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Effective Design & Sustained Quality Improvement

IDEAS Alumni Event

October 13, 2015

2:30 pm -4:30 pm

Health Quality OntarioThe provincial advisor on the quality of health care in Ontario

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The provincial advisor on the quality

of health care in Ontario

www.HQOntario.ca

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Welcome (Everyone introduce themselves)

Alumni facilitating today’s workshop:

Betty Ann Knutson – Golden Plough Lodge

Stephanie Pearsall – Halton Healthcare

Carol Bennett – Guelph General Hospital

Dr. Val Mueller – Guelph General Hospital

Shannon Maier – Guelph General Hospital

HQO facilitating today’s workshop:

Dave Zago

Tracy Lee

Joe Mauti

www.HQOntario.ca

3

Presenter Disclosures

www.HQOntario.ca

• No relationships with commercial interests

• No financial support

• No in-kind support

• No known conflict of interest

• No plan to mitigate potential bias as none are known

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Learning Objectives

After active engagement in this workshop, participants will be better

able to:

• Describe the key questions necessary to designing and sustaining

quality improvement:

– What is the problem? Why is this a problem?

– What can we do differently and how will we know it is better?

– How can we sustain our improvements?

• Demonstrate use of key QI tools to inform each question.

• Describe the importance of adaptive leadership and leading

culture change to support improvement.

• Design an improvement initiative to meet a priority and know what

resources are available to support you.

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www.ideasontario.ca 5

Model for Improvement

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Something is Wrong Here…

• A 32 year old woman with a previous vaginal delivery

• She is term, at 40 weeks but is tired of being pregnant,

feeling uncomfortable. She asks her doctor for an induction

for “postdates”

• physician documents “wants induction, knows risks.” Team

receives orders for induction, no discussion regarding

rationale.

• Induction started in the

morning, some progression

and an epidural for pain

relief

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.mnn.com/family/babies-pregnancy/blogs/pa-law-makes-it-illegal-to-touch-a-pregnant-womans-belly&ei=5uEnVZ7_AYefyQTfgIGoBw&bvm=bv.90491159,d.b2w&psig=AFQjCNHe14ot4h1qLepBnpdplzeXs1CdNQ&ust=1428763469493901

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.mnn.com/family/babies-pregnancy/blogs/pa-law-makes-it-illegal-to-touch-a-pregnant-womans-belly&ei=5uEnVZ7_AYefyQTfgIGoBw&bvm=bv.90491159,d.b2w&psig=AFQjCNHe14ot4h1qLepBnpdplzeXs1CdNQ&ust=1428763469493901


But we could do something

about this…

• In the afternoon there is concern about the baby’s

wellbeing and induction is halted for a short time and

restarted

• By later in the day labour begins but baby continues to

deteriorate, evidence of stress

• Patient rushed for stat caesarean section, chaotic

delivery as anesthesia busy in OR and back up has to be

called in

• Baby admitted to NICU


Initial Data


And here is how….

Our Aim Statement:

• By the end of the IDEAS 5 month program a process will

be implemented that guides collaborative decision-

making between women, their care providers and the

Maternal Newborn team to reduce the percentage of

postdate inductions occurring before 41 weeks, to less

than the benchmarked 5%.


Historical Perspectives

• Focus in news media regarding “off label” use of

antipsychotic medication for the management of

dementia without inclusion of diagnosis of “psychosis”

• Incidence of antipsychotic medication at Golden Plough

Lodge quoted as 52.1 % ( from CIHI data base) as

compared to provincial average of 30%

• Recognition that quality of life of people who suffer from

dementia is improved with the judicious use of

antipsychotic medication


AIM

Our Aim Statement:

• By December 2014, there will be a 50%

reduction in the administration of PRN

antipsychotic medications in a specialized care

unit (Blacklock Cottage)

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Project Charter

Title: Scope/Boundaries:

Team

Executive Sponsor

Team Lead

Process Owner

Improvement Advisor

Team Members

Problem Statement:

Aim Statement:

Measures:

Root Causes of the Problem: Change Ideas:

Anticipated Barriers and Mitigation Strategies: Anticipated Timeline

Key Milestones:

Resources Required: Signatures: Executive Sponsor: _______________________________

Process Owner: __________________________________

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5W2H Method

5W and 2H Response

5 W

What is the problem? Describe it in a single

sentence, so that others will be able to

understand what you mean.

The problem is…

Why is it a problem? What is the pain? This is a problem because…

Where do we encounter the problem? We encounter the problem at (Location) (Time)

when (Specific circumstance)…

Who is impacted? This impacts: (Staff) by…, (Patients) by…,

(Other providers) by … (others) by…

When did we first encounter the problem? We first encountered this problem…

2H

How did we know there was a problem? The symptoms of this problem are…

How often do we encounter this problem? We encounter this problem (x) times and each

encounter is (this big). The problem is getting

(better/worse).

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When starting an improvement initiative it is important to step back and reflect on your current

situation. Use the 5W2H questions below to ensure you have uncovered all key information that is

contributing to the problem area of focus. .

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What are YOU trying to accomplish?

TABLE WORK

Take 5 minutes:

Write your own problem statement and aim statement using the Project Charter

template in your kit.

Take 10 minutes:

Share your draft problem and aim statements with each other at the table.

Listen/ask for clarification.

This is NOT a problem solving exercise. It is a problem definition exercise (problem

statement) with an identification of a better future state (aim statement).

Take 3 minutes: Edit/revise your problem and aim statements.

WHOLE GROUP WORK

Be prepared to share 1 or 2 examples of a problem statement and aim statement.

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Family of Measures

Outcome

• Measures ofwhat youtrying toachieve

Process

• Measuresactivities, tasks,

processes

Balancing

• Measures of other parts of thesystem as we affect processes

and outcomes

• May measure unintendedconsequences

How many measures is the “right” number?

http://www.ideasontario.ca/

Criteria for Measures

Clearly Defined

Aligned

• Aim

Comparative Data

/Benchmarking

• Internal

• External

Actionable

• Can you influence it

Reasonable

Measurement

Properties

• Reliable

• Valid

• Sensitive to change


http://www.ideasontario.ca/


Family of Measures

• Outcome Measure: Reduce the outcome to 5% of

elective postdate inductions delivered before 41 weeks

• Process Measure:

– Discussion regarding the booked inductions at daily morning

huddles

– The percentage of patients that were booked using the induction

referral booking process

– The percentage of huddles that occur with the interdisciplinary

team members to discuss booked inductions

– Percentage of patients that receive education

– Percentage of staff that receive education

– Percentage of patients having an induction with a Bishop’s score


Family of Measures

Outcome Measure & Key Process Measures

• % reduction in PRN antipsychotic medication for

escalating responsive behaviours

• % increase in confidence of staff to deal with responsive

behaviours through the use of Gentle Persuasive

Approach (GPA)

• Increase in utilization of “white board” as a means of

communication between shifts related to responsive

behaviours


Family of Measures

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How will YOU know that your

change is an improvement? TABLE WORK

Take 5 minutes:

• Identify and write out one outcome measure and one balance

measure that ties to your aim

Take 5 minutes:

Share your draft measures with each other at the table. Listen/ask for

clarification.

WHOLE GROUP WORK

Be prepared to share 1 or 2 examples.

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The Operational Worksheet



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Root Cause Tools

Common Tools

- 5 Whys

- Process Map

- Stakeholder Analysis

- Driver Diagram

- Fishbone


Driver Diagram


Fishbone


How to Create a Driver

Diagram

1. Clarify your aim statement

2. Identify change ideas and concepts

statement around the structure,

process and norms.

3. Group and organize ideas under

themes (primary drivers).

4. Draw, review and revise.


Driver Diagram


Fishbone

Effect

Patients Providers

Places/Equipment Policies/Processes

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What changes can you make to lead

to improvement?TABLE WORK

Take 15 minutes:

• Draft a Driver Diagram

• Draft a Fishbone Diagram

• List 2-5 change ideas from your diagram(s) that you could focus

an early test for improvement and add to your Project Charter

WHOLE GROUP WORK

Be prepared to share 1 or 2 examples.

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BREAK

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Model for Improvement(Dave)

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HIGHLY ADOPTABLE IMPROVEMENT


Changes

• Key change ideas identified:

– What are your key change ideas

– Standardize method of defining expected date of delivery

– Induction checklist

– Process for referral and booking

– Daily huddles

– Develop and distribute standardized patient information

regarding induction process

– Ensure data integrity

• Tests of change using PDSA

– PDSAs included referral process, standardized EDD

determination, patient information, huddles


What we have learned:

Adaptive Leadership

• Our challenge was to address the gap between the way things were and

achieving:

– Improved health of our population (mothers and babies)

– Enhanced patient experience

– Reduce total cost of care (LOS, NICU admission etc.)

• With staff education we faced some fear, distress, avoidance and realized

people were facing loss

• How we faced these challenges with adaptive leadership

– Actively listened, let people vent their frustrations, expressed our

curiosity, allowed for disagreement and debate

– Difficult conversations

– Dialogue, tried to change at a pace that was tolerable for staff

– Emotional conviction

– Seeking to understand

– Focusing on supporters, keeping those progressive people engaged


What we have learned: Highly

Adoptable Improvement

• Factors that were moderate or high risk:

– New booking process (referral form faxed to triage)

– EDD

– Change in practice regarding booking inductions on other

physicians call schedules and relying on colleagues for follow-up

fetal health surveillance (i.e.. U/S, NST)

– Some aspects of booking after 41 weeks seemed harder for

providers

• Countermeasures

– Made changes to form based on feedback for sustainability

– Tried to eliminate double documentation

– Focus on benefits of not having to book all of your own patients

on your own call day (flexibility in scheduling and booked c/s)

– Dialogue regarding plan and fetal health surveillance with triage

visits at 41 weeks


What we have learned: Data

• It is hard to be statisticians AND clinicians, but

we have learned you need elements of both to be

effective in quality improvement initiatives and in

monitoring practices in terms of patient safety

• Keep it simple

– Quick repeated PDSAs

• Involve all the stakeholders in the collection and

use of data, gaining multiple perspectives

• At the initiation of every project focus on

leadership, strategy, stakeholders, and

measurement

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://blog.ecornell.com/3-reasons-big-data-has-big-relevance/&ei=5GJqVNWmEISWyASYkID4CA&bvm=bv.79908130,d.aWw&psig=AFQjCNECDC-ZlPSxEAOZqAl_Hfcn3B8_og&ust=1416344632027375

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://blog.ecornell.com/3-reasons-big-data-has-big-relevance/&ei=5GJqVNWmEISWyASYkID4CA&bvm=bv.79908130,d.aWw&psig=AFQjCNECDC-ZlPSxEAOZqAl_Hfcn3B8_og&ust=1416344632027375


Run Chart

Fishbone & driver diagram completed

Huddle attendance monitored

PDSA – Booking Form

PDSA Referral form

Staff & Clinician education


Changes

• Selection of Gentle Persuasive Approach (GPA) to manage

responsive behaviours that may be disturbing, disruptive and/or

potentially harmful to other residents, and/or care partners e.g. staff,

families, volunteers

• Emphasis on the use of GPA as a non-pharmalogical intervention in

managing escalating behaviours before use of PRN pharmalogical

interventions ( specifically antipsychotic drugs, such as Haldol,

Seroquel and Risperdal)

• Improved communication between shifts regarding interventions

useful in redirecting escalating responsive behaviours


Results/Impact

PDSA on Usage of “Whiteboard” between Shifts

• 5 PDSA’s done from first cycle until present

• Purpose of the “whiteboard” has altered from first cycle

• Intention initially was to alert all staff to responsive behaviours

between shifts; staff were to add yellow sticky notes as to

successful interventions they used with specific residents

• Currently the whiteboard is being used to pass on strategies to

mitigate specific behaviours(s) using GPA

• Challenges:

• consistent use of the whiteboard between shifts

• utilization of the whiteboard by other staff than nursing e.g. dietary,

life enrichment, housekeeping and keeping information on

strategies current


Overall Challenges

• Learning that RAI-MDS data was not giving us what we needed for

CQI purposes

• Differences in interpretation e.g. “moods and behaviours” versus

“behaviours” as related to “restiveness to care” in RAI-MDS

• Necessity to do data compilation manually e.g. PRN antipsychotic

medication per resident, date and type used

• Introduction of Point of Care documentation has caused PSW

workload to increase; time to document equals &/or more than 60

minutes per shift

• Revert to use of PRN antipsychotic medication to managing

escalating responsive behaviours rather than spending the time to

intervene with GPA

• Ongoing challenge of balancing “task based” workload with time

necessary to do GPA interventions


Overall Learning

• Use of Whiteboard appears to be effective as a tool for communication

between shifts when used as indicated

• Initial assessment of the use of Gentle Persuasive Approach has appeared

to have had an impact on the administration of PRN antipsychotic

medications; staff are more apt to use GPA as first intervention for

escalating behaviours; appears that use of PRN antipsychotic medication is

“last choice”, rather than ”first choice”

• The importance of examining the data related to PRN antipsychotic

medication in conjunction with the responsive behaviours and developing

strategies to reduce and/or redirect the behaviours(s) seems promising

when conducted with all key players e.g. physician, pharmacist, NP, RPN,

PSW, Life Enrichment staff, Registered Staff (RN/RPN)

• Introduction of Nurse Practitioner has proven to be invaluable for team


Sustainability

• Continue to collect and analyze data on Blacklock

Cottage

• Continue to meet as a “team” to review strategies for

mitigating responsive behaviours and examining data for

relationships; “equal voice, equal opportunity to influence

plan of care”

• Recognition of “best choice” for intervention for resident

involves all partners at the table: re-examination of how

we conduct 6 week Admission Care Conference and

Annual Care Conference ( future CQI)

• Use of whiteboard throughout Golden Plough Lodge


Run Chart


Culture Transformation

“If you want to make enemies, try to change

something”

By Woodrow Wilson


Town Hall

• Based on what you have worked on today, what

are the adaptive challenges you expect in your

improvement?

• What leadership strategies can you use to

mitigate these?


Closing

• Tools and Resources: http://shareideas.ca/

• Highly Adoptable Improvement Model

http://www.highlyadoptableqi.com/index.html

• Reflect upon day

• Rough copy of Project Charter

• Evaluation

http://www.highlyadoptableqi.com/index.html

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