listen to your team

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)


Process:(actions)


- LOS- Cost- Change in Pain

Scores


program)


Process:(actions)



Scores

- Teams called on morning rounds - Cards distributed- Patients seen in the afternoon- Time from order to pain med delivery


program)


Process:(actions)



Scores


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


Process:(actions)



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


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


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


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

listen to your team

Documents