8/6/2013

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IHI ExpeditionImproving Patient Experience and Making It Stick

Session 4

Wednesday, August 7, 2013

These presenters have

nothing to disclose

Barbara Balik, RN, EDd

Kelly McCutcheon

Adams, LICSW

Expedition Coordinator

Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the

Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the

organization’s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelor of Science in Health Science with a concentration in Business Administration.

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Expedition Director

Kelly McCutcheon Adams, LICSW has been a

Director at the Institute for Healthcare Improvement

since 2004. Her primary areas of work with IHI have

been in Critical Care and End of Life Care. She is an

experienced medical social worker with experience in

emergency department, ICU, nursing home, sub-

acute rehabilitation, and hospice settings. Ms.

McCutcheon Adams served on the faculty of the U.S.

Department of Health and Human Services Organ

Donation and Transplantation Collaboratives and

serves on the faculty of the Gift of Life Institute in

Philadelphia. She has a B.A. in Political Science from

Wellesley College and an MSW from Boston College.

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Today’s Agenda

Introductions

Debrief Action Period Assignment

Focusing on Spread and Adaptability to Improve Patient Experience

Assignment for Next Session

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Overall Program Aim

Using the IHI Patient Experience Change Package, this program will aid participants in a) harvesting updated concepts to improve

the culture and strategies for improving patient and family experience; and b) assuring the foundations for success are identified and implemented to support the stickiness of their

strategies.

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Expedition Objectives

At the end of the Expedition each participant will be able to:

Identify new concepts to test that will improve patient experience

Explain how attention to reliability affects the utility of change ideas

Describe key issues to address when planning spread of effective ideas

Modify current practices to increase reliability and ability to spread

Recommend actions to engage colleagues at all levels in patient and family experience culture change

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Schedule of Calls

Session 1 – Foundational Elements to Improve Patient and Family ExperienceDate: Wednesday, June 26, 1:00 PM – 2:30 PM ET

Session 2 – Latest Thinking and New Ideas – Engaging Others for the JourneyDate: Wednesday, July 10, 1:30 – 2:30 PM ET

Session 3 – Using Reliability Concepts to Improve Patient ExperienceDate: Wednesday, July 24, 1:30 – 2:30 PM ET

Session 4 – Spread and AdaptabilityDate: Wednesday, August 7, 1:30 – 2:30 PM ET

Session 5 – Live Case Studies of Improving Patient ExperienceDate: Wednesday, August 21, 1:30 – 2:30 PM ET

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Faculty

Barbara Balik, RN, EdD, Principal, Common Fire Healthcare Consulting, is also Senior Faculty at the Institute for Healthcare Improvement. Her areas of expertise include leadership and systems for a culture of quality and safety, including patient- and family-centered care, patient experience, systems to improve transitions in care, and transforming care prior to or with optimization of an electronic health record implementation. She works with leaders to develop adaptive systems to excel and innovate in complex organizations, and to ensure sustained improvement and innovation every day. Ms. Balik's publications include the book, The Heart of Leadership, and the IHI white paper on "Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care," among others. Previously, she served in senior leadership roles at Allina Hospitals and Clinics, United Hospital, and Minneapolis Children's Medical Center.

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Action Period Debrief

• Assignment: Fill out the reliability worksheet for a

process you are testing or have implemented to improve

patient experience.

• What did you learn from using this worksheet? Any

surprises?

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Reliability Worksheet

Process to make reliable: __White board completion______ Segment of focus: __Initial completion for new admit__________________

High Level Flow Chart

Get dry-erase

marker

Erase white

board at room

set-up

Fill-out white board:

RN, CNA, Lead, Mgr

names and #s. MD

name. Date. POC.

Pain level

Discuss

information

with patient

Update POC

within 30

minutes of

patient arrival

Reliability Goal: The required 8 sections of the white board will be completed within 30 minutes of a newly

admitted patient’s arrival to the unit 95% of the time

Organization:____Memorial Medical Center_____________________________ Date:_____May 1, 2013____________________

Defects List

for Each

Step

• Didn’t get

marker

• No markers

available

• Marker out of

ink

• Lost marker

• Don’t erase

• No eraser

• Assume board

has already

been updated

• Put wrong

information on

board

• Don’t have all

information

• Forget to fill-in

a section

• Don’t fill-in

anything

• Don’t engage

patient

• Patient

sleeping

• Language

barrier

• Patient not in

room

• Patient

confused

• Don’t update

board

• Put wrong

information on

board

• Old

information

not erased

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ROLL OUT

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A Tale of Two Hospitals:

SPREAD at Reliability Hospital

“Promising changes are

tested on a larger scale and

when changes are shown to

be an improvement, they

are spread thoughtfully and

with planning and

teamwork. “

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A Tale of Two Hospitals:

SPREAD at Inconsistency Hospital“These flavor-of-the-month

efforts are endured through

gritted teeth by staff and can

be counted on to fall by the

wayside if enough time

passes. Changes are

monitored for a couple weeks

and then process

measurement drops off. “

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Perspective from Atul Gawande

“As other countries adopted Bangladesh’s approach, global diarrheal

deaths dropped from five million a year to two million, despite a fifty-

per-cent increase in the world’s population during the past three

decades. Nonetheless, only a third of children in the developing world

receive oral rehydration therapy. Many countries tried to implement at

arm’s length, going “low touch,” without sandals on the ground. As a

recent study by the Gates Foundation and the University of Washington

has documented, those countries have failed almost entirely. People

talking to people is still how the world’s standards change.”

http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande?currentPage=all

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Question for Today

There are five frogs on a log… five decide to jump in… how

many frogs are left on the log?

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Improvement Hold Gains Spread

Creating a New System

Design Spread

Improvement

Hold Gains

Spread

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Sustaining improvements and spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a

variety of

conditions

Make part of

routine

operations

The Sequence of Improvement19

How Do You Know Your Teams are

Ready to Spread?

There is an intention to spread the work of the team in the organization

The topic of interest is a key initiative for the organization in the next year

A Senior Leader is responsible and accountable for coordination and spread of the work of the team

An initial pilot team is relatively self-sufficient

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How Can We Foster the Adoption of

Successful Change Ideas?

The traditional approaches

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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

Robert Lloyd, PhD., Institute for Healthcare Improvement

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Adoption is a SOCIAL thing!

A better

idea…

…communicated through a

social network…

…over

time

Rogers, E. M. (2003).

Diffusion of innovations. New

York, Free Press.

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A Framework for Spread

Set-up-Target population

-Adopter audiences

-Successful sites

-Key partners

-Initial spread strategy

Social System

-Key messengers

-Communities

-Technical support

-Transition issues

Knowledge Management

Measurement and Feedback

Leadership-Topic is a key strategic initiative

-Goals and incentives aligned

-Executive sponsor assigned

-Day-to-day managers identified

Better Ideas-Develop the case

-Describe the ideas

Nolan K, Schall M, Erb F, Nolan T. Jt Comm J Qual Saf 31(6):339-347, June 2005

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Phase 1: Readiness

Topic is a key strategic initiative

Executive sponsorship designated

Day-to-day leadership assigned

Successful site(s) identified

− Describe the ideas

− Develop the case

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Role of the Executive Sponsor

Designated by Senior Executive

Coaches other senior leaders

Supports day-to-day leader

− Addresses resource issues

− Responds to system issues

− Sets expectations

Carries message (sense-making)

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Role of the Day-to-day Leader

Assists Executive Sponsor in creating spread plan

Guides the execution of the spread plan

Leads Spread Team

Monitors outcomes and progress and shares with

Executive Sponsor

Communicates! Both up and down!

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Spread Team

Established by the organization's executive leaders to provide direction for the spread effort; monitors progress

Several areas of expertise and/or responsibility to consider for the team include:

− The designated senior leader;

− A day-to-day leader of the spread activities;

− And others, including line- or department-level leadership; clinical expertise; representatives of a successful pilot site; those who will lead the effort in the target population; and support services such as information technology, human resources, and quality improvement.

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Phase 2: Developing a Spread Aim

Spread What:

Target Goals:

Spread to Whom:

Time Frame:

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Communication Plan

Building Awareness

Moving adopters from decision to action

Supporting and mentoring adopters

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An Early Adopter31

Roger’s Adopter Categories

‘Traditionalists’

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

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Relative Advantage

Relative Advantage

SimpleSimple TrialableTrialable CompatibleCompatible ObservableObservable

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Attributes of an Idea that Facilitate Adoption33

The WAY in Which We Communicate is

Important

SHARE

INFORMATIONSHAPE

BEHAVIOUR

General

Publicationsflyers

newsletters

videos

articles

posters

Personal

Touchletters

cards

postcards

Interactive

Activitiestelephone

email

visits

seminars

learning sets

modeling

Face-to-faceone-to-one

mentoring

shadowing

(C) 2001, Sarah W. Fraser (Adapted from Ashkenas, 1995)

Public

EventsRoad shows

Fairs

Conferences

Exhibitions

Mass mtgs

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Moving Adopters from Decision to Action

Information about the changes

Mentors, coaches, or experts to get answers to

questions

Connections with peers

Feedback

Accountability for results

Encouragement and support from leaders

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Phase 3:

Refining and Executing the Plan

Feedback and adjustments may be needed for:

− Communication plans

− Materials and information

− Support and mentorship

− Infrastructure issues

− Social system issues

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Summary – Some Thoughts on Spread

Evidence for some ideas being spread is built as success is realized in

different situations. Adopters may need to “reinvent” the interventions.

Persons who are influencers or opinion leaders in the social system serve

as the best messengers.

For the spread of new ideas to happen in a timely fashion, the spread

process needs to be managed (i.e., plan based on prediction of best

prediction; packaging the changes; communication strategies/tactics;

identification and support of early adopters/opinion leaders; identification of

transition issues…).

Transition issues that are barriers to adoption need to be identified and

mitigated. This is a key strategy to get early adopters from decision to

action.

Langley J. Nolan K. et al. Improvement Guide. Jossey Bass, 2009.

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A Word About Education vs. Performance…

Coaching relationship between staff and leaders− Coaching skills are taught and used reliably by leaders

Clear Purpose – what and why− Often underestimated

− Skip this step and go to action

Learn from the positive deviants

− Who are your bright stars?

− Learn from the:

Managers who do well

Staff who excel

− What do they do?

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Build on 3 factors � more likely to embrace and

maintain new behaviors to achieve Purpose:

− Competence – feel skilled & comfortable in new

behavior – knowing what and how to do it

− Contribute – involved in determining the new

behavior – what, how, and when• Co-create not tell or sell

− Connected – part of a network, feeling known, cared

about and supported in learning the new behavior*

*Suchman, A, et al Eds. (2011). Leading Change in Healthcare: Transforming Organizations

using Complexity, Positive Psychology, and Relationship-Centered Care. London: Radcliffe.

A Word About Education vs. Performance…39

A Word About Education vs. Performance…

Step 1 – Prepare the individual

− See 3 Factors

− Understand what they already know – honor their

knowledge

Step 2 – Present the Activity

− Specify the key points of activity – the vital few

Step 3 – Try-out the Activity

− Individual explains key steps as they do it

− Simulation or live

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Step 4 – Follow-Up

− Specify who they go to for help

− Observe and encourage questions

− Taper off coaching as skill is established

Corrective Action

− Only if above steps are repeatedly unsuccessful

− “Help me understand what gets in the way of …?”

− “Here’s what the expectations are. How can I assist

you in achieving these beginning today?”

Modified from: Graupp, P. & Purrier, M. (2013). Getting to Standard Work in Health Care. Boca

Rotan: CRC Press.

A Word About Education vs. Performance…41

IHI Resources

100K Lives Campaign Guide on Sustainability and

Spreadhttp://www.ihi.org/knowledge/Pages/Tools/HowtoGuideSustainabilitySpread.aspx

White Paper on Spreadhttp://www.ihi.org/IHI/Topics/Improvement/SpreadingChanges/

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Action Period Assignment

Using the Seven Spreadly Sins list, reflect on a change

you are currently spreading at your organization. Are you

committing any of the “sins”? What can you do to change

course?

Share your answers via listserv by August 19th at

PatientExperienceExpedition@ls.ihi.org

Be prepared to talk about your learning at the next

session

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Getting Ready for the Last Session

We are looking for a few teams to do short presentations

at the final session about their patient experience

improvement efforts and then receive some live faculty-

coaching

If you are interested, please complete the three slide

template (will be sent separately as well as shown here)

and submit to Max Cryns (mcryns@ihi.org) by Tuesday,

August 13th

We will notify you by August 19th if you should be

prepared for a 3-4 minute presentation at the August

21st session

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SLIDE 1: Hospital Name Here

Include here the city, state, and country in which your

organization is located

Also include a picture of your organization or your team

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SLIDE 2: Successes

Include here a few of your greatest successes in

improving patient experience

Please also include the key lessons you learned along

the way

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SLIDE 3: Challenges

Include here a few of your biggest challenges in

improving patient experience

Please also include the key lessons you learned along

the way

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Expedition Communications

Listserv for session communications:

PatientExperienceExpedition@ls.ihi.org

To add colleagues, email us at info@ihi.org

Pose questions, share resources, discuss barriers or

successes

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Next Session (Last one!)

Session 5

Live Case Studies of Improving Patient Experience

Date: Wednesday, August 21, 1:30 – 2:30 PM ET

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References

Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992

Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.

Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business SchoolPress, 2000.

Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September -October 1997.

Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000.Fraser S. Spreading good practice; how to prepare the ground, Health Management,

June 2000.Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000.Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood, Il:Irwin

,1978.Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San

Francisco: Jossey-Bass 1996.Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement

Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207.

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References

McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008.

Myers, DG. Social Psychology (3rd ed.) New York: McGraw-Hill, 1990.

Nolan, KM; Schall, MW, ed.: Spreading Improvement across Your Health Care Organization. Joint Commission on Accreditation of Healthcare Organizations and the Institute for Healthcare Improvement, 2007, pp. 1-24.

Nolan K., Nielsen G, Schall M: Developing Strategies to Spread Improvements. From Front Office to Front Line: Essential Issues for Health Care Leaders, Joint Commission Resources, Berman S. (ed.) 145 - 178, 2005.

Prochaska J, Norcross J, Diclemente C. In Search of How People Change, American Psychologist, September, 1992.

Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.

Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998.

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