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HRET HIIN Virtual Event: Foundations for Change Fellowship
Sustaining Improvement
Wednesday, October 18, 201711:00 – 12:00 p.m. CT
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Welcome and Introductions
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Mallory Bender, Program Manager, HRET
Agenda
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11:00-11:05 Welcome and Introduction Mallory Bender, HRET
11:05-11:15 Action Period Discussion• Watch: Is There a Secret to Sustaining Improvements?• Read: IHI’s Sustaining Improvement White Paper• Review: Seven Spreadly Sins
Kathy Duncan, IHI
11:15-11:35 Can We Facilitate Adoption? • Identify stages of adoption and identify attributes that facilitate adoption • Describe activities that support implementing, sustaining, and spreading
changes
Kathy Duncan, IHI Lauren Macy, IHI
11:35-11:45 Sustainability Framework • Recognize key drivers of sustainability• Identify opportunities to assure drivers of sustainability are present in
improvement in which you play a part
Kathy Duncan, IHILauren Macy, IHI
11:45-11:55 Action Period Assignment • Complete Self Assessment • Complete and email your project summary report to [email protected] before
Friday (10/20)• Invite your manager to join us for the Nov. 8th Celebration call • Invite any colleagues that you may know of that would benefit from the QI
fellowships beginning in January 2018
Kathy Duncan, IHI
11:55-12:00 Bring it Home Mallory Bender, HRET
Foundations for Change Scheduled Sessions
January 18 – The Case for Improvement
May 10 – Multiple Cycles, Multiple Tests
February 1 – Take your Aim – What are We Trying to Accomplish?
June 14 – Manage Time and Attention
February 15 – What Changes Can We Make That Will Result in
Improvement?
July 12 – Be the Coach
March 1 – Map Your Course August 9 – Treasure Chest: Shadowing a Patient
March 15 – How Will We Know That a Change is an Improvement?
September 13 – Identify and Spread Improvement
March 29 – Empower Teams to Engage in Improvement
October 18 – Sustaining Improvement
April 12 – Know Yourself, Know Others
November 8 – Celebration!
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What has been your biggest “aha” moment or key learning during the fellowship?
Quality Improvement does not have to be so complicated. Start small, and go from there.Things do not move as fast as you think they do. People have different priorities.…I realized I couldn't run this race alone.….. getting a true understanding of what quality improvement is. To make a change you have to start small, and you do not need all the answers before you start to implement programs.
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What has been your biggest “aha” moment or key learning during the fellowship?
....how to accomplish a small test of change before you invest a lot of time and effort to a process that may or may NOT work. …quality improvement does not have to be complicated. Start with small changes and go from there.As someone who is new to the Quality area of nursing, the biggest "aha" moment for me has been how complex and detailed the change process is -- PDSA cycles, driver diagrams, data -- and how to use the use the different tools. Even though this fellowship has been very informative, I still feel like I have much to learn
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Assignment
• Review: Poster "Seven Spreadly Sins"• Watch: Is There a Secret to Sustaining
Improvements?• Read: Sustaining Improvement White Paper
Just a note…….Project Summary Review Due October 20
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“Adoption” is a powerful word
What does the word adoption mean to you?
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AdoptionCan We (I) Facilitate Adoption?
Utilize a sequence of activities that guide the development, test period,
and implementation of an improvement
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Create Adoption Mechanisms
• Engage leadership• Build a communication plan • Identify and utilize existing networks and social
systems • Foster a culture of urgency and persistence
Moving Adopters from Decision to Action
• Information about the changes• Mentors, coaches, or experts to get answers to
questions• Connections with peers• Feedback • Accountability for results• Encouragement and support from leaders
Adoption is a SOCIAL thing!
A better idea…
…communicated through a social network…
…over time
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
Stages of Adoption
1. Awareness2. Persuasion3. Decision4. Implementation5. Confirmation
Prochaska J, Norcross J, Diclemente C. In Search of How People Change, American Psychologist, September, 1992.
Can We Facilitate Adoption? Yes!
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Relative Advantage Simple Trialable Compatible Observable
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.
Grounding in the Model for Improvement
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“Everyone in healthcare should have two jobs: to do the work,
and to improve the work.” Paul Batalden, MD
Sustaining improvements and Spreading changes to other locations
Developing a change
Implementing a change
Testing a change
Theory and Prediction
Test under a variety of conditions
Make part of routine operations
The Sequence of Improvement
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Tools to change a system: Joseph Juran’s Trilogy
Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999
Quality Planning: Understand needs
of the customer
Quality Improvement:
Improve the Work
Quality Control: Manage the Work
Tools to change a system: Joseph Juran’s Trilogy
Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999
Quality Planning: Understand needs
of the customer
Quality Improvement:
Improve the work
Quality Control: Manage the Work
Management system is organized to anticipate and detect defects,
maintain stable operations, respond to abnormalities
Tools to change a system: Joseph Juran’s Trilogy
Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999
Quality Planning: Understand needs
of the customer
Quality Improvement: Improve the work
Management system mounts coordinated projects to improve
process capability
Quality Control: Manage the work
Tools to change a system: Joseph Juran’s Trilogy
Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999
Quality Planning: Understand needs of the customer
Establish a culture of high performance management. Positive trust relationship encourages and sustains frontline staff
engagement in QC and QI
Quality Improvement:
Improve the work
Quality Control: Manage the work
How do Leading Organizations Sustain Changes?
• All 10 systems conducted their front-line operations in strikingly similar ways
• Specifics varied regarding execution
• Consistent presence of a central actor, the front-line unit manager
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Focus on Front-line Management
It’s About Paying AttentionOur research and testing has led us to conclude:
“The key to sustaining improvement is to focus on the daily work of frontline managers, supported by high-
performance management system that prescribes standard tasks and responsibilities for managers at all
levels of the organization.”
Improvement alone is not enough. 24
Source: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)
Source: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)
S1: Standardization
S2: Accountability
S3: Visual Management
*S4: Problem Solving
*S5: Escalation
*S6: Integration
S7: Prioritization
S8: Assimilation
S9: Implementation
S10: Policy
S11: Feedback
S12: Transparency
S13: Trust
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The Secondary Drivers seem like a great “checklist” for Sustainability
Drivers of Sustained Improvement
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Aim – Improve and sustain
improvement performance
Quality Control
Standardization
Accountability
Visual Management
Problem Solving
Escalation
Integration
Quality Improvement
Culture of High Performance Management
Standardization
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What Standardization Is What Standardization Is Not
• Standard work for roles within the unit and at every organizational level
• Agreed to and developed with staff input
• Clarifies; a set of mutuallyexclusive tasks and responsibilities
• A completely comprehensive cookbook for how everything is done
• A set of parameters that constrain action and make the work harder to do
Do you have standardized processes?
How do you know? 29
Quick Check-in
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• Ask five people to describe a process• Do you get five different answers? • How much consistency is there?
Accountability
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Develop standard
work
Introduce standard
work
Observe standard
work
Record observations,
surface opportunities
Sustaining changes that work: Moving to standard work
Visual Management
• Links together other drivers• Integrated into daily huddles
to provide frame of reference
• Provides insight into observation of standard processes (accountability)
• Lists current improvement efforts and supports problem solving
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Problem-solving
• Examples of problem-solving methods and skills– Model for
Improvement– Lean Methods– Root Cause Analysis
• Supports all activities in the system– Management methods
introduced via PDSA cycles (huddles)
– Without problem-solving, management system surfaces problems that go without solutions
– Solving problems surfaced keeps staff engaged
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Integration• ‘Vertical’ Integration across levels of management
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Role Exemplary practicesSenior Leader
Senior walk rounds, enterprise visual management board
Middle Manager
Focus on accountability, observation of standard work horizontally and vertically; regular coaching of frontline staff on problem-solving escalation
Front line Comprehensive focus on standard work, rhythm of daily huddles to surface and solveproblems and prioritize improvements
Escalation (verb)
• Meaning: to increase in intensity, magnitude, etc.,• There must be a path to escalation• Staff must know what it is• The path to escalation must not fail
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Escalation
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Operationalizing the Model
• Standard work for managers • Accountability • Visual Management • Problem-solving and escalation • Integration • Escalation
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Operationalizing the Model• Standard work for managers
– Anchored by daily huddles • Accountability
– Regular review of safety standard work• Visual Management
– Visual management boards• Problem-solving and escalation
– Introducing standard problem-solving policies and education• Integration
– Tracking standard work across the organization and engaging top-level leadership
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Quality Improvement (Overlapping)
Aim – Improve and sustain
improvement performance
Quality Control
QualityImprovement
Problem Solving
Escalation
Integration
Prioritization
Assimilation
Implementation
Culture of High Performance Management
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Prioritization
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• Prioritization is a skill. Learn it. Practice it. Verbalize it.
• Assure that the aim is clear – so priorities are based on strategic goals.
• Assure staff understands aims and boundaries.
Assimilation
• Assimilation - Works very well to get new employees oriented to the process that you want right off the bat. They have no preconceived ideas, and it’s easy to get them in the habit.
Makes the "older" staff want to do it as well because the "newbies" aren't going to show
them up.
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Implementation
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Hunches Theories
Ideas
A PS D
A PS D
Investigation Demonstration Implementation
Unless changes are integrated into "daily work", changes will not stick. E.g. job descriptions and job training following current best known methods, link to supervision, etc.
Implement – Make a change a permanent part of the day to day operation of the system
Kevin Little, PhD, Informing Ecological Design, LLC ”
Operationalizing the Model
• Prioritization • Assimilation• Implementation
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Operationalizing the Model• Prioritization
– Understand the boundaries. Allow those closest to the issue to prioritize next steps
• Assimilation– Assure reliable process for new staff to know
how you ‘do work’
• Implementation– Implement a process such as bedside rounds,
methodically, assuring adaptations are appropriate
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Culture of High Performance Management (Overlapping)
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Aim – Improve and sustain
improvement performance
Quality Control
QualityImprovement
Culture of High
Performance Management
Problem-Solving
Escalation
Integration
Policy
Feedback
Transparency
Trust
Policy
• Make sure that policies are in line with current improvement projects
• Purposeful simplification of policies – Think 5• Rotate responsibilities• Remember the 80/20 rule
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Feedback
• Yes it matters, it especially matters to you and from you
• Near Misses are richLeaders: 1. Stop Talking2. Listen (you’re getting
feedback)
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Transparency and Trust
Tell. The. Truth.The more staff understands what you are trying to accomplish, the more they are willing to reach for higher goals. (Never met a clinician who didn't want to provide good, quality care.)
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Operationalizing the Model
• Policy• Feedback• Transparency• Trust
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Operationalizing the Model• Policy- Rotate responsibilities. Keep it simple. Does it make
sense?• Feedback- When rounding, reach out to several staff,
complementing the work demonstrated on the Visual Board; Know the NP, Environmental and administrative secretaries.
• Transparency- Visual board can be a place for bed huddles, safety huddles, etc. – so that info is right in front of you. Find something nice to say – acknowledge the good with all. Discuss the opportunities with leaders only.
• Trust- Earn it. Get back to them. Email outcomes. Do what you say. Eat in the cafeteria 3x week.
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Action Period Assignment
• Complete Self Assessment • Complete and email your project summary
report to [email protected] before Friday (10/20)! • Invite your manager to join us for the Nov. 8th
Celebration call • Invite any colleagues that you may know of
that would benefit from the QI fellowships beginning in January 2018
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Project Summary Template
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Project Summary due: October 20th
Celebrate!
• NOVEMBER 8! • Invite your Friends
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Bring It Home
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Mallory Bender, Program Manager, HRET
Submission and Other Items
• Please send your final project to [email protected] October 20, COB.
• TELL YOUR FRIENDS! We’ll start again in January.
• We will be sending out a final survey in the next week or so, so keep your eyes peeled!
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THANK YOU!
Next call: Wednesday, November 8, 201711:00 – 12:00 pm CT
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