APIC Intermountain Region 19 th Annual Educational Conference

October 25, 2018

Bethany Rogers, MSML, BSN, RN, LSSMBB, CPHQ, CPHRM

St. Luke’s Health System Director, Performance Improvement

Strategies for

Rapidly Improving Performance

with Systems Thinking

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What’s Your Favorite Pixar Movie?

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• Public sector organizations are increasingly compelled to transform into

high-performing organizations

What a health system produces is largely dependent upon the

quality of the processes and workflows it is made of:

QP1 + QP2 +QP3 +…QPn = QOHS

Poorly-designed processes will make the right thing to do

inconvenient or difficult

Well-designed processes will make the right thing to do the easy

thing to do

• In order to achieve our respective Missions and Visions, we must

redesign our broken processes and workflows

The Imperative

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Worker Safety

Product Safety

Process Efficiency

Output Quality

Production Cost

Customer Experience

Improvement Science

A methodical

change to a process

that seeks to

improve process

outputs:

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1760s to 1840s

• Transition from hand

production to machine

production

Horse power Steam power

Wood fuel Coal

Wood machine parts Metal

machine parts

Cottage industry Factories

• Sustained job growth

• First meaningful increase in

standard of living in centuries

Eli Whitney – 1798

Henry Ford – 1913

The Industrial Revolution

Machine Production

Mass Production

Lower Production

Cost

Increased Accessibility

Increased Consumption

Increased Demand

Increased Need for Workers

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• General quality inspection processes (pre-1920s)

Responsibility of the manufacturing supervisor or foreman

• Quality improvement pioneers

Walter Shewhart

W. Edwards Deming

Joseph Juran

• Official quality standards (1950s to present)

Military Standard (MIL-STD-105A)

International Organization for Standardization (ISO)

Malcolm Baldridge National Quality Award

Healthcare-specific (NIAHO, TJC, DNV, etc.)

Modern Improvement Influences

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Industrial Revolution to the Present Day

• PI strategies and approaches have evolved into a science

over the past 150 years

• Four distinct methodologies stand out

FOCUS PDSA

Lean Production

Six Sigma

Clinical Microsystems

The Evolution of Improvement Science

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What is the difference between a

Process Improvement TOOL and a

Process Improvement METHODOLOGY?

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• TOOL used to TEST and IMPLEMENT changes in real work settings

Assess real-world application of a proposed change concept

• Based on the Scientific Method

Hypothesize, Experiment, Evaluate, Replicate

• PDSA

PLAN the change• what will happen, by whom, by when, for how long?

DO the change • carry out a test and collect data

STUDY the effect of the change • analyze data, assess practical application challenges

ACT on the findings • as applicable, make changes to the plan or implement the change

Plan-Do-Study-Act

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Plan-Do-Study-Act

• PDSA is an EXPERIMENTATION STRUCTURE:1. Test only one variable at a time - resist the urge to change more than

one variable at once

• Cause-and-effect will be unclear; run the risk of “analysis paralysis”

2. Conduct small tests of change

• Only as many data points as are needed to learn about what parts of practical application need to be tweaked

• It is NOT the goal of a PDSA cycle to get statistically significant data

3. Plan to conduct many small tests of change

• Go into it intending to make small, frequent tweaks and start another test

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• Developed by the Associates in Process Improvement (API) and adopted by the Institute for Healthcare Improvement (IHI) as its preferred PI model

Defines three fundamental questions that must precede each PDSA cycle Designed to sharpen the focus of a PDSA

cycle so that each cycle is purposeful and clearly articulated

Is NOT intended to be a comprehensive improvement methodology

The Model for Improvement

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• Designed as an answer to the shortcomings of PDSA as a comprehensive improvement methodology Rapid-cycle improvement with defined discovery & planning phases

• FOCUS FIND an opportunity to improve

• select the process of interest, define boundaries

ORGANIZE the improvement effort• identify the team, agree on the aim

CLARIFY current knowledge • flowchart the process, collect baseline data

UNDERSTAND process variation • analyze baseline data (SPC, data subsets)

SELECT the strategy • identify ways to reduce process variation

…and then conduct PDSA cycles to test the change strategies

FOCUS PDSA

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• Manufacturing / business strategies developed in Japan

the 1970s, under the guidance of Dr. Deming

“Lean” coined by MIT researchers visiting Toyota in 1988

• Improve quality (as defined by the customer) by

eliminating waste

Supply just what the customer needs,

when they need it,

in just the right amount,

for the right price,

using minimum materials, equipment, workspace, labor

resource, and time

Lean Production

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• Three forms of Waste:

Mura – unevenness in work demand or work flow; stopping and

starting or variable volume (vs. smooth and constant)

Muri – greater demand than capacity or overburdening; pushing

to perform above capacity and burning out machines or people

Muda – waste that is necessary but non-value-added (e.g.

regulatory requirements); waste that is unnecessary (irrational)

• Value Rules: (all three must be met for an activity to be value-added)1. It must be something the customer is willing to pay for

2. It must transform the product or service in some way

3. It must be done right the first time

• DOWNTIME: Defects, Overprocessing, Waiting, (Non)-Used Talent,

Transportation, Inventory, Motion, Excess Inventory

Lean Production

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Define Value

Identify the Value Stream

Create Flow

Create Pull

Pursue Perfection

Lean Production

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• Designed by Bill Smith

(Motorola) in 1986

Any business process can be

measured, analyzed, and

improved upon… then controlled

• Reduce variation

• Increase output

• Meet the desires of the customer

• Goal: Decrease variation in the

process to make the outcomes

more predictable

Six Sigma (6σ)

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• You cannot improve what you do not measure

Consistent production of high quality services, products, or processes

• Improved process performance

• Increased customer satisfaction

• Structure: Define-Measure-Analyze-Improve-Control (DMAIC)

Define the problem, agree on the goals, listen to the Customer

Measure key performance indicators (KPIs)

Analyze the problem using root cause analysis and statistical analysis

Improve by developing and deploying possible solutions (PDSA)

Control new processes by monitoring and reacting to signal

Six Sigma (6σ)

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• Created by Dartmouth-Hitchcock Medical Center

First unique improvement methodology created for

healthcare rather than business

• Focuses on the functionality of the “microsystem” (the place

where patients, families, and caregivers meet)

Every microsystem has a mission, vision, or purpose

Every microsystem serves a discrete subpopulation of patients

Every microsystem is staffed by a capable group of professionals

Every microsystem has its own routines and processes

Every microsystem has consistent behaviors, sentiments, and results

that emerge from its patterns

Clinical Microsystems

“5Ps”

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• Strategy:

It is through understanding the

microsystem’s 5Ps that it identifies

its values, its problems, and its

solutions

Improvements are driven by

grassroots peer leadership within

each microsystem

For each problem, the microsystem

identifies a Theme, a Global Aim,

and several Specific (measurable)

Aims

Clinical Microsystems

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5P Assessment

Theme

Global Aim

Specific Aim

Change Ideas

Measures

PDSA

D

SA

P

D

SA

P

D

SA

S

Global

Aim

1

2

3

The Dartmouth Microsystem

Improvement Curriculum (DMIC)

Ramp

Clinical Microsystems

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How It All Fits Together

F O C U S

Understanding the

Problem and the

Scope

Assessing Current State

Planning and

Testing Possible

Future States

Making Short

Term Gains

Long Term

6σ

Lean

FOCUS

PDSA

Clinical

Micro-

systems

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Strategic

EmphasisStrengths Weaknesses

FOCUS PDSA Rapid-Cycle

Improvement

Simplicity Does not address

sustaining gains

Lean

Production

Waste Elimination

and Efficiency

Offers an abundant suite of

evaluation tools and change

concepts

Does not have a robust

measurement component

Six Sigma Statistical Process

Control

Meaningful measurement;

separating signal from noise

Difficult to apply with small

denominators; does not

provide change concepts

Clinical

Microsystems

Frontline Worker

Engagement

Created for healthcare Initial emphasis on

Assessment is time-

consuming

Comparing Methodologies*

*PDSA and The Model for Improvement are not included in this comparison,

as they are not independent improvement methodologies

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Jumping to Solution

Can you identify this

upside-down

celebrity?

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• The easiest solutions to jump to are Person-Oriented solutions

intended to make people less fallible:

telling people to do it right / better / faster /

more carefully,

sending an e-mail,

sending out a Single-Point Lesson / Tip Sheet,

creating a new form,

holding a staff meeting,

providing more training / classes,

writing or revising a policy, etc.

Jumping to Solution

Plan

Workaround

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What We Have

Right Now

What We May or

May Not Have

Right Now

What We Don’t

Have Right Now

That We Need

• A general idea of

what the problem is

• A general idea of

what we’re here to

do

• Thoughts on what is

contributing to or

creating the problem

• Ideas on how to fix it

• Assurance that our

assumptions are

right

• Evidence that our

solutions will work

• Confidence that our

solutions will stick

The PI Advantage

Bridge this gap using improvement science

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• In contrast, System-Oriented strategies attempt to safeguard

against the impact of errors or to reduce the ability of the error

to occur

Error-proofing,

Automation,

Redundancies,

Checklists,

Usability testing,

Visual management,

Alerts,

Standardization, etc.

The PI Advantage

Can we eliminate human error or fully control human behavior?

No; we have to design our systems anticipating error / deviation and protect against it before and after

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• Two Schools

School A: Private College in Intermountain West

School B: Private University in New England

• Same Problem

New grass in Quad being damaged by foot traffic

• Different Problem-Solving Strategies

Person-Oriented

System-Oriented

The PI Advantage

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System-Oriented or Person-Oriented?

School A’s Problem-Solving Strategy

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System-Oriented or Person-Oriented?

School B’s Problem-Solving Strategy

Making

observations

of the foot

traffic

Analyzing

the data:Most-traveled

paths?

Natural angles

created?

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School B’s Problem-Solving Strategy

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Rapid Cycle Improvement

• “Working meetings”

Preparatory work between each meeting

Produce something by the end of each meeting

Each meeting’s tasks move you closer to Rapid Cycle Testing• Kickoff Problem Statement, Aim Statement, Workflow Overview (SIPOC-R)

• Meetings 2-3 Review data / process to identify a high-impact workflow

• Meeting 4 Test of Change (ToC) Plan, Specific Aim Statement

• Meetings 5-8 Review ToC results, make revisions, test again

• Meeting 9 Final ToC Plan

• Meeting 10 Implementation Plan

• Meeting 11 Evaluation and Celebration!

How Do You Get It Done Fast?

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PDSA Cycles

• Goal: Assess the real-world application of a proposed change concept

Rapid – “What can we test by next Tuesday?”

• 1 Day

• 2 Nurses

• 3 Shifts

Cycle – Expectation of repeating tests again and again

Improvement – Changing the test each time based on worker feedback

• Hands-on, active, responsive process

• Make changes; test again

Rapid Cycle Testing

Shrink

the

change

PLAN / DO

STUDYACT

Small Test of Change

Get Feedback

Make Changes

PDSA Practice

The Ball Game

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• Break up into teams of at least 6 individuals: Players (4+): Perform the exercise, conduct tests of change

Timekeeper (1): Times each test

Recorder (1): Documents test times, change concepts tested, and

learnings from each PDSA cycle

• Each team needs: 1 ball

1 stopwatch (use smartphone timer function)

DMAIC/PDSA document to record test times, change concepts tested,

and learnings from each PDSA cycle

Teams and Roles

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• Every Player must participate in the cycle

• To complete a cycle, the ball must return to the person who started with it

• You cannot pass the ball to the person next to you

• The ball must travel through the air

• The ball cannot be rolled across surfaces (e.g. floors, walls, tables, chairs, etc.)

The Rules

The PDSA Simulation Exercise1. Create a process for giving and receiving the ball in your group, adhering to The Rules

above

2. Conduct a timed baseline test

3. Come up with change ideas to reduce your baseline time by half

4. (As time allows) Come up with change ideas to reduce your baseline time by half again

Ready… Set… Go!

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• Which team had the fastest cycle?

How did you do it?

• Would you have had the same kind of improvement if you

had stayed with your original strategy and strongly

encouraged people to do it the same way, but faster?

Debrief

Questions?