listen to your team
Post on 24-Feb-2016
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Listen to your team
Let your stakeholders: nurses, residents, pharmacists, etc. tell you the how.
Identify Areas for Improvement(current state)
PCS Roun
ds(day 1)
Informal ✔ in
w/ primar
y teams
FAMILY
MTGS
Write notes with
“official
recs”
45 year old woman with malignant bowel obstruction due to colon cancer with nausea,
vomiting and abd pain, progressive inability to take oral meds/hydration
3 hrs1 hr 3 hrs 2 hrs
PCS Roun
ds(day 2)
• Team wrote orders “just before they went home.
• Patient unaware of “new” regimen.• Did not ask for additional PRNs• Nurse didn’t provide infor on
available meds
Day 2 pain
scores unchang
ed
Write orders
ORPage
team with updated
recs
Table exercise: Identify Areas for Improvement – 10 minutes
PCS Roun
ds
Informal ✔ in
w/ primar
y teams
FAMILY
MTGS
Write notes with
“official
recs”
3 hrs1 hr 3 hrs 1 hrs
PCS Roun
ds(day 2)
• Team wrote orders “just before they went home.
• Patient unaware of “new” regimen.• Did not ask for additional PRNs• Nurse didn’t provide infor on
available meds
Day 2 pain
scores unchang
ed
Write orders
ORPage
team with updated
recs
Identify Areas for Improvement
PCS Roun
ds
Call the primary team with clear to-do now recsORwrite orders after each patient is seen
Informal ✔ in
w/ primar
y teams
Write notes with
“official
recs”
Offer to write orders for the team if they
are busy?
Call the bedside nurse to let him/her know of new orders?
One team memb
er does PM
check in
Gives patient information card on their pain regimen
Write note with updated PM recs
Page team with updated recs
Nurse updates the card for patient
AM workflow
PM workflow
– Set the vision for improvement– Understand the problem – Identify Areas for Improvement
• Devise a measurement strategy– Prioritize small tests of change–Measure Change– Sustain the change
10:15
Using a QI framework to improve care
Will these interventions result in improvement?
INTERVENTION
Not all changes are improvements … But all improvements are the result of changes!
Deciding what to measure
Process:(actions)
Outcomes(patient level results)
Structure(adherence to the
program)
Deciding what to measure
Process:(actions)
Outcomes(patient level results)
- LOS- Cost- Change in Pain
Scores
Structure(adherence to the
program)
Deciding what to measure
Process:(actions)
Outcomes(patient level results)
- LOS- Cost- Change in Pain
Scores
- Teams called on morning rounds - Cards distributed- Patients seen in the afternoon- Time from order to pain med delivery
Structure(adherence to the
program)
Deciding what to measure
Process:(actions)
Outcomes(patient level results)
- LOS- Cost- Change in Pain
Scores
Structure(adherence to the
program)
-Measuring Day 1 to Day 2 scores
-Knowing first call on rounds
-Ongoing nursing ed
- Teams called on morning rounds - Cards distributed- Patients seen in the afternoon- Time from order to pain med delivery
Deciding what to measure
Process:(actions)
Outcomes(patient level results)
Structure(adherence to the
program)- Teams called on morning rounds - Cards distributed- Patients seen in the afternoon- Time from order to pain med delivery
Balancing Measures(potential harm)
- Oversedation- Rapid
Response- Family
Complaints
- LOS- Cost- Change in Pain
Scores
-Measuring Day 1 to Day 2 scores
-Knowing first call on rounds
-Ongoing nursing ed
15 Minutes: What are the right measures for your group?
• OUTCOMES:
• PROCESSES:
• STRUCTURE:
Five Minutes: What are the right measures for your group?
• OUTCOMES:– Day 1 to Day 2 improvement– Day 1 to Discharge improvement– Patient Satisfaction with “Staff did everything to help with pain”
• PROCESSES:– Time from recommendations to orders– Time from order to med delivery– % Patients visited again in the afternoon
• STRUCTURE: – Use of patient-centered pain medication cards– Permission from primary teams to write orders– Knowledge of team first contact
– Set the vision for improvement– Understand the problem – Identify Areas for Improvement– Devise a measurement strategy
• Prioritize small tests of change– Measure change– Sustain the change
10:55
Using a QI framework to improve care
High Effort
High Impact
Low Effort
Low Impact
Thankless tasks
Easy Wins
Call the primary team after each patient is seen with clear to-do now recs
One team memb
er does PM
check in
Gives patient information card on their pain regimen
Page team & Write note with updated PM recs
QI is a four legged stool
Systems Change:Change staffing, protocols, create hard stops, and electronic shortcutsCulture Change: Change the way you talk about the problem; talk about the organization you want to be. Create a vision.
Education: Think about how
you change educate people in their role. Ensure
capability, knowledge and
skills are ready for change.Data audit &
feedback: Provide people
with their performance.
Let them know you are
watching and you care.
One team memb
er does PM
check in
Table exercise: 10 min Think about the four pillars of change, and come up with a need for your group in each category
Write down where it fits on the QI “stool”
EDUCATION
DATA AUDIT & FEEDBACK
SYSTEMS CHANGE
CULTURE CHANGE
?
High Effort
High Impact
Low Effort
Low Impact
Thankless tasks
Easy Wins
Call the primary team after each patient is seen with clear to-do now recs
One team memb
er does PM
check in
Gives patient information card on their pain regimen
Write note with updated PM recs
Prioritize small tests of change
Doing small tests of change will let you know if your ideas are working.
Must be accompanied by ongoing measurement.
Case Example: Broken PCA process• Aim: Improve timely pain management• Intervention: Write orders / Talk to team after each patient seen
on rounds• Plan / Do:
– Implemented workflow for order entry and team contact on rounds
• Study: Discovered patients with highest pain scores NOT getting pain meds!– PCA orders taking 6 hours to complete, patient without necessary PRNs in
the interim
• Act: Address PCA issues– Work with pharmacy to improve workflow for making PCAs– Build interim PRNs into PCA orderset so higher doses of PRNs can be given
until PCA arrives
PDSA Worksheet for Testing Change Aim: (overall goal you wish to achieve)
Describe your first (or next) test of change: Person responsible
When to be done
Where to be done
Every goal will require multiple smaller tests of change
Plan: List the tasks needed to set up this test of change Person
responsibleWhen to be done
Where to be done
.
Do Describe what actually happened when you ran the test Study Describe the measured results and how they compared to the predictions Act Describe what modifications to the plan will be made for the next cycle from what you learned
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