Western Node Spread Call #3Feb 19th, 2009

1. Understand what you need to measure for spread

◦ 4 categories of measurement◦ Team examples

2. Identifying some sampling strategies◦ Integrating measurement into systems

3. Understand how to develop feedback loops for continuous improvement/learning

Set-up-Target population -Adopter audiences -Successful sites -Key partners-Initial spread strategy

A Framework for Spread

Social System-Key messengers -Communities -Technical support-Transition issues

Communication Strategies (awareness & technical)

Knowledge Management

Measurement and Feedback

Leadership-Topic is a key strategic initiative

-Goals and incentives aligned-Executive sponsor assigned

-Day-to-day managers identified

Better Ideas-Develop the case -Describe the ideas

Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun:31 (6):339-347.

4

Develop a Spread AIM Leadership Set-up/ infrastructure Communication Social System Measurement and Feedback

Forms part of your measurement

6

Spread What:

Target Level of Performance:

Spread to Whom:

Time frame:

Developing a Spread Aim

7

Spread What: All measures in the SSI Bundle

Target Level of Performance: Zero Cases of SSI

Spread to Whom: All surgical populations in our 10 hospital system

Time Frame: By September 2010

Sample Spread Aim: Prevent Surgical Site Infections by Implementing the SSI

Bundle

8

Set-up/Infrastructure◦ Establishing steering committees◦ Orienting leadership groups◦ Organizing data collection◦ Developing materials◦ Identifying successful sites

General Communication◦ Wide spread dissemination of information about

the initiative◦ Sending out comparative data◦ Holding meetings with a broad range of potential

adopters

4 Categories to reflect AIM and 4 levels of spread activity

1. Awareness of the change◦ Reflects spread of communication

2. Adoption of the Change◦ Reflects the integrity of the adoption

3. Outcome of the Change◦ Reflects the evidence of better ideas

4. Progress of the Change◦ Reflects the places and stage of the adoption

For the Big picture on Spread

Awareness

Adoption

Outcome Progress

Regina Qu’Appelle Health Region Spread Measures for Med Rec

1.‘Awareness of the Proposed Change’• Number of nurses, unit clerks, pharmacists and physicians attending the group education sessions, individual mentoring sessions

2.‘Adoption of the Proposed Change’• Percentage of charts stamped by the Unit Clerk• Percentage of PIP forms used by Nurse to record BPMH• Percentage of PIP forms used by Physicians to order/address home medications

3.‘Outcome of the Change’• Percentage of identified discrepancies that are resolved by the physicians use of the PIP form

4.‘Progress of the Change’• Percentage of units and rural acute care sites reporting on the above adoption and outcome measures each week

HMIO = Home medication and initial orders

IHI spread tracking model via excel

Average Waiting Times: All Primary Care

Clinics in VHA System

0

20

40

60

80

100

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June Jul Aug Sep Oct Nov Dec Jan

2 0

0 0

2 0

0 1

2

0

Overall Outcome Measure

Measures using Small Multiples:

Overall System and 4 sites

0

10

20

30

40

50

60

70

80

90

100

Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec

OUR SITE

0

10

20

30

40

50

60

70

80

90

100

Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec

SITE2

0

10

20

30

40

50

60

70

80

90

100

Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec

SITE3

0

10

20

30

40

50

60

70

80

90

100

Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec

SITE4

These graphs are called small multiples. They are designed for a quick visual comparisons of the data from each site The graphs are all presented on the same scale (both x and y axis)

Sampling

1. Simple Random Sample◦ Selection of data by use of random numbers generated by a random

number list or mechanical devise

2. Systematic Random Sample◦ Selection of data by choosing a random starting point and then

selecting data at specified intervals

3. Judgment Sampling◦ Select samples based on judgment of those with process knowledge

to learn about impact of change on specific portions of a process

Lloyd Provost, API & Sandy Murray CTC, The Data Guide, Learning from Data to improve Health Care, pg 2-16, 2-17.

10-15% monthly volume sufficient for QI Minimum of 10 Collect same way over time Retrospective – data must be in formal

charting Prospective – data collection sheets,

interviews

EG. You are currently collecting discrepancy rates for MED REC monthly on admissions and you get 30 admissions per month to that unit.

30x15%=5 which is less than min, thus you would collect on min of 10 charts monthly

Consider the # admissions to all units working on MED REC as the denominator

Thus 10-15% of the total admissions is the number of charts to review per month. Divide that by the number of units and you will get the number of charts per unit

EG. You are spreading to 5 additional units. You need to still collect on the pilot unit. Each unit gets 30 admissions/month.

30x6=180 x15% = 27 charts/6 units =5 charts per unit per month.Simple random sampling: Generate a list per unit, roll dice and

select chart number as per dice roll up to 5 charts per unitSystematic random sampling: Generate a list of all admissions

per unit (30, 30, 30). On each list roll a dice for start number, then every 6th chart(30admissions /5charts required = every 6th chart for total of 5 charts. Repeat for each unit.

Balance enough data with realistic workload

Ensure the data collection sheet identifies what unit/area

Sampling would most often apply to adoption measures & outcome measures

Data collection is for answering your questions about a process. Be clear on what you want to know

Formalize regular reporting process to leader tasked with accountability for this

work

Brandon Regional Health MB

Who Needs to Know?Who’s accountable ?

• Set up a regular reporting process and format• Use existing committees, structures if applicable• A senior leader needs to hold the accountability for this work•Have a system where if decline is evident in the measure, it is someone’s role to support the spread work.

Aim: (Aim includes your numeric goals)

Why is this important?:

CharterCharter

Changes – Proposed Changes – Proposed (P), Tested (T), (P), Tested (T), Implemented (I)Implemented (I)

Senior Senior Role/Recommendations Role/Recommendations

/ Next Steps/ Next Steps

Lessons Lessons Learned/AnecdotesLearned/Anecdotes

Graphs of MeasuresGraphs of Measures

•Type here: be clear about what is proposed (P) (to be tested) vs. testing (T), vs.implemented (I)

•Type here

•Type here: what do you need from Project Sponsor, Participant Sponsor at this time to move project?

•Recommendations

•Next Steps for project

Project TITLEQIC School Participant Name, Participant Sponsor, Project Sponsor

QIC School Participant Contact Info: Add e-mail/phone here

Team MembersTeam Members

Names/Role here

Make fonts large, title, labels, datesand notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8readable graphs here. If no graph yet forMeasure either create “empty” graph or listName of measure(s) not yet graphed.

Refining the spread plan and continually learning

“When the music changes, so does the

dance.” African Proverb

Measurement is meant to answer questions about how spread is going

Collect just enough to balance knowing and workload

Initial spread plan is less than 20 % of your time, 80% is refining, adjusting and supporting the changes

Be flexible, spread is a learning event not a dictatorial one!

New Generation of Ideas on Spread, Dec 8, 2008 Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad, IHI National Forum

Strategies for Spreading Improvements in Health Care, October 14, 2004 Marie W. Schall, Institute for Healthcare Improvement

Holding the Gains and Spread, July 11, 2006Bruce Harries, Improvement Associates

The Seven ‘Spreadly’ Sins, October 18, 2006 Roger Resar, MD & Carol Haraden, PhD IHI

Sustainability and Spread, August 28, 2006Diane Jacobsen, MPH, CPHQ, IHI National Director

Continuing the Conversation Holding the Gains and Spreading Good Ideas: From Local Improvement to System-wide Change October 4, 2007 Marie Schall, MA Institute for Healthcare Improvement

National Health Services (NHS) Modernization Agency Improvement - Sustainability and its relationship with spread and adoption. www.institute.nhs.uk/improvementleadersguides

Hinchey Judge KA. Et al., Factors Contributing to Sustaining and Spreading learning Collaborative Improvements, Qualitative Research Study Findings by the Primary Care Development Corporation, Dec 2007.

Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun:31 (6):339-347.

Paul Plsek, Spreading Good Ideas for Better Health Care - A Practical Toolkit Volume 2 - Veterans Health Administration 2000 Research Series. VHA, 2000.

Paul E. Plsek,  Charles M. Kilo From resistance to attraction: a different approach to change - Positively Influencing Physicians Physician Executive,  Nov-Dec, 1999.

Dr. Lynne Maher, Emerging themes for improvement and innovation, presentation QHN Fall Forum, November 21, 2007.

Developing your initial spread plan, IHI Boston Spread Workshop Feb. 2007

Barb Saunders, Spread of Improvement Efforts – Guideline for Fraser Health, March 10, 2005

Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun;31(6):339-347

Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992

Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.

Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press, 2000.

Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October 1997.

Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000.

Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000.

Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood,

Il:Irwin ,1978.

Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996.

Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207.

Myers, D.G. Social Psychology (3rd ed.) New York: McGraw-Hill, 1990.

Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992.

Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.

Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998.

References