushing lines
• Cycle 3 - Call results of all aPTTs to patient
  care unit within 2 hours, or monitor
  at bedside
• Cycle 4 - Use anticoagulation flow sheets and
  maintain them with patient MAR

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Reduce Adverse Drug Effects
Concept Design Ramping Cycles
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Cycles for Testing Changes

• Cycle 1 - Standardize terminology and dose
  expressions
• Cycle 2 - Standardize method of ordering
  neonatal electrolyte solutions
• Cycle 3 - Include patient monitoring
  parameters on preprinted orders

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AIM
Concept D
Concept C
Concept B
Concept A
Change Concepts, Theories, Ideas
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Accelerate improvement by using the Model for
Improvement
What Cycle can we complete by next
Tuesday? Willing to compromise on scope, size,
rigor, and sophistication, but the Cycle must be
completed by Tuesday.
Act
Plan
Study
Do
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Decrease the Time Frame for a Cycle

• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes

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Reasons for Failed Tests

• 1. Change not well executed
• 2. Support processes inadequate
• 3. Hypothesis/hunch wrong
• Change executed but did not result in local
  improvement
• Local improvement did not impact global measure

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Spread Considerations

• Generally takes more time than tests
• Increased scope will lead to increased resistance
  
• Develop support processes to maintain change
• High expectation to see improvement (no failures)

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Adopter Categorization Speed of Adoption
Innovators
Late Majority
Early Majority
Early Adopters
Tradition-alists
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2
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Critical Success Factors for this Model

• Clear aim that seeks aggressive change
• (30-50 range)
• Identify or research successful key strategies
• Keep tests small, action-oriented and immediate
• Track change using run/control charts

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Critical Success Factors for this Model

• Replicate and spread good results
• Set an end point to reach the aim
• Provide the right people

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Three Ingredients of an Effective Team
System Leadership
Technical Expertise
Day-to-day Leadership
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System Leadership

• Fully supports rapid improvement project
• Should have authority over all areas affected by
  change
• Helps to remove barriers and obstacles to
  improvement

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Senior LeadershipFostering Success

• Target rapid improvement goal as a key
  organizational performance goal (how does it fit
  with strategic goals/objectives?)
• Team success becomes your priority
• Develop team as template for others
• Recognize teamwork as an organization-wide
  process to be embraced by all

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Fostering Success (contd)

• Make sure everyone is aware of the team efforts,
  that tests are being tried, and systemwide
  improvement is the goal
• Tolerate mistakes and failed tests, learn from
  them and move forward
• Openly celebrate successes with teams
• Have team members/leaders meet regularly with
  senior leaders to share progress

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Technical Expertise

• Subject matter expert-knows process well
• Understands system as it relates to improvement
  project
• Clinician many times fills this role
• Must champion improvement efforts and drive the
  system changes for improvement
• Good working relationship with colleagues

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Day-to-Day Leadership

• Works in the system on a daily basis
• Understands system details and the effects change
  will have upon the system
• Critical to driving project forward on a daily
  basis, assures application of change ideas
• Good working relationship with others
• Should be team leader for the project

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Barriers

• Failing to shift from blame to personal
  responsibility
• Failing to empower the team members
• Failing to keep your focus small and rapid

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Barriers

• Not being able to articulate the ways that the
  corporate vision is furthered by this work
• Not being able to get a bureaucratic decision
  made
• Peer influence is informal or lacking
• Staying with a leader that wont or cant lead

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Barriers

• Disagreeing on the importance of data
• Competition from QI who wants to own it or kill
  it
• Trying to measure too much, trying to learn too
  much

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Measurement Development Tool

• Part 1. Identification of indicator
• What is your goal? What is the rationale for
  selecting this goal?
• What is the indicator you will use to measure
  this goal?
• Why has this indicator been selected?
• List the organizational units, departments,
  functions or teams to which the indicator
  applies.

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Measurement Development Tool (cont.)

• 5. What impact will collecting data have on
  patients or employees?
• 6. Are there literature references for this
  indicator? (specify source)
• Is there baseline data for this indicator? If
  yes, what is the current baseline and what was
  the measurement period?
• Is there a target for this indicator? What is
  the target?

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Measurement Development Tool (cont.)

• Part 2. Development of Indicator and Data
  Collection
• Define the indicator. Include numerator,
  denominator, all inclusions, exclusions, and
  required data elements.
• Describe data collection plan.
• How often and for how long will you collect the
  data?
• Will you use sampling? If so, what sampling?
• How will you collect the data? Data sheets,
  survey, focus group discussions, interviews, etc.

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Measurement Development Tool (cont.)
d. Who will collect the data? e. How will the
data be coded, edited and verified? Who will
perform these tasks? f. How will the data be
tabulated and analyzed? g. How will the data be
used? h. Who will have access to the raw data and
reported data?
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Run Chart

• Purpose
• The run chart is a simple graph used to monitor a
  process or activity so any trends or runs can be
  easily identified. Run charts are easy to use and
  read. They can
• display the value of one data point against
  another in relations to time
• record occurrences (vertical axis) over a period
  of time (horizontal axis)
• illustrate the natural variation in the process
  or activity.

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Run Chart

• Steps
• 1. Choose which data you will record on the
  vertical axis, and which on the horizontal. Time
  periods are usually plotted on the horizontal
  axis.
• 2. Decide if you will be recording data as
  individual numbers, averages, or percentages.
• 3. For ease of plotting and reading data, use a
  background of grid rulings.
• 4. To plot each data point, locate the correct
  measurements on each axis and move your pencil
  along one axis grid until it meets the other.
  Mark the point.
• 5. After all the points have been plotted,
  connect them with an unbroken line.
• 6. Analyze the line for trends, changes, or
  periods of stability in the process you are
  monitoring.

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Rapid Improvement Concepts in Health Care Appendix
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Progress Checklist

• Plan
• ? Identify objectives
• ? Identify questions and predictions
• ? Create action plan
• Do
• ? Carry out the action plan
• ? Document problems/unexpected observations
• ? Collect data on key indicators
• Study
• ? Analyze data and effects
• ? Compare data to predictors
• ? Summarize what was learned
• Act
• ? Build into system
• ? Identify next cycle

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Publication No. 4020-OH-015-2/2004. This
material was prepared by Ohio KePRO under a
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