Model For Improvement MFI

1. Model For ImprovementMFI

2. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement Act Plan Study Do Improvement Guide, Chapter 1, p.24 Appendix C, p. 454

3. Model for Improvement AIM What are we trying to accomplish How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do Improvement Guide, Chapter 1, p.24 Appendix C, p. 454 Some is not a number, soon is not a time

4. Recommended elements in an aim statement • What is expected to happen • The timeframe for accomplishing the aim • The system to be improved • The patient population that change process is going to be applied to • How much/by when

5. Has it met the qualities of a good aim? What is expected to happen The timeframe for accomplishing the aim The system to be improved The patient population that change process is going to be applied to How much/by when Example of Aim statement Example 1 We aim to reduce the average length of stay for >64 year old (and >54 year old Maori and Pacific) hip fracture patients from 22 days to 19 days by the 30th of June 2013. Example 2 The aim of this project is to keep the people well in community by increasing the number of patients with chronic respiratory condition enrolled into Better Breathing (pulmonary rehabilitation) Programme (BBP) from 60 to 250 per year by June 30th 2013     

6. Breakout – Aim statement

7. Model for Improvement What are we trying to accomplish? MEASURES How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do Improvement Guide, Chapter 1, p.24 Appendix C, p. 454

8. Measurement “Crude measures of the right things are better than precise measures of the wrong things.” “Improvement strategy: More frequent samples (over time) of ‘good enough’ measures”

9. Roles of measurement • Key measures are required to assess team’s progress against the aim • Balancing measures are required to ensure that improvement in one part of the system does not cause damage in another area • Data (including from patients and staff) can be used to focus improvement and refine changes • Specific measures can be used doing PDSA cycles to inform future cycles

10. Methods of Measurement • Chart review • Observation of behaviour • Surveys • Questionnaires • Coding data • Checklists

11. Measurement guidelines To answer: “How will we know that a change is an improvement?” usually requires more than one measure: • A balanced set of a few (3 – 8) key measures • Integrate measurement into the daily routine • Think about balancing, process and outcome measures (be careful about overdoing process measures) • Plot the data in a time series

12. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? Developing Change What change can we make that will result in improvement? Act Plan Improvement Guide, Chapter 1, p.24 Appendix C, p. 454 Study Do

13. All Improvement requires change, but not all changes result in improvement How do we develop fundamental change that will result in improvement?

14. What is a Theory? • A description of our best understanding about why things are the way they are • What are some theories? • Biology – Theory of Evolution • Physics – Theory of General Relativity • Economics – Game Theory • Psychology – Maslow’s Theory of the Hierarchy of Needs

15. Driver Diagram - a tool to visualize our Theory • A driver diagram is an approach to describing our theories of improvement: • Used to help organize our theories and ideas in an improvement effort. • The initial driver diagram for an improvement project might lay out the descriptive theory of improved outcomes that can then be tested and enhanced to develop a predictive theory. • The driver diagram should be updated throughout an improvement effort and used to track progress in theory building. Improvement Guide, p.429-431

16. Drivers Effect Cause Conceptual Driver Diagram Outcome Change Concepts 1⁰ driver 2⁰ driver Specific Change Ideas 2⁰ driver 1 Ideas: 1 2 3 4 5 6 7 8 9 . . . . . . N Concept 1 1⁰ driver 1 Concept 2 2⁰ driver 2 Concept 3 Aim or Outcome 2⁰ driver 3 Concept 4 2⁰ driver 4 1⁰ driver 2 Concept 5 2⁰ driver 5 Concept 6

20. Where ideas come from Outcome Change Concepts 1⁰ driver 2⁰ driver Specific Change Ideas Where ideas come from: Medical Literature Websites like www.ihi.org Team members who have innovative thoughts about what to do differently Structured Creativity Sessions (use of change concepts, provocations, random entry, etc.) Other Teams Improvement Advisors 2⁰ driver 1 Ideas: 1 2 3 4 5 6 7 8 9 . . . . . . N Concept 1 1⁰ driver 1 Concept 2 2⁰ driver 2 Concept 3 Aim or Outcome 2⁰ driver 3 Concept 4 2⁰ driver 4 1⁰ driver 2 Concept 5 2⁰ driver 5 Concept 6

21. Breakout – Developing Change

22. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Testing Study Do Improvement Guide, Chapter 1, p.24 Appendix C, p. 454

23. Science behind PDSA 1939 1951 1986 1939 Step 1- Design, Step 2 – Produce, Step 3 - Sell was converted to a circle with a forth step added: Step 4 - Redesign through marketing research. 1993 Scientific Method Hypothesis Prediction Experiment Evaluate/Analysis Build on previous knowledge Acquire/generate new knowledge

24. The Plan-Do-Study-Act Cycle Most Important Part of a PDSA cycle Because with out it we don’t have a comparison for the purpose of learning - Improvement Guide, Chapter 5, p. 97

25. Why prediction? • Prediction combined with a learning cycle interrogates our understanding of a system. • It reveals gaps in our knowledge and provides us a starting place for growth. • Without it our learning is accidental at best but with it we are able to direct our efforts toward building a more complete picture of how things work in the system.

26. Repeated Use of the PDSA Cycle A P S D D S P A A P S D A P S D Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Ideas Very Small Scale Test Improvement Guide, Chapter 7, p. 146

27. The work of improvement Primary Driver 1 Primary Driver 2 Primary Driver 3 Change Idea 1 Change Idea 1 Change Idea 1 Change Idea 3 Change Idea 3 Change Idea 3 Change Idea 2 Change Idea 2 Change Idea 2

28. Transition of Care PDSA Tree Date: 27/11/2012 Reviewed 27/02/2013 Staff to set a GDD based on the top 10 DRGs-Michele 5/12 Nurse setting the GDD Pt awareness on GDD GDD match with actual Dx date Reason of GDD not met-Ruth& Michele 12/12 Who, How, When? Staff awareness on GDD GDD in MDT meeting Establish GDD & Daily Review Doc to use care plan to review GDD-Ruth/Michele 5/12 Pt awareness on GDD-Surgical To have a standardised process to provide each patient with a GDD How and what is the best way to establish a GDD? # of clinical directors believe in establishing GDD GDD by Doc post acute ward round – Brian 17/12 Check consultant aware of GDD in mind Process Map Janene/Michele 23/1 GDD in ward 33 Janene & Michele 23/1 Is the GDD documented on care plan? GDD mentioned in notes GDD given to surgical pt and any plans documented CAT tool to indentify why Pt waiting CAT tool usefulness Reasons of Pt waiting on Bed Add time of Dx Surgical-17/4 Post ward round delay in services for Pt > 7 days Visual Display of GDD-Surgical Transitions of Care PDSA Tree Goal Discharge Date Pt less than 48 hour Cultural Support to inform – Maika/Ian 23/12 Patient & Family Nurse to inform Pt- Ruth Aim: To improve the number of inpatients having GDD from 0% to 100% also To increase the number of inpatients achieving the GDD for from 0% to 100% by July 2013. Sharing GDD DOC to use care plan for updated GDD info Doc reviewing /confirming GDD-Ajay 5/12 Drs To have a standardised process to share GDD Best way to communicate the GDD to patient and interested parties? Update GDD on white board Staff Update GDD on WiMS Other Services E-referral – Erin 5/12 Ascertain ref process in ward 6 PDSA box Timely task referral Dx Checklist Clivena/Helen 10/4 Repeat PDSA Active PDSA Adopt Adapt Abandon What's Happening Prediction: GDD will improve the patient experience and efficiency. Also this will reduce the LoS What ref system are available in service dir. Achieving the GDD Identifying Pt need @ admission in EC 4 pts (Ajay Kumar/ Fionna W) 13/1 Repeat with interventions 10/5 Identifying Pt need @ admission in EC (Ajay Kumar/ Fionna W) Checklist/Process map in notes 17/4 Fionna GDD orientation to HO rotation 17/4 To have the processes in place to achieve the GDD How can we achieve the GDD as a team GDD assigned in EC-Fionna 17/4 Early Dx if Pr referred to NASC earlier Delay in x-fer to AT&R Dx Summary ?? To attend CN meeting Referral system assessment & documentation from acute to AT&R Test the checklist for ref to DN 27/3 Surgical HHC to receive Dx list twice daily Discharge to HHC Known patient dx communication to HHC Owner: Prem Kumar

29. Every morning find the right colour socks with in 5 seconds * Right Colour Right Socks * Time to find the socks * The mess created * My satisfaction* * After wash placement time

30. Break out Exercise • On your table there is a stack of index cards with numbers written on them • Give these to 8 people around your table • Each of you has now been assigned a number – you can find your number by locating the middle number on your card (i.e. if your card says 1-4-8, then you are number 4)

31. Break out Exercise • Your current process involves tossing the tennis ball provided from person to person, following the sequence provided on the index cards (i.e. Person 1 tosses to Person 4 who tosses to person 8 and so on, until the ball returns to person 1) • Assign a time keeper/ball drop counter (preferably not a ball tosser) • Practice your process one time – Time keeper please time how long the team takes to complete the process and the number of times they drop the tennis ball

32. Break out Exercise • Team Aim: We aim to reduce the time taken for every person to touch the ball from X to Y. We also aim to reduce our ball drops from A to B. • Form a theory, come up with change ideas, use the MFI to test those ideas • Rules: • The initial sequence as provided by the cards must be adhered to • You may only test one change idea at a time

33. Break out Exercise