The Model for Improvement

Home Care Medication Reconciliation Pilot

Dannie Currie, RN, MN, DHSASafety Improvement AdvisorAtlantic Node Safer Healthcare Now!

Model For Improvement *

•A simple yet powerful tool for accelerating improvement

•The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming

Model For Improvement *The model has two parts:

• Three fundamental questions,Used to establish AIM; MEASURES, AND CHANGE IDEAS.

•The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of change to determine if the change is an improvement.

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming

• Action Oriented

• Trial and Learning

• Leadership

Model For Improvement

To ensure a common understanding and focus by making explicit:– AIMS– Measurement targets– Changes– Timelines– Roles and Responsibilities

• To communicate effectively with senior leadership and other stakeholders

Improvement Charters

• Define and Review your system:

- Who does the client see?

- Who is needed to implement?

- Who needs to know about the changes?

- Who supports the changes?

• Work with those who will work with you

• Each member is a champion in their area

Team

• Executive Sponsor

• Team Leader

• Core Team members: consider including clinical, managerial, and quality support

• Ad Hoc Team members eg. Staff education, community pharmacist, IT support etc.

• Communication target groups

Team Roles and Responsibilities

Team

Team Roles and Responsibilities

• What are you going to do?

• How much?

• By when?

Aim

Bold Aim, Firm Deadlines• Align aim with strategic goals of the organization

• Write a clear and concise statement of aim

• Make the target for improvement bold and unambiguous

• Include deadline

• Include scope, boundaries, constraints and anything else that is needed to keep the team focused

Bold Aim, Firm DeadlinesTo Reduce Adverse Drug Events by having 100% of

eligible clients, admitted to Home Care services from acute care hospitals, receive a BPMH within 24 hours and have Medication Discrepancies reconciled by the prescribing clinician within 5 days, by March 2009.

“Some is not a number. Soon is not a time”

Donald Berwick, MD

Institute for Healthcare Improvement

Bold Aim, Firm Deadlines

Three Main Types :

– Outcome Measures

– Process Measures

– Balancing Measures

Measures

Model For Improvement • Outcome measures:

– Are driven by the specific objectives identified in the AIM statement, e.g. decrease # of medication discrepancies

– Are understood from the consumer’s perspective eg. Reduced discrepancies

• Process measures – Indicate whether a specific change is having the intended

effect, e.g. % of clients with a BPMH on admission– Indicate if process changes are leading to improvements

• Balancing measures:

– Are related measures to understand the impact of changes on the broader system, e.g resident/staff satisfaction

– They can be the other effects of planned changes e.g. Increased admission time; decreased rework

Model For Improvement

Measures

• Choose 2-6 measures that are useful and manageable

• Should be operationally defined e.g. rework

• Should be integrated into clinical documentation

• Include a balanced set of measures to avoid sub-optimization

• Purpose is for learning not judgment

Measures

1.0 % of eligible clients with a BPMH (100%) p

2.0 Average time (minutes) to complete a BPMH (Set by Team) b

3.0 % with one discrepancy requiring clarification (Set by Team o

4.0 Type of discrepancy coded (100%) o

Measures

4.0 Type of Discrepancy Codes:A-1: Medication not currently prescribed

A-2: No longer taking Medication as prescribed (commission)

A-3: OTC not taken as directed

A-4: Drug Allergy

A-5: Drug Duplication; inadvertently Px more than 1 from same class

A-6: Drug Interaction

A-7: Drug Formulation ie sustained vs immediate release

B-1: Difference in Dose

C-1: Difference in Route

D-1: Difference in Frequency

E-1: Other:

Measures

• A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

• Creatively combing these change concepts with knowledge about the specific work can help generate ideas for tests of change. PDSAs are used to test the specific ideas.

• Change concepts are usually at a high level of abstraction, but evoke multiple ideas for a specific process.– Examples:

• Reduce handoffs• Consider all parties as part of the same system• Improve work flow• Eliminate waste

• Berwick, Boushon,& Roessner, 2007

Change Concept

Aim: Assure customers do not leave bank cards

behind

Change Concept

Aim: Assure customers do not leave bank cards

behindIdea: Beeping sound

Idea: Beeping sound

Concept:

Use reminder

s

Change Concept

Aim: Assure customers do not leave bank cards

behindIdea: Beeping sound

Concept:

Use reminder

s

Electric shock

Voice reminders

Siren

Based on Edward DeBono’s Concept Fan

Change Concept

• Change Package• Getting Started Kits• Creative and Critical thinking• Hunches• Best practices• Asking process users and subject matter experts for

ideas• Community of Practice• Insight from research and benchmarking

Change Ideas

Change Ideas

While all changes do not lead to improvement, all improvement requires change.

Berwick, Boushon,& Roessner, 2007

Change

Rapid Cycle ChangeCycle- A structured trial of a process change.

• Plan- a specific planning phase

• Do- a time to try the change and observe what happens

• Study- an analysis of the results of the trial

• Act- devising next steps based on analysis

• One PDSA cycle should lead to the Plan of a subsequent cycle.

• Berwick, Boushon,& Roessner, 2007

A PS D

A PS D

AP

SD

APSD

Change Ideas

Learning From Data

Very Small test

Follow up tests

Wide Scale tests of change

Implementation of Change

Changes Result in Improvement

Moving From Testing to Implementing

• Initiation of Rapid Cycle tests is dependent on getting the first test of change started

• Do Not try to Perfect the change then implement…consider your work a masterpiece in progress

• Failure is a great Opportunity to plan to do better next time…

• Frequency of Testing determines the speed of the process improvement ie daily testing = improvement in weeks; weekly = improvement in 3-4 months

Rapid Cycle Change

What are we trying toWhat are we trying toaccomplish?accomplish?

How will we know that aHow will we know that achange is an improvement?change is an improvement?

What changes can we make that willWhat changes can we make that willresult in an improvement?result in an improvement?

Act Plan

Study Do

Model for improvement

Aims

Measurement

Langley, Nolan et al 1996

Change Ideas

Trial & Learning

Acknowledgements

• Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/GausModelforImprovement.htm?TabId=2

• Harris, B. (2007). Change Concepts.

• Murray, M (2006). “Small Steps, Big Changes” workshop.

• Reasear, R. (2007). Institute for Healthcare Improvement “Designing Reliability Into Healthcare Processes: Based on the work of the Institute for Healthcare Improvement Innovation”