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Process Improvementfor the Heart Failure patientfor the Heart Failure patient
Paul Helgerson, MD
Associate Chief of Staff, Process Improvement
VA Palo Alto Healthcare System
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Learning Objectives
• Involve participants in local heart failureimprovement initiatives
• Introduce the improvement framework as atool to facilitate future effortstool to facilitate future efforts
• Identify means of successfully implementingchange and finding new opportunity
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Questions for Consideration
What are the most effective steps we cantake as an organization to improve the careof the CHF patient?
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Common Answers
• Improved adherence to guidelines/evidencebasis
• Deliver further advanced therapies (e.g. LVAD)
• Decrease admissions/readmissions/keep more• Decrease admissions/readmissions/keep morecare in the home
• Improve collaborative decision makingregarding goals of care
• We already do a pretty good job!
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Domains of Improvement
EvidenceBasis
Operationsand
Efficiency
PatientCentered
Care
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VA-TAMMCSIdentifying A Framework
• Vision > Identify Values
• Analysis > Enumerate Priorities
• Team > Interdisciplinary, Front Line
• Aim > Direction, Leadership• Aim > Direction, Leadership
• Map > Understand our Work
• Measure > Chart Progress
• Change > Active, Rapid Cycle
• Sustain > Plan for Lasting Effect
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One Way
V A T A M M C S
VisionVisionAnalysis
“DecidingPhase”
MakeChanges
“DoingPhase”
SustainSpread
“Keep DoingPhase”
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Project Selection Matrix Tool is a useful way to choose a project
Criteria
Project
1 2 3 4
Likelihood of Success5 10 8 10
Improvement Framework
VA
Likelihood of Success5 10 8 10
$$ Impact (cost or revenue)10 5 6 1
Patient Satisfaction10 4 5 10
Employee Satisfaction10 2 5 10
Completion in 4-6 weeks1 10 10 10
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Improvement Framework
Map
84 steps63 non-value steps21 value-added steps
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Improvement Framework
Map
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A Typical Healthcare Process
Start Finish
Rework
Value Added Work
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Exam Room
Exam Room
Exam Room
Exam Room
RN Station
Exam Room
Exam Room
Exam Room
Check-in
ProviderCharting
Calls Patient
Exam Room
Exam
Ro
om
Exam Room
Exam Room
Exam RoomE
xam
Ro
om
Exam
Ro
om
Exam
Ro
om
Procedures
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5.1%
4.8%
4.2%
5.2%
3.4%
3.2% 2.9%
3.7%
3.3%
4.3%
3.3%2.9%
3.4%
4.0%
5.0%
6.0%
VAPAHCS Blood Culture Contamination Rate
RPIW(late July)
Competency Fair2A & 3C
(early November)
CompetencyFair ICU & IICU(early October)
*LMS module online*Orders default toperipheral draw
(late January 2011)
Customizedkits in use(August 2011)
3.2%
2.4%
2.9%
2.5%
2.9%
1.5%
2.6%2.6%
0.0%
1.0%
2.0%
3.0%
JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
National Standard = 3%
VAPAHCS Goal = 2%
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A P
S D
Implementation of
PDSA: The “How” to Change
Improvement Framework
Change
HunchesTheories
Ideas
A P
S D
Very small scaletest
Follow-uptests
Wide-scale tests ofchange
Implementation ofchange
Langley, Nolan, et.al. The Improvement Guide:
A Practical Approach to Enhancing OrganizationalPerformance. Jossey-Bass. San Francisco, CA.1996
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Improvement Hold Gains Spread
??? more like …
What’s the Sequence?
Improvement
Hold Gains
SpreadSource: Institute for Healthcare Improvement (IHI)
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Defining “Spreadable”
• Demonstrable Effectiveness
– Implies formal recording/reporting
• Trialable
• Modular/encapsulated• Modular/encapsulated
– Can I describe exactly what I did? Can I turn it intoa “kit”
• Low “cost” (expense, easy)
– Can the new innovation actually become the pathof least resistance
17
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Rules of Diffusion(by Donald Berwick)
• Identify changes that are ready tospread
• Find innovators and support them• Find innovators and support them
• Invest in early adopters and allowcommunication with innovators
• Make early adopters observable
• Allow re-invention of innovation
• Trust and enable innovation
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Local Initiatives
• CHF Process Improvement Team
– Initial goal of improving patient education in CHF
– Scoped to inpatient and outpatient domains
– Valuable output, valuable lessons of scope and– Valuable output, valuable lessons of scope and“rapid cycle change” practice
• ARC Collaborative/Project RED
– Overlapping “vision” of fewer readmission
– Compelling blend of evidence and implementationscience
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Project RED
• Educate the patient throughout the hospital stay
• Make appointments for follow-up prior to discharge
• Hardwire a follow-up plan for pending test results
• Organize post-discharge services• Organize post-discharge services
• Medication plan (reconciliation, availability)
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Project RED
• Reconcile plan with guidelines and pathways
• Action plan for problems/emergencies
• Ensure a comprehensive discharge summary isavailable to the “right” peopleavailable to the “right” people
• “Teachback” of the plan
• Provide a written summary of the discharge plan
• Provide telephone reinforcement of the plan
Source: http://www.ahrq.gov/qual/projectred/