Model for Improvement and Tests of Change

1. Model for Improvement and Tests of Change Denise Remus, PhD, RN Improvement Advisor, Cynosure Health / HRET HEN

2. Drive Improvement Faster • Science of improvement • Accountability • Structure change • Document progress • Be fearless

4. One day Alice came to a fork in the road and saw a Cheshire Cat. “Which road do I take?” she asked. His response was a question “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat “it doesn’t matter.” Lewis Carroll

5. Aim Statements • What are we trying to accomplish? • Communicate expectations • Measurable (how good?) • Time specific (by when?) • Define the specific population (s) (who?) • Clear, concise and unambiguous

6. Aim Statement WHERE? WHAT? WHO? HOW MUCH? BY WHEN?

7. Aim Statement Examples Readmissions: At Mount Pleasant Medical Center, we will reduce readmissions, within 30 days, for all our patients by 20% by December 31, 2013. Readmissions: At St. Mary’s Hospital, we will reduce 30 day readmissions for heart failure patients by 20% by December 31, 2013.

8. Does your organization have an aim statement?

9. Which Measures?

10. Measures

11. Where is your Greatest Opportunity to? Reduce HarmImprove Processes

12. Consider. . . • What are you already measuring? • What are you planning to measure? Identify existing measures Are they in the Encyclopedia? If not, user-defined measure option

13. Readmissions Example • Outcome Measure: Readmission to hospital within 15 days of discharge (all cause, hospital-specific) • Process Measure: Patients Receiving Complete Discharge Education Verified by Teach-Back or Other Means

15. The PDSA Cycle “What will happen if we try something different?” “What’s next? ” “Let’s try it!” “Did it work?”

16. The Sequence for Improvement Act Plan Study Do Make part of routine operations Sustaining improvements and Spreading changes to other locations Test under a variety of conditions Implementing a change Testing a change Theory and Prediction Developing a change

17. Repeated Use of the PDSA Cycle for Testing Model for Improvement What are we trying to accomplish? How will we know thata change is an improvement? What change can we make that will result in improvement? Changes That Result in Improvement Spreading DATA Sustaining the gains Implementation of Change Wide-Scale Tests of Change Hunches Theories Ideas Sequential building of knowledge under a wide range of conditions Follow-up Tests Very Small Scale Test

18. Guidelines For Testing Change • Do not try to get buy-in, consensus • Be innovative to make the test feasible • Collect useful data during each test • Test over a wide range of conditions

19. Guidelines For Testing Change • Fail early, fail often • What can we do by next Tuesday? • Pick willing volunteers • AIM big, but test small • Steal shamelessly

20. Remember to. . . • Adapt • Adopt • Abandon

21. Common Traps • Plan Do, Plan Do • Do Act, Do Act • No testing, only data collection • No ramps of tests, random PDSAs • Undisciplined PDSAs, no documentation • No prediction – what are we going to learn? • Beware of Cycles longer than 30 days

22. Tips for Testing • Use a form to document your test. • Scale down – think “Drop Two.” • Oneness • Know the situation in your organization.

23. Failed Test…Now What? • Be sure to distinguish the reason: • Change was not executed • Change was executed, but not effective • If the prediction was wrong – not a failure! • Change was executed but did not result in improvement • Local improvement did not impact the secondary driver or outcome • In either case, we’ve improved our understanding of the system!

24. Value of “Failed” Tests “I did not fail one thousand times; I found one thousand ways how not to make a light bulb.” Thomas Edison

26. What are you going to test? Example: Test draft readmission risk assessment tool

27. What do you need to conduct the test? • A specific form? • Specific tool? • Specific equipment? Example: - Draft readmission risk assessment tool - Instructions for completing the tool

28. Who will be involved in the test? • Which discipline? • RN? • Pharmacist? • Case Manager? • MD? • Others? • Lay person / volunteer • Patient Example: - Mary, RN

29. How will you educate & inform the participant(s)? • Staff meeting? • Huddle? • Flyer? Example: Readmission team member to review risk assessment tool and instructions for completing it with Mary RN.

30. Where will the test occur? • Which unit? • Which department? Example: Telemetry Unit

31. When will the test occur? Specifics • What day? • What shift? • What time? Example: All new admissions that Mary, RN has on July 31st

32. How will you know you’ve been successful? Specifics • What was learned? • What worked? • What didn’t? • What to change next time? How will you know it is successful? • Example: Feedback from Mary, RN regarding . . . • - Time to complete risk assessment • - Ease of locating information to complete • - Suggestions for improvement in tool or instructions

33. Rapid Cycle Test of Change

34. Improvement Project Worksheet

35. Share . . .