Welcome back to the IHI Improvement Coach …app.ihi.org/Events/Attachments/Event-2897/Document-6300/...Welcome back to the IHI Improvement Coach Professional Development Program Workshop

Welcome back to the IHI Improvement Coach Professional Development Program Workshop 1Day 3

Welcome back, warm up, questions from day 2

1

Day 2 Debrief

2

Workshop 1: Day 3 Overview

Time Agenda Item

7:00 AM Breakfast available

8:00 AM

9:45 AM Break

• Welcome back, warm up, questions from day 2

• How will we test our change ideas?

• Running real PDSA cycles

• A PDSA exercise

• A case study

• How will we test our change ideas? Planning a PDSA cycle

11:45 AM Lunch

12:45 PM

2:00 PM Break

• Facilitation, part A

• Teamwork and communication: Understanding working styles

• A case study

• Tying it all together

• Day 3 debrief and next steps

4:00 PM Adjourn

3

How do we test our change ideas?

Running Real PDSA Cycles

Day 3

William Peters

February 1st, 2017

Running real PDSA cycles …

Source: Associates for Process Improvement

• Be able to correctly run real PDSA cycles

• Appreciate why it is so critical to ask a question(s) and make a

prediction(s) in the Plan part of a PDSA cycle

• Know the vital task of comparing the data in the Study to the

predictions detailed in the Plan

• Recognize the critical nature that running PDSA cycles, building

knowledge, has on the success of the project and overall

organization

• Appreciate the idea that a failed test is still considered success!

Quality Improvement Fundamentals LLC

5

Running real PDSA cycles …

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

Source: Associates for Process Improvement

Many of these!

The secret? How I know

someone KNOWS PDSA?

“we compare our DATA in the

Study to our PREDICTION(s)

in the Plan”

What is inherent in making a

prediction?


6

It is not necessary to change. Survival is

not mandatory. ~W. Edwards Deming

When you are through changing, you are

through. ~Bruce Barton

If nothing ever changed, there'd be no

butterflies. ~Author Unknown

If you want to make enemies, try to change

something. ~Woodrow Wilson(he never met Deming, never learned most people are

open to trying good ideas)

On change …


7

DESIGN DESIGN APPROVE

In the conference room

The Typical Approach…

IMPLEMENT

DESIGN DESIGN

…..and in the real world.

8

TEST &

MODIFY

TEST &

MODIFY

APPROVEIF NECESSARY

TEST &

MODIFY

The Quality Improvement Approach

START TO

IMPLEMENT

DESIGN

In the conference room

…..and in the real world.

9

Use scarce resources wisely

Learn more from doing than planning

Learn about the change: Cost, How much improvement,

Side effects

Reduce resistance to change

Increase peoples’ degree of belief in the change

PDSA Cycles: Why Test?

Improvement Guide, 2009, Chapter 7, p. 142

10

At the heart of all improvement

We use SCIENCE to test CHANGES we

THEORIZE will lead to improvement.

Three questions that guide and

support pragmatic rational action

But HOW & WHY does it work so well?


11

Remember this?

• The Lens of Profound Knowledge: Theory of Knowledge

and the use of data for improvement … how it works …

Question: “can I get a drink without missing something key?”

Prediction: “yes!, I can make it really fast, < 1 min.!”

The project problem: “I’m thirsty!”

Theory: fountain is close, so, I should have time, 1 min.?

Knowledge: fountain right outside door, w/cool water

Observation/life/experience/doing/living/seeing

New Data: fountain was removedQuality Improvement Fundamentals LLC

12

“No Pass Zone” in effect

(Outcome)

Process Measures focus improvement on processes that directly impact results (outcome indicator)

Lift devices all operational and have

standardized belts

Fall Assessment at admission

Non-cluttered patient room with equipment in

correct position

Focusing on just the results is the

old American “Management by

Objective”

Reminders to nurses about need to prevent falls. Negative consequences

for a nurse whose patient falls

Falls(process)

(process)

(process)

(process)

(process)

Number of

Falls(Outcome measure)

Number of Catches(process measure)

(trash it in favor of a “Just Culture”)

Percent FA at Admin(process measure)

Number of Device Errors(process measure)

“Percent SupraNeat”or maybe “Count of Clutter”

Every outcome is the result of

perfectly designed processes!


13

We need data over time to show improvement


1Improvement is the result

of a change in the process

and gains are held …3

result is positive, relevant, meaningful …

2

on a measure that matters to the organization

4

REAL

SUSTAINABLE

IMPROVEMENT

14

All improvement requires change but

not all change results in improvement

A simple truth…

The People v. Process (4% v. 96%)


15

A lot of people know what CPR stands for

All forms of intelligent life practice science:– Humans: we can do science consciously

– Non-humans: still practice science, don’t know it, but still do …

Building knowledge:– The organization: live and die by the amount of knowledge

– Stuff you “didn’t know you didn’t know”

– About a pretty good idea NOW instead of waiting for “silver bullet”

Test a change BEFORE implementing it!– Huge cost of failure associated with a change IMPLEMENTED before

tested. Failure cannot be measured in $ alone!

– Staff have power to change their work. Testing changes w/PDSA empowers staff, leverages deep SMK and reduces staff resistance.

More detail…


16

Activity ≠ Change

Is a change:

Use a new form

Run a review meeting

Use the form on the next 10 cases

New outreach process

Is NOT a change:

(but may be a necessary

preliminary task however)

Planning

Having a meeting

Educating staff

Creating a protocol

Assigning responsibility

A change forces new behavior patterns in

people, or changes the steps/function

within a piece of technology

17

Where “PDSA” fits in …

The “Aim”:“Unit Two will reduce the number of falls with injury

to ZERO by the end of 2014 with the guidance of

Sue Grace CNO”

The measures:Number of Falls

Number of Falls with Injury

Percent Restraints (balancing measure)

Change:1st order change (more resources, more of the

same ideas) VS. 2nd Order Change

(Fundamental change)

PDSA:Multiple cycles run, multiple ideas tested, WHAT

DOES and DOES NOT produce improvement?

BUILD KNOWLEDGE ABOUT THE SYSTEM!

Are negative results as useful as positive

results when caring for a patient? Quality Improvement Fundamentals LLC

18

“I did not fail one thousand times; I have found one thousand ways that won’t work.”

Thomas Edison

19

Failed Test…Now What?

Be sure to distinguish the reason:

– Change was not executed

– Change was executed, but not effective

If the prediction was wrong – not a failure!

– Change was executed but did not result in improvement

– Local improvement did not impact the secondary driver or

outcome

– In either case, we’ve improved our understanding of the system!


20

Cycles of Tests Build Knowledge and

Confidence

Proposals, theories, hunches, intuition

Changes that will result in improvement

21

Sustaining improvements

and Spreading changes to

other locations

Developing

a change

Implementing a

change

Testing a

change

Act Plan

Study Do

A pretty

good idea, a

hunch

Test under a

variety of

conditions

Make part of

routine

operations

Act Plan

Study Do

Act Plan

Study Do

Over time, more cycles mean …

… m

ore

KN

OW

LE

DG

E!

Avoid the cost of failure!

“Just do it” vs. (carpet)


22

Clinicians already use science

Nurse: “my patient is a newly diagnosed diabetic that is showing signs of confusion, is

sweating a lot and complains of dizziness”

Nurse: “I need to get this blood sugar back in

the normal range between 70 – 110, ASAP!”

Nurse: “Blood sugar was showing noise

until the most recent measure, it was 40!”

Nurse: “patient needs sugar”

“I will order a juice from NuServ and have pt drink immediately. I

predict this will raise blood sugar”.

“I’m giving patient juice and watching them drink it all.

Patient was delighted to do so”.

“Latest blood sugar is 78”

Reduce dose of insulin before meals

P

DS

A


23

If reality were just that easy…

Some ideas for change are a lot more

complicated than “Just do its”

How would we test the idea for

change …

“Med Pass Sterile Cockpit”

… I guess we could just implement it?

Jump to implementation or test?


24

Work With and/or Steal Shamelessly

From Others (and give Them Credit)

• Likely someone from your sector has solved the problem or

a piece of it

• If not, likely someone from your sector is currently trying to

solve the problem

• If not, likely someone from your sector has tried to solve

the problem and has failed (and you can learn from them)

• If not, someone from an adjacent sector has worked to

solve a similar problem

• If not, someone from a completely different sector has

worked to solve a problem that could be helpful with the

problem you are facing

25

The nurse who thought of the idea “Med Pass Sterile Cockpit” learned of it from a past employer

– Great! “Borrowing” a change idea is a quick way to improve!

– A lot of nurses were concerned about interruptions that happened during a med pass

– What is a “sterile cockpit”, where did this come from?

– The nurses idea was to have the nurse doing med pass wear a hat that marked her as “do not disturb”.

– Nurse wanted the change idea done now! “We should do this now!”

Beg, borrow & steal …


26

Benefits of “try B4 buy”…

Jumping to implementation could potentially:– Have a cost of failure is everything doesn’t go smoothly

– Doesn’t take into consideration expert opinion/ideas of staff

– Might not please medical or non-clinical staff

– “Unintentional Chaos” because people are well intentioned …

Testing the idea would potentially:– Lower resistance of nursing staff

– Lower resistance of medical staff

– Attract all involved to improvement, to empowerment!

– Lead to the best possible “Sterile Cockpit Med Pass” process


27

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

PLAN: the hardest part of

running a cycle

… and then list ALL the gory details! ALL!When: btw Monday 9/1 and Wednesday 9/3, 9:30 pass

only.

Where: Unit One only, Who: Michelle Roberts all 3 days

Data: vocal feedback from Michelle, RNs on duty, MDs

rounding and any staff who visit unit one, # of

interruptions

How: nurse will place hat on when entering med room. The

only interruptions allowed are emergencies. Unit clerk will

educate staff not involved with test about rules of hat.

Let’s run a cycle …

If we create a “sterile cockpit” during med pass, will nurses find value in not being interrupted? How can we reliably identify a nurse doing a med pass?

The Plan always, ALWAYS, contains a question

and a prediction to the question!

Q

(Prediction never Y/N, no learning in that! WHY? WHY and HOW will it work? WHAT IS YOUR THEORY!)

Interruptions can lead to errors. We had an error here from being interrupted that almost cost the life of a patient! Less interruptions will reduce the room for errors. The nurse doing the med pass will find this idea very attractive.I think we can identify the nurse doing med pass by using a brightly colored hat.

P

After the 1st cycle you can

make life a lot easier by

copy/paste for 2nd cycle …Quality Improvement Fundamentals LLC

28

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

DO: tweak the PLAN &

make sure PLAN is followed


The DO is the part when we execute on our PLAN

• Note any tweaks made to PLAN in order to not

cancel test. Reality usually breaks a PLAN

• Are we testing the idea as laid out in the PLAN?

DO9/1/2014: we had to ask Marcy and Daryl to take the

duties of the unit clerk since she was out sick

9/1/2014: initial response from Michelle is very positive.

“I don’t get anxious when someone walks by. Normally I

would think “someone is looking for me””

9/2/2014: Unit clerk still out sick. Marcy going to

continue education people who walk onto unit about the

meaning of the hat

9/2/2014: another RN noted that she gets interrupted by

PTs too. She made her own script that reduces this

9/3/2014: Unit clerk back but Marcy and Daryl going to

finish out last day of test

9/3/2014: test followed planQuality Improvement Fundamentals LLC

29

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

STUDY: compare data to

predictions


The STUDY is where we compare our data to our

predictions. Does the data support our

predictions?• Data can be soft (qualitative), can be the opinions and

observations of SMEs

• Data can be hard (quantitative), can be hard numbers

like the # of interruptions

Best practices is to use both hard & soft data in cycles!

STUDYMichelle absolutely loved the huge reduction in interruptions. She counted 6 interruptions over the 3 days, a number she insisted was way lower than without the hat on. All the interruptions were from staff not aware of the details of the test going on. She recommends the hat be switched to a sash bc the hat isn’t that comfortable and will probably fall off depending on hairstyle. Michelle forgot how often PTs interrupt med pass with simple concerns (5 times). RN Lilly noted she asks her patients a set of questions aimed at reducing simple requests while she does med pass. All 3 doctors and staff visiting unit thought the idea was great.

If the data does not support the

prediction in the PLAN we first

check the DO to make sure we

tested the idea as PLANEDQuality Improvement Fundamentals LLC

30

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

ACT: Implement?, Tweak?

or Abandon?


ACT is where decide our next steps based on the

data being compared to the prediction• Tweak is trying again a different way the next cycle

• Implement is making the change permanent

• Abandon is not pursuing the idea any more

ACTBased on the number of interruptions, and vocal feedback from all, this idea is worth pursuing. One more cycle is needed to gather enough data to make the case for change compelling for the other three nursing units. For the next cycle, the hat is out and Michelle is going to create 3 sashes each with “Please do not disturb in med pass” stenciled on the front in large letters. All three nurses on Unit One will use the sashes during med pass for the next three weeks. RN Lilly is going to run a cycle with two other nurses to try her script she uses on PTs before the med pass. If we can verify with data the script works at reducing interruptions on the PT side then we will have hard data to support adopting it house wide. We don’t know how many interruptions happen during a typical med pass so a cycle will be run to collect this data to use to sell the idea house wide (and maybe spread to our sister hospitals)

What do we do BEFORE abandoning an idea for change?

Did you know … research uses PDSP[ublish]!


31

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize


or Abandon?







Did you know … research uses PDSP[ublish]

So after one cycle we:- Know hat won’t work and we will use a labeled sash- The idea brings value as shown in hard/soft data- Uncovered the idea of patient med pass interruptions- Found out RN Lilly has her own script that reduces PT

interruptions so we will test (cycle) a few nurses using it to see if it works and to find the “best fit script” that reduces minor PT requests during med pass

- Learned we don’t know how many interruptions happen so a cycle of learning will be used to find out (use this data to sell)

- Got a lot of people involved in thinking, in improvement, we made improvement an attractive thing

- We reduced resistance to a new change because a lot of staff were involved. Staff will hone final change. EMPOWERMENT!


32

On PDSA cycles in general

What is the unit of measure in In tennis? Weight lifting?The unit of measure in improvement is the cycle (PDSA).The best predictor of an improvement teams success at reaching goals is # of … ???

How small should my test be? Think small tests, small enough to accurately answer the questions with enough data to sell idea to others. 1 nurse, 1 Patient, 1 doctor, 1 day…Before implementing a TESTED change, triangulate three things:

When starting improvement, look for the “firestarters” in your organization. Don’t try to convert anyone. Go to the willing, the rest will follow later.

Degree of Belief

ResistanceCost of Failure


33

KNOWLEDGE is what we want/need!

* More knowledge means better change ideas

* An org lives and dies by what it knows

KNOWLEDGE, with it, no cycle is a failure

“This idea we tested did not result in improvement!”

In healthcare, are negative results as useful as positive?

Theory is so important. The org, WE, need to share our

theory because it drives progress, provides a SHARED

UNDERSTANDING.

Document cycles to avoid well-intentioned chaos, others

can help refine the cycle and the organization can use this

knowledge later because it stored is on the network.

Thinking in cycles is easier with each successive cycle.

A wonderful way to reduce anxiety.

On PDSA cycles in general


34

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

PLAN: the hardest part of

running a cycle

Let’s run another cycle …

Will switching to specialized floor mats at side of residents beds result in lower falls and increased resident and env ser satisfaction?

The Plan always, ALWAYS, contains a question

and a prediction to the question!

Q

(Prediction never Y/N, no learning in that! WHY? WHY and HOW will it work? WHAT IS YOUR THEORY!)

Mary will observe no falls during the 3 days.

Environmental services will prefer the placement of the newer mats right after cleaning as they will no longer have wait 15 minutes to come back later to place the older mats.

Residents will appreciate the floor mat always being there instead of having to check to see if there is a mat on the bedside before standing up.

I further predict mold will not be a problem because these same mats are used by public pools

After this cycle, we will have feedback that will confirm we should order mats for the entire facility.

P

After the 1st cycle you can

make life a lot easier by

copy/paste for 2nd cycle …

A large nursing home that wants to purchase

$12,000 of floor mats to reduce falls. The idea

was brought up by an employee who asked some

questions while at a local pool.

This environmental services employee was aware

that a couple of bad falls had occurred because of

missing floor mats. They were missing because

after cleaning the floors they had to dry for 15

minutes before the mats are placed back down on

floor.

Environmental Services employees sometimes

wait > 15 minutes because of competing

priorities/requests.


35

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

Plan continued, the gory details:

WHAT: Four of Meyers part # 23746,

“SwabDeck Perforated No-Slip Mat” will be

placed at the side of residents beds

WHERE: in rooms 202, 204, 206 and 208.

WHO: Environmental services staff Andre

Torksen will place mats immediately after the

end of floor cleaning.

DATA: All four residents ambulate and are

currently assigned to Mary Swanson till the end

of the month. She will obtain feedback from the

assigned CNA (Todd Carson) and residents on

their perception of the value of the new mats.

WHEN: New mats come in Monday June 23rd.

This test will start on June 25th with the first floor

cleaning around 4:00 P.M. and run through the

last floor cleaning Friday at 4:00 P.M. (for a total

of three cleaning cycles).



36

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

DoPlan was carried out as detailed with the exception

that CNA was assigned to another unit on second day

of test. Mary Swanson educated different CNA Liz

Petrowski on the test and will ask her for feedback on

the mats as well as Tod Carson

Environmental Services has said it is way easier on

them to clean and place floor mats. It is one less

round they have to make. Also don’t have chance to

be pulled in another direction before placing mats

back down

Environmental Services also brought up that many

times they have to move personal belongings out of

the way when cleaning floors. Falls have happened

because of personal items.



37

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize

StudyMary observed no falls during the 3 days and

environmental Services said it is way easier on

them to clean and place floor mats. It is one less

round they have to make. Also don’t have chance

to be pulled in another direction before placing

mats back down. This test made them aware

they often move personal belonging in order to

clean floor. Moved items during all cleanings.

Residents commented on 3 occasions that having

the mat down at all times was nice.

CNAs said it was nice to know they wouldn’t slip on

wet floor. One CNA said they had almost fell

before bc of a wet floor around resident’s bed.

Mold cannot form under mat due to material used.

More falls have occurred here due to personal

items versus the missing floor mats.


STUDY: compare data to

predictions


38

Plan• Objective

• Questions &

predictions


Who?When?

How? Where?


• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle


analysis

• Compare to

predictions

• Summarize


or Abandon?







Did you know … research uses PDSP[ublish]

So after one cycle we:- Found another larger area for opportunity to reduce falls- Discovered this test of a change idea led to another idea

because environmental services was asked for feedback

ActAlthough no falls occurred during the 3 floor cleanings,

the “discovery” that residents' personal items are often

moved by environmental services leads us to put a hold

on this idea and pursue testing ideas for change related

to stowing and organizing these items.

Mary, Todd, the residents and environmental services

have been asked to brainstorm ideas for change related

to personal belongings.

Floor mat idea shelved until this area of opp is worked.


39

We can provide you with a best practices PDSA short form to

start testing right away

Just make sure you share before Plan, before you start to test

Is there a PDSA tool to use?40

Best indicator of a projects success is the # of cycles run

PLAN is the longest part to generate

PLAN must have a change, question & a prediction in detail

PLAN must have some sort of data to learn from

PLAN also must have all the gory details, who, what, when …

DO is used to record last minute changes, are we testing what…

STUDY is used to compare our data to our predictions from PLAN

ACT is used to abandon, adapt, adopt change

ACT typically leads to another test

THE MAIN GOAL IS TO BUILD KNOWLEDGE …

… which eventually leads to improvement!

In summary …


41

Break

How will we test our change ideas: A PDSA exerciseImprovement Coach Professional Development Program

Workshop 1, Day 3

February 1, 2017

Karen BaldozaChristina Gunther-Murphy

Session objectives

• Apply rapid-cycle PDSA testing

• Understand how theory and prediction help your

learning

• Demonstrate how to collect real-time

measurement

• Appreciate the opportunity for learning together

44

Session agenda

Topic Time

Set-up 10 minutes

Play 15 minutes

Debrief 15 minutes

45

A model for learning and change

The Model for Improvement was developed by Associates in Process Improvement. [Source: 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.]

46

Preparation

• Get into groups of 3-5 people (so 2 teams per

table)

• Designate a spinner, timekeeper, and recorder

47

Objective: Test to spin a US coin for the longest amount of time in 15 minutes

Materials:• US coins - quarter, dime, nickel, penny• PDSA tracker form• Run chart template • Smartphone timer

Let’s

Play!

# Plan Do Study Act# What questions?

Theories?Prediction

What do you see? How Long?

How did what you see match prediction?

What now? Adopt, adapt, abandon?

1

2345678910

25

20

15

10

5

1 2 3 4 5 6 7 8 9 10PDSA Test Cycle

Seco

nd

s

Data Collection on a Run Chart

PDSA Tracker

# Plan Do Study Act

#What questions? Theories? Prediction What do you see? How Long? How did what you see match prediction?

What now? Adopt, adapt, abandon?

1 Large coins last longer Nickle = 10 seconds Started to wobble. Time = 7 No, Three seconds short. Large Size/weight Adapt - Test Quarter

2 Bigger quarter will spin longer Quarter = 10 seconds Started to lose spin fast. Time = 8 Two seconds short. Size may be more important Adapt?

3

4

5

6

7

8

9

10

10

7

5

3

1

1 2 3 4 5 6 7 8 9 10

PDSA Test Cycle

Seco

nd

sData Collection on a Run Chart

PDSA Tracker

Get Me To My

Meeting On Time

A Personal Improvement Project

By Phyllis M. Virgil,

IHI Improvement Advisor

51

Session Objectives

• See the life cycle of a personal

improvement project from start to finish

• Recognize the value of using a personal

improvement project to learn and model

the way

52

Personal Improvement Project

• Required part of my QI education.

• Provided personal experience and

testimony.

• Results gave an ideal tool to introduce

and teach a complex topic.

Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.

53

54

Customers’ Voice


55

Customer Voice

• Timeliness expected by customers.

• “Fashionably late was no longer in style.”

• Provided real opportunity for personal

improvement.


56

Organize an Effort

Team Leader - Me

Team Facilitator - Me

Others consulted: Department/Position

Boss Ad Hoc Facilitator

Customers Persons who suggested PIP

Co-worker 1 Willing listener

Co-worker 2 Another willing listener

Co-worker 3 And yet another listener


57

Improvement Roadmap

Week

1-2

Week

3-4

Week

5-6

Week

7-8

Week

9-12

Q1 Aim

Q2 Measure

Q3 Ideas

Q4 Test

Q4 Sustain


58

Ground Rules

I would use the Model for Improvement as

my thought process.

I would collect data and plot it overtime on

run/control charts.

I would PDSA (test) my improvements.


59

Block Diagram

Schedule Meeting

Prepare for Meeting

Get to Meeting

End Meeting


60

Boundaries

Schedule Meeting

Prepare for Meeting

Get to Meeting

End Meeting

Look at Watch for Time At Meeting Ready to Work


61

Aim Statement

Within 12 weeks I will delight my

associates & customers, by

being on time every time.

At Meeting Ready to Work


62

63

Measure

Understand Quality Requirements

Measure Performance Overtime


What is MOST

Critical to Quality?

Meeting Arrival Timeliness

Selected it because customers were commenting

on this important aspect of my process.

Dimensions of Service Quality

1. Time & Timeliness

2. Completeness

3. Courtesy

4. Consistency

5. Accessibility/Convenience

6. Accuracy

7. Responsiveness


65

Operational Definition

Actual Timeliness of Arrival (ATA) as

measured by the minute variation from the

scheduled start time

(plus = late, minus = early)


66

Timelines Data Collection Plan/FormCombined with Time Plot Chart

Combined with

run/control

chart form.

ATA Data:

Minutes Early or Late

Date


67

Control Chart Actual Time of Arrival

One Special Cause Found

Median = 1 min. LATE

Upper Limit = 10 min. EARLY

Lower Limit = 8 min.LATE

Positive

Special

Cause


68

Actual Arrival Time

Data Analysis

ATA control chart showed that on average I was

arriving one minute late, and my performance varied

between 10 minutes late and 8 minutes early.

I found one positive special cause beyond 8 minutes

early which I believed was a result of my own

exaggerated awareness of my behavior given my

study (similar to the “Hawthorn” effect).


69

Actual Time of Arrival

Special Cause Strategy

I decided to collect more data rather than

act on this one point special cause. I

theorized that my process performance

would settle down as it became normal for

me to chart my arrival times.


70

Control Chart Actual Time of Arrival

Performance Stable and Predictable

Median = On TIME

Upper Limit =

16 minutes EARLY

Lower Limit =

16 minutes LATE


71

Customer Requirements

On Time

Ready to Work


72

Purpose of Tracking Data and

Understanding Variation

C T

Q

1

I will know change is an improvement when my

actual arrival time is always be below zero.

Mean of Zero


73


74

Identify Change Ideas

Understand what causes

variation in performance.


Current Process Flowchart

Get meeting

materials

together.

Look at

watch.

Continue

other work.

Should I go

now? Do a little

something.

Gather

supplies

needed.

Refresh

self.

Get coffee.

A

Decide it is

too early to

get ready.

NO

YES

Arrive at

meeting.

Coffee

available?

Search,

make, or

give up.

Materials

found?

Search

until found,

or give up

NO

YES

A

NO

B

B

YES

Walk to

Meeting


76

Cause Effect Diagram(AKA: Fishbone Diagram)

Arrival at

Meeting

Gathering

Timing Refreshing

Materials

Supplies

Timex Coffee

CosmeticsJudgement


77

Get meeting

materials

together.

Look at

watch.

Continue

other work.

Should I go

now? Do a little

something.

Gather

supplies

needed.

Refresh

self.

Get coffee.

A

Decide it is

too early to

get ready.

NO

YES

Arrive at

meeting.

Coffee

available?

Search,

make, or

give up.

Materials

found?

Search

until found,

or give up

NO

YES

A

NO

B

B

YES

Walk to

Meeting


Drivers of Improvement

Remove Unnecessary Steps

78

Key Drivers Impacting

Actual Arrival Time (Outcome)

Judgment on Timing

Getting materials together

Searching for coffee


79

Change Ideas

Look and Act

Flash Prep Process


80

81

PDSA1 Look and Act

Get meeting

materials

together.

Look at

watch.

Gather

supplies

needed.

Refresh

self.

Get coffee.

A

Arrive at

meeting.

Coffee

available?

Search,

make, or

give up.

Materials

found?

Search

until found,

or give up

NO

YES

A

NO

B

B

YES

Walk to

MeetingDecided to eliminate

continued work of any sort. When

I looked at my watch I will

immediately proceed to getting

ready to go.

Made a Simple

Improvement(Remove, Reorder, Combine)


82

Flash Prep

Getting Materials Together

I figured if I was really organized I could cut out a

good chunk of my prep time, and consequently

leave earlier to get to an event.


83

Process Measure

Operational Definition

Material Gathering Time

Measured in minutes lapsed starting at the

time I begin my effort to collect materials and

ending with the time all materials are all in my

arms, and I am ready to go.


84

Control Chart Material Gathering Time

Two Special Causes Found

Median = 4 min.

Upper Limit = 11 min.

Lower Limit = 0 min.


85

Analysis of Variation


On average it took me 4 minutes to find my materials.

When I added control limits I found two special causesabove the upper control limit.

The first was when my process was interrupted by a telephone call.

The second was when someone

stopped for a surprise meeting.


86

PDSA 2 Special Cause

Improvement Action

Institute a permanent self control policy whereas

I will not answer the phone while getting ready,

and I will politely and firmly turn surprise visitors

away to meet at a later time.


87

PDSA 3 Materials in a Flash

Instituting a “ready at grab”

desktop system.

Organize for a “constant state of

readiness”.

By using clearly labeled “multicolored

pocket folders” for all active projects


88

PDSA 3 Change Prediction

• I predicted that I would be on time almost

every time.

• I thought my customers would be happy.

• My pre-meeting stress level would decline.


89

PDSA 3 Study

Gathering time dramatically reduced.

Materials found in lightening speed.

On time most all of the time.


90

Control Chart Material Gathering TimePerformance Stable, Predictable, Dramatically Improved

From Minutes to Seconds!

Median = 30 SECONDS

Upper Limit = 97 SECONDS

Lower Limit = 2 SECONDS

Note: The improvement was so significant I had to change my scaling from minutes to seconds!


91


Comparison of Limits Old/New

Before

NEW (O to 1.5 min.)

OLD (2 to 11 min.)

Result = 90%

IMPROVEMENT

After


92

Control Chart Actual Time of ArrivalStable, Predictable, and Dramatically Improved!

Result = 200% IMPROVEMENT

IMPROVED PERFORMANCEBASELINE PERFORMANCE

On Time, most every time!


93

To Sustain Gains

I will always organize my major

project materials in multi-colored

pocket folders, and keep them on

the top of my desk ready to go!


94

© Phyllis M. Virgil Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.

95

How will we test our change ideas? Planning a PDSA cycle

Day 3

William Peters

February 1st, 2017

Lunch

Facilitation SkillsPart A

February 1, 2017

Day 3

Phyllis Virgil

Session Handouts

Team Tools

Facilitator Interventions

99

Session Objectives

• List key team facilitator skills

• Describe four questions to decide when to

intervene

• Identify tools and tips for interventions

• Discuss strategies to handle difficult behaviors

100

Session Agenda

Topic Time

Definitions and descriptions 20 minutes

When to intervene & what to say 20 minutes

Tools and Tips for Interventions 15 minutes

Handling Difficult Behaviors 20 minutes

101

Facilitation Definition

• Fa·cil·i·ta·tion (noun) - ‘To make easy or

easier’ (Oxford Dictionary, Thesaurus, 1996)

Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources

and Services Administration HIV/AIDS Bureau.

102

Facilitation Aim

Aim of group facilitation:

To help establish and maintain an

environment within learning is created

and common goals are achieved.



103

The End of Good Meeting Facilitation

• Transfer of knowledge and skill

• Team self facilitation

Source: Phyllis M. Virgil, Team TrainingPhoto Credit: England Highways Agency England via Flickr

104

Let’s start thinking...

What are the behaviors (or skills) of

successful facilitators that you have

experienced?



Photo Credit: CDC/ Dawn Arlotta acquired from Public Health Image Library

105

Table Exercise Facilitator Skills (15”)

Identify the behaviors (or skills) of successful facilitators that you have

experienced (10”)

• Assign group facilitator

• Use structured brainstorming to list behaviors or skills of successful

facilitators that you have experienced

• Record about 20 ideas on one flipchart page, label A-Z...

• Using multi-voting dot method to identify what skills your group

thinks are especially important: everyone dot their top 5 choices (no

double dotting)

• Circle the items that got the most votes

Be prepared to report out top five to the large group (5”)

Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources and Services Administration HIV/AIDS Bureau.

106

Key Facilitator Skills

• Planning Skills - plan ahead and anticipate challenges

• Diagnostic Skills – ‘read’ verbal/non-verbal clues of the

group, understand team dynamics and recognize barriers to

team effectiveness

• Intervention Skills – understand when (or when not) to ask

questions, offer feedback, provide problem solving methods,

push for outcomes, ensure involvement or wrap up

• Goal-getting Skills – keep the outcome of the group in mind

• Evaluative Skills – formally assess group outcomes


107

Should I Intervene?

Source: Phyllis M. Virgil, Team Training

108

The Role of “Traffic Cop”

Specific words and phrases useful in directing traffic:

Observing

Clarifying

Focusing

Stimulating

Balancing

Summarizing


109

Table Exercise

• Identify group facilitator and recorder

• Identify specific words and phrases which would be useful in directing traffic

for your assigned role (10 min)

Observing = Table 1

Clarifying = Table 2

Focusing = Table 3

Stimulating = Table 4

Balancing = Table 5

Summarizing = Table 6 & 7

• Record on your flip chart and be prepared to report out to large group


110

111

Interventions Not Detentions

A Facilitators Tool Box

Source: Phyllis M. Virgil, Facilitators Tool Box

112

Interventions Not Detentions

A Facilitators Tool Box

Ground Rules

1) No interruptions.

2) Speak one at a time.

3) Cell phones on off.

4) Listen.

5). ……………….

6). …………….


113

Providing Feedback Without Fallout

• Describe, specific, behaviors...

• In a timely, respectful manner, in a manageable amount

4 STEP INTERVENTION

D-E-S-Cribe

1) Describe behavior(s)

2) ID Possible Effect

P-A-U-S-E

&

L-I-S-T-E-N

3) Solicit input

4) Choose what to do


114

Getting to Yes by Fisher and Ury


115

Diffusing Conflict and Confusion

Structured Discussion

1. What is your position?

2. Why? (data, experience, rationale)


116

Toss it back to the team...

• Remember meetings are team sport.

• Resist being the savior.

• Summarize positions, and throw

decisions back to the team.

• Ask what does the team want to do?

• Follow structured discussion with open

discussion.

• Go two rounds if necessary.


117

Dysfunctional Behaviors

/

Photo credit: Pixabay

118

Facilitator Interventions

Dysfunctional Behavior Possible Intervention

Overly Talkative, Dominates Table 1

Rambles, Inarticulate Table 1

Blaming Table 2

Intimidation, pulls rank Table 2

Leaps to Decisions Table 3

Withdrawn or Shy Table 3

Source (c) M. K. Key, The Art of Facilitating Teams: A Two-Day Course.

119

Facilitator Interventions (continued)

Sniping Table 4

Side Conversations Table 4

Plop or Discounting Table 5

Leading and Loaded ?s Table 5

Opinion as Fact Table 6

Hidden Agenda Table 6

Interrupting Table 7

Broken Record Table 7

Source (c) M. K. Key, The Art of Facilitating Teams: A Two-Day Course.

120

Table Exercise (15 minutes)

Identify Facilitator Intervention Strategies (10”)

• Assign group facilitator

• Develop one or two possible interventions for

your assigned behaviors

• Record these on your flipchart

Be prepared to report to larger group (5”)

121

Session Review

• Listed key facilitator skills

• Identified four questions to decide when to

intervene

• Reviewed 12 tools for team intervention

• Discussed strategies to handle difficult behaviors

122

Remember...when facilitating a team

You are also working to build capacity. Teach your teams how to plan

and manage effective meetings by modeling, then relax!

Time

Co

ach

Invo

lvem

en

t

Low

High

New

Team

Mature

Team

Source: Phyllis M. Virgil,

Graphic Source: Executive Learning Inc. Team Training Materials.

Photo Credit: Andrés Nieto Porras

123

Break

124

Teamwork and Communication: Understanding Working StylesImprovement Coach Professional Development Program

Workshop 1, Day 3

February 1, 2017

Karen Baldoza

Session objectives

• Summarize key concepts from the human side

of change

• Describe four working styles and how to apply

this knowledge to yourself and your

improvement teams

• Identify small changes you can make to your

own style to be more effective

126

Session agenda

Topic Time

Overview: The human side of

change and working styles

10 minutes

Exercise 35 minutes

Debrief 7 minutes

Wrap-up and flexing your style 8 minutes

127

Appreciation

of a system

Understanding

Variation

Theory

of

Knowledge

Human Side of Change

The Lens of Profound Knowledge

QI

The system of profound

knowledge provides a

lens. It provides a new

map of theory by which

to understand and

optimize our

organizations. It

provides an opportunity

for dialogue!

128

Key concepts from the Human Side of Change

Improvement Guide, page 84

Differences in people

• People have their own preferences, aspirations, motivations, and learning

styles

• People may have differing beliefs and values

• Changes aimed at improvement have to recognize the differences in people

and account for them

Behavior is driven by motivation

• Observing the behavior of others does not often give us a clear window into

what is motivating someone’s behavior

• We tend to perceive the behavior of others through our own filters

• Understanding what is motivating someone rather than relying on our

interpretation of the behavior can help us take appropriate actions to build

commitment to change

129

…what you are trying to do.

Your self-perception is

based on…

…what they are seeing you do.

Their perception of you is

based on…

MOTIVATIONMOTIVATION

internal

130

Different personalities in a team

• A team can perform better if the team recognizes

and deals with different personality types

• The team can use their different strengths as an

asset

• How can you learn how different team members

operate and benefit from these different

perspectives?

131

Understanding yourself and

others

Flexing the gap across

the chasm of behavioral differences

'Strengths' for each style become

'Weaknesses' when

overused

Back-up Styles' that emerge in

response to excessive

stress

Working styles: An approach to

understanding self and others

132

133

Source: People Styles at Work and Beyond – Making Bad

Relationships Good and Good Relationships Better/ Robert Bolton and Dorothy Grover

Bolton, 2nd ed. 2009.

A - Analytical

•Cautious actions and decisions

•Likes organization and structure•Dislikes involvement with others•Asks many questions about specific details

•Prefers objective, task-oriented work environment

•Wants to be accurate and therefore relies too much on data collection

•Seeks security and self actualization

B - Driver

•Takes action and acts decisively

•Likes control•Dislikes inaction•Prefers maximum freedom to manage self and others

•Cool and independent, competitive with others

•Low tolerance for feelings, attitudes and advice of others

•Works quickly and efficiently by themselves

C - Amiable

•Slow at taking action and making decisions

•Likes close, personal relationships•Dislikes interpersonal conflict

•Supports and "actively" l istens to others

•Weak at goal setting and self-direction

•Demonstrates excellent ability to gain support from others

•Works slowly and cohesively with others

•Seeks security and inclusion

D - Expressive

•Spontaneous actions and decisions, risk taker

•Not limited by tradition•Likes involvement

•Generates new and innovative ideas•Tends to dream and get others caught

up in the dream

•Jumps from one activity to another

•Works quickly and excitingly with others

•Not good with follow-through

Working Styles Characteristics

Overview

of the

Styles

Less

Less

More

More

Assertiveness

Re

spo

nsiv

ene

ss

134

Working Styles profile

• Working styles are predictable patterns of

behavior that others can observe.

• Knowledge of these styles can be a huge

benefit when working in teams.

• Every style has its strengths and

weaknesses.

135

The goal: Know thy self!

• Be aware of your habitual patterns of behavior

• Recognize how others perceive you and how you come across

• Learn to make small adjustments that will increase the quality and productivity of your interactions (Don’t let your style get in the way of productive interactions)

136

But, realize that 75% of the people with

whom you work…..

• Work differently from you when in groups

• Plan differently when with others

• Are motivated by different things

• Differ in willingness to take risks

• Make use of time differently

• Make decisions differently

• Manage tasks differently

137

Know others

• Observe others more correctly and truthfully– Recognize

others’ behavior

• Learn to be accepting of others’ behavior without too

high a degree of tension

• Understand others’ behavioral preferences so that you

understand what you can do to make the team more

productive

• Attempt to meet the needs and preferences of the

project and people involved

• Interact with others as they prefer to be interacted with

138

138

Keep in mind…

No style is “best” – each has strengths

and limitations

We do not fall neatly in any one box,

but are often a mixture of “styles”

139

Analytical

• Cautious actions and decisions

• Likes organization and structure

• Dislikes involvement with others

• Asks many questions about specific details

• Prefers objective, task-oriented work

environment

• Wants to be accurate

• Seeks security and self actualization

140

Amiable

• Supports and "actively" listens to others

• Demonstrates excellent ability to gain support from others

• Works cohesively with others

• Likes close, personal relationships

• Slow at taking action and making decisions

• Dislikes interpersonal conflict

• Weak at goal setting and self-direction

• Seeks security and inclusion

141141

Driver

• Takes action and acts decisively

• Likes control

• Dislikes inaction

• Prefers maximum freedom to manage self and others

• Cool and independent, competitive with others

• Low tolerance for feelings, attitudes, and advice of others

• Works quickly and efficiently by themselves

142142

Expressive

• Spontaneous actions and decisions

• Risk taker

• Not limited by tradition

• Likes involvement

• Generates new and innovative ideas

• Tends to dream and get others caught up in the dream

• Jumps from one activity to another

• Works quickly and excitingly with others

143

So you need to know thy self

and others!

• Observe others more correctly and truthfully -Recognize others’ behavior

• Learn to be accepting of others’ behavior without too high a degree of tension

• Understand others’ behavioral preferences so that you understand what you can do to make the team more productive

• Attempt to meet the needs and preferences of the project and people involved

• Interact with others, as they prefer to be interacted with

144

Exercise: The Four Basic Working Styles Groups

Am E

DAn• Identify which of the four basic Working Styles groups you

fall into

• In the case of a tied score, you should pick the working

style you feel is most like you

• Go to the designated flipchart for your Working Style

group.

145

Working Style Group __________________

Appreciate Don’t Appreciate

How to Influence this

Style

Expressive

Exercise: The Four Basic Working Styles Groups

Am E

DAn

Once each group lists the key aspects of its Working Style we

will rotate around the room and let each group comment on the

other groups’ notes.

146

What did you learn?

• Did this exercise cause you to think

differently about people who have different

working styles than you do?

• What insights did you gain from this

exercise about yourself?

• How will you use this experience to work

differently with your improvement team?

147

A few more useful concepts in understanding

behavior

• Strengths, when overdone or misapplied,

can be perceived as weaknesses

• Personal filters influence perceptions of

self and others

From Elias Porter, PhD, Relationship Awareness Theory

148

Potential strengths of each People Style

Analytical

• Logical• Systematic

• Thorough• Prudent

• Serious

Driver

• Efficient• Decisive

• Pragmatic• Independent

• Candid

Amiable

• Cooperative• Supportive

• Diplomatic• Patient

• Loyal

Expressive

• Persuasive• Enthusiastic

• Outgoing• Spontaneous

• Fun-loving

People Styles at Work and Beyond, Bolton and Bolton, 2nd ed. 2009, page 64

149

Strengths, when overdone or misapplied,

can be perceived as weaknesses

Analytical

• Task-oriented Impersonal

• Systematic Bureaucratic

• Thorough Nitpicky

• Prudent Indecisive

Driver

• Results-Oriented Impersonal

• Pragmatic Shortsighted

• Independent Poor collaborator

• CandidAbrasive

Amiable

• Supportive Permissive

• Diplomatic Conflict avoider

• Cautious Risk averse

• People-oriented Inattentive to

task

Expressive

• Persuasive Poor listener

• Fast-paced Impatient

• Visionary Impractical

• Fun-loving Distractive

Some examples…

150

Flexing your style

• Not all the time – when it is important

• Change your own behavior

• Adjust 1-3 key behaviors

• Four Steps:

1. Identify (3 questions)

2. Plan (P)

3. Implement (D)

4. Evaluation (S, A)

151

151

B - Driver Strategies as a team leader or member Strategies when under stress

Takes action and acts decisively LISTEN TO OTHERS! Under stress – Often takes over, dictates

Likes control Acknowledge different points of view Offer options for moving forward

Dislikes inaction Be Patient Recommit to results and time frame

Prefers maximum freedom to manage self and others

“Calm Down” internally Calm down

Cool and independent, competitive with others

Pay attention to others’ feelings Seek input from others

Low tolerance for feelings, attitudes and advice of others

Use time efficiently Delay decision-making

Works quickly and efficiently by themselves

Provide Options Restate others’ concerns

A - Analytical Strategies as a team leader or member Strategies when under stress

Cautious actions and decisions MAKE A DECISION Under Stress – Often avoids and withdraws

Likes organization and structure Be more flexible, more open-minded Logically discuss the issue

Dislikes Involvement with others Openly show more concern for other people Acknowledge a need for time

Asks many questions about specific details Be decisive with data Set a deadline

Prefers objective, task –oriented work environment

Listen for people’s feelings Ask questions

Wants to be accurate and therefore relies too much on data collection

Use time accurately Seek opinions from others

Seeks security and self-actualization Provide evidence and service to influence decision-making

Working Styles Tips Sheet152

Working Styles Tips Sheet

C - Amiable Strategies as a team leader/member Strategies under stress

Slow at taking action and making decisions Assert your opinions Under stress- concedes to others, acquiesces

Likes close, personal relationships Be Less sensitive Allow them to express disagreement

Dislikes interpersonal conflict Be willing to take risks Speak Up

Supports and “actively” listens to others Say “no” more often State your thoughts in a logical concise manner

Weak at goal setting and self-direction Let people know what you think Ask open questions about concerns

Demonstrates excellent ability to gain support from others

Support relationships to establish rapport

Seeks security and inclusion Incorporate facts into your opinion

D - Expressive Strategies as a team leader/member Strategies when under stressSpontaneous actions and decisions, risk taker RESTRAIN and check Under stress- Often attacks and confronts

Not limited by tradition Talk less Separate emotions from factsLikes involvement Spend more time looking at the facts Acknowledge feelings and points of viewGenerates new and innovative ideas Control time and emotion Refrain from pouncing on the quiet onesTends to dream and get others caught up in the dream

Think before you speak Seek to gather information from all team members

Jumps from one activity to another Incorporate facts into your decisionsNot good with follow-through Encourage decision making with incentives and

stories

153

A final thought…

Managers (team members) who consistently

accomplish a lot are notably inconsistent in

their manner of attacking problems and

approaching situations.

They continually change their focus, priorities,

behavior patterns, and their own leadership

styles based on with whom they interact.

Harvard Business Review

Skinner and Sasser, Versatile and Inconsistent, HBR, November 1977

154

Case Study: Antibiotics within 4 hours of arrival

February 1st, 2017

William Peters

Day 3

Increased focus on

Pneumonia from Board

and Medical Staff, want to

do better…

Certain Leaders believed

we need a more structured,

proven way to engage in

improvements…

Decrease the time to

Antibiotics for pneumonia

patients (<4 hours)

Institute for Healthcare

Improvement “Improvement

Advisor” program

Improving Pneumonia Care: Antibiotics

within 4 hours of Arrival

Background:156

Used the Model for Improvement

Used The Model to

get project rolling

by asking the first

three questions

and putting them

in to a “Charter”

157

We will dramatically

reduce the time to first

dose antibiotics for ER

and direct admit

pneumonia patients.

Whenever medically

efficacious, we will

ensure these patients

receive their first dose

of antibiotics within 4

hours of arrival.

4

from Door to first dose within

Aim Statement:


158

What are we trying to accomplish? Dramatically reduce the time to first dose antibiotics for Emergency

Room and Direct admit pneumonia patients

100% of our community acquired pneumonia patients will receive antibiotics within the first 4 hours

…and Why?

Pneumonia is the 6th leading cause of death in the U.S.

3rd at DCH during Fiscal Year 2005

Variation in length of stay – longer stays mean higher cost, less reimbursement

Pneumonia patients who receive timely antibiotics (less than 4 hours of hospital) arrival have been shown in studies to have statistically significant reduced mortality rates both in the hospital and for 30 days after admission

These same patient have shorter lengths-of-stay compared to pneumonia patients who had received antibiotics later than 4 hours

Lower length of stay will reduce variable cost for treatment for pneumonia patients

Charter


159

Success was obtained by

answering the 3 questions in the

“Model for Improvement” followed

by “rapid cycle testing”

We will dramatically reduce the time to first dose antibiotics for ER and direct admit pneumonia patients.

Percent Pneumonia Patients receiving Antibiotics

within 4 hours of Arrival.

&Time from Arrival to First Dose Antibiotics for

Pneumonia Patients

A Flow Chart was created for both sides of

the process; ER and Direct Admit.

Reduce effects of failed large test by

doing small scale tests. This increases

buy-in and reduces resistance

Subject Matter Experts generate ideas for

change by using logic, “Change Concepts”

and Creativity


160

Flow Chart for ER Admits

Walk-In

Arrival

Ambulance

Arrival

Short-Reg,

Triage and RN

Assessment

Initiate Rad

Standing

Order?

Short-Reg

(Arrival T ime)Triage

X

yes

no

RN

Assessment

Initiate Rad

Standing

Order?

yes

no

MD

AssessmentA

APneumonia

Patient?

Patient

Out

yes

no

MD Orders

Labs

Rad Standing

Order Already

Followed? no

yes

MD Orders

Chest X-rayED Clerk

Enters Orders

Radiology

Assesses OrderB

BPatient ready

for Chest X-

ray?

no

yes Radiology

Ready for

Patient?

no ?

delaydelay

Chest X-ray

Performed

Chest X-ray film

made available to

ED

Chest X-ray

interpreted by ED

MD

Diagnosis of

Pneumonia

made?

Patient

Out

no

yes

Confirm with

Radiologist

C

IV Accessed?

yes

no

IV retry

successful?

no

yes

Call IV

TherapyIV Therapy

ArrivesIV Accessed

X

E


161

Flow Chart for ER Admits

yes

ED MD Orders

AntibioticBlood Cultures

Drawn?no noC

Pneumonia

Patient

Admitted?

Patient

Out

no

no

PMD

Contacted?

PMD

agrees to

admit?

yes

Patient

Out

yes

ED RN Aware

of Order

ED Clerk enters

orders for Blood

Cultures

D

D 1st Blood

Cultures Drawn

2nd Blood

Cultures Drawn

30

Min.

no

Antibiotic

in Pyxis?

ED RN Calls

Pharmacy

yes

yes

Nurse prepares

Antibiotic

Documented first

dose antibiotics given

by ED RN

Nurse orders

X-rayRadiology

Assesses Order

Patient ready

for Chest X-

ray?

no

yes Radiology

Ready for

Patient?

no

delaydelay

Chest X-ray

Performed

Chest X-ray film

made available to

ED

Pharmacy mixes

X E

Antibiotic

delivered

to RN with

scripting

Removing this single step

reduced average wait time by

18 minutes


162

Some ideas/areas we tested …

Triage in ED

Chest X-Ray Process

ED – MD change

ED Education Blitz

Rx Delivery Processes

IP Admission

ADC – Admit process

Protocol Changes

Med First

?


163

Did we improve?

Changes produced a new level of performance …

New lower average time to first dose antibiotics. Average now around 116 minutes.


164

Did we improve?

Changes produced a new level of performance …

Past 5 months at 100%. Process of caring for patients has change significantly.

165

Comparing 2 groups towards the end of Improvement Effort revealed:

Antibiotics received: > 4 Hours (n=121) < 4 Hours (n=497)

Percent 30 day readmit 14% 10%

Average LOS 7.2 5.2

Average variable cost per case $6,048 $5,721

Press-Ganey Inpatient Survey:“Wait for tests and treatments” 81.5 (79th percentile) 86.1 (99th percentile)

…additional benefits…

• Successful test of the Model for Improvement.

• Jump start on upcoming P4P at individual physician level.

• A publicly reported Quality indicator we will now be doing very well at.

• Another step towards guaranteeing APU from Medicare.

Results


166

Tying it all together

February 1st, 2017

William Peters

Day 3

Day 3 Debrief and Next Steps

Program design and key dates

Jan 12

12-1:30 PM ET

Prep

Webinar

Jan 30-Feb 1

San

Francisco

Workshop

1

Apr 6

12-1:30 PM ET

Final

WebinarWorkshop

2

Mar 13-15

San

Francisco

Feb 16

12-3 PM ET

Feb 22

12-3 PM ET

Mar 2

12-3 PM ET

Virtual

Workshop

1

Virtual

Workshop

2

Virtual

Workshop

3

Support

IHI.org Email distribution list Faculty consults

Coaching feedback from fellow coaches and faculty

Documents

Welcome back to the IHI Improvement Coach …app.ihi.org/Events/Attachments/Event-2897/Document-6300/...Welcome back to the IHI Improvement Coach Professional Development Program Workshop