leading quality improvement -...

2/21/2017

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Leading Quality Improvement

Essentials for ManagersLesson 3: Practice Improvement Essentials

February 21, 2017

These presenters have

nothing to disclose

Janet Porter, PhDDave Munch, MDKathy Duncan, RN

Today’s Host2

Rebecca Goldberg, Project Coordinator, Institute for

Healthcare Improvement (IHI), coordinates multiple

projects focused on increasing value in health care by

improving quality and reducing costs. Currently,

Rebecca’s primary responsibility is coordinating and

hosting IHI’s Expeditions, monthly virtual support

programs focused on specific topic areas. Rebecca is a

recent graduate of Georgetown University in

Washington, D.C., where she obtained her Bachelor of

Science degree in human science with a minor in public

health.

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Phone Connection (Preferred)3

To join by phone:

1) Click on the “Participants”

and “Chat” icon in the top,

right hand side of your

screen to open the

necessary panels

2) Click the button on

the right hand side of the

screen.

3) A pop-up box will appear

with the option “I will call

in.” Click that option.

4) Please dial the phone

number, the event

number and your attendee

ID to connect correctly .

WebEx Quick Reference

• Please use chat to

“All Participants”

for questions

• For technology

issues only, please

chat to “Host”

4

Enter Text

Select Chat recipient

Raise your hand

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5

Chat

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Name and the Organization you represent

Example: Sam Jones, Midwest Health

Please send your message to All Participants

LQI Structure

9 Lessons in the program

– Each lesson is composed of:

1. Preparation work on the Learning Management System (videos,

articles, case studies, and an assignment)

2. A coaching call for that Lesson (WebEx call with faculty)

– Lesson preparation work opens two weeks before the lesson’s

coaching call (Lesson 4 pre-work will open after this call)

– While you complete your preparation activities, please feel free

to email the listserv, [email protected], or the Lesson faculty

with questions

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mailto:[email protected]

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Lead Faculty7

Kathy D. Duncan, RN, faculty, Institute for Healthcare

Improvement (IHI), directs IHI Expeditions and manages IHI's

work in rural settings. Previously, she provided spread expertise to

Project JOINTS, co-led the 5 Million Lives Campaign National

Field Team, and was faculty for the Improving Outcomes for High

Risk and Critically Ill Patients Innovation Community. She also

served as the content lead for the Campaign's Prevention of

Pressure Ulcers and Deployment of Rapid Response Teams

areas. She is a member of the Scientific Advisory Board for the

AHA NRCPR, NQF's Coordination of Care Advisory Panel, and

NDNQI's Pressure Ulcer Advisory Committee. Prior to joining IHI,

Ms. Duncan led initiatives to decrease ICU mortality and morbidity

as the director of critical care for a large community hospital.

Supporting Faculty8

David Munch, MD, Senior Vice President and Chief Clinical

Officer, Healthcare Performance Partners, leads the

organization’s clinical and Lean Healthcare engagements. He

previously served as Chief Clinical and Quality Officer at

Exempla Lutheran Medical Center, where he led their Lean

Production applications for more than five years, resulting in

substantial improvements in both clinical and non-clinical

processes. Dr. Munch has been a frequent speaker on

leadership effectiveness and Lean transformation for a number

of health care organizations, including The University of

Rochester Medical Center, Yale-New Haven Health System,

Tulane University Medical Center, Pittsburgh Regional Health

Initiative, Institute for Clinical Systems Improvement, and the

Voluntary Hospital Association. He served on the Agency for

Healthcare Research and Quality's High Reliability Advisory

Group, and he has an extensive background in hospital

operations, health plan governance, physician organization

governance, and clinical practice in Internal Medicine.

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LQI Objectives

At the end of the program, participants will be able to:

Describe the skills, tools, and resources needed by

a middle manager to lead quality improvement

efforts in their local settings

Demonstrate how to link department-level

improvement activities to the organization’s goals

and overall strategic plan

List at least three ways middle managers can be

successful in partnering with front-line staff in quality

improvement activities

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LQI Lessons

Lesson 1 – Know Yourself, Janet Porter

Lesson 2 – Managing Time and Attention, Dave Munch

Lesson 3 – Practice Improvement Essentials, Kathy Duncan

Lesson 4 – Coach Your Team, Dave Munch

Lesson 5 – Patient Engagement, Janet Porter

Lesson 6 – Problem Solving in a Culture of Safety, Dave Munch

Lesson 7 – Managing Systems and Connections, Dave Munch

Lesson 8 – Identify and Spread Successful Improvement, Kathy

Duncan

Lesson 9 – Empower Teams to Engage in Improvement, Janet

Porter

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Today’s Objectives

Apply the Model for Improvement to at least one

improvement opportunity.

Use a PDSA cycle to test at least one change

Identify which team members you need to engage in a

specific test of change

Demonstrate how to analyze data over time using a run

chart and run chart rules

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Action Period Assignment

Write an aim statement (How much, by when) for the

problem you want to address or improve.

Identify at least one thing you will measure to help you

determine if a change is an improvement.

Identify at least one change you want to test.

Thanks:

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,

Norman, C. L., & Provost, L. P. The Improvement Guide:

A Practical Approach to Enhancing Organizational

Performance. San Francisco, CA: Jossey-Bass, 1996.

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4 Components of an Aim Statement

State the aims clearly (What do you want to

accomplish? How good, by when?)

Define location or population

Set stretch goals

Include numerical goals/targets

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Write an aim statement (How much, by when) for the

problem you want to address or improve.

– 23 aim statements

– Thank you for trusting me with your work and allowing me to

specifically respond with guidance

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A Good Aim Statement

Identifies the system to be improved (scope, patient

population, processes to address, providers, etc.)

– Occasionally the system scope was left out. Easy to do, but it is powerful to describe the exact scope. Don’t assume we know where it is – Name it.

– 4 south

– Med surg

– Outpatients

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Identifies the system to be improved (scope, patient population,

processes to address, providers, etc.)

– Often the aim was around tasks to be completed (compliance, education of, etc.) instead of the actual improvement addressed.

– Focus: What do you want to happen? What is the main goal?

– Decrease readmissions

– Decrease sepsis mortality

– Identify patients at high risk for readmission

– OKAY-To develop and test a nurse driven protocol …..

– BETTER- 95% of the patients on NTICU and MICU with symptoms will be screened for C Diff by 4/30.


Has specific numerical goals

– Great work! All but one had very ambitious numbers! Percentages, real world numbers

– Reduce by 50%

– 90%

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Includes timeframe (by when)

ALL had a timeframe! Some ambitious, some not so much. Great to specify a date!

– Some had a vague date “May” “3rd Quarter” “end of the year”

– December 31, 2017

– April 30, 2017

– July 1, 2017

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Action Items for Action Period

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Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change





Three Types of Measurement

Outcome Measures

– Voice of the customer or patient. How is the system

performing? What are the results?

Process Measures

– Voice of the performance of the process or system. Are the

parts/steps in the system or process performing as planned?

Balancing Measures

– Looking at a system from different directions or dimensions.

What happened to the system as we improved the outcome

and process measures? (e.g. unanticipated consequences,

other factors influencing outcome). Don’t “rob Peter to

pay Paul”

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Key Points of Measurement

The purpose of measurement in Improvement is for

learning not judgment!

All measures have limitations, but the limitations do

not negate their value for learning.

Measures tell a story; goals or targets provide a

reference point to evaluate performance.

These measures should operationalize the Aim

Data should be plotted over time --- annotate graphs

Focus on the Vital Few

Action Period: One Measure

Be specific. Simple. Remember your

aim.

Correct a fib education form.

Compliance with CVP insertion checklist

Note is in the binder by the 14.

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Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change





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Where might you find changes?

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Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change





Principles for Testing

A test of change should answer a specific question

A test of change requires a theory and prediction

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Test on a Small Scale

Incorporate redundancy in the test by making the change side-by-side with the existing system

Conduct the test over a short period of time

Conduct the test with one member of your team or with one patient

Learn quickly and go BIG, FASTER

Why Test?

Why not just implement than spread?

Increase degree of belief

Document expectations

Build a common understanding

Evaluate theories and predictions

Test ideas under different conditions

Learn and adapt

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“The survey says” last 100

examples of a test

#1 answer – are TASKS

Task vs. Test

Remember: a Test must answer a question.

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Test vs. task

Educate 100% of staff on 4W regarding

screening protocols by April 1, 2017

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Test vs. task

Develop and implement a protocol for

sterilization of all surgical equipment.

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Test vs. task

Complete EKG in Triage on 3 pts on January

15 (Kathy)

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Test vs. task

Facilitate weekly meetings to discuss

pressure ulcer processes.

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Test vs. task

Ask 2 patients or family members to complete

the “all about me card”.

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Now it is your turn!

I am going to give you a case study – and need your to

chat in your thoughts

AIM Statement

Measures

Changes

Tests

Ready, Set, Go! (Chat)

P37

What is our aim? 38

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How will we know our

change is an improvement?

What changes will we make?

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Study41

Repeated Use of the Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D



What change can we make thatwill result in improvement?


Source: Improvement Guide, p 10

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Yes!

Measurement: Operational Definitions

Statement of the measurement process used

Need to come to agreement on two things:

– A method of measurement or test

– A set criteria for judgment

Provost. L. & Murray. (2008, November) The Date Guide: Learning from Data to Improve Health Care. Austin, TX: API.

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Data Display

Label chart

Data should take middle third to half

Keep it as simple as possible

Annotate

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

1 2 3 4 5 6 7 8 9 10 11 12

Month

Response Time Compliance - Life Threatening Emergency (I Chart)

Annotations of Changes46

160

180

200

220

240

260

280

300

320

LO

S (

min

ute

s)

Goal

Work-up done on floor

Bed ahead

Individual responsiblefor bed control

Quick-look x-rays

2/16/98 3/16 4/13 5/11 6/8

Week

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Tracking Data Over Time

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70

35

0

10

20

30

40

50

60

70

80

Avg

Before

Change

Avg After

Change

Cycle

Tim

e (

min

.)

Cycle time results for units 1, 2 and 3

010

20304050

607080

90100

date Jan

Feb

Mar Apr

May Jun Jul

Aug

Sep

Oct

Nov

Dec

Change

Made

Cycle

Tim

e (m

in.)

010

20304050

607080

90100

date

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov Dec

Change

Made

Cycl

e Ti

me

(min

.)

Unit 1

Unit 3

Unit 2

010

20304050

607080

90100

date

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov Dec

Change

MadeCycl

e Ti

me

(min

.) Unit 2

Non-Random Rules for Run Charts

Source: The Data Guide by L. Provost and S. Murray, Austin, Texas, February, 2007: p3-10.

A Shift:

6 or more

An astronomical

data point

Too many or

too few runs

A Trend

5 or more

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How do we classify variation?

Common Cause VariationIs inherent in the design of the process

Is due to regular, natural or ordinary causes

Affects all the outcomes of a process

Results in a “stable” process that is predictable

Also known as random or unassignable variation

Special Cause Variation

Is due to irregular or unnatural causes

that are not inherent in the design of

the process

Affect some, but not necessarily all aspects of the process

Results in an “unstable” process that

is not predictable

Also known as non-random or

assignable variation

Questions?

Please chat in or, if you are connected by

phone, raise your hand to be unmuted!

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Closing Poll

How useful was this lesson on a scale from 1-5?

Given today's topic, what would you like to learn more

about?

Any other comments on today's lesson?

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1 2 3 4 5

Not Useful Somewhat Useful

Very Useful

LQI Communications

• All sessions are recorded• Recording and materials sent in post-call email and uploaded to

your MyIHI account

• Pre-work materials are located in LMS

• Listserv address for session communications:

[email protected]

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Lesson 4

Dave Munch, MDSenior Vice President & Chief Clinical Officer

Healthcare Performance Partners

Gallatin, TN

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Tuesday, March 7, 1 PM ET

Coach Your Team

Thank You!54

Rebecca Goldberg

[email protected]

Please let us know if you have any questions or

feedback following today’s LQI Coaching Call.


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