You want us to doWHAT?

Perinatal & Neonatal Learning NetworkDecember 3, 2013

Jennifer Ustianov MS RN IBCLCPerinatal Content Lead

NICHQ

Objectives

• Outline the case for widespread use of maternal and neonatal risk assessment tools

• Describe how the use of Improvement Science can assist implementation within an existing system of care

• Plan the tasks and first test of change for implementing the widespread use/adoption of risk assessment tools

Why me?

Leadership Introspection

Why now?

Maternal and Neonatal risksWhat was learned in 2012?

• Over 30% of maternal and infant discharges had identifiable risk

• Member hospitals have very good processes for getting patients out of the hospital

• Significant numbers of patients with risks were not identified for the specific intervention of early post-discharge evaluation

Why not now?Creating the Case

• Insert updated MD stats on neonatal and maternal outcomes

Key Elements of Breakthrough Improvement

Will to do what it takes to change to a new system

Ideas on which to base the design of the new system

Execution of the ideas

Factors which effect the Will to change

• Need and urgency for change• Life experiences• Positive and negative experience • Personality• Resources and Support

Ideas: bases for design of new system

Ideas come from:• Strong evidence• Good knowledge (our own or others)• Hunches• Open, supportive and agile team-based

environments

Execution of the ideas

• Tap on expertise• Multidisciplinary planning team• Use tools and methods tested by others.• Test, Study; Test, Study; Test, Study.• Leadership support.• Identify and remove barriers and old way.• Illicit involvement and feedback.• Embrace grumbling as an opportunity.• Remember: with true change comes learning

Model for Improvement

Three Fundamental Questions for Improvement

1. What are we trying to accomplish?

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

3. What changes can we make that will result in improvement?

PNN and the Model for Improvement (MFI)

What are we trying to accomplish? Project Aim

How will you know change is an improvement? Measurement Strategy

What change can we make that will result in improvement? Workplan

Test and Implement

Perinatal & Neonatal Risk AssessmentAim Statement

Our aim is to improve communication between hospital-based and community –based providers and between hospital staff and families through standardization of the discharge process for mothers and babies, including the late pre-term infant. Success will be measured through both process and outcome measures

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

TESTING

AimBy June 2014 the Neonatal Risk Assessment Tool will be implemented

MEASURESOutcome: 95% of neonates with identified risks will have documented appropriate referrals Process: 80% of new admission will have a completed neonatal risk assessment within 24 hours

Tasks:•Data collection: How, who, when to collect data•Design flags in EHR•Identify community referral network•Create audit tool•Education of ALL staff•Celebrate wins

Tests:P: Patti RN will use the Risk Assessment Tool for the first admission D: Patti was too busy to implement –critical caseS: No assessment done in first 24 hoursEdit/Act: Next test will include communication to next shift re whether assessment was completely

Making it Happen for Improved Outcomes

Team Planning

• Draft Aim statement• Draft one Outcome Measure • Draft one Process Measures

P-D-S-A Cycles

• A way to turn Ideas into Action (P D)

• A way to connect Action to Learning (S A)

Using PDSA cycles to learn our way through improvement

4. Implementation testing

1. Early tests are simple and designed to learn then succeed

2. Then do f/u test over a variety of conditions to understand scalability and identify weaknesses

3. More wide-spread tests

A PS D

APS

D

A PS D

D SP A

DATA

A PS D

APS

D

D SP A

DATA

One provider, one shift/time of day

A few providers, one shift/time of day

One provider, different shift/time of day

A few providers, varied shift/time of day

AIM

Change Concepts, Theories, Ideas

Concept B

Concept C

Concept A

Concept D

PDSAs Why Testing

• Increase belief that the change will result in improvement– dealing with uncertainty– dealing with skeptics/ minimize resistance upon implementation

• Opportunity for “failures” without impacting performance• Get idea of how much improvement can be expected from

the change• Learn how to adapt the change to conditions in the local

environment• Evaluate costs and side-effects of the change

Risk Assessment Tool

• Started at admission to capture pre-existing risk factors

• Continued through admission to capture new onset risks

• Framework for education, counseling, consultations, and discharge referrals

• 1 tool to capture risk and coordinate care

Eight Step To Change

Overview of Kotter’s Points, 19951. Establish a sense of urgency

Based on market, competitive, social, performance (etc.) realities, the change must be seen as critical to organizational survival/success

2. Form a powerful guiding coalition Assemble a leadership group with enough commitment, credibility,

influence, and authority to lead, model, and sustain the change effort

3. Create a Vision A clearly stated “higher” vision that speaks powerfully to participants

and personally spurs them to “go the extra mile”

4. Communicating the Vision Use multiple vehicles and venues to communicate the new vision/strategies Teach new behaviors by the example.

RISK:Not

Sufficiently Compelling

!!!

RISK:

Not A Credible/ Cohesive

Team!!!

RISK:Vague,

Insufficient Motivation

!!!

RISK:Less than

Over-Comm by Factor of

10!!!

Overview of Kotter’s Points, 1995

5. Empower others to act on the vision Get rid of obstacles; Change systems /structures that seriously undermine the vision; Encourage risk taking

6. Plan for and create short-term wins Plan for and create visible performance improvements ; Recognize and reward employees involved in the improvements

7. Consolidate improvements and produce still more change Use increased credibility to amplify change in systems, structures, and policies; Hire, promote, and develop employees who can implement the vision; Reinvigorate process with new projects, themes, and change agents

8. Institutionalize new approaches Articulate and reward the connections between the new behaviors and corporate success; plan leadership succession consistent with the vision

RISK:Not

Neutralizing Resistance

!!!

RISK:Leaving

Successes to Chance

!!!

RISK:Declaring

Victory Too Soon

!!!

RISK:Declaring

Victory Too Soon

!!!

1. The path of least resistance - best use of the people willing to change

2. Impact - biggest improvements early in implementation

3. Learning - the most learning happens as the change is implemented

4. Resources - best scheduling and use of available resources5. Interdependence

- will the change work without all its components?

Implementing Change - Strategies to Consider

Reduce likelihood of mistake/error– Decrease the likelihood that a needed item is left off

the surgery cart by prepackaging kits of instruments and other surgical items

– Make it impossible to attach the vacuum line to an oxygen outlet by installing different sizes or shapes for vacuum and oxygen connectors

– Get rid of old versions of forms!

Implementing Change – Foolproof the New Process/Procedure

Change the Culture – Holding the Gains

• Make reversal as difficult as possible

• Establish a standard process

• Use measurement and audits

• Pay attention to maintenance processes, especially orientation and training

Partnering with Patients

• When does this begin• How do we individualize our education• Who make it happen?

Engaging Partners and Community Stakeholders

• Who are our partners in mitigating risk– How do we engage them– How can we partner in this work

• Who are your community resources– Do you KNOW what they offer– Do you TRUST what they provide– Do you BELIEVE they can make a difference

Kotter’s 8 Reasons Why Attempts at Change Fail

1. Not establishing a great enough sense of urgency. 2. Not creating a powerful enough guiding coalition. 3. Lacking a clear vision. 4. Under-communicating the vision by a factor of ten. 5. Not removing obstacles to the new vision. 6. Not systematically planning for and creating short-term

wins. 7. Declaring victory too soon. 8. Not anchoring changes in the corporate culture.

Team Planning

• Reflect on you Aim and Measures• Use the worksheet provided to plan:– Your tasks– Your first PDSA (who, what, where, when)– Report on aspect of this work to another team