Sustaining Improvement in Daily WorkKevin Little, PhD – IHI Improvement Adviser

Jeff Rakover, MPP – IHI Research Associate

Richard Scoville, PhD – IHI Improvement Adviser

Learning Lab SL4

The presenters have

nothing to disclose

Sunday, December 10, 2017

#IHIFORUM

Presenters

Kevin Little, PhD – IHI Improvement Adviser

Jeff Rakover, MPP – IHI Research Associate

Richard Scoville, PhD – IHI Improvement Adviser

P2

Objectives of this Learning Lab

Distinguish between management for quality control,

quality improvement, and quality assurance

Use IHI’s quality control framework to design a system

for sustaining quality at the front-line

Create a plan for testing and implementing a quality

control system at your own organization.

P3

How Do Leading Organizations Sustain?

Interviews with 10 leading North American healthcare organizations.

Three in-depth case studies

Literature review

“By focusing first on implementing standard work with frontline clinical units and managers, such as a charge nurse or team lead, organizations can build a solid ‘bottom-up’ foundation for Quality Control and Quality Improvement that then supports more robust high-performance management at the system level.”

http://www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx

The Model for Improvement

© Associates for Process Improvement

How It’s Supposed To Work

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APD

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Ideas, suggestions, intuition

Implemented changes, reliable operations

Learning from data

Change ideas, suggestions, intuition

Permanent, reliable, sustained improvement!?

But What Goes Up…

Same old dysfunctional system

…Too Often Backslides!

Juran’s Trilogy

Reliability & Sustainability

Quality Trilogy

✓ Control

✓ Improvement

✓ Planning

P8

Definition of Reliability for Health Care

The capability of a process, procedure or health service to

perform its intended function in the required time under

existing conditions.*

The system’s ability to do what it is supposed to do, for

every patient, every time.

Reliable execution of standard process is the

‘platform’ upon which clinicians can best

exercise their craft.

Measuring Reliability

Reliability =

Number of Actions That Achieve The Intended Result

Total Number of Opportunities for Action

Reliability measures are very common, based on standard protocols:

• Percent of diabetic patients with foot exams at previous visit

• Percent of surgeries with checklist completed

• Percent of sepsis patients with antibiotics administered within 1

hour of recognition of sepsis.

• Percent of patients who received all VAP bundle elements

• Percent of service users seen within 28 days of referral

How to Maintain Reliable Performance?

Our 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 a high-

performance management system that prescribes standard

tasks and responsibilities for managers at all levels of the

organization.”

Scoville, R., K. Little, J. Rakover, K. Luther and K. Mate. Sustaining Improvement. IHI White Paper. Cambridge,

Massachusetts: Institute for Healthcare Improvement; 2016. IHI Whitepaper. Cambridge, MA, Institute for Healthcare Improvement. Avaliable at IHI.ORG.

Improvement alone is not enough.

Joseph Juran: The Quality Trilogy

Manage the work

Improve the work

Design and manage systems

capable of delivering quality

“Quality Control”

“Quality Improvement”

“Quality Planning”

Source: Juran Institute

The Trilogy in Action

Source: Juran Institute

Better

ImprovementControl

Control

?

How can we manage to build and operate systems that meet patient (client, customer) needs

consistently over time?

StandardWork

DoMonitor

Adjust

Plan

DoStudy

Act

ImprovedDesign

EscalateProblem?

Yes

ProcessAnalysis

ChangeIdeas

Quality Control

Quality Improvement

Exercise: Your System

1. Discuss with the person sitting next to you:

What key process are you focused on today?

What measure(s) could (do) you use to assess the

reliable performance of that process?

2. Share at your table:

Adapt PDSA Testing a Reliability Measure file to plan

a test of a reliability measure in your 'own' project next

week.

P15

Control Systems in Action (Part 1)

Drivers of sustained quality control

Example: Ambulatory Surgery

P16

Drivers of QC: A ‘Sustainability Model’ P17

Aim: Sustained, effective quality management

P1: Quality Control

P2: Quality Improvement

P3: Culture of high-performance management

Standardization

Visual Management

Problem Solving

Escalation

Integration

Accountability

Transparency

Trust

…

Drivers of Quality Control (for your notes)

1. Standardization: Once a process has been improved, sustaining it requires the

elaboration of standard work by staff in the service unit. Roles and responsibilities of staff

and front-line managers, along with detailed, checklist-based work routines are

documented, maintained, and monitored on a daily basis.

2. Accountability: Brief, daily front-line huddles involving unit staff and supervisors focus

the team’s attention on the performance of standard work. Regular review and

participation by higher level managers sustains the huddles, and provides opportunities

for managers to fully understand front-line issues and coach staff.

3. Visual Management: Simple data displays provide the backdrop for the daily huddles.

These displays show performance on key process indicators and outcomes over time, log

front-line problems and their disposition, and track the progress of improvement projects.

4. Problem-solving and Improvement: Huddles reveal everyday issues and difficulties

with standard work processes. Many of these can be speedily resolved by front line staff;

others require investigation and testing of possible solutions. Front line staff need basic

proficiency in techniques such as root cause analysis and Plan-Do-Study-Act testing to

achieve workable solutions.

5. Escalation: Problems that require substantial process redesign or inter-department

coordination cannot be solved at the front-line and may trigger a formal quality

improvement project. Emergent issues such as critical equipment failures or serious

patient harm may require immediate escalation to top management. Explicit procedures

are needed to triage problems and escalate them to the proper level of management.

6. Integration: Effective operational management and strategic improvement require that

the organization operate as a coordinated whole. Process goals, standard work, and QI

project aims must be integrated across organizational levels and coordinated among units

and departments through a standard planning and reporting process.

P18

How Does the QC System Work Together?19

Daily HuddlesObservation of Work

Problem Solving

Visual Management

Daily Standard WorkStandardWork

DoMonitor

Adjust

Integration✓ Strategy & Aims✓ Key Metrics

Escalation

Putting the Drivers to Work 20

• Standard work for managers

Anchored by daily huddles

• Accountability Regular review of standard work

• Visual management Making performance a daily concern

• Problem-solving & escalation

Appropriate responses to daily problems

• Integration Aligned standard work at all levels of the org chart

Drivers of QC: A ‘Sustainability Model’ P21

Aim: Sustained, effective quality management

P1: Quality Control

P2: Quality Improvement

P3: Culture of high-performance management

Standardization

Visual Management

Problem Solving

Escalation

Integration

Accountability

Transparency

Trust

…

AHRQ’s Safety Program for Ambulatory Surgery

Overview

✓ Funded by Agency for Healthcare Research and

Quality (AHRQ) as part of the National Action Plan to

Prevent Healthcare-Associated Infections (HAI)

✓ 665 registered ASCs from 47 States and DC

participated in 8 program cohorts

Objectives

✓ Reduce surgical infection and complication rates

✓ Improve safety culture through improved teamwork

and communication

http://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-

surgery/index.html

22

Where IHI’s Pilot Testing Came In

ASCs Engage in AHRQ Safety Initiative

Step 1

Engagement by cohorts of ASCs in the initiative

Step 4

Development of standard process to hardwire safety improvement efforts (e.g., embedded checklists in EMR)

Step 3

Improvement work to implement surgical safety checklist and sterilization practices

Step 2

Training in system-level safety practices (e.g., protocols to surface safety concerns)

Step 5Sustaining the gains

Operationalizesimple frontline management model:• Daily huddles• Visual management

boards• Escalation protocols

IHI’s Pilot Testing

Main testing took place over three month period

HRET improvement advisers assisted in site selection

and recruitment

Site visits were two-days, with assistance from quality

specialists working in the ASCs

Work focused on testing and implementing the

sustainability model

Sustainability at Andrews Institute

Andrews Institute for Orthopedics and

Sports Medicine

Commercial ASC in Gulf Breeze, FL

Approximately 6500 procedures per

year spanning numerous services

(orthopedic, gastroenterology, ENT,

podiatry, general surgery, urology,

pain management)

Site “champion” is a quality manager with deep expertise

in quality improvement methods as well as an RN and

national leader in ASC QI work

QI champion partners with site administrator who has

responsibility for day-to-day clinical management and

supervision

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Huddles “Anchor” Other Drivers P31

Visual Management

• Metrics viewed & remarked

• Team updates data daily

Accountability• Supervisors monitor

huddles, feed back huddle compliance to teams

Escalation• Team escalates issues

beyond its immediate control.

Problem Solving

• Team reviews / disposes current issues in huddle.

Integration• Team selects local

metrics that align with strategic goals.

Standard Agenda for a Daily 5m Huddle P32

1. Concerns, problems observed in past day:

• Patients

• Staff

• Process, equipment, etc.

2. Anticipated issues for today

3. Review of tracked problems

4. Input from staff

5. Announcements

Huddles – A Sequence of Tests

A Series of PDSA tests:

1. For one day: Can we huddle for no more than 10

minutes at the start of the day to look back and look

ahead?

2. For one week: Can we huddle for no more than 10

minutes at the start of the day for 5 consecutive days

using a standard agenda?

3. For one month: Can we huddle for no more than 10

minutes at the start of the day for 4 weeks using a

standard agenda?

P33

Exercise: Testing Huddles in Your System

Adapt PDSA Testing Daily Huddles file to your 'own'

project:

Design 3 sequential PDSAs to test huddles in your

system, to be completed next week:

✓ Where and when will the huddle(s) occur

✓ Who will lead them? What preparation is required?

✓ How will you know that the huddles are working well?

✓ How will you use the learning from each PDSA cycle

to inform the next?

P34

Control Systems in Action (Part 2)

Example: Greater Baltimore Medical Center

Visual Management

Involving Leadership

P35

Drivers of QC: A ‘Sustainability Model’ P36

Aim: Sustained, effective quality management

P1: Quality Control

P2: Quality Improvement

P3: Culture of high-performance management

Standardization

Visual Management

Problem Solving

Escalation

Integration

Accountability

Transparency

Trust

…

Visual Management: Huddling With Data 37

GBMC Healthcare, Inc. Baltimore, MarylandP38

Greater Baltimore Medical Center is a 281-bed acute care not-for-profit community hospital that opened in 1965.

Located on a 72 acre campus in Towson serving patients primary residing in Baltimore and Harford Counties as well as Baltimore City.

52,916 ED visits annually27,651 Surgical procedures (IP & OP)

3,893 Births

GBMC Vision Phrase and Quadruple AIM

Vision Phrase:

To every patient, every time, we will provide the care that

we would want for our own loved ones.

Quadruple AIM:

1. Better Health Outcomes

2. Best Care Experience

3. Least Waste (Lower Cost)

4. Most Joy for those providing

care

P39

Improvement Journey

Lean Journey – Begins 2010

• Waste Walks / Education

• Rapid Cycle Improvement (Kaizen) events

• Interdepartmental 4.5 day events

• Value-Stream Mapping or Transactional Process

Improvement

Fragmented Results / Culture not evolving

- Improvement interpreted as an event, not every day work.

- Tools learned are not used often. People lose confidence to

enroll others.

Lean Daily Management – Begins 2013

P40

Goals for LDM (Lean Daily Management)

1. Culture change. Improvement IS our daily work.

2. Front line engagement. Learn ability to see

opportunities and the tools to solve them.

3. Manager accountability. Identify the metrics, engage

team in problem solving, refine standard work/visual

management.

4. Executives as coaches/mentors and barrier busters.

Keep focus on our AIMS.

P41

Components of a LDM Department board P42

• Metrics tied to Quadruple AIM (Health, Care, Waste, Joy)

• Lots of RED. We are focused on our problems.

• Engagement of staff.

• Evidence of problem solving.

GBMC LDM gemba walk

9:00 AM Executive Huddle

Begin gemba walk. (5 teams/routes, 2 weeks per route)

Department LDM board presentation.

Post-walk huddle.

Share learning. Email to ALL staff on executive metrics

and learning.

GBMC LDM is conducted 365 days/year. On weekends

and holidays, the administrator on call walks to all of the

boards.

P43

LDM Executive Engagement

• Be present.

• Connect to vision.

• Say “Thank You”.

• Provide coaching

using inquiry.

• Remove barriers.

P44

GBMC Results

Prior to LDM (2011), patients experienced 216 Serious

Safety Events. (HAPU, CAUTI, CLABSI, SSI, Falls

w/injury.)

We have gone over 3 years without a stage III or IV

pressure ulcer.

We went over 2 years without an inpatient fall with

fracture

CAUTI reduction

of 92%

SSI reduced by 85%

P45

A Few Simple Rules…

1. Keep the aim of the Visual Management board in mind:

performance at a glance

2. The main users are you and your staff

3. Choose just a few items to start off

4. Choose items you can update regularly

5. Choose a space convenient for daily huddles to keep

your board

6. A dedicated whiteboard proves convenient, but you can

start with paper if easier

A Visual Management Board Example 47

Applying PDSA Thinking to Visual ManagementP48

PDSA Cycle # What question(s) are you trying to answer?

Preparation

Get Ready Can we draft a visualmanagement board?

Identify items that will work for your center. Find wall space to hang or write up. Plan to ask a couple of staff: “What do we need to know about the statusof our work unit every day?

1 For one day: Can we use the draft visual management board in a daily huddle?

Plan to refer to at least one item on the visual management board in the huddle. Default: Start with the reliability measure status

2 For one week: Can we use the board in a daily huddle and update it daily?

Update and use the board for five consecutive days. Your plan should include time of key huddle members to study what's working and what isn't.

3 For one month: Can we use the visual management board in a daily huddle and update it daily?

How will you track daily use and updates? Hint: Look for a visual way that is easy to use.

Exercise: Develop and Test your Visual Board

• Get Ready: Identify and sketch

ingredients for your 'own' project visual

board

--why is each ingredient necessary?

• Draft PDSA cycles 1-3 (as far as time

allows)

49

Problem Solving and Escalation

P50

Drivers of QC: A ‘Sustainability Model’ P51

Aim: Sustained, effective quality management

P1: Quality Control

P2: Quality Improvement

P3: Culture of high-performance management

Standardization

Visual Management

Problem Solving

Escalation

Integration

Accountability

Transparency

Trust

…

Accountability and Integration

Observation of standard work (huddle attendance and

gemba walk) are basis for next level leader standard

work.

Consider huddle of unit leaders to discuss inter-

department issues (e.g., sterilization, scheduling,

handoffs).

Expand observation beyond basic standard work (e.g., a

safety checklist) to multiple types of standard work (e.g.,

handoffs, patient education, longitudinal care)

Remember to report progress to senior leaders to ensure

continuous buy-in and help remove barriers to progress,

as well as to encourage use of similar systems at other

levels of organization (e.g., executive huddles)

Two Types of Problems

TYPE 1

Coping with the immediate issue; getting on with the

work

TYPE 2

Taking action so that the problem does not recur.

P53

Problem-Solving and Escalation

Examples of Problems 55

Type of Problem

Who Can Solve? Type 1 – Cope Type 2 - Prevent

Us • Find a staff sub• Borrow missing

supplies• Calibrate a device

• Change process sequence for flash sterilization

• Reorganize surgical packs to minimize missing items

Others • Call in additional staff for emergency situation

• Raise immediate safety concern

• Improve handoff to post-op to reduce wait

• Implement follow up calls with patients to coach on PT compliance.

Exercise: Examples of Problems

For your own process, generate examples for each of

the cells in the 2 x 2 table.

56

Who Can Solve Type 1 Type 3

Our Team

Others

Type of Problem

Exercise: PDSAs for Management Pull

Who should be invited to observe your huddles and

interact with you on problems that require help beyond

your team?

What do want to accomplish with the observation?

How will you know if you accomplished your aim?

Generate a sequence of PDSA cycles to test a link

between your daily huddle and 'next level' of management

in your 'own' project.

57

Problem-Solving: Some Tips

Problem solving aims to at reliable performance

If your organization has a standard problem-solving

method, learn to use it

Use root cause analysis to investigate and document

harm or other problematic events

Incorporate routine use of CUS or a similar method into

frontline work

Praise problem-raising, avoid blame.

Focus on causes and testable solutions.

P58

Summary and Wrap-Up

What We Have Learned So Far

P59

What We Have Learned So Far

✓ All elements support safety

standard work by staff

✓ Daily huddles anchor visual

management and

accountability (and most other

elements)

✓ Problem-solving and esca-

lation are linked

✓ Integration supported by rigor,

sound practice below

1. The elements of the sustainability model are mutually re-enforcing.

What We Have Learned So Far

2. Daily Huddles Provide the Ritual for Paying Attention

to Process

Empower staff –gives everyone a voice; culture is blame-averse

Forum for problem identification and tracking solutions

Visual management at huddles keeps quality metrics in view

Daily rhythm builds habits, gives management system visibility and structure

What We Have Learned So Far

3. QI skills are indispensable for implementing the

model

Standardization QI skills support development and introduction of standard work (e.g., MFI); ability to develop hypotheses and run small tests of change

Accountability Manager front-line presence and QI skills support team engagement in huddles and other standard daily work

Visual Management

Visual board tracks problem solving and current QI projects; data provide feedback on key process metrics and improvement

Escalation Staff use QI to solve local small-scale problems themselves; complex problems require process redesign use QI

Integration QI projects aligned with organization’s strategic priorities and mission.

What We Have Learned So Far4. Problem Solving and Escalation Both Needed

A Management System Architecture: Standard Work for All

Don’t Forget about your Staff! P65

Aim: Sustained, effective quality management

P1: Quality Control

P2: Quality Improvement

P3: Culture of high-performance management

Standardization

Visual Management

Problem Solving

Escalation

Integration

Accountability

Transparency

Trust

…

Where to Start?

Choose a pilot unit with certain characteristics

Stability: Low staff churn, few symptoms of

burnout

Alignment around goals: Managers

understand what’s expected of them, how

their work is going to change, why the

changes are important.

Management ‘hygiene’: Regular

management practices are in place; effective

budgeting, relatively stable processes

Engagement: Have a respected local

champion who can build excitement for

change, encourage participation, coach,

celebrate success

P66

Where to Start? – 2

Consider the type of unit as well:

P67

Easier

• Currently defined standard processes; may resemble an assembly line

• Examples:✓Surgical unit✓Endoscopy suite✓Radiology unit

Harder

• Widely varying processes; a lot of custom work

• Examples:✓General medical unit✓ED✓Narrow sub-specialty with

broad diagnostic variety

Lessons

You can get started at the unit level

You can make some progress

You will eventually hit a ceiling

Ultimately, interrelated units (the units that your unit

depends on for patients and sends patients to) need to

be applying these management methods too

AND, your senior leaders need to have their own

standard work, fluency with problem solving, and ideally

huddles and visual management methods that ensure

that they remove barriers to your progress in a timely

manner– so that they lift the ceiling or blow the roof!

68

Summary

Sustaining improvement (i.e. Quality Control; high

reliability) means paying continual attention to the

process at the front line. Huddles are fundamental.

Juran’s Trilogy provides a conceptual framework for

Quality Control.

Drivers: Standardization; Accountability; Visual

Management, Problem Solving & Escalation; Integration.

Lean Daily Management is an example, used at GBMC

IHI pilot tested the Sustainability Model at Andrews and 1

other ASC: uptake was enthusiastic.

Andrews ASC attributes increased safety practices and

culture to the Model.

Huddle-based problem solving & escalation process

maintains control over time.

P69

P70

Contact

Kevin Little

✓ klittle@iecodesign.com

Jeff Rakover

✓ jrakover@IHI.org

Richard Scoville

✓ richard@rscoville.net

P71

For additional study

J. Lancaster (2017) The Work of Management: A Daily Path to Sustainable Improvement, LEI, Cambridge, MA

D. Mann (2015) Creating a Lean Culture: Tools to Sustain Lean Conversions, 3rd edition, CRC Press, Boca Raton, FL.

R. Scoville et al. (2014). ‘Sustaining Improvement.’ IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement. Available at http://www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx

Kevin Little's blog postsdaily-huddles-1-helping-people-do-a-better-job

daily-huddles-2-setting-the-stage-for-organizational-learning

self-control-for-individuals-and-teams

enhancing-experience-intuition-and-guts

P72