Teaching and Coaching the Model for Improvement and PDSA Cycles

1
Teaching and Coaching the Model for Improvement
and PDSA Cycles

• Supporting Improvement and Innovation Dr. Chris
  Rauscher
• Sylvia Robinson

2
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

3
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?
4
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?

5
What are we trying to accomplish?

• Develop an aim statement

6
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

7
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.)

8
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

9
How do we know that a change is an improvement?

• Measurement!

10
If you aim at nothing. you hit it every time!
Measurement tells us whether or not we are
hitting our target!
11
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

12
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

13
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

14
The Triple Aim

• Care experience
• Population health outcomes
• Cost

15
Annotated run chart

• Plot small samples frequently over time

16
Measurement Infrastructure

• Routine set of measures with clear definitions
• Processes and procedures for the collection and
  entry of data into an information system
• Creation of monthly run charts that display
  improvement ..or not
• Monthly improvement team meeting to
• Review and evaluate the data
• Plan tests of change to improve data

17
What changes can we make that will result in
improvement?

• Change packages
• Clinical Guidelines
• Expanded Chronic Care Model
• Advanced Access
• Redesign
• Self-management
• New change ideas that result from testing

18
Using a concept to create an idea to test
Specific Idea to test A
Principle or Concept
Thought Process
Specific Idea to test B
19
The PDSA cyclefour steps Plan, Do, Study, Act

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

Act
Plan
Study
Do
20
Use the PDSA cycle for

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

21
Testing versus implementation

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

22
The PDSA cycle
23
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

24
The PDSA Cycle
25
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

26
Acceleration of change

• Plan multiple cycles ahead
• Example Plan four Planned Visits one for of
  the next 4 weeks
• Quicker learning
• Maintained focus
• Easier revision of the test cycle you remember
  what worked, what didnt
• You maintain momentum
• Improvement happens quicker

27
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
  studythe results
• Action was rationally based on what was learned

28
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
29
Do Study

• Reasons for failed tests
• Change not executed well
• Support processes inadequate
• 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.

30
Acceleration of change

• Scale down size of test ( of patients, location)
• Test earlier if you think about testing
• Next month do it next week
• Next week do it tomorrow
• Tomorrow do it today

31
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

32
Form for planning a PDSA cycle
33
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
34
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
35
Personal aim Become a fearless knitter
Goal Not afraid To try any lace pattern
Idea Learn to knit lace
DATA
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.
36
Seniors clinic aim Determine risk status post
emergency care and discharge
Systematic determination of risk
DATA
Cycle 5 Added numbers so clerk could do stats,
clerk pulls list all working days
Cycle 4 Added yes/no for coding.
Cycle 3 Needed more demo data and organize like
our custom report
Screen via Telephone call
Cycle 2 Added care transitions questions
Cycle 1 Adapted form from Elder Health, pull
list 2x/week
37
Overall aim Improve chronic care
Specific Test Cycles
Self-management
Delivery System design
Decision Support
Community Engagement
Clinical Information System
38
Overall Aim improve patient partnership
Specific Test Cycles
Respect Dignity
Information
Participation
Collaboration
39
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?
40
Now lets use the guidance for inquiry using the
model for improvement