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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

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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.

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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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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

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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.