Model for Improvement and Tests of Change

Denise Remus, PhD, RNImprovement Advisor, Cynosure Health / HRET HEN

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40/20 Goal

Adverse Drug Events (ADE) Injuries from Falls and Immobility

Central Line-Associated Blood Stream Infections (CLABSI)

Catheter-Associated Urinary Tract Infection (CAUTI)

Ventilator Associated Pneumonia (VAP) Venous Thromboembolism (VTE)

Pressure Ulcers Safe Surgery / Surgical Site Infections

Obstetrical Harm Readmissions

Reduce Harm by 40% and Reduce Readmissions by 20%

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Drive Improvement Faster

• Science of improvement• Accountability• Structure change• Document progress• Be fearless, take risks, be wiling to fail

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One day Alice came to a fork in the road and saw a Cheshire Cat. “Which road do I take?” she asked. His response was a question “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat “it doesn’t matter.”

Lewis Carroll

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Aim Statements

• What are we trying to accomplish?

• Communicate expectations

• Measurable (how good?)

• Time specific (by when?)

• Define the specific population (s) (who?)

• Clear, concise and unambiguous

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WHAT?

HOW MUCH?

WHERE?

BY WHEN?

Aim Statement

WHO?

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Aim Statement Example

VTE: At St. Luke’s Hospital, we will reduce hospital-acquired VTE for all inpatients by 40% by December 31, 2013.

• What: Hospital-acquired VTE

• Where: St. Luke’s Hospital

• Who: All inpatients

• By When: December 31, 2013

• How Much: By 40%

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Measure

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Select Measures

• For each clinical topic, must report data for at least

1 Process Measure and

1 Outcome Measure

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Measures

• Voice of the customer or patient• How is the system performing? • What is the result?

Outcome Measures

• Voice of the workings of the system• Are the parts / steps in the system or

process working as planned?

Process Measures

• What happened as we improved the outcome and process measures?

• Unanticipated consequences, other factors influencing the outcome?

Balancing Measures

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Reduce HarmImprove Processes

Where is your Greatest Opportunity to?

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Consider. . .

• What are you already measuring?• What are you planning to measure?

1. Identify existing measures2. Are they in the HRET HEN

Encyclopedia of Measures?3. If not, user-defined measure option

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VTE Example – Potential Measures

• Process Measures: – ICU VTE Prophylaxis (JC VTE-2)– VTE Discharge Instructions (JC VTE-5)

• Outcome Measures:– Potentially Preventable VTE (JC VTE-6)– Post-op PE or DVT (All Adults) (AHRQ PSI 12)

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Does your organization have an aim statement?

Which process and outcome measures will

you report?

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The PDSA Cycle

Plan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

“What will happen if we try something different?”

“Let’s try it!”“Did it work?”

“What’s next? ”

The Sequence for Improvement

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

Repeated Use of the PDSA Cycle for Testing

Changes That Result in

Improvement

Hunches Theories

Ideas

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sequential building of knowledge under a wide range

of conditions

Spreading

AP D

S

AP

D S

APD

SA P

DS

Sustaining the gains

Guidelines For Testing Change

• Do not try to get buy-in, consensus

• Be innovative to make the test feasible

• Collect useful data during each test

• Test over a wide range of conditions

Guidelines For Testing Change

• Fail early, fail often• What can we do by next

Tuesday?• Pick willing volunteers• AIM big, but test small• Steal shamelessly

Remember to. . .

• Adapt

• Adopt

• Abandon

Common Traps

• Plan Do, Plan Do

• Do Act, Do Act

• No testing, only data collection

• No ramps of tests, random PDSAs

• Undisciplined PDSAs, no documentation

• No prediction – what are we going to learn?

• Beware of Cycles longer than 30 days

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Tips for Testing

• Use a form to document your test.

• Scale down – think “Drop Two.”

• Oneness

• Know the situation in your organization.

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Value of “Failed” Tests

Do something. If it works, do more of it. If it doesn't, do something else.

Franklin D. Roosevelt

• Learning• Accelerate development• Innovation

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Failed Test…Now What?

• Be sure to distinguish the reason: – Change was not executed – Change was executed, but not effective

• If the prediction was wrong – not a failure!– Change was executed but did not result in

improvement– Local improvement did not impact the secondary

driver or outcome– In either case, we’ve improved our understanding of

the system!

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• What are you going to test?• What do you need to conduct the test?• Who will be involved in the test?• How will you educate & inform the

participant(s)?• Where will the test occur?• When will the test occur?• How will you know if you’ve been successful?

Rapid Cycle Test of Change

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Rapid Cycle Test of Change

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Improvement Project Worksheet

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