AMI Virtual Learning Collaborative

AMI Virtual Learning Collaborative

Building on LS1-A

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LS1-A Re-Cap• Introduced to WebEx technology

• Overview of Virtual Learning Collaborative and Expectations

• Expert presentation on Thrombolytic Therapy

• Process Mapping

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What Worked Well

• The content and presentations

• Sharing by Participants

• Engagement

• Use of Examples

• Polls/Feedback

• Being able to ask questions

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What Worked Well• Being able to participate without travelling

is a huge plus

• Easy Access/ able to access it almost anywhere, easy to follow

• Having presentation from specialist and then being able to apply to our specific practice

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What Worked Well

• Hearing while seeing, coordination

• Having interaction with colleagues from the provinces and regions

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Improvement Opportunities

1. Slides and handouts

2. Times listed only as ADT

3. Voice delay and overlap

Change Ideas to Test

1. Post on CoP

2. Include NL time in correspondence

3. Use emoticon to flag issue

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Improvement Opportunities

4. Passing the ‘Ball’

5. Voice clarity fluctuation

6. WebEx training

before Session

Change Ideas to Test

4. Establish Co-Host role

5. Speak directly into microphone; headset/ hands free

6. Next VLC pre sessions

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Comments/Questions

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AMI Virtual Learning Collaborative

The Model for Improvement

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Measurement

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming

Overview

• Measures & Targets

• Inclusion & Exclusion Criteria

• Individual Data Collection Form

• Elapsed Time by Patient Worksheet

• Measurement Worksheet

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What are OurMeasures?

• % STEMI or new LBBB who received thrombolytic within 30 minutes of arrival at ED.

• % STEMI or new LBBB who received an ECG within 10 minutes of arrival at ED.

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What are ourTargets?

• 90% STEMI or new LBBB receive thrombolytic within 30 minutes of arrival at ED.

• 90% STEMI or new LBBB receive an ECG within 10 minutes of arrival at ED.

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Why These Measures?

• Based on CCORT AMI Indicators (CMAJ 2008: 179: 909-15)

• Time is muscle (myocardium)

• Two measures which are key to timely thrombolysis

• We know there is room for improvement

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Measure 4.0ALytic Within 30 Minutes of Arrival

DenominatorInclusion:• All STEMI or new LBBB confirmed by ECG• Lytic within 6 hours of arrival at ED• Lytic as primary reperfusion therapy

Exclusion:• Patients with NSTEMI, non-Q wave or subendocardial MIs • Transfers in who received lytics in another acute care

facility or ambulance• Under 18 years of age

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Measure 4.0ALytic Within 30 Minutes of Arrival

Numerator

• All those in the denominator who received lytic within 30 minutes of arrival at ED

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Measure 10.0ECG Within 10 Minutes of Arrival

DenominatorInclusion:• Patients admitted through Emergency with diagnosis of

STEMI or new LBBB confirmed by ECG

Exclusion: • Received a lytic in ambulance• Transferred from another acute care facility• Under 18 years of age

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Measure 10.0ECG Within 10 Minutes

Numerator

• All those in the denominator who had an ECG within 10 minutes of arrival at ED– If ECG completed by EMS (pre-hospital) this

is considered within 10 minutes of arrival at ED

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Additional Process Measures

• Time 1st medical contact to 1st ECG

• Time 1st medical contact to arrival at ED

• Time diagnostic ECG done to read by MD

• Time diagnostic ECG read by MD to thrombolysis

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Individual Data Collection Form

Use a data sheet for each month of data submission

Each workbook has 2 worksheets – (1) Individual pt.

times & (2) Elapsed time by pt

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Individual Data Collection Form

Enter name of hospital,

Select Month and Year from drop down

box

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Individual Data Collection Form

Enter individual pt data as they arrive in

ED

MRN = Medical Record Number- Use identifier of your choice

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Individual Data Collection Form

Seq

uential pt. # Enter times in appropriate cols.

optional comments about pt

Pt. id

entifier

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Individual Data Collection Form

Notes:1.Walk-In (pt.#1) – “1st medical contact” usually same as “Arrived ED”2.Transport by Ambulance (pt.#2&#3) – “1st medical contact” occurs before “Arrived ED”3.ECG and Lytics in ED (pt.#2) – “1st ECG” after “Arrived ED” and before “Lytics started”4.ECG in ambulance and Lytics in ED (pt.#3) – “1st ECG” before “Arrived ED” and “Lytics started”5.If ECG and Lytics in ambulance (pt.not shown) – “1st ECG” and “Lytics Started” before “Arrived ED”

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Elapsed Time by Pt Worksheet

Automatic calculations

Now on second worksheet = Elapsed

Time by Pt.

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Elapsed Time by Pt Worksheet

Classification of patient for

measure 4.0A

All elapsed times are automatically calculated from data entered on “Individual

Times” worksheet

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Elapsed Time by Pt Worksheet

Number of teams meeting criteria w/i 30 mins and those not meeting criteria w/I 30 mins

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Measurement Worksheet

Enter data on “Data Entry Sheet

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Measurement Worksheet

Enter name of hospital, region and description of patient sample in ‘windows’

outlined in red.

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Measurement Worksheet

In column for appropriate month and year identify implementation stage and collection method

1. Baseline = 1st month of data submission2. Full = after reaching goal and holding it for 3 consecutive data submissions3. Early = everything else.

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Measurement WorksheetEnter data from Elapsed

Time / Individual Data Collection form in “red”

outlined cells for Denominator

Enter data from Elapsed Time / Individual Data

Collection form in cell for Numerator

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Contact information

Central Measurement Team

Virginia Flintoft virginia.flintoft@utoronto.ca416-946-8350

Alex Titeushn.ea@utoronto.ca416-946-3103

Model For Improvement *

•A simple yet powerful tool for accelerating improvement

•The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming

Model For Improvement *The model has two parts:

• Three fundamental questions,Used to establish AIM; MEASURES, AND CHANGE IDEAS.

•The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of change to determine if the change is an improvement.

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP

**The Plan-Do-Study-Act cycle was developed by W. E. Deming

• Action Oriented

• Trial and Learning

• Leadership

Model For Improvement

Operationalizes the Improvement Model– Improvement theory– Project management

Team Charter

To ensure a common understanding and focus by making explicit:– AIMS– Measurement targets– Changes– Timelines– Roles and Responsibilities

To communicate effectively with senior leadership and other stakeholders

Team Charter

• Review your system: - Who does the patient see? - Who is needed to implement? - Who needs to know about the changes? - Who supports the changes?

• Work with those who will work with you

• Each member is a champion in their area

Team

• Core Team Members– Clinicians providing care i.e. nurses, technicians, therapists,

paramedic– Clinical and administrative leaders i.e. Clinical Nurse Specialist,

Nurse Manager

• Ad Hoc– Physician Champion– Quality Improvement personnel– Clerical Support

Team

Team Leader• Completing and clarifying the team charter in a manner

that ensures the support of team members and team sponsor.

• Organizing and running effective meetings and maintaining team records ie minutes, correspondence, improvement data

• Facilitating work within the team and ensuring participation at and between meetings

• Communicate about the improvement work with the sponsor, team members, stakeholders and the larger organization.

Roles and Responsibilities

Team Members• Sharing content knowledge, skill and experience • Communicating and developing a shared understanding

within the team of the work process to be improved or changed.

• Testing change ideas within the team and in the real work context

• Leading and supporting coworkers to adapt the new process

• Completing tasks or assignments within and between meetings

• Establishing two-way communication with their colleagues and the team

Roles and Responsibilities

Team Sponsor• Clarifying the improvement mandate and aligning it

within the organizations strategic and operational objectives

• Connecting and communicating with appropriate stakeholders

• Allowing time and other resources• Establishing an accountability mechanism • Facilitating the work of the team within the larger

organization. • Engaging a team leader and a coach• Initiating the team charter

Roles and Responsibilities

Team Coach

• Facilitating the use of improvement tools and techniques

• Monitoring and facilitating healthy team behaviors

• Providing technical expertise and guidance focusing on team process

• Supporting the team leader to plan effective team meetings

• Assisting with measurement for improvement eg data collection, submission, analysis and display

Roles and Responsibilities

Identify your team members and assign Roles and Responsibilities.

Exercise #1

Team Example

Participant Sharing

• What are you going to do?

• How much?

• By when?

AIM

Bold Aim, Firm Deadlines• Align aim with strategic goals of the organization

• Write a clear and concise statement of aim

• Make the target for improvement bold and unambiguous

• Include deadline

• Include scope, boundaries, constraints and anything else that is needed to keep the team focused

Example

Write your AIM statement

Exercise #2

Team Example

Participant Sharing

“Some is not a number. Soon is not a time”

Donald Berwick, MD

Institute for Healthcare Improvement

Bold Aim, Firm Deadlines

Three Main Types :

– Outcome Measures

– Process Measures

– Balancing Measures

Measures

Model For Improvement • Outcome measures:

– Are driven by the specific objectives identified in the AIM statement, e.g. # decreased 30 Day AMI Mortality Rate

– Are understood from the consumer’s perspective eg. Reduced discrepancies

• Process measures – Indicate whether a specific change is having the intended

effect, e.g. ECG within 10 minutes; lytics door to needle within 30 minutes

– Indicate if process changes are leading to improvements

• Balancing measures:

– Are related measures to understand the impact of changes on the broader system, e.g Patient/staff satisfaction

– They can be the other effects of planned changes e.g. Increased admission time; decreased rework

Model For Improvement

Measures

• Measures should be useful and manageable (2-6)

• Should be operationally defined e.g. Hospital Arrival = Arrival: The earliest documented time the patient arrived at the hospital; this may differ from the admission time

• Should be integrated into clinical documentation

• Purpose is for learning not judgment

Measures

Break & Networking

Please be back in 15 minutes

• What Changes can we make that will lead to an improvement?

Changes

• A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

• Creatively combing these change concepts with knowledge about the specific work can help generate ideas for tests of change. PDSAs are used to test the specific ideas.

• Change concepts are usually at a high level of abstraction, but evoke multiple ideas for a specific process.– Examples:

• Reduce handoffs• Consider all parties as part of the same system• Improve work flow• Eliminate waste

• Berwick, Boushon,& Roessner, 2007

Change Concept

Aim: Assure customers do not leave bank cards

behind

Change Concept

Aim: Assure customers do not leave bank cards

behindIdea: Beeping sound

Idea: Beeping sound

Concept:

Use reminder

s

Change Concept

Aim: Assure customers do not leave bank cards

behindIdea: Beeping sound

Concept:

Use reminder

s

Electric shock

Voice reminders

Siren

Based on Edward DeBono’s Concept Fan

Change Concept

• Change Package• Getting Started Kits• Creative and Critical thinking• Hunches• Best practices• Asking process users and subject matter experts for

ideas• Community of Practice• Insight from research and benchmarking

Change Ideas

While all changes do not lead to improvement, all improvement requires change.

Berwick, Boushon,& Roessner, 2007

Change

What’s in a Change Package?

Change Package

• Using the Change Package select, modify, or add change ideas and record them in your Charter

.

Exercise 3

Break & Networking

Please be back in 15 minutes

Getting things moving: Plan, Do, Study,

What change will you implement by next Tuesday?

PDSA

PDSA Testing Change

• Plan- a specific planning phase

• Do- a time to try the change and observe what happens

• Study- an analysis of the results of the trial

• Act- devising next steps based on analysis

• Berwick, Boushon,& Roessner, 2007

AIM: State your overall goal you would like to reachExample: 90% of eligible patients will have thrombolytic agents administered within 30 minutes of hospital arrival by March 2010

Describe your first (next) test of change Person Responsible

When to be done

Where to be done

Test Synchronizing clocks, watches and equipment (individual, departmental, and equipment)

John RN Oct 26/08

ED

Rapid Cycle Testing

List the tasks needed to set up this test of change

Person Responsible

When to be done

Where to be done

1. Identify time ‘data points’ in patient flow thru ED

2. Audit current clocks and equipment for current time

3. Audit a sample staff watch time

4. Design and test a protocol for daily synchronization of clocks, watches and equipment

5. Arrange a huddle

6. Complete the “testing” worksheet

Mary RN

Jane Team Lead

Susan Unit Manager

Mary RN with team

Susan Unit Manager

John RN

12-1230

Oct 22-09

Oct 22-25-09

10 am on Oct 23-09

Oct 26 1400

Sept 12 before 1500h

Here

ED

ED

ED Conference Rm

ED Nursing Desk

Conference Rm Med Unit #1

Plan

Predict what will happen when the test is carried out

Measures to determine if prediction succeeds

1. Equipment, watches and clocks will need to be adjusted.

2. The protocol will need refinements

3. The huddle will identify new change ideas for testing

1. Self Report Y/N

2. Discussed and recorded in huddle

3. Yes/No

Plan

• Do: Describe what actually happened when you ran the test– Most clocks and watches were easily reset but equipment posed more

of a challenge because some were off unit at the time..

• Study: Describe the measured results and how they compared to the predictions– 3 of 5 clocks; 4 of 6 watches; and evry piece of equipment needed the

time

• Act: Describe what modifications to the plan will be made for next time.– All ED staff, EKG technicians and physicians will be asked to set their

time in sync with the clock in the ED trauma room

Completing Test of Change

Completing Test of Change

•The idea of using huddles, as opposed to the standard one-hour meeting, arose from a need to speed up the work of improvement teams.

•Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.

Berwick, Boushon,& Roessner, 2007

As you move thru cycles increase size of the test:

1-5-25• Getting it working well with one;

• Test it on five more;

• After 25, establish in organization

Rapid Cycle Change

A PS D

A PS D

AP

SD

APSD

Change Ideas

Learning From Data

Very Small test

Follow up tests

Wide Scale tests of change

Implementation of Change

Changes Result in Improvement

Moving From Testing to Implementing

• 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

PDSA Cycles for Testing

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

• Evaluate costs and side-effects of the change

• Minimize resistance upon implementation

PDSA Cycles for Testing

Why Test-Why Not Just Implement??

• Select a change idea

• Complete the Plan

• Conduct the test in your work setting by NEXT TUESDAY

• Complete the Do, Study, Act sections

Exercise

Parallel Ramps

Testing ……………….Implementation…….Spread

Aim

P DS A

Improve Work Flow

Focus on Product/Service

Change the work environment

Manage variation

Design System to avoid mistakes

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A P D

S A

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A

P DS A

Thrombolytic to eligiblePatients within 30 minutes of ED arrival

• Initiation of Rapid Cycle tests is dependent on getting the first test of change started

• Do Not try to Perfect the change then implement…consider your work a masterpiece in progress

• Failure is a great Opportunity to plan to do better next time…

• Frequency of Testing determines the speed of the process improvement ie daily testing = improvement in weeks; weekly = improvement in 3-4 months

Rapid Cycle Change

What are we trying toWhat are we trying toaccomplish?accomplish?

How will we know that aHow will we know that achange is an improvement?change is an improvement?

What changes can we make that willWhat changes can we make that willresult in an improvement?result in an improvement?

Act Plan

Study Do

Model for improvement

Aims

Measurement

Langley, Nolan et al 1996

Change Ideas

Trial & Learning

Questions?

Rapid Cycle Change

Acknowledgements

• Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/GausModelforImprovement.htm?TabId=2

• Harris, B. (2007). Change Concepts.

• Murray, M (2006). “Small Steps, Big Changes” workshop.

• Reasear, R. (2007). Institute for Healthcare Improvement “Designing Reliability Into Healthcare Processes: Based on the work of the Institute for Healthcare Improvement Innovation”