Sustaining & Spreading Local Improvements in Medication

Reconciliation

Kim StreitenbergerQuality Analyst, The Hospital for Sick Children

Patient Safety Consultant, ISMP-CanadaNational Medication Reconciliation Faculty

Medication Reconciliation WorkshopJune 4-5, 2007

Objectives

Describe the key components needed to sustain & spread improvementDiscuss how to determine whether you are ready to spread local improvementsIdentify the components of a spread planReview Sick Kids’ approach to developing a spread plan

What is sustainability & spread?

Sustainability:locking in & building upon improvements made at local levelmaintaining the improvements made by implementing medication reconciliation in your pilot area(s)

Spread:actively disseminating best practice & knowledge about the improvement & implementing it in every available care setting within a systemtranslating what you’ve learned when implementing medication reconciliation in your pilot area(s) to other area(s) of your organization or system

GSK - Sustainability & Spread, IHI 2006

A few key considerations

Spread & sustainability are inextricably linked

Need evidence of improvement before spreading - measurement

Local improvements must be sustained before they are spread

Consider sustainability & spread from the moment you start introducing a new intervention

Key components for success

1. Supportive management structure2. Structures to “foolproof” change3. Robust, transparent feedback systems4. Shared sense of the systems needing

improvement5. Culture of improvement & deeply

engaged staff6. Formal capacity-building programs

Supportive management structure

Senior leader responsibility for sustaining & spreading the improvement Formal accountability systems for tracking performanceStructured monthly review of resultsDirect communication from board & executive about the importance of the initiativeLeadership led celebration of pilot project successes

Structures to “foolproof”change

Available tools & technology support the intervention

IT systemsWebsitesTraining materials, “getting started kit”, change packages, toolkits

Internal structures & processes make it difficult to revert to “old ways” of doing thingsIntervention is embedded in existing processes e.g. med rec form doubles as order form

Robust feedback systems

A measurement system is in place to generate improvement dataSystems are available to communicate initiative activity & resultsOrganizational/system awareness of initiative results/successesPublic display of improvement data

website, screensavers, posters

Shared sense of systems to be improved

All stakeholders share an understanding of the processes & systems they are trying to improve

Clear process maps, FMEA, gap analysis

Stakeholders are clear about their contribution to the improvement

Clearly defined roles & responsibilities

Culture of improvement – engaged staff

There is visible organizational pride re: performance & improvementStaff view improvement as part of their job & consider themselves as key stakeholders in any initiativeJob descriptions include involvement in improvement initiativesThere are opportunities for stakeholders to provide feedback on improvement processes & share ideas for improvement

Formal capacity-building programs

Leadership & frontline staff education & training is an organizational priorityFocus on building organization-wide skill in quality improvement methodsSeamless integration of improvement work in daily activities of unit or facilityAll stakeholders receive education on content of initiative & ongoing training on improvement methodology

FMEA, process mapping, model for improvement, measurement etc.

Resources

Adequate & appropriate staff to plan, implement and sustain initiativeAvailability of ongoing resources e.g. staff, funding, infrastructureDedicated time for staff involved

The NHS new improvement wheel

NHS Modernisation Agency 2006

Are you ready to spread?

Is improvement in this area a strategic initiative within the organization?

How will the executive be involved on an ongoing basis?

Is there a successful pilot site that has implemented the new intervention, system or process? If no, what is the strategy to create a good example? If yes, is your pilot data demonstrating real improvement?

Are you ready to spread? cont’d

Is the intervention near the final stage of development? If there is room for further changes, would these completely alter the way the solution has been introduced?

Have the relative advantages of the changes been documented for all adopter audiences?

Are the changes packaged so they can be easily understood and tested by the adopters?

Is there a person or team who will manage the day to day spread activities?

Are you ready to spread? cont’d

Has an initial plan for spread been developed? Consider:

Culture & social systems of adopters

Ways to attract early adopters e.g. identify individuals who are influential with peers, plan broad based communication & sharing of results

Potential infrastructure changes needed

NHS Modernisation Agency, 2005

Nolan et al, Using a framework for spread: the case of patient access in the Veteran’s Health Administration, Joint Commission Journal on Quality & Patient Safety, 2006

Developing a plan for spread

3 key steps:1. Laying the Foundation for Spread2. Developing an Initial Plan3. Refining the Plan

IHI 100K Lives GSK: Sustainability & Spread, 2006

Laying the foundation for spread

Clear communication from CEO & executive teamDesignated executive sponsorDay to day project manager/leader with knowledge of organizational systems, processes & improvement methodsEstablish a spread team Share results of successful pilots

Developing an initial plan

Establish a goal or aimWhat are you trying to spread?Hospital-wide targetsTarget populationSpread timeframe

Leverage experience of pilot unitsEstablish operational accountability for spread

use unit/dept reporting relationships , committees, line managers

Consider infrastructure changes to facilitate spread e.g. data collection resources, IS systems

Developing an initial plan cont’d

Develop a multi-level communication planDevelop measurement strategy

Process & outcome measuresAdoption of intervention over time

E.g. % of units implementedSet targetsInclude how you will communicate results

Refining the plan

Adjustments may be necessary to accelerate spreadIdentify need for adjustments to plan through process/outcome & rate of adoption dataGather information from participating areas e.g. focus groups, formal reports, surveys, informal discussions

The 7 deadly sins of spread!

1. Starting with a large pilot area – The Go Big or Go Home Strategy!

2. Find one person to do It ALL3. Be vigilant and work harder4. If it works in the pilot Unit, DON’T change it for

spread5. Appoint the successful team leader as the driver for

spread to the WHOLE hospital6. Evaluate spread on a quarterly basis7. Expect marked improvement in hospital wide

outcomes early on

Carol Haraden & Roger Resar, IHI

Spreading medication reconciliation at Sick Kids

Developed spread plan advisory teamVP Quality & EducationDirector of EducationVP Professional Services & Chief Nurse ExecutiveInterim Chief Nursing EducationDirector Quality & Risk ManagementMedical Director Patient Safety Medication reconciliation project leader Pilot unit physician champion & quality leaderPilot unit house staff repDirector Information Services

Advisory team activities

Developed strategy for spread - series of “waves”Developing formal spread planDeveloped an aim or goal for spreadCompleted assessment to establish unit priority for spreadIdentification & allocation of resources for spread

Spread plan project outline

Spread work plan & timelines

Assessment of unit readiness

10%10%10%20%50%WEIGHT

Patient ActivityMonthly admissions

Unit basedTechnicians

Staffing Workflow patternsIT readiness

Unit cultureChange FatiguePatient FlowMultiple Services

LeadershipPhysicianFrontline Staff

DEFINITION

Patient Activity

Pharmacy Resources

Overall Resources

Overall Ease of Implementation

Stakeholder Engagement

CRITERION

Defining unit priority for spread

3.2144438BBMT

3.2344338AHaem/Onc

3.934444NICU

4.1503455CNeurosurg

4.6544454DCardiology

TOTAL SCORE

Patient Activity

Pharmacy Resources

Overall Resources

Overall Ease of Implementation

Stakeholder Engagement

CRITERION

Spread infrastructure

Develop internal improvement collaborativeImprovement collaborative “steering team”Identify unit based med rec championse.g. physician, quality leader, clinical managerDevelopment of consistent measurement, education & communication plans

Why an improvement collaborative?

Brings together multiple similar areas/sites with a common aim to adapt and spread existing knowledge

Maximizes opportunity to share and learn from each other

Accelerates improvement

Spread resources

Dedicated resources – hospital-wide spread leaderEngage unit leadership

CHS DirectorDivision/Dept Chief

Identify unit championsPhysician championFrontline leader champion e.g. Clinical Manager

Building capacity – unit champion

Unit Champion GSKLocal & national contextCollaborative model Business case for med rec – evidence & rationaleMedication reconciliation processesMeasurement strategy, processes & toolsLeading teamsManaging changeImprovement modelTools & resources

e.g. team charter template, team monthly report, PDSA cycle worksheets

Team charter template

Team monthly report

PDSA cycle worksheet

Building capacity – teams

Team Toolkit Rationale & evidenceMedication reconciliation processesMeasurementImprovement model

Team workshopKickoff celebration!

Next steps

Confirm unit priority for “roll-out”Finalize work plan & timelinesDevelop Education plan, content & tools

Team leader workshopImprovement team workshop

Develop Communication plan & toolsCollaborative CoPMedication reconciliation posters

Resources

IHI 100K Lives GSK: Sustainability & Spread, 2006

Nolan et al, Using a framework for spread: the case of patient access in the veterans health administration, Joint Commission Journal on Quality & Patient Safety, 31:6, June 2005.

NHS Modernisation Agency, Improvement leaders’guide to sustainability & spread. http://www.modern.nhs.uk/improvementguides/sustainability/fw.html