Small Tests of ChangeVTE

Travis DollakImprovement Advisor

WHA

Courtesy Reminders: •Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) •Please do not take calls and place the phone on HOLD during the presentation.

Today’s Call

1. Past 30 Days2. VTE Big Picture Strategy3. PDCA Cycles

A. Designing TestsB. Adapt, adopt, abandon

4. Tracking Innovation5. Next 30 Days

ACTION ITEMS

Develop Aim Statement

Staff Safety Assessment

Assess your interventions

Test ONE intervention

Submit Outcome and Process Measure

Past 30 Days

Mid-month feedbackPace • The pace is perfect• A lot is being asked, but my team is keeping

upSmall Test of Change• Improve discharge information• Improve awareness of the need to ambulate

Poll Question #1• What progress have you made on analyzing the

staff safety assessment /secondary drivers and choosing an initiative to test? a) We have not administered the staff safety

assessment b) We administered the assessment and are still

collecting the responsesc) We have analyzed both the assessment and

secondary drivers but have not chosen any interventions

d) We have completed the analysis, chosen interventions and are testing the interventions

VTE Big Picture Strategy1) Distill evidence into protocol

2) Integrate protocol with risk assessment into all admit/transfer orders

3) Ongoing monitoring of impact to tweak protocol

4) Devise method to detect those without prophylaxis in real time and intervene using multiple methods

Source: Designing and Implementing Effective VTE Prevention Protocols, Greg Maynard M.D.

Poll Question #1 Results• What progress have you made on analyzing the

staff safety assessment /secondary drivers and choosing an initiative to test? a) We have not administered the staff safety

assessment b) We administered the assessment and are still

collecting the responsesc) We have analyzed both the assessment and

secondary drivers but have not chosen any interventions

d) We have completed the analysis, chosen interventions and are testing the interventions

The Essential First Intervention

1) a standardized VTE risk assessment, linked to…2) a menu of appropriate prophylaxis options, plus..3) a list of contraindications to pharmacologic VTE prophylaxis

VTE ProtocolVTE Protocol

Challenges:Make it easy to use (“automatic”)

Mare sure it captures almost all patientsTrade-off between guidance and ease of use/efficiency

Source: Designing and Implementing Effective VTE Prevention Protocols, Greg Maynard M.D.

Mistakes in VTE Protocols/Prevention Orders

• Too Complicated • No real guidance (Prompt ≠ Protocol)• Too much ‘guidance’ collects dust• Too many categories of risk• Allowing mechanical prophylaxis too much• Failure to pilot, revise, monitor• Linkage between risk assessment and prophylaxis

choices are separated

Source: Designing and Implementing Effective VTE Prevention Protocols, Greg Maynard M.D.

VTE Prevention Order

Too Complicated?

Other Simplified Protocols/Order Sets

http://www.whaqualitycenter.org/PartnersforPatients/VenousThromboembolism/VTEReferences.aspx

Questions

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Moving to PDSA Cyclesavoiding the mistake of failing to pilot,

monitor, and revise

A BIG Paradigm Shift

The “old”7 step

process

The ‘Old Way’

The “old”7 step

process

A More Sustainable Process

Sustainable Improvement

The ‘New Way’

Sustainable Improvement

Repeated Use of the PDSA CycleSmall Tests of Change

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Changes That Result in

Improvement

Implementation of Change

Hunches Theories Change Ideas

A PS D

APS

D

A P

S DD S

P ADATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

IHI – Adapted from “The Improvement Guide” by Lloyd Provost

Revise and Re-evaluate: Key Decision

Remember the first interventions do not always work

Adapt, adopt, abandonAdapt—make the changes needed to make it

workableAdopt – keep it (document and report results)Abandon—let it go, if it didn’t work, don’t try to

Test of Change Design

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TEST PREDICTION RESULTS Decision

1. Want nurse X & physician Y on second shift unit B to use new protocol

Faster assessment, more likely to understand/complete prophylaxis

Adapt

2. Improve ambulation on night shift with one RN

Expect 80% compliance with night patient ambulation

Nurse was able to meet prediction

Adopt

3. Want 2 physicians to use new protocol next Mon-Wed

Expect 90% of patients to have completed assessment

TBD Adopt Adapt Abandon

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TEST PREDICTION RESULTS Decision

1. Want nurse X & physician Y on second shift unit B to use new protocol

Faster assessment, more likely to understand/complete prophylaxis

Adapt

2. Improve ambulation on night shift with one RN

Expect 80% compliance with night patient ambulation

Nurse was able to meet prediction

Adopt

3. Want 2 physicians to use new protocol next Mon-Wed

Expect 90% of patients to have completed assessment

TBD Adopt Adapt Abandon

Tracking Test of Change is PDSA

Action Item# 1: Complete and Document 3 Small Tests of Change

Complete 3 Small Tests of Change

Prioritize Your Interventions

Low Impact

High Impact

Difficult to Implement

Easy to Implement

• Flow sheet to follow patient

•Staff Safety Assessment idea

• Pharmacist round concurrently

Target Area

1

• Simplify screening tool• Educate patients on risk of VTE

How to ‘speed up’ & try additional tests

• Getting others to try initiative, multiple tracks

Improving Ambulation

Education Process

New Screening Tool/Protocol

Tips for Multiple Tests• Scale down the scope of tests.

Dimensions of the tests that can be scaled down include the number of patients, doctors, and others involved in the test ("Sample the next 3" instead of "Get a sample of 30"),

• Be sure your pilot is really a pilot.When possible, choose changes that do not require a long process of approval, especially during the early testing phase.

• Be prepared to end the test of a change.If the test shows that a change is not leading to improvement, the test should be stopped.

Tips for Multiple Tests• Pick willing volunteers. Work with those who want to work

with you.("I know Dr. Jones will help us" instead of "How can we convince Dr. Smith to buy in?")

• Don’t reinvent the wheel.

• Pick easy changes to try.Use the change matrix.

• Avoid technical slowdowns.Don’t wait for the new computer to arrive; try recording test measurements and charting trends with paper and pencil instead.

TEST PREDICTION RESULTS Decision

1. Want nurse X & physician Y on second shift unit B to use new protocol

Faster assessment, more likely to understand/complete prophylaxis

Adapt

2. Improve ambulation on night shift with one RN

Expect 80% compliance with night patient ambulation

Nurse was able to meet prediction

Adopt

3. Want 2 physicians to use new protocol next Mon-Wed

Expect 90% of patients to have completed assessment

TBD Adopt Adapt Abandon

Action Item #2 – Sharing Between Facilities

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Your Story

You are probably wondering…

Won’t this take too much time?

Why go so slow?Engagement is Non-linear

Action Item #3: Determine your tipping Point

# Staff involved in process x 20-30% = Tipping PointExample :

25 nurses who follow hourly rounding expectations x 20% = at least 5 nurses (tipping point)

Poll Question #2: Please choose the top two errors that you feel happen most frequently in your organization regarding improvement projects. • Moved too fast to ‘Protocol and Procedure’ •Not had the right people involved•Forgotten to engage frontline staff in trying new changes – little buy in•Not monitored your measures consistently over time•Forgot to reinforce training on the new way of doing things•Used the same core group of people to fix the problem•Not address the root causes of performance deficiency

August Action Items

ACTION ITEMSComplete 3 more cycles of your test ORBegin testing another intervention

Be prepared to present your test of change log

Determine your tipping point

Submit Monthly Outcome and Process Measure

Poll Question #2: Results Please choose the top two errors that you feel happen most frequently in your organization regarding improvement projects. • Moved too fast to ‘Protocol and Procedure’ •Not had the right people involved•Forgotten to engage frontline staff in trying new changes – little buy in•Not monitored your measures consistently over time•Forgot to reinforce training on the new way of doing things•Used the same core group of people to fix the problem•Not address the root causes of performance deficiency

Tools Available on WHA Quality Center

• July Webinar Tool Kit (staff safety assessment, prioritization matrix)

• August Test of Change Presentation Slide Deck

• Forums

Thank You!Questions?

• Mid Month Survey – Asking about pace, slides• Please take survey following webinar• Next webinar: September 12th

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