segmentation in reliability design (application of the christensen model) roger resar april 2006
TRANSCRIPT
Segmentation in Reliability Design(Application of the Christensen Model)
Roger Resar
April 2006
Building of Descriptive
• Researcher must pass through it in order to develop more advance theory
• Consists of three steps– Observation– Classification– Defining relationships
Clay Christensen Harvard Business Review
Statements of association
Categorization based on attributes of phenomena Anomalies will
need to be observed
Descriptive Theory
Observe describe and measure the phenomena
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Reliability Descriptive Theory
3 Tier approach when applied to radiology interpretations in the ED achieved a high level of reliability
Nolan et al JAMA
Statements of association
Categorization based on attributes of phenomena Anomalies will
need to be observed
Descriptive Theory
Observe describe and measure the phenomena
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Current IHI Normative Theory To Achieve a 10-2 Level Reliability
Based on work by the IHI innovation team, some hospitals in the Pursuing Perfection and P4P work, and publications by Nolan et al, a three tier approach has been taught as a methodology when applied to CMS conditions can achieve 10-2 performance. (All or none measurement)
Statements of causality
Categorization of the circumstances in which we might find ourselves Anomalies will
need to be observed
Normative Theory
Observe describe and measure the phenomena
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Reliability Community Observations When the Current Normative
Theory is Used • When the 3 tier model is applied to the broad CMS
measures few hospitals are able to consistently achieve the 10-2 goal
• Those hospitals achieving the10-2 goal for all measures within a CMS condition commonly accomplish this with manpower and a very high level of vigilance
• Within a given condition when successful 10-2 performance occurs on a single measure a good three tier strategy can be observed (although commonly a deliberate 3 tier strategy was not as much designed as discovered)
Statement of Causality
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
We ought to apply the 3 tier approach to the CMS conditions
10-2 Performance will be observed when the 3 tier approach is used on the CMS conditions
Anomalies Observed
Current Normative Theory
•Using 3 tier design to the CMS conditions approach 10-2 not consistently observed
•Individual measures within conditions achieved 10-2 with obvious 3 tier design
•Segments of the population achieve 10-2 in
all or none measures
Anomalies Observed• Certain measures of the CMS conditions achieve 10-2 level of
reliability. When studied the 3 tier design is commonly used not as a deliberate strategy, but as a haphazard design.
• Whenever applied to the broad CMS condition hospitals have difficulties
• Teams can predictably take certain segments of the population or certain measures and can achieve a 10-2 level of reliability
Examples of Anomalies
• Smoking cessation, pneumovax or flu shots when taken on as a hospital wide measure reaches greater than an 10-2 performance.
• Timed measures such as antibiotic administration or time to a heart catheterization laboratory reaches 10-2 levels of performance
• Certain segments of the population attain 10-2 reliability (admissions from the ED with a known diagnosis of CAP)
New Theory Based on Anomalies
The work on the CMS conditions can achieve a 10-2 level of performance if appropriate segments are identified and each segment is designed using the 3 tier approach if necessary
Preliminary statement of causality
Observing the current reliability community suggests certain anomalies that draw questions to the 3 tier design for conditions. Observations the segments appear to be more reliable in design
New Descriptive Theory
Segments based on admission route, time of first case, responsible area are useful in design for 10-2 performance
Dividing the CMS conditions into appropriate segments and applying the 3 tier design will achieve 10-2 for the whole condition
Statement of Causality
Using the 3 Tier approach to the design on the segments of the condition and or measures will achieve 10-2 reliability in the whole
We ought to apply the 3 tier approach to the CMS conditions using a segmental approach
10-2 Performance will be observed when the 3 tier approach is used on the appropriate segments of the CMS conditions
Anomalies will need to be observed
New Normative Theory
Why Segments
• Allows for control of some variables• Defines the boundaries around which expectations can
be formed• More likely to test the validity of the design rather than
confront barriers• Fosters a deeper understanding of the design complexity
required• Forces understanding of the differences between
segments as design strategies• Permits design beyond the disease • Allows the formation of more predictable timelines
Applying Segments to the Normative Model
• The current work on reliability will stress the concept of segment definition tied to process and outcome measures
• Segment definition and relationships to improvement will be driven by a design table
• Observations of anomalies will be part of future community work to refine the normative theory
Segment Strategy Change/Rule Structure Change Process Change
Design Table for Segment Theory Improvement Work
Finding your first segment• The segment must represent a reasonable volume
• The segment should have clear cut defined boundaries
• The segment should have willing participants so the barrier of agreeing is not a problem
• The segment should allow for key articulated variables or barriers to be neutralized
Segment Strategy Change/Rule Structure Change Process Change
Patients admitted to the hospital through the ED with a diagnosis of CAP
An organizational policy is developed to split the responsibility for the CAP measures to attain a combined 10-2 performance
Smaoking,Pneumovax measures will be handled on the admitting floor as an institution wide protocol
Timed strategy with a 3 hour call will be expected for the ED physicians on presumed CAP
ED develops a unique protocol for all patients with a presumed diagnosis of CAP when admitted to the ED
Hospital wide smoking cessation and immunization protocols are developed with appropriate training and support and applies to all patients admitted to the hospital
ED sets up a 4 hour timeline from arrival to the ED with required antibiotic decision at 3 hours
ED process in place. Feed back to the ED on the oxygenation, cultures, and antibiotic measures done on concurrently based on sampling
Detailed processes set up out side of the ED and monitored by a responsible entity for smoking, pneumovax etc. Feedback to responsible entity
Presumptive diagnosis at admission to ED starts a ED protocol with timer to accomplish 4 hours antibiotic. Feedback on time defects
Using the Design Table for CAP Planning Using Segments
Segment Strategy Change/Rule Structure Change Process Change
Patients admitted to the hospital through the ED with a diagnosis of CAP
See previous slide See previous slide See previous slide
Patients admitted to the hospital with a challenging diagnosis which includes CAP and results in CAP being diagnosed later
Patients with a possible diagnosis of CAP are monitored until a final decision is made
Institutional agreement on the 4 hour rule starts when the diagnosis is made on the floor (even though for reporting this is a defect).
Method developed to determine when a final diagnosis is made and how to communicate back to the required measures for CAP and subsequent baseline performance of the CAP measures.
Feed back to the units responsible for care of the challenging diagnosis on performance done concurrently by sampling
Patients admitted directly to the floor with a diagnosis of CAP
All admitting diagnoses are required to be screened for certain key diagnoses with notification of the unit this is a key diagnosis
A CAP diagnosis on any unit requires a baseline performance of the CAP measures.
Feed back of performance to each unit
Any patient discharged when key measures have not been performed
Institutional policy that defects which still might be mitigated require a recovery.
Resources made available to contact patients and correct the correctable defects
Key processes to describe how mitigation will actually occur. Scripts to be developed. Feedback on follow-up reliability .
Using the Design Table for CAP Planning Using Segments
Next Steps
• Identify your first segment (If you have a first segment what is your level of reliability)
• Confirm that your segment has the key requirements for segmental definition and design
• Fill out the segment flow sheet and the design table• Local customization will develop the structure changes
and process changes• The segments will vary depending on organization size• Anomalies from the segmental design need to be studied
to authenticate the new normative theory