Improvement Science In

Action WebEx:

More on Chartering

Improvement Projects

Sandy Murray, Debbie Ray, Jonathan Merrell

April 8th , 2014

Oregon Health Authority

•Please join session by computer

first…

•If joined by phone first, please

hang up and dial back in at: 866-

469-3239

•Please follow directions and do

include participant #

WebEx Reminders

Please do not place your phone on hold!

Getting back in

Mute/unmute

Asking questions

– Hands, voice, chat

Your Program Faculty and Staff 3

Jonathan Merrell Faculty

Debbie Ray Faculty

Kathryn Brooks Project Manager

Sandy Murray Faculty

OHA – ISIA Participants 4

Org # Proj Org # Proj Org # Proj

AllCare (9)

1 Heath Share (5)

1 PrimaryHealth Josephine Co. (8)

2

Intercommunity CCO (3)

1 Transformation Center (7)

1

Cascade (2)

1 Jackson Care Con. (10)

2

Trillium (3)

1

Columbia Pacific Co-ord Care (4)

1

OHA (non DMAP (8)

2?

Umpqua HA (3)

1

Cover Oregon –OHA (1)

1

On Track (1) Western OR Ad.Health (13)

2

DMAP (OHA) (1)

1 Oregon Consensus (2)

Xxxx Willamette Valley CH (4)

Eastern Ore CCO (5)

1 Pacific Source Central OR (8)

1

Yamhill Co. (8)

2

FamilyCare, Inc (6)

Pacific Source Columbia (11)

1

Agenda: 60 min. Call #2 Charters, OHA ISIA

Time Topic Lead

12:30 – 12:35 pm PT

Welcome, Check-In, WebEx Reminders

Sandy

12:35 – 12:45 pm PT

Charter Background and Listener Role during Charter Presentations

Sandy

12:45 – 1:25 pm PT Charter Presentations and Feedback

Lesa-Dixon Gray Kristin Chatfield

1:25 – 1:30 pm PT Q&A – Close Session Sandy

Note

We decided not to use the Carey article

– It will not be found on your website

7

Some Norms

“All teach….all learn”

Respect for one another’s sharing

Sharing is at your comfort level

8

Where would you rate your current

skill level with Charters?

Information: Know what charter is

Skill: Can apply charter

in identified situations

Knowledge: Know how to use

charter, when, and where to use

Understanding experience; Can adapt charter to

need, explain why

Wisdom: Can teach theory and

use of charter

0- 20 21-40 41-60 61-80 81 -100

Use of the Model to ensure changes

are Improvements

Ref: API Model for Improvement

The Project Charter provides the set up for answering the three questions.

Driver Diagram

D1

D2

D5

D3

D4

Primary Drivers Secondary Drivers

Specific Ideas to Test or Change Concepts

AIM

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.

Example of a Driver Diagram

Get more specific and

say population and

what target rate is

Language: Oral Comprehension.

Increase by 20% on average children reaching a fluent level in the development of language: oral comprehension, writing and vocabulary in the five schools UBC-RM between October 2012 and November 2013.

Language: Vocabulary.

Language: Writing.

Socialemotional devalopment.

Increase exposure to oral texts.

Use reading comprehension strategies.

Introduce new words.

Reinforce new words during the week.

Emergent writing activities with a defined purpose and audience.

Room organization and behavior management.

Working on self control.

Reading fairytales.

Predict.

Summarize.

Reading story with precise definition and a friendly word

Involve representatives (family experience).

8 steps in vocabulary using more than one interaction per word.

Check the new Word at the end of the week.

Writing in block.

Set of ideas.

Rules and logical consequences.

Make connections.

Reading of non literary texts (Informative texts).

Song of standards for story.

Mark transitions (singing, instruments, etc.)

Give responsibilities.

Use sticks inquisitive / wand.

Specify the steps before developing activities.

Positive reinforcement.

Active breaks.

Sitting strategically.

Work in pairs.

Scaffolding.

Regulate participation.

Ear - mouth

Reading buddies.

Turn and talk.

Poster rules.

AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE CONCEPTS SPECIFIC CHANGES TO TEST

Project Driver Diagram

Carolina Valenzuela

Types of Change in a System First Order Changes

– Solve problems or react

– Return the system to prior condition

– Tradeoff among measures

– Short term impact

Second Order Changes

– Design or redesign of some aspect of the system; process, product, service or system as a whole.

– Necessary for improvement beyond problems

– Fundamentally alters the system and what people do

– Impacts several measures

– Long term impact

The Improvement Guide, 2nd edition, p. 78

Multiple Levels of Planning in the Organization

Inputs Planning Strategic

Objectives

Charters

and DD

Inputs Strategic

Objectives

Charters

and DD

Inputs Charters

and DD

Planning for

the Entire

Organization

Planning for a

Department

or Section

in the

Organization

Planning for

Other Group

Within a

Department

Section

Ref: API QBS 1-36

Planning

Planning

The Total Health

Care System

A P S D

A P

S D

Small-scale

tests of change

System or

Population of Focus

for the BTS (defined by team’s

Aim)

A P S D

System to be Improved: Criticality of Determining a

Pilot Populations

Primary Drivers Secondary Drivers

Driver Diagram: Reducing all-cause 30-Day Readmission Rates

Aim: • Reduce all-cause 30-day

readmission rates from 10.37% to 9.85% or less within 24 months

• This project: 5% reduction on two pilot units within 12 months

1. Perform an Enhanced Assessment of Post-Hospital Needs

2. Provide effective teaching and facilitate learning

4. Ensure post-hospital care follow-up

A. Involve the patient, family caregiver(s), and community provider(s) as full partners in completing an assessment of the patient’s home-going needs

B. Reconcile medications upon admission C. Create a customized discharge plan based on the

assessment

A. Involve all learners in patient education B. Redesign the patient education process C. Redesign patient teaching print materials D. Use Teach Back

A. Reassess the patient’s medical and social risk for readmission

B. Schedule timely and appropriate follow-up care

3. Provide real-time handover communications

A. Give patient and family members a patient-friendly post-hospital care plan that includes a clear medication list

B. Provide customized, real-time critical information to the next clinical care provider(s).

C. Warm handover for high-risk patients Outcome Measures: 1. 30-day all cause

Readmissions 2. Patient and family

satisfaction with transition out of the hospital

3. Patient and family satisfaction with coordination of care in community

Balancing Measures: Re-hospitalization rates 1. 30-Day All-Cause

Readmission to Observation Status

2. Emergency Room Visits within 30 Days of Hospital Discharge

Jacob Lippa

Charter Presentations

Presenter’s role

– Present your Driver Diagram and Charter (12-14 min.)

– Allow time for questions and feedback (4-5 min.)

Listener’s role – Active listening

– Constructive feedback…what could be strengthened?

– Your lessons learned from this charter/DD

What are we trying to accomplish?

– General Description (briefly defines WHAT broadly)

– Reason for the Effort (Problem statement; defines WHY important)

– Expected Outcomes (defines WHAT specifically, still not HOW, are numeric)

How do we know that a change is an improvement?

– Feedback, Measures or Indicators: define the measures that will be used to

monitor the impact of this 3-9 MONTH improvement effort:

– Connect clearly to aim (to the outcome we are after)

– Can measure at least monthly

What changes can we make that will lead to improvement?

– Initial activities, changes to test

– Boundaries or guidance

– Resources

– Sponsorship

Team composition

– Size (5-8 suggested)

– Subject matter expertise (including client or patient)

20

Charter Presentations

OHA-PHD-Maternal and Child Health

– Lesa Dixon-Gray

Pacific Source Community Solutions

Coordinated Care Organization, Central

Oregon Region

– Kristin Chatfield

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

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

24

OHA ISIA Agenda At A Glance, April 30th to May 2nd, 2014

Time Wednesday, 30 April Thursday, 1 May Friday, 2 May

7:15-8:00 Breakfast and Registration Breakfast Breakfast

8:00-8:30 Intro, Welcome, Overview Opener and Review/Questions Opener

Run charts The Third Question: Getting Great Ideas

for Change: Change Concepts-

Application to Project

Overview of Science of Improvement

Application to Project

Strength Deployment Inventory

Reliability Science and Your Project-

Application to Project Model for Improvement

Testing Changes 6 Essential Skills for Improvement

Lunch (1 hour)

The First Question (Aim, Charter, Driver

Diagram, MUSIQ, Charter assessment)

Application to Project

Strength Deployment Inventory Accelerating Testing

Application to Project Teamwork Skills

The Second Question (Measurement,

Family of Measures, Outcome, Process,

Balancing)

Application to Project

The Third Question: Getting Great

Ideas for Change (Logical methods,

use of data, Flow Charts, Fishbone,

Affinity, Force Field Analysis

Understanding Variation (Pareto,

Histograms, Scatter and Intro to

Shewhart charts)

Graphical Excellence

Generating Ideas: Creativity Methods

Close 5:45 Clarification of Next Day and Homework

Assignments

Clarification of Next Day and

Homework Assignments

Clarification Upcoming Calls and

Assignments End 4:00

6pm -7pm Office Hours (Team Consultations) Office Hours (Team Consultations)

Prework Assignments 25

• If you haven’t yet listened to Pre-Work call recording please

do so before the Workshop

– https://ihi.webex.com/ihi/lsr.php?RCID=96831286bd4c459fa8c578de

b3e1e3e0

1. Develop a draft charter and driver diagram

– If you would like faculty review prior to our workshop please send

(between now and 14 April) – debbieray.quality@gmail.com

2. Use the MUSIQ tool to determine MUSIQ score for the

project

– Best if done with your team but, if not team yet do from your

perspective

– Bring MUSIQ results to ISIA Workshop-we will use it there

– MUSIQ file accessible on your ihi.org site for ISIA

Logistics: Workshop April 30th-May 2nd 26

1. Conference begins with breakfast at 7:15 a.m., April 30th. Instructions

begin at 8 a.m. The conference concludes at 4 p.m. on Friday, May

2nd.

2. Remember to reserve your room at the Eugene Hilton. See flyer or

contact your Innovator Agent for details.

3. Make certain that you bring adequate copies, or electronic capability, of

your charter and DD to the Workshop with which your team can work

– Your team will use workshop time to review/revise/improve charter and

DD and further develop your project.

4.Bring an IBM compatible laptop with Excel on it (1 per 2 people) for use on

our second day in order to practice building run charts with template.

- Must have administrative rights so you can load an Excel file.

- Template on IHI web site for ISIA

Our Next WebEx Charter and Driver Diagram Call (1.5 hours)

– Thursday, May 22nd

– 12:30-2:00 pm PT

We will need volunteers to share –we will solicit at the

Workshop

– Revised Charter and DD

– Measures

– PDSA Cycles

Connection Information • 1. Go to https://ihi.webex.com (Note: There is no “www” in the address.)

• 2. Join the session titled OHA-IHI Improvement Science in Action Pre-

work Call (you’ll need to enter your name and email address)

• 3. Once you’ve joined the session, dial in by phone:

• Phone number: 866-469-3239

27

Contact Information 28

For all questions about the program, contact:

Monica Hammer, Transformation Analyst

monica.hammer@state.or.us or 971-673-2832

If you want review prior to the ISIA Workshop send

your draft charter and driver diagram to: Debbie Ray, Faculty

debbieray.quality@gmail.com

Your Questions Are Important 29

Can speak them, “chat” them, raise hand….just please do ask them!!