Accelerated Change: We Can Do It

1
Accelerated ChangeWe Can Do It!
Improvement Facilitator Training Toronto -
March 16, 2009 Dr. Ben Chan, CEOOntario Health
Quality Council
2
OHQC Mandate A Dual Role

• An independent body, created by the Government of
  Ontario to
• Report directly to Ontarians on the state of our
  publicly funded health system and
• Support quality improvement

3
Attributes of Quality High Performing Health
System

• Effective
• Efficient
• Equitable
• Accessible
• Safe
• Patient-centred

• Focused on population health
• Integrated
• Appropriately resourced

4
Whats Wrong with Quality?
5
Effectiveness Slow Uptake of Evidence-Based
Practices

• INSERT Bar Chart from report page 91

6
Safety Falls in LTC
7
Safety Drugs in LTC
8
Patient ExperienceNeed to Engage Patients More
in Decisions
9
Future Public Reporting in LTC

• Reporting on OHQC website on individual LTC
  homes, including
• Pressure ulcers, falls, incontinence
• Keeping people healthy (worsening depression,
  cognition, ADLs)
• ED visit avoidance
• resident family satisfaction
• Staff satisfaction, work environment

10
Translating Research into Evidence

• The lag between publication of landmark clinical
  trials and application in practice (to 50 use)
  is unnecessarily long, in the range of about 15
  to 20 years.
• Balas and Boren, 2000

11
Balas, Boren 2000
12
We Want Accelerated Change
13
But Why Is Change So Slow?
14
Who Owns The Problem?
Who Owns The Solutions?
15
Veterans Affairs, USAFalls Reduction
Collaborative, 37 sites
16
Texas Pressure Ulcer Collaborative 20 Nursing
Homes
17
(No Transcript)
18
Kensington Gardens Falls Reduction
19
Sask ICU Collaborative

• Aim
• improve sedation for intubated pts appropriate
  venous thromboembolism prophylaxis in 7 of 8 ICUs
  in Saskatchewan
• Measures
• RASS score for appropriate sedation
• of pts on VTE prophylaxis where indicated
• Change ideas / concepts
• Assessment tools, reminders, flowsheets

20
Saskatchewan ICU Collaborative
21
Saskatchewan ICU Collaborative
22
Pressure Ulcers
23
Pressure Ulcers

• Aim
• Reduce by 20 pressure ulcer prevalence in 8 LTC
  sites in Saskatchewan in 1 year
• Measures
• Incidence prevalence of pressure ulcers
• Use of Braden scoring
• Change ideas / concepts
• Provincial guidelines adopted from RNAO
• Risk scoring
• Turning, moving, repositioning patient
  appropriately
• Management of nutrition, incontinence
• Use of special devices if high risk

24
Saskatchewan Pressure Ulcer InitiativeLTC
Facilities, 2006
25
The Power To Make A Difference

• QI Science empowering front-line providers
  with tools to fix problems with quality in their
  work environment

26
Qulturum, Jonkoping County

• Swedish health region with highest quality,
  lowest costs
• IHI Pursuing Perfection site
• Long history of investment in quality
• Qulturum Dedicated centre for QI learning

27
QI Skills Development

• Core skills needed throughout workforce

28
Understanding The System
29
Process Mapping ImprovementExample Breast
Screening in Saskatchewan
Yes
Screening Mammography
Suspicious?
Letter to MD
MD calls pt to office
Pt sees MD in office
No
MD books Dx Imaging
Letter to FP, re-book in 2 years
Dx Imaging Done
30
Fast Track Process
Yes
Screening Mammography
Suspicious?
Notify FP
FP calls pt to office
Pt sees FP in office
No
Screening Pgm books Dx Imaging
Dx Imaging Done
Letter to FP, re-book in 2 years
31
(No Transcript)
32
Causes of Poor Quality
33
Ishikawa Diagramsaka Fishbone, Cause Effect
Diagrams
Why Do People Fall At Home?
34
Process-Style Ishikawas

• Use to brainstorm problems with processes
• Prod thinking about possible ideas to address
  problems

35
(No Transcript)
36
Aim Statements for QI Projects

• What are we trying to accomplish?
• Reduce falls in our facility or group.

37
Aim Statements for QI Projects

• What are we trying to accomplish?
• Reduce the rate of falls / month from 10 to 6 for
  all residents in Shady Pines LTC. Do this by
  November 2009.

38
Well Designed Aim Statements

• Is it clear?
• Is it measurable?
• Is time specified?
• Is the target population identifiable?
• Can you hear the promise for better patient
  outcomes?

39
Creating Definable Vision for Quality

• Some is not a number, soon is not a time
• Don Berwick, December 2004, at launch of the
  100,000 Lives Campaign

40
Target Setting

• Consider best ever practice by leading site /
  institution anywhere
• Consider theoretical idea of optimal care
• Dont be constrained by best region in Ontario
• Consider decreasing defects by ½ on each QI
  project iteration

41
MeasuresHow Will We Know a Change is an
Improvement?

• Outcome measures
• What is the main impact we are trying to have?
• Consider related process measures
• What are the things we need to do daily or weekly
  to make sure we have an impact?
• Consider balancing measures
• What do want to protect as we work towards our
  aim?

42
What Changes Can We Make That Can Result in
Improvement?
43
Source of Change Ideas

• Best practices literature
• other QI initiatives
• Ideas from your peers
• Your own system analysis
• Think of ideas that address root causes
  identified in Ishikawa diagrams
• Think of processes that could be improved from
  process map
• Your own brainstorming

44
Some Fall Prevention Change Concepts

• Develop routine practices/standardize
• Increase consistency
• Design Systems to Avoid Mistakes
• Reminders, cues, etc
• Engage the healthcare provider/resident/family
• Awareness and engagement
• Improve Work Design
• changing work environment, improving work flow

45
Change Concepts Ideas
46
Change Management Skills
Lets strike a committee, do a lit search,
carefully design the perfect system in 4 months
then roll it out
47
Change Management Skills
Lets strike a committee, do a lit search,
carefully design the perfect system in 4 months
then roll it out
48
What should a PDSA look like?

• Objective
• What do you want to learn/try?
• Plan
• Who, what, where, when?
• Measurement
• Predict outcome as a group
• Do
• Just do it!
• Study
• What worked? What didnt? Predict correctly?
• Act
• Next steps

• Write It down!

49

• learn as you go
• small tests, not (necessarily) small changes

50
What should a PDSA look like?

• Objective
• What do you want to learn/try?
• Plan
• Who, what, where, when?
• Measurement
• Predict outcome as a group
• Do
• Just do it!
• Study
• What worked? What didnt? Predict correctly?
• Act
• Next steps

• Write It down!

51
Multiple PDSA Cycle Ramps

• Try different ways of implementing change concept

Coordination w/ educators
Standing orders, checklists
Pt self-mgt
52
The Ideal

• Testing Ideas for Change,
• Optimizing Means of Implementation

Continuous Measurement to Drive Improvement
53
Frequent Sample Measurement Annotated Run Charts
54

Run charts

• visual display of your data over time
• Measure continuously (not just before, after)

55
Key Measures - Diabetes
56
Key Measures - CAD
57
(No Transcript)
58
Team What does it mean to you?
59
The Quality Improvement Team understands the
unit/home

• What are competing initiatives?
• How does this align with organizations core
  strategies, priorities?
• What resources do we need?
• What can we deliver in quality?
• Is there a business case for this QI initiative?

60
Building a QI Team

• Select representatives of key parts of process
• Keep size manageable (10)
• Secure resources for their time
• Build in conflict management skills
• Identify executive sponsor (esp. for large
  organizations, e.g. hospitals, CCACs)

61
Leadership
62
Leadership What We Want

• Leaders pick falls as key priority
• Falls prevention is aligned with a big system
  goals (e.g. decrease ED overcrowding)
• Leaders set stretch targets
• Leaders support, clear roadblocks
• Leaders set action plan for what each part of
  organization needs to accomplish to meet goal
• Leaders communicate goal strategy across
  organization
• Leaders are held accountable for results

63
Learning Collaboratives
64
Learning Workshops
Storyboards
Ideas forImprovement
Interdisciplinary Teams
65
Key Messages

• You can make change happen
• Change, problem solving skills at the front line
• System is ill not you
• Learn to diagnosis the system get it back to
  health
• Supported by, united with leadership

66
Contact Us

• Email ohqc_at_ohqc.ca
• FREE QI tools resources at
• www.ohqc.ca