Model for Improvement

Model for Improvement

What can we change that will

result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a

change is an improvement?

What are we trying to accomplish? AIM

MEASUREMENTCHANGE

PDSA –testing a change

MARUWhat is Maru trying to achieve?How many ideas does he try?Is he successful?What was the possible negative outcome?

From YouTube

Rapid Cycle Change

What can we change that will result in an improvement?

PLAN

DO

STUDY

ACT

How will we know that a change is an improvement?

What are we trying to accomplish?

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

AIM of this change: PROBLEM :

AIM of this change:

Do a PDSA to solve a problem at home

AIM: unpack the dishwasher in a more efficient way

PROBLEM : unpacking the dishwasher is inefficient

Put half the cups and half the glasses in the cupboard just above the dishwasher

How easy it is to unpack the dishwasher

- Tom to rearrange cupboard today

- -Mary and Tom to unpack into one cupboard for 4 days

Mary – it will look horrible and I will hate itTom – it will be easy and Mary will like it

Model for Improvement



PLAN

DO

STUDY

ACT



What are we trying to accomplish? AIM

MEASUREMENTCHANGE

Measurement

Are we getting closer to our target?

Outcome measure

Measurement

Did we use the whole bundlein every patient every time?

Process measure (Bundle compliance)

Measurement

Was the change an improvement?

Measuring the impact of a change

Measuring over time

• a volunteer to write

• a volunteer to measure

• graph paper

Annotated Run Chart

Community Need

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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0

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# pregnant women HIV tested at 1st ANC Visit

Change Made in June

Interpreting Data: what is the story?

Mar Sep0

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IBefore (Feb) After (Aug)

What is the real story?

Mar Sep0

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Jan Feb Mar AprMayJun Jul AugSep Oct NovDec0

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Jan

Feb Mar Apr

May Ju

n Jul

Aug Sep OctNov Dec

0255075

100125


JanFebMar AprMayJun Jul AugSepOct NovDec0

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Jan FebMar AprMayJun Jul AugSepOct NovDec0

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Change Made

Change Made

Change Made

Change Made in June

Feb Aug

Feb AugFeb Aug

Feb Aug Feb Aug

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Change Made

Prevention of Mother to Child Transmission.

A sub-district in a province in SA

Positive PCRs at 6 weeks (target <5%) Feb 2010 8.2%Feb 2011 3.2%

Improvement?

JUN 2009 FEB 2010 JUN 2010 FEB 20110

1

2

3

4

5

6

7

8

9

PCR positive rates

Positive PCRs at 6 weeks (target <5%) Feb 2010 8.2%Feb 2011 3.2%

Improvement?

Median

Shift: 6 points in row on same side of the median Note: A point exactly on the centerline does not cancel or count towards a shift

Median

Median

Trend: 5 points in row headed in same directionNote: Ties between two consecutive points

don’t cancel or add to a trend

Rule 3

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10

Mea

sure

or C

hara

cerist

ic

Median 11.4

Data line crosses onceToo few runs: total 2 runs

Run Chart: Rules for Identifying Statistically Significant Change

Rule 1 Rule 2

Rule 4Rule 3

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Astronomical Point: a obviously, even blatantly different valueNote: Every set of data will have a highest and lowest data point. This does not mean the high or low are astronomical

Runs: too few or too many runs

Provost and Murray

Run Charts• One of the most powerful tools for improvement

• Describe a process over time

• Shows trends the process is experiencing

• Can be used to analyse whether the change was an improvement

• Data can be used to drive change

Outcome measurement

Are we getting to our target?

Was the change an improvement?

How do we measure HAIs?

Measuring infection rates

Lessons from an ICU

Quality Improvement 101

Problem?

Measuring Infection Rates

• Total number of infective cases per 1,000 device days:

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Definition of VAP

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”

Overcoming Numerator Issues

Total No. of VAP cases

Ventilator daysX 1,000

Numerator

Denominator

Patients with

Overcoming Numerator Issues – diagnosing the HAI (workbook)

Checklists forDiagnosing the HA Infectionused by theteam

Overcoming Denominator Issues

At the same time every day theUnit managercounts devicesin use in the ward

Measuring HAI

Percentages and rates

% (or rate) = Numerator/ denominator

eg

Rate of infection = readmissions for septic caesarian section wounds per week / number of Caesarian Sections performed per week

Rate of infection = Number of VAP / 1000 device days

Safety CalendarWelsh 1000 lives campaign

IDeveloped by Annette Bartley

Welsh Patient Safety Project

Measuring HAI

The concept of ‘days between’ infections

For measure ‘rare’ events (occur < 10%)

Off the internet, Google pictures




Maternal deaths – Malawi

For the “NO Maternal Death” Campaign a colorful, laminated A4 paper that said “Days without a Maternal Death: ______”. were hung in every Labour Ward for all (providers, patients and guardians) to see and the number was filled in daily with a dry erase marker

Days between icecreams

Days betweenicecream

Icecream

1st 2nd3rd 4th 5th

510

15

20

25

Days between events (infection)

Days Betweenevents(egInfection)

Sequence of events (eg Infection)

1st 2nd3rd 4th 5th

510

15

20

25

Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana

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IMeasuring rare events and time-between measures. James Benneyan IHI

July Aug Sep Oct

5/7 13/8 7/9 5/10

5/7 9/9 8/10

6/7 12/9 15/10

11/7 15/9 19/10

25/7 20/10

27/7 21/10

25/10

ICU: Sequence of VAP infections by date 2010

Use the tools to Display the data

July Aug Sep Oct

5/7 13/8 7/9 5/10

5/7 9/9 8/10

6/7 12/9 15/10

11/7 15/9 9/10

25/7 20/10

27/7 21/10

25/10

Date of infection

# Days since last infection

Days Be-tweenInfection

Sequence of Infections

So far we have:

1.Mapped the size of the project in your facility2.Prioritise a unit and bundle to start with3.Written an aim

Now, write down:

1.Your aim2. Process Measures (Bundle compliance)3.The outcome measures

i) Rate = numerator/denominator (describe)ii) Days betweeniii) Welsh Safety Cross calendariv) Other

4.How you will feedback the data every month toi) The frontline staffii) ManagementMark with a * areas that you want to strengthen

Improving your Outcome Measure

1) NumeratorStandardised diagnosis of infection

2) What is the measure for HAI?Rate = Infection/device dayDays between (CLABSI, VAP, UTI)Days or cases between SSI

3) Collecting and collating data: What (definition)/ Where/ How (tools)/ Who/ When

4) Presenting the data:Format - Safety Cross, GraphsFeedback/presentation - Management platform

Note the areas that need strengthening1.Your aim2. Process Measures (Bundle compliance)3.The outcome measures

i) Rate = numerator/denominator (describe) *ii) Days between

iii) Welsh Safety calendar *iv) Other

4.How you will feedback the data every month to

i) The frontline staff *ii) Management ** Areas that need strengthening

Select a priority area for improvement

• resolving it will have a big impact• it is under your control to test a change• you can start on Monday

Establishing or Improving your outcome measure/s

Plan a PDSA using the Model for Improvement



PLAN

DO

STUDY

ACT



What are we trying to accomplish? aim

measurementchange

AIM of this change: PROBLEM :

Design a PDSA to improve one of the areas with a *

AIM: use the Welsh Safety Cross

PROBLEM : staff aren’t engaged in the project

What WhenWhereWhoHow

AIM increase awareness through measurement

AIM: the Welsh Safety Cross is completed

Staff know what it means

Welsh Safety Cross will improve the profile of the project. Will need to engage staff with colouring it in or they won’t take any notice

Documents

Model for Improvement