Accelerating Improvement:

1
Accelerating Improvement
Changes, Cycles, Improvements and Implementation
Kelly Westfall Washington State Collaborative May
22-23, 2006 (Prepared with assistance from Lloyd
Provost, Associates in Process Improvement, and
the Institute for Healthcare Improvement)
2
Model for Improvement
What are we trying to accomplish? (a.k.a., Aim)
How will we know that a change is an improvement?
(a.k.a., Measurement)
What change can we make that will result in
improvement? (a.k.a., Change Package)
3
Planned Care Model
4
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

5
Use the PDSA Cycle for...

• Testing or adapting a change idea

6
What is a Change Idea?

• A general idea for changing a process
• Usually high-level
• Evokes multiple ideas for specific processes
• Examples
• Simplify
• Reduce handoffs
• Consider all parties as part of the same system

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From Change Ideas to Key Changes

• A.k.a, Process Changes
• Change in a system or process that may lead to
  breakthrough improvement
• More focused and detailed than Changes Ideas
• Examples
• Screen patients at high risk for diabetes every
  year using diagnostic screening tests
• Implement an office tracking system, reminder
  system, and office-initiated notification system
  for

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WSC Change Ideas and Key Changes (see your
Handbook)

• Key Changes
• Actions found in literature study of successful
  practices
• Suggested actionable changes found successful by
  other chronic condition Collaboratives

• Change Ideas
• Planned Care Model Components
• Clinical Standards of Care

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Testing
Small Sample within Pilot Population

• Data collection
• Try it all
• Failures

Testing
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Tips for Testing Changes

• Scale down size of test ( of patients, clinics)
• Plan multiple cycles for a test of a change
• Test with volunteers
• Do not try to get buy-in, consensus, etc.
• Pick easy changes to try
• Be prepared to end the test of change

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Use the PDSA Cycle for

• Testing or adapting a change
• Implementing sustaining a change

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Testing and Implementing
Entire Pilot Population
Small Sample within Pilot Population

• Affects key measures
• No failures
• Sustaining change supports

• Data collection
• Try it all
• Failures

Testing
Implementing
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Testing vs. Implementing

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

• Change is permanent
• High expectation to see improvement (no failures)
• Increased scope will lead to increased resistance
• Takes more time than testing

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Tips for Implementing Change

• The path of least resistance best use of the
  people willing to change
• Impact biggest improvements early in
  implementation
• Number of people involved changes that have the
  most direct implementation

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Sustaining Change

• Make reversal as difficult as possible
• Establish a standard process
• Use measurement and audits
• Pay attention to maintenance processes,
  especially orientation and training

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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-scale tests of change in pilot
Follow-up tests
Hunches Theories Ideas
Very small scale test
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Using the Chronic Care Model for a Specific
Chronic Population
Community Resources and Policy
Clinical Information Systems
Organiz-ation of health care
Self- Manage- ment Support
Delivery System Design
Decision Support
Develop Strategies for Each Component of the
Chronic Care Model
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Take Home Messages

• Your PDSA cycles should help implement a specific
  Change
• Think of two steps to making changes
• First Testing
• Second Implementing
• Use PDSA cycles
• Can do both steps at the same time for different
  change ideas
• Next time moving past your pilot population

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References

• The Improvement Guide A Practical Approach to
  Enhancing Organizational Performance. G. Langley,
  K. Nolan, T. Nolan, C. Norman, L. Provost.
  Jossey-Bass Publishers., San Francisco, 1996,
  Chapter 7 and Chapter 13.
• Diffusion of Innovations,, Everett Rogers, The
  Free Press, NY, 1962, 1983, and 1995
• A Primer on Leading the Improvement of Systems,
  BMJ, Don Berwick, 312 pp 619-622, 1996.
• Diffusion of Innovations within Organizations
  Electronic Switching in the Bell System, Karen
  Cool, Igemar, Dierickx, Gabriel Szulanski,
  Organization Science, Vol 8, no. 5, Sept/Oct,
  1997, pp 543-559.
• Physicians as Leaders in Improving Health Care,
  Annals of Internal Medicine, 128 pp 289-292,
  1998.