Listen to your team

1. Listen to your team Let your stakeholders: nurses, residents, pharmacists, etc. tell you the how.

2. Identify Areas for Improvement(current state) 45 year old woman with malignant bowel obstruction due to colon cancer with nausea, vomiting and abd pain, progressive inability to take oral meds/hydration PCS Rounds (day 1) Informal ✔ in w/ primary teams FAMILY MTGS Write notes with “official recs” Write orders OR Page team with updated recs 1hr 3hrs 3 hrs 2 hrs PCS Rounds (day 2) Day 2 pain scores unchanged • Team wrote orders “just before they went home. • Patient unaware of “new” regimen. • Did not ask for additional PRNs • Nurse didn’t provide infor on available meds

3. Table exercise: Identify Areas for Improvement – 10 minutes PCS Rounds Informal ✔ in w/ primary teams FAMILY MTGS Write notes with “official recs” Write orders OR Page team with updated recs 1hr 1hrs 3hrs 3 hrs PCS Rounds (day 2) Day 2 pain scores unchanged • Team wrote orders “just before they went home. • Patient unaware of “new” regimen. • Did not ask for additional PRNs • Nurse didn’t provide infor on available meds

4. Identify Areas for Improvement AM workflow Offer to write orders for the team if they are busy? PCS Rounds Informal ✔ in w/ primary teams Call the primary team with clear to-do now recs OR write orders after each patient is seen Call the bedside nurse to let him/her know of new orders? PM workflow One team member does PM check in Write notes with “official recs” Write note with updated PM recs Page team with updated recs Nurse updates the card for patient Gives patient information card on their pain regimen

5. Using a QI framework to improve care • Set the vision for improvement • Understand the problem • Identify Areas for Improvement • Devise a measurement strategy • Prioritize small tests of change • Measure Change • Sustain the change 10:15

6. Will these interventions result in improvement? INTERVENTION Not all changes are improvements … But all improvements are the result of changes!

7. Deciding what to measure Outcomes (patient level results) Process: (actions) Structure (adherence to the program)

8. Deciding what to measure • LOS • Cost • Change in Pain Scores Outcomes (patient level results) Process: (actions) Structure (adherence to the program)

9. Deciding what to measure • LOS • Cost • Change in Pain Scores Outcomes (patient level results) Process: (actions) Structure (adherence to the program) - Teams called on morning rounds - Cards distributed - Patients seen in the afternoon - Time from order to pain med delivery

10. Deciding what to measure • LOS • Cost • Change in Pain Scores Outcomes (patient level results) Process: (actions) Structure (adherence to the program) • Measuring Day 1 to Day 2 scores • Knowing first call on rounds • Ongoing nursing ed - Teams called on morning rounds - Cards distributed - Patients seen in the afternoon - Time from order to pain med delivery

11. Deciding what to measure • LOS • Cost • Change in Pain Scores Balancing Measures (potential harm) Outcomes (patient level results) • Oversedation • Rapid Response • Family Complaints Process: (actions) Structure (adherence to the program) • Measuring Day 1 to Day 2 scores • Knowing first call on rounds • Ongoing nursing ed - Teams called on morning rounds - Cards distributed - Patients seen in the afternoon - Time from order to pain med delivery

12. 15 Minutes: What are the right measures for your group? • OUTCOMES: • PROCESSES: • STRUCTURE:

13. Five Minutes: What are the right measures for your group? • OUTCOMES: • Day 1 to Day 2 improvement • Day 1 to Discharge improvement • Patient Satisfaction with “Staff did everything to help with pain” • PROCESSES: • Time from recommendations to orders • Time from order to med delivery • % Patients visited again in the afternoon • STRUCTURE: • Use of patient-centered pain medication cards • Permission from primary teams to write orders • Knowledge of team first contact

14. Using a QI framework to improve care • Set the vision for improvement • Understand the problem • Identify Areas for Improvement • Devise a measurement strategy • Prioritize small tests of change • Measure change • Sustain the change 10:55

15. High Effort One team member does PM check in Gives patient information card on their pain regimen Page team & Write note with updated PM recs Thankless tasks Call the primary team after each patient is seen with clear to-do now recs Low Impact High Impact Easy Wins Low Effort

16. QI is a four legged stool Education: Think about how you change educate people in their role. Ensure capability, knowledge and skills are ready for change. Systems Change: Change staffing, protocols, create hard stops, and electronic shortcuts One team member does PM check in Data audit & feedback: Provide people with their performance. Let them know you are watching and you care. Culture Change: Change the way you talk about the problem; talk about the organization you want to be. Create a vision.

17. Table exercise: 10 min Think about the four pillars of change, and come up with a need for your group in each category EDUCATION SYSTEMS CHANGE ? DATA AUDIT & FEEDBACK CULTURE CHANGE Write down where it fits on the QI “stool”

18. High Effort One team member does PM check in Gives patient information card on their pain regimen Thankless tasks Write note with updated PM recs Low Impact High Impact Call the primary team after each patient is seen with clear to-do now recs Easy Wins Low Effort

19. Prioritize small tests of change Doing small tests of change will let you know if your ideas are working. Must be accompanied by ongoing measurement.

20. Case Example: Broken PCA process • Aim: Improve timely pain management • Intervention: Write orders / Talk to team after each patient seen on rounds • Plan / Do: • Implemented workflow for order entry and team contact on rounds • Study: Discovered patients with highest pain scores NOT getting pain meds! • PCA orders taking 6 hours to complete, patient without necessary PRNs in the interim • Act: Address PCA issues • Work with pharmacy to improve workflow for making PCAs • Build interim PRNs into PCA orderset so higher doses of PRNs can be given until PCA arrives

21. PDSA Worksheet for Testing Change Aim: (overall goal you wish to achieve) Every goal will require multiple smaller tests of change Plan: DoDescribe what actually happened when you ran the test StudyDescribe the measured results and how they compared to the predictions ActDescribe what modifications to the plan will be made for the next cycle from what you learned