using reliability concepts to improve patient experience - ihi
TRANSCRIPT
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Using Reliability Concepts to Improve Patient ExperienceBarbara Balik, EdD, RN; Aefina Partners
Gail Nielsen, BSHCA, FAHRA, Former Director of Learning and Innovation, Iowa Health System (Now UnityPoint Health)
Kevin Little, PhD, Informing Ecological Design, LLC
These presenters have nothing to disclose.
PFCC Seminar
November 5, 2014
Objectives
Describe the steps to develop and sustain
reliable processes to deliver Always Events
Evaluate the readiness of at least one care
setting to create and sustain reliable
delivery of an Always Events
Outline a plan to translate an Always Event
into a work process
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Understand
Patient
experience
“What matters
to me”
From Patient to
Process
State the
Always
Event(s)
Translate
Always
Event(s) into
Standard Work
Practice and Improve
Standard Work, over time
(Daily Management)
Use Standard Work
Process
Know how to
measure defects and
mitigate
Plan
Do the work
DO
Measure and
Communicate
Study/Act
Big Picture:
Link
between
Always
Events and
Reliable
Process
Performance
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Translate an Always Event into Standard
Work
Given a statement of the Always Event:
1. Choose a care setting
• is there will to improve patient/family experience?
• is there capacity to incorporate the Always Event perspective?
2. Specify patient segment
3. Choose a work process within the care setting
4. Change the work to assure occurrence of the Always Event:
What: Establish baseline standard
How: Engage point of care team and Patients/Family in co-design of work
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Laboratory for Change
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Family Services Always Event:
"I always know what happens next"
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Step Example
Service Setting
Home & Community-based Waiver/Case Management, Site X
ClientSegment
Native English-speaking parents of children aged 13-17, with one child eligible for services
Work Process Intake process (initial interview and data gathering/assessment)
Find your laboratory for change
1. Always Event
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2. Care
Setting3. Patient
Segment4. Process
Feedback loops
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Why choose just one care setting to start?
• Testing and learning takes investment, spend wisely to develop a successful example
• One translation of the Always Event will not work for every care setting – but making the translation in one care setting will reveal key details
• A successful unit is the foundation for spreading change to others
1. Choose a care setting
• Where is there capacity to incorporate
the Always Event perspective?
• Where is there will to improve the
patient /family experience?
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Capacity (a): What's the Skill Level of
Management in the Candidate Care Setting
Advanced skills in
Daily Management
and improvement
in addition to
operations skills
Basic skills in
operating the
unit, no special
skills in Daily
Management or
improvement.
?
Capacity (b): Assess Load, depends on skill
What is
management
skill?
Load OK Load Near Limit Overloaded
(Don't Go
There!)
Basic
No formal
improvement
project underway;
coaching available
for AE project.
One other "90
day" formal
improvement
project
underway;
coaching
available for AE
project.
Engaged in major
change in work:
moving to a new
location, new
manager or
supervisor,
deploying EMR
system, …Advanced
Engaged in no more
than 2 "90 day"
projects while
managing and
adjusting daily
operations
Engaged in 3 "90
day" projects
while managing
and adjusting daily
operations
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Will of Key Players in the Candidate Care Setting
Has a staff member of the care setting been part of
the conversation to define the Always Event?
Is the formal manager or supervisor eager to
translate the Always Event into daily care?
Is there an informal leader (respected staff member)
eager to translate the Always Event into daily care?
(Points 2 and 3: Do formal and informal leaders see
value in the Always Event work?)
2. Choose a Patient/Client Segment
Easy to identify
Willing participants
High enough volume to be able to test daily
or every other day
“If we cannot make our translation effective
for this segment, what are our chances with
other segments?”
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3. Choose a work process within the care
setting
1. Cycles multiple times a day (high enough
volume for testing)
2. Staff believes process should deliver the
Always Event
3. "If we can't make the translation of the
Always Event for this process, what chance
do we have for our other processes?"
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Home Health Always Event "My doctor and nurse always know what matters to me."
Step Example
Care Setting
West Bay Home Health
PatientSegment
Patients referred for home health services who are transitioning from hospital to home -- patients who score out high risk for readmission (Two Question Screen)
Work Process
Meet the Patient: Admissions Nurse initial meeting with Patient
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Two question screen: Assesses risk on number of readmissions in past year and interaction with Teach-back, see
Figure 12 in
http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx
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Always Events: Every Patient, Every
TimeWe need to develop and maintain reliable processes.
Reliability means "failure-free operation over time."*
For us, this means every patient experiences the Always
Event, at every opportunity--no failures to deliver.
Advanced reliability concepts and tools exist to work
towards failure-free operation.*
We will start with standardizing targeted work processes.
*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.
Case Study – Concepts into Action!
What we’ve already covered: – Outcomes defined by patient/family – How to understand what matters
– Merges expertise of Patients/Families with professional expertise
– E.g. Patient wants to know ‘what happens next’
– Caregivers have a number of ways to achieve this – shared decision making; white boards; patient portal; education materials
– The vital role of leaders
– How this all integrates: experience, safety, quality, financial vitality
A question –– What Always Event, problem or potential are you working on in your
Action Plan?
– Keep it in mind as we walk through a case study
– We will want you to apply in own example
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James, 68 years old, lives at home with wife Martha
• Admitted to the hospital with shortness of breath
• Diagnosis: pneumonia + underlying onset of heart failure
• Instructed on new medications + diet before discharge
• Told to see his physician in the office in two weeks
• After returning home reminded to schedule physician’s office
• Finally able to set up a visit for three weeks later
• Never filled furosemide Rx; thought the expense unnecessary
• Noticed swelling in legs; didn't want to bother "busy doctor"
Listening to Patients and Families:James and Martha
James readmitted to hospital after 11 days• Increased SOB, mildly elevated BNP
• Weight increase of 25 lbs., marked edema lower legs
• Stress level high; blood pressure elevated, new drug
added
Martha admitted for emergent surgery; James still in the hospital
• After James’ discharge he began eating fast food
• Worried about his wife, juggled visits to her bedside,
managed the roofing project on their home
• Martha came home from the hospital, James readmitted
with exacerbation of his HF
Listening to Patients and Families:James and Martha
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How many opportunities did you hear in James’s and Martha’s story?
Focus
Why are we focused on this problem
(through the patients’ eyes)?
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Table discussion – 4 minutes
In the story of James and Martha;
What would you do next?
Understand the Current State
The Steps
The performance
Our Assumptions
What is the gap between current state and always?
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Table Discussion - 5 minutes
Have you used observation to discover how your processes really work?
If so, what did you learn?
What was hard about that?
Is there another way you’ve found to understand current state?
Tools to Discover Change Ideas
�Identify logical root causes of problems
�Ask “Why?” 5 times to provoke a change idea
�Use data tools for clues to provoke your thinking
�Stratification (Pareto analysis)
�Control charts: Special cause signals
�Design screening experiments* to test many changes
to find the few that matter
*see Moen et al. (2012) Quality Improvement through Planned Experimentation, 3rd edition,
New York: McGraw-Hill, chapter 5
Tool for
Everyone
Tool for
Specialists
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Problem Solving and Learning Tool
(Simple form of A3)
Current State:
Observe and draw the process
Target State:
What would be more ideal?
Clarify Problem for this Patient (customer) :
Analyze:
- why ?
- why?
- why?
- why?
- why?
(Must be testable)
Action:
PDSA Cycles
(include measures!)
Test question to redesign: “Did the defect happen
again?” Yes/No (Yes = keep testing)
What Who When
Adapted from: Designed to Adapt: Leading Healthcare in Challenging Times by John Kenagy and A3 Problem
Solving for Healthcare: A Practical Method for Eliminating Waste by Cindy Jimmerson
Asking 5 Why’s with James and Martha
Why’s must hang together
reading top to bottom and
bottom to top
Last “Why?” must be clear,
singular and testable
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Asking 5 Why’s with James and Martha
James was readmitted 4 days after his previous hospitalization
Why? He hadn’t called the physician about trouble breathing
Why? He didn’t understand importance of calling doctor with symptoms
Why? He heard the teaching, but couldn’t remember
Why? He didn’t have a Teach Back session on reasons to call the doctor
Why? Because the nurse, distracted by a family member’s questions, forgot to ask for TB. The unit was very busy that day.
Large Group Discussion – 3 minutes
Do these “Why’s” meet all of the guidelines?”
The 5th Why should be:
�Clear
�Singular
�Testable
“Where might you apply the Ask 5 Whys to inform your
AE?”
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Co-design New Process
Co-design taps into the wisdom of those close to the work
�Including patients and families is fundamental to Always Events
Tests and prototypes allow rapid learning with little risk
Table Discussion – 4 minutes
Build on existing strengths and resources:
What’s already working?
What existing meetings, workgroups or other venues currently exist that offer opportunity for current state discovery and co-design of new AE processes?”
Where are patients and families already engaged in face-to-face activities that touch your AE?
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Implement for Reliability
Making it Stick
Through disciplined process
vs.
“Teach and assume completion”
Build an infrastructure for standardizing
your selected process
Specify the process clearly:
• Who:
• What:
• With What:
• When:
• Where:
• How:
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Teaching New Processes
NEW WAY (TWI)
Test to reliable process
Specify the process
Design education - Include help aids
Teach test group in workplace
Stick around to see if they can do it as taught (1:1 coaching)
If needed, redesign education, process or both
Teach the next group; can they do it as taught?
OLD WAY
Teach & leave:
Use static slides
During busy staff
meetings
In remote
conference
rooms
© Gail A Nielsen 2012
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“We can’t solve problems by using the same kind of thinking we used when we created them.”
Albert Einstein
How people learn to do their work?
1. Identify key jobs2. Break down by teacher**
“Know what”“Know how”“Know why”
3.Teach one-on-one4. “If the student hasn’t learned,
the teacher hasn’t taught.”
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”the way to get a person to quickly
remember to do a job correctly, safely and
conscientiously.” p. 73
** manager; educator; etc.
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Job Aid Example: Teach-back
Teach-back*1. Greet
2. Teach
3. Ask for Teach-back
4. Check and reteach if needed
5. Document
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*acute care setting; aim:
Improve patient-family ability,
understand diagnoses, to
perform self-care, and to take
medications
Template from Getting to Standard Work in Healthcare by Graupp and Purrier
Job Aid for Teach-back based on Always Use Teach-back Toolkit at www.teachbacktraining.org
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Reflection and Discussion – 5 Minutes
Do you have a process for specifying standard work?
“Which piece of your process might lend itself to a first test of clarifying who, what, when, why, where, how?”
“What technology supports would make your work easier? Who can you talk to about that?” “Which senior exec might help?”
“What will you ask of leaders?"
Using the same teaching materials, Teach Back questions and
teaching techniques in hospital, in home by home health care,
and a 7-day follow-up call
As staff became more competent and used Teach Back more
reliably, more patients could retain more vital information
Least retention is seen in the hospital; reinforcement helps
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Improving Teaching Across Settings
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Discussion – 5 minutes
How will you measure progress towards Always?
“How might you measure outcomes and processes?”
“How might you set up a way for people to tell you when
a process isn’t working as expected?”
“Name two ways you can continue to learn, over time,
when the process begins to deteriorate because
something else changed around it?”
Adapt and Spread
Move always to everywhere -
“Every Patient Every Time”
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On the Way to Always…..
Data from the prototype that informed development of the Always Use Teach-back! Toolkit
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Monitoring Process Measures Over Time
Teach-back
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43Patients’ Response:
Providers Spoke in Clear Language
Reliable Use of Teach-back
Toolkit• Free, online,
interactive training for hospitals, home care and office practices
• For individuals, their managers and coaches
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Making it easier to train everyone in all settings
www.teachbacktraining.org
Referenced Slide 15 at https://cahps.ahrq.gov/surveys-
guidance/hospital/hcahps_slide_sets/discharge_information/dischargeinformation.html
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Tables Pick a Question to Discuss – 5 minutes
How might you make it easier for everyone to learn
faster/better and do the process with fewer steps?
What technology, policy, or other support do you need?
After spread to all people who touch your AE process,
how might you know when your process is not working
and what contributes to failures?
What do you need to measure “Always” in the widest
application you can envision?
Translate an Always Event into Standard Work
Given a statement of the Always Event:
1. Choose a care setting
• Is there will to improve patient/family experience?
• Is there capacity to incorporate the Always Event perspective?
2. Specify patient segment
3. Choose a work process within the care setting
4. Change the work to assure occurrence of the Always Event:
• What: Establish baseline standard
• How: Engage point of care team in co-design of work
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Your Turn: Identifying a Laboratory for Change
Use the worksheet to try out steps 1-3
Now it’s Your Turn!
Using the Tools provided:
Begin to translate your Always Event or
Process into standard work
Work as a team
Signal when you need help
Incorporate into your Action Plan
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Resources
Ando Y. and Kumar P., Daily Management The TQM Way: The Key to Success in Tata Steel, Madras,
India: Productivity and Quality Publishing Pvt Ltd; 2011.
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series
white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006.
(http://www.ihi.org/knowledge/Pages/IHIWhitePapers/LeadershipGuidetoPatientSafetyWhitePaper.as
px)
Braaten, J, Bellhouse, D. Improving Patient Care by Making Small Sustainable Changes. Nursing
Economics, May-June 2007, Vol 25, No. 3, 162-66.
Edmondson, A. (2012). Teaming: How Organizations Learn, Innovate, and Compete in the
Knowledge Economy. San Francisco: Jossey-Bass.
Graupp P. and Purrier M. Getting to Standard Work in Health Care. Boca Raton, Florida: CRC Press;
2013.
Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for
Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ
Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008.
Kenagy, J. (2009). Designed to Adapt. Second River Publishing.
Langley G. et al. The Improvement Guide, 2nd edition, San Francisco: Jossey-Bass; 2009; especially chapter 8: “Implementing a change.”
Resources
Lean Enterprise Institute website: three-part post on standardized work by John Shook, http://www.lean.org/shook/DisplayObject.cfm?o=1321http://www.lean.org/shook/DisplayObject.cfm?o=1320http://www.lean.org/shook/DisplayObject.cfm?o=1319 .
• Nolan, T., Resar, R., Haraden, C., Griffin, F. Improving the Reliability of Health Care. Institute for Healthcare Improvement, Innovation Series, 2004, page 1.
Spear, S. (2010). The High Velocity Edge. New York: McGraw Hill.
Spear, S., Bowen, HK. Decoding the DNA of the Toyota Production System. Harvard Business Review, Sept-Oct 1999; 77; 99-106.
Spear, S. Learning to Lead at Toyota. Harvard Business Review, May 2004; 78-86.
Spear, S. Fixing Health Care from the Inside, Today. Harvard Business Review, Sept 2005; 78-91.
Spear, S., Schmidhofer, M. Ambiguity & Workarounds as Contributors to Medical Error. Annals of Internal Medicine, April, 19, 2005, Vol. 142, No.8, 627-630.
Tucker, A. & Edmondson, A. Why Hospitals Don’t Learn from Failures: Organizational & Psychological Dynamics that Inhibit System Change. California Management Review, Vol. 45. No 2, Winter 2003, 55-72.