Model for Improvement: Review Aims and Key Drivers and Discuss Tests of Change

1. Model for Improvement: Review Aims and Key Drivers and Discuss Tests of Change Jack Jordan September 2012

2. Learning Objectives At the end of this session the participant will be able to: • Understand the Model for Improvement • Learn how to apply PDSA cycles • Select measures for their improvement efforts • Have strategies for more successful tests

3. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do Model for Improvement (Nolan, et al.)

4. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do Model for Improvement(Nolan, et al.)

5. Finding Good Changes • What change could we try that may be an improvement? • Search • Theory of Change (do they map to any of your key drivers?) • Participation

6. Methods for Generating New Ideas • Change Concepts • Using Technology • Critical Thinking • IDEO Brainstorming • Metaphorical Thinking • Observation • Provocation • Prototyping • Idealized Design

7. A. Eliminate Waste B. Improve Work Flow C. Optimize Inventory D. Change the Work Environment E. Enhance the Producer/Customer Relationship F. Manage Time G. Manage Variation H. Design Systems to Avoid Mistakes I. Focus on a Product/Service Change Concepts(The Improvement Guide, p. 293-359).

8. Moving from Concepts to Ideas • Improve process to reduce anxiety • Give patients and families access to information • Use beepers for family and friends waiting • Make beepers available to • families of all surgery patients next week. Conceptual, Vague, Strategic Specific Ideas, Actionable

9. Act Plan Study Do WhyTest? The PDSA Cycle

10. Why Test? • Possible Objectives of PDSA Cycles for Testing • Increase your belief that the change will result in improvement • Opportunity for learning from “failures” without impacting performance • Document 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 • Minimize resistance upon implementation

11. Deciding on the Scale of the Test CURRENT SITUATION Current Commitment Within Organization Source: Langley et al., Improvement Guide

12. A P DATA A S D S P D A P S D A P S D Repeated Use of the Cycles Changes That Result in Improvement Hunches Theories Ideas

13. P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P Detail Design A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Running Hitting Fielding Throwing Multiple PDSA Cycle Ramps: Baseball

14. P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P Detail Design A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Self Care Support Delivery System Design Decision Support Clinical Information Systems Multiple PDSA Cycle Ramps: Chronic Illness Care

15. Repeated Use of the PDSA Cycle Reduce BMI to less than 30 by March 31 Weight before shower in AM Change Pkg. Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Hunches Theories Ideas Follow-up Tests Very Small Scale Test

16. Strategy: Remain aware of diet and manage intake. Find options to eat better. Using Multiple PDSA Cycles to Test & AdaptChange Ideas Stayed in point limit three of seven days DATA Cycle 4: Try two new vegetable dishes this week Cycle 3: Adjust daily breakfast plan to allow for ample dinner points Currently 15 – 20 extra points a day of food Cycle 2: Stick to allotted points for one day Cycle 1: Count Weight Watchers Points of every meal for a week

17. Multiple PDSA Cycle “Ramps” Testing and adaptation Improve breakfast Add veggies Cut lunch portion and add fruit Add long walk Every day Change Concepts

19. Successful Cycles to Test and Adapt Changes • Plan multiple cycles to test and adapt change • Think a couple of cycles ahead • Scale down size of test (# of products, locations) • Test with volunteers • Do not try to get buy-in or consensus for the test • Be innovative to make testing feasible • Collect useful data during each test • Eventually, test over a wide range of conditions

20. PDSA Cycles for Implementation • The change is permanent - need to develop all support processes to maintain change • High expectation to see improvement (no failures) • Increased scope will lead to increased resistance • Generally takes more time than tests

21. Testing Ideas • Reasons to not test ideas • Requires too much commitment (trialability) • Idea does not seem much better or involves more work (Relative Advantage) • Idea is hard to understand and complicated (Simplicity) • The idea is completely foreign or culturally unacceptable (Compatibility) • The results are hard to see or take a long time (Observability) Based on the work of Everett Rodgers – Diffusion of Innovations

22. Why Testing Ideas on a Small Scale Works • Small scale reduced complexity – less actors, less items to consider • Small scale tests are the ultimate in trialablity • Small scale test require observability and minimize the problems with relative advantage • Compatibility is still a concern

23. Example: Glucose Protocol in SICU • 1 pharmacist and 2 RNs start with Portland protocol and use it on one CT surgery patient for one day. • Debrief – what worked? What was confusing? How were glucose readings? • Modify the protocol based on the feedback and attempt a second day • Debrief – what worked? What was confusing? How were glucose readings?

24. Example: Glucose Protocol in SICU cont. 2 • Modify the protocol (version 3) based on the feedback. Expand to 1 pharmacist and 4 RNs use it on all CT surgery patient for one day. • Debrief – what worked? What was confusing? How were glucose readings? • Modify the protocol based on the feedback and attempt a fourth day • Debrief – what worked? What was confusing? How were glucose readings?

25. Example: Glucose Protocol in SICU cont 3 • Modify the protocol (version 5) based on the feedback. Educate all CT surgery RNs and expand to all CT surgery patient for one week. • Debrief – what worked? What was confusing? How were glucose readings? • Modify the protocol based on the feedback and attempt a third week • Debrief – what worked? What was confusing? How were glucose readings?

26. PDSA Exercise Learning the Number Sequence What are we trying to accomplish? We found a new technology represented by asequenceof numbers that can help our clinics improve quality. We want to discover the rule (or theory) thatgenerated this sequence. The sequence we found was: Each team should run PDSA tests to determine the rule that generated this sequence. When you are sure that you have the rule (based on enough tests), then implement the technology in your organization

27. PDSA Cycle for Learning the Sequence

28. Your Assignment • Define measures • Identify three changes using the PDSA worksheet • Run at least two tests of change

29. Tool Template: PDSA Worksheet