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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
Atlantic Node
What Worked Well
• The content and presentations
• Sharing by Participants
• Engagement
• Use of Examples
• Polls/Feedback
• Being able to ask questions
Atlantic Node
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
Atlantic Node
What Worked Well
• Hearing while seeing, coordination
• Having interaction with colleagues from the provinces and regions
Atlantic Node
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
Atlantic Node
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
Atlantic Node
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
Atlantic Node
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
Atlantic Node
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
Atlantic Node
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
Atlantic Node
Atlantic Node
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
Atlantic Node
Individual Data Collection Form
Notes:1.Walk-In (pt.#1) – “1st medical contact” usually same as “Arrived ED”2.Transport by Ambulance (pt.#2) – “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”
Atlantic Node
Elapsed Time by Pt Worksheet
Automatic calculations
Now on second worksheet = Elapsed
Time by Pt.
Atlantic Node
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
Atlantic Node
Elapsed Time by Pt Worksheet
Number of teams meeting criteria w/i 30 mins and those not meeting criteria w/I 30 mins
Atlantic Node
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
Atlantic Node
Contact information
Central Measurement Team
Virginia Flintoft [email protected]
Alex [email protected]
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
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
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
“Some is not a number. Soon is not a time”
Donald Berwick, MD
Institute for Healthcare Improvement
Bold Aim, Firm Deadlines
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
• 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
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
• Using the Change Package select, modify, or add change ideas and record them in your Charter
.
Exercise 3
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
• 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
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”