Finishing What We StartedCarol Haraden, PhD

This presenter has nothing to disclose.

April 11, 2014

Coverage and Completeness

Coverage: the improvement has been implemented in every clinical setting that will benefit patients

Completeness: the improvement creates the same superior results in every clinical setting that will benefit patients

How are we doing with this?

What are the barriers?

What helps?

3

4

Think of a change you have implemented.

Have you been able to spread this change everywhere you want? (coverage)

Were you able to sustain the initial improvements at all spread locations? (completeness)

If you answered no to the second or third question, why didn’t your

efforts succeed?

Dialogue #1- 3 minutes

Improvement Hold Gains Spread

Creating a New System

Design Spread

Improvement

Hold Gains

Spread

Old Way

New Way

The Sequence of Improvement

Sustaining improvements and Spreading changes to other locations= coverage and completeness

Developing a change

Implementing a change: spread

Testing a change: prototype, pilot

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

How Can We Foster the Adoption of Successful Change Ideas?

The Traditional Approaches

PolicyManual

EmailDate: February 2014

To: All Staff

From: Management

Starting next Monday, all staff will be

expected to implement the new

procedure we just tested in the 3 West

med/surg unit.

It worked there so in order to save time,

everyone will now start doing the new

procedure like 3 West.

Thank you for your

cooperation.

An Early Adopter

Will this be one of your team members?

SEPSIS

Bundle

Clarify “Where” We Spread

What is your level of our ambition?

– Every unit or ward in a hospital?

– Every service line (clinical & operations)?

– Every hospital in a system or region?

– All primary care clinics?

– All inpatient and outpatient mental health?

– All levels of care across a population?

1. Consider the change you discussed in Dialogue #1 OR a change you plan to make in the near future.

2. Identify all of the locations and/or people who will need to make that change. For example: all ORs, primary care practices, med-surgical units

3. Do you have a robust prototype that serves as an example of success? How do you know? If not, STOP HERE!

11Dialogue #2 - 3 minutes

Sustaining improvements and Spreading changes to other locations= coverage and completeness

Developing a change

Implementing a change: spread

Testing a change: prototype, pilot

Act Plan

Study Do

Teams test and improve

Spread planned and executed by senior leaders

Results tracked by front

line and leadership

Improvement

strategic

Focus at Each Step

Sustaining improvements and Spreading changes to other locations= coverage and completeness

Developing a change

Implementing a change fully one clinical area

Testing a change: prototype, pilot

Act Plan

Study Do

Focus: Stabilize process reliability, frontline notice and improve variation: measure outcomes

Focus: spread to new and sustain at previous; frontline notice and improve variation

Focus: Improve process reliability; reduce common cause variation; measure and reflect daily; outcomes when process

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Focus Variation Measure

Testing in prototype and pilot

Process Reliability Frontline notice and manage

-Process daily and reflect daily-Outcomes: unlikely to see change until greater coverage

Implement in one clinical area

-Process reliability under varying conditions-Improved outcomes in clinical area

Frontline notice and manage

-Process daily and reflect daily-Outcomes unlikely to see change until greater coverage

Spread to all relevant areas

-process reliability sustained in previous areas-outcomes improving at scale

-Leadership notice and manage across system-Frontline notice and manage in area

See next slide

How long do we measure?

• Daily till stable• Weekly x 6; if stable then: • Biweekly x 4; if stable then:• Monthly x 4; if stable then • Quarterly, no less

Variation within clinical area? Manage in area

Variation across clinical areas? Leadership investigates and manages

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The Seven Spreadly Sins(If you do these things, spread efforts will fail!)

Step #1 Start with large pilots

Step #2 Find one person willing to do it all

Step #3 Expect vigilance and hard work to solve the problem

Step #4 If a pilot works then spread the pilot unchanged

Step #5 Require the person and team who drove the pilot to be responsible for system-wide spread

Step #6 Look at process and outcome measures on a quarterly basis

Step #7 Early on expect marked improvement in outcomes without attention to process reliability

Consider an example where a change has spread poorly.

Did you commit any of the 7 Spreadly Sins? (see previous

slide)

Which one(s)?

Dialogue #3 - 4 minutes

Maturity Model of Improvement(under development) Steven J. Spear – High Velocity Edge

Level Characteristics

5Leaders lead Leaders actively engaged in leading changes

4Leaders cheer

Systems change organically creating value as they do

3Spectator x3

Systems stabilized; episodic process improvement

2Spectator

Adopting tools and systems

1Buffers

Some standard work

0Chaos

“Winging it”

Maturity Model of Improvement(under development) Steven J. Spear – High Velocity EdgeLevel Characteristics Description “Results”

5Leaders

lead

Leaders actively engaged in leading changes

Leaders work with teams to create improvement in the work areas . Leaders as coaches.

Continuous improvement system throughout organizationNew levels of performance. Breakthroughs attained

4Leaders

cheer

Systems change organically creating value as they do

Local microsystems complete the work and solve problems and improve processes daily. Continuous PDSA cycles.

Pockets of continuous improvementLeaders showcase work of top performersIslands of excellence

3Spectator

x3

Systems stabilized; episodic process improvement

Repeated process re-build “Experts return

Improvement occurs. Staff maintains, but does not continueSporadic good results, many sustained

2Spectator

Adopting tools and systems

Chartered teams, Kaizen’s, redesigns as organizational initiatives. “PI team leaves, project ends”

No improvement beyond initial levelSame projects repeated again and again

1Buffers

Some standard work People in roles standardize their individual work (ex. Charge nurses, chief residents, managers)

Local order, system chaos; People and systems act as buffers. Small improvements –not replicable or sustained“Positive Deviants” lead small workgroups and units

0Chaos

“Winging it” Daily work, daily problems No processes, random variationNo improvement

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• Adopters may need to “reinvent” the interventions.

• Key strategy to get early adopters from decision to

action? Identify issues that are barriers to adoption

and remove

• Goal: coverage AND completeness

• The spread process needs to be managedLangley J. Nolan K. et al. Improvement Guide. Jossey Bass, 2009. 

Some Thoughts on Spread

Develop the Measurement and Feedback System

Key Contacts Bill NichollLiz ArmourSG&R - Fiona Gibson

Activity Hand Hygiene Safety Briefings SBARMedicines

ReconciliationAnti Coag

ManagementTrigger Tool Daily Goals SEWS PVC Bundle

Month November November November November November November November November

Clinical/Practice AreaTay Ward PRIEarn Ward PRIRehab Stroke UnitSimpson Day Hospital

Legend ( more than one legend can be entered to display progress eg. Testing & implementing within one month)

Testing TFully Implemented FSpreading SNot yet Measuring NMNot Yet in Place NPNot Applicable NA

Tests Carried Out

Challenges

Successes

Plans for Spread

Perth & Kinross CHP- Spread Plan

Date: November 07Completed by:

Tracking the Spread of Specific Ideas Across Multiple Sites

 

Pilot 1

 

Pilot 2

 

Spread 1

 

Spread 2

 

Spread 3         

Progress Score 3.5   3.0   2.0   3.0   1.5

  A B C D   A B C D   A B C D   A B C D   A B C D

VTE Prophylaxis       x         x     x             x   x      

Sepsis       x         x         x         x     x    

Unit Briefings       x         x         x         x     x    

VAP       x         x         x         x   0      

Hazard Drug/Area # 1     x         x     x         x             x  

Early Warning System x             x     0         0         0      

Reconciliation     x         x       x         x           x  

Pressure ulcers       x         x         x         x         x

Central lines       x         x       x           x         x

Patient Involvement   x         x       x         x         x      

Simulation     x    NA        

NA        

NA        

NA      

Legend: A= Planning B= Start C= In Progress D= Fully Implemented

Don’t be a slave to the plan!

You will learn a lot that may require a change to your plan

Don’t be frustrated by having to back up and reevaluate - just don’t take forever!

– Change takes longer than you thought!– Some units want the change NOW!– Some never want it!

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Good luck with your journey!

Spreadland