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Model For Improvement *
•A simple yet powerful tool for accelerating improvement
•The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes
*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP
**The Plan-Do-Study-Act cycle was developed by W. E. Deming
Model For Improvement *The model has two parts:
• Three fundamental questions,Used to establish AIM; MEASURES, AND CHANGE IDEAS.
•The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of change to determine if the change is an improvement.
*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP
**The Plan-Do-Study-Act cycle was developed by W. E. Deming
Bold Aim, Firm Deadlines• Align aim with strategic goals of the organization
• Write a clear and concise statement of aim
• Make the target for improvement bold and unambiguous
• Include deadline
• Include scope, boundaries, constraints and anything else that is needed to keep the team focused
“Some is not a number. Soon is not a time”
Donald Berwick, MD
Institute for Healthcare Improvement
Bold Aim, Firm Deadlines
Model For Improvement • Outcome measures:
– Are driven by the specific objectives identified in the AIM statement, e.g. # of medication discrepancies
– Are understood from the consumer’s perspective eg. Reduced discrepancies
• Process measures – Indicate whether a specific change is having the intended
effect, e.g. % of residents with a BPMH on admission– Indicate if process changes are leading to improvements
• Balancing measures:
– Are related measures to understand the impact of changes on the broader system, e.g resident/staff satisfaction
– They can be the other effects of planned changes e.g. Increased admission time; decreased rework
Model For Improvement
Measures
• Choose 2-6 measures that are useful and manageable
• Should be operationally defined e.g. rework
• Should be integrated into clinical documentation
• Include a balanced set of measures to avoid sub-optimization
• Purpose is for learning not judgment
Outcome; Process; Balancing ?
– Mean number of undocumented intentional discrepancies
– Mean number of unintentional discrepancies
– Percentage of LTC residents reconciled on admission
– Other
Measures
• A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.
• Creatively combing these change concepts with knowledge about the specific work can help generate ideas for tests of change. PDSAs are used to test the specific ideas.
• Change concepts are usually at a high level of abstraction, but evoke multiple ideas for a specific process.– Examples:
• Reduce handoffs• Consider all parties as part of the same system• Improve work flow• Eliminate waste
• Berwick, Boushon,& Roessner, 2007
Change Concept
Aim: Assure customers do not leave bank cards
behindIdea: Beeping sound
Idea: Beeping sound
Concept:
Use reminder
s
Change Concept
Aim: Assure customers do not leave bank cards
behindIdea: Beeping sound
Concept:
Use reminder
s
Electric shock
Voice reminders
Siren
Based on Edward DeBono’s Concept Fan
Change Concept
• Change Package• Getting Started Kits• Creative and Critical thinking• Hunches• Best practices• Asking process users and subject matter experts for
ideas• Community of Practice• Insight from research and benchmarking
Change Ideas
While all changes do not lead to improvement, all improvement requires change.
Berwick, Boushon,& Roessner, 2007
Change
Rapid Cycle ChangeCycle- A structured trial of a process change.
• Plan- a specific planning phase
• Do- a time to try the change and observe what happens
• Study- an analysis of the results of the trial
• Act- devising next steps based on analysis
• One PDSA cycle should lead to the Plan of a subsequent cycle.
• Berwick, Boushon,& Roessner, 2007
A PS D
A PS D
AP
SD
APSD
Change Ideas
Learning From Data
Very Small test
Follow up tests
Wide Scale tests of change
Implementation of Change
Changes Result in Improvement
Moving From Testing to Implementing
• Initiation of Rapid Cycle tests is dependent on getting the first test of change started
• Do Not try to Perfect the change then implement…consider your work a masterpiece in progress
• Failure is a great Opportunity to plan to do better next time…
• Frequency of Testing determines the speed of the process improvement ie daily testing = improvement in weeks; weekly = improvement in 3-4 months
Rapid Cycle Change
What are we trying toWhat are we trying toaccomplish?accomplish?
How will we know that aHow will we know that achange is an improvement?change is an improvement?
What changes can we make that willWhat changes can we make that willresult in an improvement?result in an improvement?
Act Plan
Study Do
Model for improvement
Aims
Measurement
Langley, Nolan et al 1996
Change Ideas
Trial & Learning
Acknowledgements
• Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/GausModelforImprovement.htm?TabId=2
• Harris, B. (2007). Change Concepts.
• Murray, M (2006). “Small Steps, Big Changes” workshop.
• Reasear, R. (2007). Institute for Healthcare Improvement “Designing Reliability Into Healthcare Processes: Based on the work of the Institute for Healthcare Improvement Innovation”