Barb Boushon, Mike Davies, MD Mark Murray and Associates 916-441-3070 Murraytant@msn.com The Process...

Barb Boushon,Barb Boushon,

Mike Davies, MDMike Davies, MD

Mark Murray and AssociatesMark Murray and Associates

916-441-3070916-441-3070Murraytant@msn.com

The Process Improvement Model: Aims, Measures, Tests/Changes and Teams

Why Change Strategies Often Don’t

Work

• Lots of planning then lots of implementing– Analysis paralysis– Lack of consensus on problem and

solution– Implemention vs. test– Risky change process

Why Change Strategies Often Don’t Work

• Pushing one solution/idea– One person’s perspective– How do we know it works?– Lack of agreement– Ignores context/circumstances

Improvement Involves “Experimentation”

• Setting aims/goals• Generating ideas • Testing • Measuring progress• Reflection

Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

AAIMSIMSAAIMSIMS

What are we trying to What are we trying to accomplish?accomplish?

AimsWhat is an Aim?

– Statement of Intention“What are we trying to accomplish?”

– Aligned with strategic goals

– Based on data

– Stated clearly using numeric goals– Involves senior leaders

Aims and Goals

Goal: Improve hospital flow by reducing delays within and between departments

Aims:• Reduce the input delay• Reduce the throughput delay• Reduce the output delay

The Patient Journey: Inputs; Throughput; Output

ER Visit Wait for MD

Decision to admitto admit

Length of stayon unit

Decision toDischarge todischarge

Length of stay inin nursinghome

ER Input ER Throughput

ER Output

Beds InputBedsThroughput

Beds Output

NH Input

NH Throughput

Sample Input Aims• Within 12 months, 100% of patients seeking

care in the ED will see the MD within 15 minutes of their arrival.

• Within 12 months, 100% of surgeries will begin at the scheduled time

• Within 12 months, 100% of lab specimens will be collected within 20 minutes of the order being received within the department

• Within 12 months, the time from receiving the order for CT to patient receiving the CT will be reduced by 25% from xx minutes to xx minutes.

Sample Throughput Aims

• Within 12 months, the average cycle time in the ED will be reduced from xx minutes to 45 minutes 

• Within 12 months the average cycle time for surgery will be reduced by 25% from xx minutes to xx minutes 

• Within 12 months, the average process time for a xx (lab) will be reduced from xx minutes to xx minutes

• Within 12 months, the average length of stay for xx unit will be reduced by xx% from xx hours to xx hours

Sample Output Aim

• Within 12 months 100% of patients will be admitted to the receiving unit within 30 minutes of notification from ER (or OR, or PACU, or ICU)

MMEASURESEASURESMMEASURESEASURES

How will we know that a How will we know that a change is an improvement?change is an improvement?

MeasuresMeasures: How will we know a

change is an improvement?• Baseline measures• Plot data over time.• Focus on simple measures directly

related to aim• Sampling• Integrate measurement into daily work.• Create simple annotated run graphs.

CT Exams

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5.0

10.0

15.0

20.0

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ys

3rd Next Avail. Appt. for Non-Emergent CT Scan

Measures• Delay

– Input– Throughput– Output

• Demand (and variation)

• Supply• Activity• Satisfaction• Defects

– No-shows– Internal and external diversions– Readmission rate

“Kinds” of Data• Judgment

– Research– Performance appraisal – “do something TO you”

• Improvement– Process improvement efforts– “do something WITH you”

Flow Mapping• Record each process step on a

separate piece of sticky paper• Put the steps in the right order• Record who is responsible for

each step• Add forgotten steps• Agree to all of above• Analyze

Flow Mapping Example

OpenOpen toothpastetoothpaste

Wet Wet toothbrushtoothbrush

Apply Apply pastepaste

to brushto brush

Brush Brush teethteeth

Turn Turn off off lightlight

Put awayPut awaypaste paste and and

brushbrush

Rinse Rinse mouthmouth

Rinse Rinse brushbrush

Changes and TestsChanges and TestsChanges and TestsChanges and Tests

What What changes changes can we make can we make that will result in an that will result in an

improvement?improvement?

Tests and ChangesHow will you reach your aim?

– Testing changes

– With likelihood of success

– For re-assurance in environment

– Adopting successful strategies based on your tests.

Flow of Work Change Principles

• Balance upstream and downstream demand and supply for all services

• Eliminate any backlogs of work• Reduce the queues from one entity to

the other• Develop contingency plans to address

demand or supply variation

Flow of Work Change Principles

• Reduce demand• Identify and manage each supply

constraint• Synchronize the work• Predict and anticipate needs• Optimize environment: equipment, staff

and space

Tests and ChangesTests: Cycles for Learning and

Improvement

• Rapid Cycles

• Multiple tests of multiple changes

• Testing vs. implementation

How to Implement a Change

Belief thatchange willresult inimprovement

High

Low

SuccessfulChange

Unsuccessful Change

Still Needs Further Testing

Developing Testing Implementing

From Lloyd Provost

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

PDSA Cycles• Are Not Plans!• Are small in scale

– Thinking months – think weeks; thinking weeks – think days; thinking days – think hours

– Thinking facility – think unit; thinking unit – think teams; thinking teams, think ONE team

– Thinking all patients – think a type of patient; thinking a type of patient, think a sample; thinking sample then 3-5 may be enough

PA

S A

P

DS

A

P

DS

A

P

DS

A

PA

S A

P

DS

A

P

DS

A

P

DS

A

PA

S A

P

DS

A

P

DS

A

P

DS

A

BalanceDemandAnd Supply

DecreaseAppt. Types Decrease

Demand

Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

Summary• Keep focused on Aim – Measure –

Change• Changes are “small experiments”• Experiment wisely – PSDA• Learn from small changes over wide

conditions before implementing widely• Get started and keep going

Model for ImprovementAim: What are we trying to accomplish?

Measurement:How will we know that a change is an improvement?

What Changes can we make that will result in an improvement?

Cycle for Learning

and

Improvement

ACT

STUDY

PLAN

DO

Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

TeamsTeamsTeamsTeams

Important Questions• What is our current team number and

composition?• Are we clear about our mission and goals?• Are we working together as smoothly and

efficiently as we could?• Are we providing high quality care for our

patients?• Is working with this team any fun?• Do we get the job done well?

What are the Attributes of a Team?

• Proactive vs. reactive• Communicative vs. isolated• Accountable to each other, and to

the patient• Use measures for feedback• Delivers safe and high quality care

Attributes continued…….

• Cross-trained versus territorial• Integrated versus separated• Continuous flow versus flow based

on urgency• All staff work to highest level of

training, experience, and licensure

Role

• Test and implement changes• Measure and record pertinent

data• Communicate (successes and

unintended consequences)

Profile

• Willing to be involved in the process

• Interested in the issues• Ready to participate in discussion

and test changes• Possess knowledge related to the

process

Membership

• Senior department leader(s)• Clinical team physician leader • Day-to-day leadership • Technical experts

Senior Dept. Leader• Department’s sponsor for the Hospital

Flow Improvement Initiative • Authority to institute change • Authority to allocate the time and

resources necessary to achieve the team’s aim

Physician Leader• Good working relationship with colleagues

and with the day-to-day leader(s)• Interested in driving change in the

system/department and will be a champion for the work

• Opinion leader in the department (individuals sought out for advice who are not afraid to test change)

Day-to Day Leader• Critical driving force of the project,

assuring that tests of change are implemented and overseeing data collection

• Understands not only the details of the system, but also the various effects of making change(s) in the system

• Able to work effectively with the physician champion(s)

Day-to-Day Leader (cont.)

• Team’s “key contact” for the initiative • Responsible for coordinating

communications between the department team and the Steering Team

• Organize team meetings, assist with completion of agreed-upon tasks, assure follow-thru with assignments, and facilitate communication

Technical Expert(s)• Knows the department well and

understands the various processes and tasks of care – Understands the processes/tasks of entry

into the department– Understands the care processes within the

department– Understands the processes/task of how the

patient leaves the department

Meetings

• Schedules• Tasks• Effective meetings

Effective Meetings

• Develop a plan or purpose ahead of time

• Use agendas• Start and end on time• Review aim at each meeting• Take minutes• Review progress

Effective Meetings (cont.)

• Manage discussion• Deal with difficult meetings or

individuals• Celebrate• Close the meeting• Address environmental issues

Teamwork!

Outsid

e

Diagn

ostic

s

Beds

OR

ED

ICU

Teams

Team Meeting 1Objective 1: To refine and finalize your aims

for this collaborative.Objective 2: To refine team membershipProcess: • Select a recorder and a reporter.• Refine and record your aims

– Input delay– Throughput delay– Output delay

• Refine your team• Prepare to report back.