Session Four Foundational Element: Improvement Infrastructure Kelly - PDF document

2/22/2012 Session Four Foundational Element: Improvement Infrastructure Kelly McCutcheon Adams, MSW, LICSW, IHI Director Barbara Balik, RN, EdD, IHI Faculty February 22, 2012 2:00 – 3:00pm EST David Kim David Kim , Institute for Healthcare Improvement (IHI), is responsible for managing and coordinating a variety of programs based on Key Processes on the IHI Improvement Map. Mr. Kim is a graduate of Boston University. He has been with the IHI for 2 years. He enjoys sports, food, and travel. 2 1

2/22/2012 WebEx Quick Reference • Welcome to today’s session! • Please use Chat to “All Raise your hand Participants” for questions • For technology issues only, please Chat to “Host” • WebEx Technical Support: 866-569-3239 • Dial-in Info: Communicate / Join Teleconference (in menu) Select Chat recipient Enter Text 3 When Chatting… Please send your message to All Participants 4 2

2/22/2012 Kelly McCutcheon Adams, MSW, LICSW Kelly McCutcheon Adams, MSW, LICSW, Director, Institute for Healthcare Improvement (IHI), has served in this capacity for eight years for a variety of IHI Collaboratives and programs, particularly those focused on critical care. She is a medical social worker with experience in hospice, nursing home, sub-acute rehabilitation, emergency department, and ICU settings. She has also served as faculty for the US Department of Health and Human Services Organ Donation Collaborative and for the Gift of Life Institute. 5 Barbara Balik, RN, EdD Barbara Balik, RN, EdD, Principal, Common Fire Healthcare Consulting, is also Senior Faculty at the Institute of Healthcare Improvement. Her areas of expertise include leadership and systems for a culture of quality and safety, including patient- and family- centered care, patient experience, systems to improve transitions in care, and transforming care prior to or with optimization of an electronic health record implementation. She works with leaders to develop adaptive systems to excel and innovate in complex organizations, and to ensure sustained improvement and innovation every day. Ms. Balik's publications include the book, The Heart of Leadership , and the IHI white paper on “Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care,” among others. Previously, she served in senior leadership roles at Allina Hospitals and Clinics, United Hospital, and Minneapolis Children's Medical Center. 6 3

2/22/2012 Overall Objectives At the end of this program, participants would be able to: • Articulate key foundational elements in support of all domains of patient experience improvement • Share specific testable ideas for improving nurse communication, pain management, and cleanliness • Plan small tests of change to try during the Expedition 7 Session Agenda • Homework – We did you learn? • Patient Experience Change Package o Our focus today: Improvement Infrastructure • Model for Improvement and Run Charts – Joan Grebe, IHI Improvement Advisor • Lessons from the Field – Andy Foret, Operations Director, John Randolph Medical Center • Time for Q&A • Homework 8 4

2/22/2012 Homework • Session 3: ─ Test one of the Patient Engagement Key Changes ─ What did you learn? 9 Patient Experience Change Package: Overview Key areas for improving specific domains of patient experience: Nurse Communication, Cleanliness, and Pain Management Staff and Physicians Connection Patient and Family Today’s Session Improvement/ Leadership Engagement Infrastructure Foundational Elements for Improving Patient Experience 5

2/22/2012 Foundational Elements for Improving Patient Experience Today’s Session Improvement/ Leadership Engagement Infrastructure Leaders take ownership of defining Staff, leaders, and physicians engage Improvement teams are solidly purpose of work and modeling patients and families so that efforts to grounded in skills to effect reliable desired behaviors. improve patient experience reflect change and gain meaningful actual patient experience. understanding of data Improvement Infrastructure Key Change Ideas: • Daily Improvement • Measurement System • Reliability • Patient Journey 12 6

2/22/2012 Improvement Infrastructure Key Change Idea Daily Improvement Incorporate improvement methodologies (e.g. the Model for Improvement) into daily work of care team. Develop a process to obtain improvement ideas. Empower staff to test improvements rapidly and on a small-scale and develop a process for feedback, revision, and eventual spread. Include night and weekend staff. 13 Improvement Infrastructure Key Change Idea Measurement System Develop a quantitative and qualitative measurement system to provide timely, pertinent patient experience data for all departments. Aid leaders, staff, and physicians to gain meaningful understanding of data variation to ground decision-making. Move beyond daily evaluation of measures that do not have daily meaning (example: discontinue overly-frequent checking of HCAHPS scores with over-reactive responses to normal variation). 14 7

2/22/2012 Improvement Infrastructure Key Change Idea Reliability Use human factors and reliability science to design simple but effective processes that are in use 95% or more of the time. Measure reliability of key processes to guide continued improvement efforts. 15 Improvement Infrastructure Key Change Idea Patient Journey Observe with current and past patients and families their patient experience journey using direct observation and inquiry looking for what is important to them both technically and emotionally. 16 8

2/22/2012 Perspectives from an Improvement Advisor Joan M. Grebe, MA, OT, AICF, Improvement Advisor (IA), Institute for Healthcare Improvement, currently supports the Improvement Science Professional Development Program in New Zealand and the Community Clinic Innovation Challenge. She was previously the IA for the IHI Sepsis Collaborative, the IHI High-Risk and Critically Ill Patient Community, the Patient Experience Collaborative and the Assistant Director for IHI in the National Vascular Access Improvement Initiative “Fistula First” project. In addition to her work with IHI, she is an independent health care consultant specializing in facilitating quality improvement teams, and educating others about quality improvement tools and techniques. Ms. Grebe began her work in health care more than 20 years ago as an occupational therapist and rehabilitation administrator in a variety of settings. 17 Model for Improvement Aim of Improvement What are we trying to accomplish? Measurement How will we know that a of change is an improvement? Improvement What change can we make that will result in improvement? Developing a Change Ac t Plan Testing a Change Study Do Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996. 18 9

2/22/2012 The Sequence for Improvement Sustaining Make part improvements and of routine Spreading the changes operations to other locations Test under Implementing a a variety of change conditions Testing a Act Plan Theory change and Prediction Study Do Developing a change Wait Times: Pictures of the Process Facility A 100 80 90 80 Wait Time (Minutes) 70 70 60 Wait time in minutes 50 60 40 30 Change 50 Implemented 20 10 40 0 n b r r y n l g t t v c a p u p c a e a u J u o e J F M A M J A e O N D S 30 Facility B 100 20 90 80 Wait Time (Minutes) 70 10 60 50 0 40 Change 30 Average Before Change Average After Change Implemented 20 10 0 10

2/22/2012 Data display using a Run Chart The centerline (CL) on a Run Chart is the Median 6.00 or Average 5.75 5.50 5.25 Measure Pounds of Red Bag Waste 5.00 4.75 (CL) Median=4.610 4.50 4.25 4.00 3.75 3.50 3.25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Time Point Number Use four simple run rules to determine if special cause variation is present Slide courtesy of Robert Lloyd, Ph. D. Run Chart Rules 1. Shifts -6 or more points above or 3. Too few, too many runs (use a table to below center line determine) 6.00 5.75 5.50 5.25 Pounds of Red Bag Waste 5.00 4.75 4.50 4.25 4.00 3.75 3.50 3.25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Point Number 2. Trends- 5 or more consecutive points 4. Astronomical-a point far away from all increasing or decreasing others in graph Errors 30 25 Number of errors 20 15 10 5 0 Date Special cause (non-random) variation is an Unstable process, for improvement you need to Investigate the reason for the special cause and Take corrective action, either to continue or get rid of the special cause variation Common cause (random) variation is a Stable process, for improvement you need to Change the whole process 11