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4/17/2014
1
Improvement Science in Action:
Driver Diagrams & MUSIQ
Oregon Health Authority
April 30, 2014 Jonathan Merrell
API, Inc.© All Rights Reserved. S
Objectives
1. Describe the components and utility of a Driver Diagram
2. Evaluate your Driver Diagram. Identify improvements if applicable
4/17/2014
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What is a Driver Diagram?
API, Inc.© All Rights Reserved. S
A tool for organizing information that displays our theory of what will drive improvement in an improvement project as we seek to answer the first question in the Model for Improvement - “What change can we make that will result in improvement?”
Driver Diagram Definitions:
• A Driver Diagram is an improvement tool used to organize theories and ideas in an improvement effort. It displays visually, our theory about why things are the way they are and/or potential areas we can leverage to change the status quo. The driver diagram is often used to scope or size a project and to clarify the plan for reaching the aim.
• Primary Drivers: major processes, operating rules, or structures that will contribute to moving towards the aim.
• Secondary Drivers: elements or portions of the primary drivers. The secondary drivers are system components necessary in order to impact primary drivers, and thus reach project aim.
• Specific Changes/Change Concepts: Specific changes are concrete actionable ideas to take to testing. Change concepts are broad concepts (e.g. move steps in the process closer together) that are not yet specific enough to be actionable but which will be used to generate specific ideas for change. Note: measures can be indicated on the DD as it becomes more mature.
S
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A Theory of How to Improve
Primary
DriversOutcome
Secondary Drivers
(processes, norms,
structures)Changes
Aim:
Expresses
stakeholder
value!
P. Driver
S. Driver 1Change 1
P. Driver
S. Driver 2
S. Driver 3
S. Driver 1
S. Driver 2
Change 2
Change 3
Cause Effect Drives
System for Improving Oral Health
Reduce burden of dental
disease
• % pts with new
cavitation
• % pts complaining of
pain
• % of pts with OR Tx
Outcome Primary DriversSecondary
Drivers
Active, informed families
Reliable delivery of
evidence based
preventive & restorative
care
Patient oral health literacy
Community support
• CHCs, private dentists,
pediatricians, PCPs
• Payers
Early, regular risk-based
evaluation & guidance
Use of conservative
procedures
• Fluoride exposure
• ART
Patient self management
• Improved diet
• Improved hygiene
Improved patient access:
‘Dental Home’
Qualified OR Tx
Team-based care
Coordination with PCPs:
referrals
Balancing demand and
capacity
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Driver Diagram Template
D1
D2
D5
D3
D4
Primary Drivers Secondary Drivers
Specific Ideas to Test or
Change Concepts
AIM
Measures: (Outcome, Process, Balancing)
Driver Diagram to Reduce Surgical Mortality
Driver Diagram: A Primary Tool for QI
S
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R
Reduce Inpatient Falls on 4Cand 6WReduce falls to
<3.5/1000 patient
days and reduce
moderate or higher
harm from falls to
<0.1/1000 patient
days
Driver Diagram for Reducing In-Patient FallsAim Primary Drivers Secondary Drivers Specific Changes to
TestReliable
Assessment
Reliable Care
Patient and Family
Centered Care
Patient Condition
Good/reliable tools for assessment
Mental health
Frailty
Patient understanding of their own abilities
Physical strength/stability
Willingness of patient and carersto cooperate
Care plans regularly updated
Care plans are easy to use
Appropriate level of monitoring/supervision of patients
Timely assessment
Staff trained and know how to use assessment tools
Staff awareness/education
Falls noticed board/story board/hiddles
Fallsafe Care Bundle
Use of pressure pads
cctv or mirrors in corridors
Use of sitters for some patients
Slipper socks
New signs on doors easier to read
Patient understanding of their own abilities
Adapted from Gavin Sells, NHS Scotland, Wave 24 2011/2012Used with permission.
Format on Extranet--------------------Driver Diagram Early in Project
Used with Permission: Amy Topel, Wave 21
More Mature DD
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6
Malawi – Maternal Mortality
Phase Three: Receipt of Adequate and Appropriate Treatment
Family Friendly
Care
Effective
Support
Systems
Information
Driven Decision
Making
Clinically
Excellent Care
for Women
Clinically
Excellent Care
for Newborns
Elements of Effective
Obstetric Care
Key Drivers Ideas to Test
Prompt ID of Obstructed Labour
Prompt ID of need for CEOC
Control infection through protocols
Timely treatment of bleeding
Active management of 3rd stage
Motivated staff
Blood Availability
Floor Stocks Available
Prompt recognition and treatment of asphyxia
Routine classification to identify and track risk
Prevention, prompt recognition, and treatment
of infections/sepsis
Safe care to avoid hypothermia & promote b.f.
Individualized patient focused care
Respect and dignity of women maintained
throughout care
Proactive interpersonal communication
Regular collection/analysis of key data
Accurate and complete patient records
Maternal death and near miss audits
Measure patient, guardian, staff satisfaction
Go
al: 5
0%
Red
uction
in M
ate
rna
l an
d N
eo
nata
l D
ea
ths
Learning Structure for Reducing Waits and Delays in the Outpatient Orthopedics Department
Access to appointments
Waiting times during appointments
Shape the Demand
Match Supply to Demand: Clinic appointments and general radiography
Re-design Care
Processes
Key Drivers (Focus Areas)
Outcomes
• Partnerships between specialty and primary care practices
• Predicting patient demand • Adapt strategies to decrease
demand
• Link and coordinate schedules for office practices and procedures
• Manage case load and scope of practice
Interventions
Balancing Measures: Patient Satisfaction Physician Satisfaction Staff Satisfaction Throughput Costs
• Using TPS strategies, design work processes that are reliable, adaptable, and continuously improving
• Reduce complexity and streamline patient flow
• Build care teams to maximize the time and expertise of specialists
•Provide an assessment and recommendations of current outpatient, inpatient, and diagnostic scheduling practices
• Develop measurement system to manage fluctuations in supply and demand • Create contingency plans
• Optimize the care team • Predict and anticipate patient needs • Reduce complexity • Standardize
. Treat work as a series of experiments • Address problems immediately • Disseminate solutions
Specific Approaches
Process Measures: Continuity Appointment demand Appointment supply No-show rates Appointment cycle time Case load New referrals Physician and Midlevel FTE
• Work down the backlog • Decrease demand for visits • Use scheduling system to smooth demand • Plan for seasonal events
•Input equity •Reduce scheduling complexity •Service agreements •Graduate to referring physician
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Driver Diagram – Catheter Associated Urinary Tract Infections
Correct
indications
Daily reviews
Engaged leaders
Effective infection
control
Prompt removal
Primary Drivers Secondary Drivers
Specific Ideas to Test or
Change Concepts
Hand hygiene
Sterile technique
Collection bag positioning
Sample collection
Communication
Teamwork
Forcing functions
Reduce reactheterization
Failures “front of mind”
Document decisions
Identify failures
Hardwired process
Attention to improvements
AIM
Reduce CAUTI by
30% compared to
the 2010 baseline by
August 31, 2013
Standardize order forms
Daily huddles
Script rounds/daily huddles
Involve pts/caregivers
Visible reminders for aseptic technique
Assemble insertion kits
Educate ancillary staff
Make post-op removal the default option
Develop contingency plans for retention
Report CAUTIs monthly
Present patient stories
Leadership reality rounding
Make results visible on units
Outcome measures
- # CAUTI
- Rate/1000
catheter days
Process measures (from
Primary & Secondary Drivers)
- % urinary catheters removed
POD 1 or 2
- % meeting insertion criteria
- % assessed for ongoing
need
Balancing Measure(s)
Pt satisfaction
Employee
satisfaction John W. Young, MBA RN National Association of Public Hospitals and Health System
Ann Brown, Wave 23
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Identify patients who should have colon cancer screening and have not received it
Increase access to colonoscopies
Facilitate delivery of evidence-based care in colon cancer screening
Decrease •Waiting time between referral and colonoscopy •Waiting time for results of colonoscopy Increase • Colon cancer screening rates • Direct colonoscopy referrals through EMR • Results of colon cancer screening in EMR
Whole panel performance reports
Preventive care EMR flowsheet (individual patients @ each visit)
Use Direct colonoscopy Navigators (facilitated communication, preps, directions, scheduling)
Referral to Direct colonoscopy from inside the EMR
Communication/care coordination between GI and referring PCP (f/u interval, pathology findings)
Improving Colon Cancer Screening at Internal Medicine Faculty Practice
Primary Drivers: Secondary Drivers:
Aim
9-22-07
IHI
Specific Changes:
Calie Santana, Wave 21
• Link colonoscopy database with EMR for automatic result reporting into the flowsheet
•Generate bimonthly reports of colon cancer screening rates and actions taken by providers and work toward goal rate of 80%
• Create a referral form
for Direct colonoscopy in the EMR
• Create a benchmark for time from referral to colonoscopy schedule (access to test), and time from referral to Navigator completed all necessary steps (efficiency of program) and work towards benchmark goal
• Review current workflow of result communication in the EMR
• Develop workflow that minimizes data entry by referring provider
Identify severe sepsis early in ED patients
Provide appropriate, reliable and timely care to patients with sepsis/severe sepsis using evidence-based therapies
Coordination of treatment services
Create team process to support sepsis therapies
Decrease
•Mortality
•Complications
•Costs
•LOS
Improve
•Sepsis/Severe Sepsis Bundle Compliance
• Early recognition of severe sepsis/septic shock
•Recognizable, reliable language standards for sepsis care
Education/communication to frontline staff
Uniform Sepsis Screening/Sepsis Screening tool
Sepsis Algorithm and Standard Order Set
Bundle elements: Antibiotics within 180 mins and after blood cultures Serum lactate w/in 30 min Fluid challenge eligibility/delivery
Contingency team for 1st 24 hours of sepsis trigger
Pharmacy
Lab
Caregiver communication
Improve Severe Sepsis Care and Reduce Sepsis Mortality
Primary Drivers: Secondary Drivers:
Desired Outcomes:
Organized team methodology for patient care transitions
Josephine Melchione, Wave 21
Specific Changes:
??
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Primary Drivers Secondary Drivers Change Concepts Specific Change Ideas
Knowledge of
medications
Discussing medication
benefits and side effects
Eliciting concerns and
questions
Focus on the outcome to a customer
Listen to customers
Reach agreement on expectations
Coach customers to use a
product/service
Optimize level of inspection
Script to aid discussion
Shared decision making
model
Document decision of
patient/carer
SALT assessment of identify
best means of
communication
Patient/carer satisfaction
and experience of
medication discussions and
usage
Effective
communication
Communication aids for
aphasic patients
Involve carers
Medication Delivery
System
For those with cognitive
impairment
For those with functional
limitations
Patient choice
Use reminders
Use differentiation
Use constraints
Use affordances
Follow up compliance
check(need to decide OPD,
telephone call, home visit,
questionnaire, etc)
Documentation of how
medications will be taken
and delivered
Coordination of care
Incorporate into weekly
MDT meeting
Ensure medications dose,
frequency, route and
patient decisions stated
on discharge letter to GP
Standardization
Desensitize
Improve predictions
Develop contingency plans
Manage uncertainty, not task
Match amount to need
Document in case notes
Document in discharge letter
to GP
Improve
Medication compliance in stroke patients by 50%
Aim
Asan Akpan, Wave 21
Identify & rescue worsening patients
Provide appropriate, reliable and timely care to high-risk and critically ill patients using evidence-based therapies
Create highly effective multi-disciplinary team
Integrate patient & family into care so they receive care they want
Develop an infrastructure that promotes quality care
Decrease
•Mortality
•Complications
•Costs
Improve
•Satisfaction
Early Warning System
Rapid Response System
Protocols and Standing Orders
Bundles
Care planning
Reliable communication
Family involvement
Clarification of wishes
End of life care
Consistent care delivery
Flow
Leadership
Financial Stewardship
Driver Diagram: Improving Outcomes for High-Risk and Critically Ill Patients
Primary Drivers: Secondary Drivers:
Desired Outcomes:
Specific Changes:
See next page
Example: Another way to
organize change package:
Driver Diagram
Driver Diagram IG: PP. 286,412,429
4/17/2014
10
Primary Driver Secondary Driver Key Change Concepts Specific change ideas
P1. Identify & S1. Rapid response system Implement a Rapid Response Team Standardize call criteria
rescue
worsening
Define response team members (including a
sponsor)
patients Establish protocols/guidelines
Educate units about when and how to call
Create process to gather data about calls
Use steering committee for development
and on-going testing oversight
Perfect triggering Review call criteria effectiveness
Test/Add an Early Warning System
Review missed opportunities (e.g.
unscheduled transfers to ICU)
Work towards "goal" call rate
Perfect responding Develop discipline-specific criteria for team
members
Review team performance in three spheres:
care provided, response time, and caller
satisfaction
Develop tool box to be brought to activations
(examples: i-stat, IV tubing, lab tubes, BP
cuff, documentation form)
Do case review
Track response time
Perfect evaluation Review overall process to evaluate need to
improve
Develop data tool for tracking
S2. Early warning systems Use objective measures to assess disease severity Test a measurement tool such as MEWS
Use an overall bed-board to assess layout of
unit
Create a process for use of scoring tools Create rules for when to call RN, MD, and
activate system
Improve identification of severe sepsis Apply the Evaluation for Severe Sepsis
Screening Tool in clinical areas such as the
ED, wards, and ICU
Have nurses and Rapid Response Team
complete severe sepsis screening
P2. Provide
appropriate,
reliable and
timely care to
high-risk &
critically ill
patients using
evidence-
based
therapies
S3. Protocols and Standing
Order Sets
Develop weaning protocol Pre-extubation worksheet
Create non-physician-driven protocol
Daily assessment of readiness to wean
Weaning trial when criteria are met
Avoid or minimize use of paralytics
Avoid fluid overload
Use NPPV when appropriate to avoid
intubation
Develop sedation protocol Avoid IV drips. Encourage IV push and
oral/enteral routes
Titrate to a sedation scale
Use daily sedation interruption
Restart sedation at 1/2 to 3/4 of dose
following sedation interruption as
appropriate
Match the drug to the symptoms (use
psychotropic medications for delirium and
agitation)
Reduce use of sedatives: awaken patients
and/or extubate rather than sedate; help
patients manage anxiety; use guided
imagery to comfort anxious patients
Establish criteria for restraints
Make appropriate use of restraints and
mittens
Let’s Construct A Driver Diagram
Re-Design your existing DD or Design a new DD for your project
Use the Aim of your Project
1. Work as a team please 2. Use flip chart paper and wall space or use your
laptop. 3. Quickly choose a recorder – 30 sec. 4. Identify primary and secondary drivers and ideas
for change. draw the diagram. (Measures are a bonus!) – __ minutes work time.
5. Each group will share results.
Recommended