These presenters have nothing to disclose Designing Improvement Initiatives Gareth Parry, Amy Reid, Amrita Dasgupta June 28, 2016
2 A learning healthcare system is [one that] is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.
Talk to your neighbor: What have you tried to improve this week?
An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU Peter Pronovost, et al December 2006 Conclusions : An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.
Why Many Improvement Initiatives Are F ound to “Fail”
6 Mark W. Friedberg et al. February 25, 2014 Conclusions: A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement. Conclusions: Implementation of surgical safety checklists in Ontario, Canada, was not associated with a significant reductions in operative mortality or complications. (4) Friedberg, MW, et al. (2014). Association between participation in a multi-payer medical home intervention and changes in quality, utilization, and costs of care, Journal of the American Medical Association. (5) Urbach, DR, et al. (2014). Introduction of Surgical Safety Checklists in Ontario, Canada , New England Journal of Medicine .
7 “..described in the 1980s by American program evaluator Peter Rossi as the “Iron Law” of … arguing that as a new model is implemented widely across a broad range of settings, the effect will tend toward zero .”
Innovation to Prototyping: 8 Small Number of Settings Applied in a narrow range of contexts Improvement in 100% of sites Parry, GJ, et al. (2013). Recommendations for Evaluation of Health Care Improvement Initiatives, Academic Pediatrics
Initial Testing: 9 Small Number of Settings Applied in a wider range of contexts Improvement in 80% of sites Parry GJ, et al (2013).
More Settings as Range of Contexts 10 Begins to Expand Applied in a wider range of contexts Improvement in 70% of sites Parry GJ, et al (2013).
11 Wide Range of Contexts Applied in a wide range of contexts Improvement in 50% of sites Parry GJ, et al (2013).
Reduction in Effectiveness from Applying Same 12 Fixed-Protocol Program in Different Contexts Innovation sample Parry GJ, et al (2013).
Reduction in Effectiveness from Applying Same 13 Fixed-Protocol Program in Different Contexts Innovation Evaluation sample sample Immediate wide-scale implementation Parry GJ, et al (2013).
14 Where Can Protocol Be Amended to Work Innovation sample Identify contexts in which it can be amended to work as we move from Innovation to Prototype to Test and Spread Parry GJ, et al (2013).
Core Concepts & Detailed Tasks Detailed Tasks Core Concepts and Local Adaptations Use a reliable MEWS >=5 method to identify deteriorating patients in real MEWS >=4 time. 2 Nurses 1 Physician When a patient is deteriorating, 1 Nurse provide the most 1 Physician appropriate assessment and care as soon as 1 Physician possible Theory Action
Reflection Question How do you identify the core concepts of a new model?
17 Degree of Belief Evidence Act
Degree of Belief in Change Ideas High degree of belief Moderate Low Innovation Testing Scale up and Generate/discover new Test whether a model Spread models of care with works or can be amended Implementation of models evidence of to work in specific contexts. shown to apply in a broad improvement in a small range of contexts. number of settings.
The scientific basis of improvement 19 <1950s Deming 1900-1993 Langley et al 1997 – What is it? History of System of Profound The Model for Science Knowledge Improvement What are we trying to The Scientific accomplish? Method Understanding Psychology How will we know that a Variation Epistemology change is an improvement? What change can we make that CI Lewis Appreciation will result in improvement? of a System Plato Carl Popper Foucault Act Plan Etc… Theory of Knowledge Do Study
20 1) Generating the pressure (will) for ICUs to take part 2) A networked community 3) Re-framing BSIs as a social problem 4) Approaches that shaped a culture of commitment 5) Use of data as a disciplinary force 6) Hard edges Dixon-Woods, M, et al. (2011).
From an Improvement Perspective: Empower those at the point of care to test, predict, fail Learning forward and learn what is takes to bring about improvement. Improvement requires social change and that people are more likely to act if they believe. Social Change Work with, rather than doing to. Context Interventions need to be amended to local settings Matters (contexts). Concepts rather than fixed protocols are a good Initial starting point for people to test and learn whether Concepts improvement interventions can be amended to their setting.
What are we learning? The Kirkpatrick Evaluation of Learning Framework has four levels: What was the participants’ experience? 1. – Did the participants have an excellent experience working on the improvement project? What did the participants learn? 2. – Did they learn improvement methods and begin testing? Did they modify their behavior? 3. – Did they work differently and see change in their process measures? Did the organization improve their performance? 4. – Did they improve their outcomes?
Content Theory: What changes will teams make that will result in improvement? Explains how we predict that the change concepts and improvement drivers applied in the project will lead to improved outcomes. Participant Experience Organizational, Process/ Activities of the Level 1 Patient-level Behavior Improvement Outcomes Changes Leaders LEVEL 4 Level 3 Learning Agents Level 2 Execution Theory: What will the improvement initiative do that will lead teams to adopt the process changes? Explains what improvement leaders or agents will do that will lead front-line teams to adopt the changes described in the content theory. Parry et al Recommendations for Evaluation of Health Care Improvement Initiatives 2013 Acad Peds
24 Five Core Components Core Component 1) Goals Aim Statement That will maximize the chances that 2) Content Theory The results and learning Driver Diagram or Change Package derived from the evaluation of an 3) Execution Theory improvement initiative Logic Model can be clearly communicated. 4) Data Measurement & Learning Measurement Plan 5) Dissemination Dissemination Plan
Five Core Components Amritia Dasgupta
Core Component 1) Goals Aim Statement 2) Content Theory Driver Diagram or Change Package 3) Execution Theory Logic Model 4) Data Measurement & Learning Measurement Plan 5) Dissemination Dissemination Plan
Goals: Aim Statement
28 Hope is not a plan . Some is not a number . Soon is not a time . -Don Berwick, MD
29 Goals & Aims at Multiple Levels Aspirational Aim : Stretch goal used mainly to inspire those engaged in the improvement work. Achievable Aim : Measurable target believed to be achievable during a project’s timeframe, captured in aim statements.
30 Aim Statement How much, by when, for whom? An aim statement describes what we expect to achieve in the timeframe of the project, taking the form of “how much, by when, for whom”. The system or bounds of the project are also defined.
31 Building an Aim Pre-Work Protect time to develop an attainable and informed aim Review what has been achieved in the past in similar work and settings Consider voices needed to set the aim and build buy-in Creating the Aim Understand the current state in your system, answer a need in the community Ongoing Check progress as you go and refocus aim as needed
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