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Putting It All TogetherTranslating Learning Into Action

May 7, 20143:15 – 4:15 PM ET

Kevin Little, PhD

Context for JRLC: Improve Value

Health outcomes = clinical outcomes AND

Patient Reported Outcomes (PROs)

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JRLC Aim: How much, by When

Reduce costs of TJR by 5% (denominator)

while maintaining or improving clinical and

patient reported outcomes (numerator) by

December 2014.

133

EXECUTION METHOD: THE MODEL FOR IMPROVEMENT

Hitting the highlights

134

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If you know where you want to go, how

can you get there?135

Will to

Change

Ideas for

Change

Execution

Based on Nolan, T.W. A primer on leading improvement in health care. Presented at the Fifth European Forum on Quality

Improvement in Health Care, Amsterdam, March 24, 2000.

Ingredients Needed to Change

Informing Ecological Design,

LLC

136

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Will to

Change

Ideas for

Change

Execution

Nolan, T.W. A primer on leading improvement in health care. Presented at the Fifth European Forum on Quality

Improvement in Health Care, Amsterdam, March 24, 2000.

Informing Ecological Design,

LLC

137

Inspiration from other organizations,

motivation to deliver great value to

patients

Examples from

other

organizations,

insights

from process

analysis Method to change and then hold

the gain

Ingredients Needed to Change

138

1. What are we trying toaccomplish?

2. How will we know that achange is an improvement?

3. What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

IHI road map for

project work: a

way to move from

talking and thinking

to action

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Three factors drive the scale for tests of a change

Organizational Commitment

Belief in the effectiveness of the change

Risk of failure

A test scale of "size 1" is almost always appropriate…

Source: Table 7.1 G. Langley et al. (2009), The Improvement Guide, 2nd edition, Jossey-Bass, San Francisco ©

Associates in Process Improvement, used with permission.

Guidance on Scale of a Test

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Testing vs Implementing

Feature Test Implement

Focus Learning Producing

Tolerance for failure

High (25% or more

cycles can fail yet

still drive effective

learning)

Low

Number of people affected Small Large

Potential for social resistance* Low High

Change in support processes

and tools (feedback, training,

IT tools, documents, policies,

contracts…)

Not usually needed Usually required

141

*"If it weren't for the people, improvement would be easy." Peter Scholtes ca. 1985

Source: The Improvement Guide, 2nd edition pp. 174-175Source TIG pp. 174-175

Three Paths to Implementation

Path Potential Benefit Potential Cost

Just Do It

Shortest time between vetted

idea and regular practice &

improved performance

Maximizes organizational

pain and costs if change

fails in practice

Parallel Approach

Redundancy: current system

retained while new system

runs. Assures that organization

can still deliver services and

care; sometimes effective for IT

changeovers.

Effort to manage two

systems, management

capacity a constraint

Sequential Approach

Phase in steps, if the change

allows--some changes require

"All at once" deployment.

Requires management of

phases; management

capacity a constraint

142

pp. 175-185 TIG

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Repeated Use of the PDSA Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement:

After cycles have

demonstrated that

the change CAN

work, use more

cycles to help you

figure out how the

change WILL work,

every day

A P

S D

A P

S D

Investigation Demonstration Implementation

143

PDSA into Standardized Work

Hunches

Theories

Ideas

Changes That

Result in

Improvement:

After cycles have

demonstrated that

the change CAN

work, use more

cycles to help you

figure out how the

change WILL work,

every day

A P

S D

A P

S D

Investigation Demonstration Implementation

144

Incorporate

changes into

standardized

work

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WORK SESSION

145

Team Task: Action by next Thursday

1. Pick one opportunity (5 minutes)

2. Answer 3 questions (5 minutes)

3. Identify scale of testing(5 minutes)

4. Develop details of one PDSA (10 minutes)

5. Group debrief (10 minutes)

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147

References

IHI Open School Course QI 102: The Model for Improvement: Your Engine for Change (free of charge):

http://app.ihi.org/lms/coursedetailview.aspx?CourseGUID=41b3d74d-f418-4193-86a4-ac29c9565ff1&CatalogGUID=6cb1c614-884b-43ef-9abd-d90849f183d4

Graupp P and Purrier M Getting to Standard Work in Health Care. Boca Raton: CRC Press; 2013.Langley G et al. The Improvement Guide, 2nd edition. San Francisco: Jossey-Bass; 2009.Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. http://www.ihi.org/resources/Pages/IHIWhitePapers/ImprovingtheReliabilityofHealthCare.aspx Perla RJ, Provost LP, Murray SK. "The run chart: A simple analytical tool for learning from variation in healthcare processes", BMJ Quality & Safety, 2011 Jan 20(1):46-51.

Lean Enterprise Institute website: three-part post on standardized work by John ShookPart 1: http://www.lean.org/shook/DisplayObject.cfm?o=13203

Part 2: http://www.lean.org/shook/DisplayObject.cfm?o=1319

Part 3: http://www.lean.org/shook/DisplayObject.cfm?o=1321

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APPENDIX: REFERENCE SLIDES FROM 24 APRIL 2014

149

Execution Recommendation-1

• Your team has finite capacity in the next six months.

• You won't be able to pursue every opportunity.

• Choosing to pursue one opportunity means less capacity

to tackle other opportunities.

• Use or borrow a way to organize, review and select

targeted opportunities before starting too many initiatives

• Fine balance between over-thinking and not thinking

enough!(reference: D. Kahneman (2011), Thinking, Fast and Slow)

150

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151

First Draft of a Prioritization Matrix: Kadlec Regional

Medical Center, preliminary data

Execution Tool: Top Level

• Document your aim and

your plan to accomplish

it

• Use your organization's

template or borrow a

Charter outline from us,

basis for monthly report

152

Project Charter

1. Aim: What are we trying to accomplish?

Reduce costs of TJR by 5% (denominator) while maintaining or improving

clinical and patient reported outcomes (numerator) by Dec 2014.

2. Measures: How will we know that a change is an improvement?

A) cost measurement estimate on caremeasurement.com (compare

baseline to summer and fall 2014 estimates)

B) outcome measures

--LOS

--Discharge disposition

--30 day all cause readmission

--PRO scores (e.g. composite from HOOS/KOOS or WOMAC) if

available

C) Process measures

SCIP compliance

[add local measures]

3. Change opportunities: What change can we make that will result in

improvement?

(1)….

(2)…..

(K)….

Guidance: Project Background (details behind the Aim statement) staffing,

connection to PRO deployment, schedule for reporting, local requirements.

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Execution Tool: Opportunity Level

• Translate each

opportunity into a

project

• Document each project

aim and your plan to

accomplish it

• Use your organization's

template or borrow a

Charter outline from us.

153

Example: A Kadlec Opportunity154

Screen high-risk patients for ↑HbA1c, ↑BMI/

poor nutritional status, smoking cessation,

allowing time to mitigate risk for

complications while reducing cancellations

day of surgery.

Process Measure: % of high-risk patients

screened 21-28 days prior to scheduled

surgery.

Outcome Measures and Cost Measure: Lag?

• Develop and apply high risk algorithm to

H&P obtained during surgeon consult

• Develop and apply standard order set

for early screening

1. What are we trying toaccomplish?

2. How will we know that achange is an improvement?

3. What change(s) can we make thatwill result in improvement?

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Why Test?

Increase your belief that change(s) will work

Predict expected improvement

Learn how to adapt to the local environment

Evaluate costs and side effects

Minimize resistance upon implementation

Informing Ecological Design,

LLC

155

Basic components of each step

Act

• What changes

are to be made?

• Next cycle?

Plan• Objective

• Questions and

predictions (why)

• Plan to carry out the cycle

(who, what, where, when)

• Plan for data collection

Study• Complete the

analysis of the data

• Compare data to

predictions

• Summarize

what was

learned

Do• Carry out the plan

• Document problems

and unexpected

observations

• Begin analysis

of the data

Informing Ecological Design,

LLC

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What’s the big deal? We

already do PDSA all the time!

157

…To Be Considered a PDSA Cycle

The test or observation was planned

– (Including a plan for collecting data and a prediction about

results.)

The plan was attempted (do the plan).

Time was set aside to analyze the data and study the

results

Action was rationally based on what was learned.

Informing Ecological Design,

LLC

158

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Why Predict?

Enhances learning

Forces use of test cycle measures

Adds fun to your improvement work

Informing Ecological Design,

LLC

159

Start small, ramp up

In terms of your work: Test your change on ONE

UNIT (one patient pre-op visit, one surgery, one risk

assessment)

In terms of time: What can you learn in one day, one

morning, one hour, five minutes? (shorter the

better)

Rule of 5: if predictions hold for test of size 1, go to 5

(scale up) to expose your change to varying conditions

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Kadlec Examples Scale Up

Change PDSA # Number of Units

Use screening

algorithm to id high-

risk patients

1 1 patient record

2 5 patient records

Apply standard order

set to high-risk

patients

1 1 patient

2 5 patients

161

Collect Data Over Time

Useful data beat perfect data

– Pencil and paper system is OK!

– Qualitative data now beats quantitative data later

Record what went wrong during the data collection

Sampling can reduce data burden

Informing Ecological Design,

LLC

162

The ‘Plan’ step includes plan to collect data for

each PDSA Cycle.

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Kadlec Example Data Over Time163

Patient

ID

Date Scheduled

for Surgery

Assessed

?

High

Risk?

Screened

21-28 days

prior to

Surgery?

1 5/13/2014 No NA NA

2 5/15/2014 Yes No NA

3 5/15/2014 Yes Yes Yes

…

Surgery

Scheduled

Week

N Assessed

N

High

Risk

Screened

21-28

Days

before

surgery?

% Hi Risk

Patients

Screened

12-May 4 3 3 2 67%

19-May 5 4 2 1 50%

26-May 3 3 2 2 100%

2-Jun 6 6 3 3 100%

Changed work flow

Effective run

charts will show

measures in

surgical order (e.g.

LOS) or weekly--

fast feedback!