How to Spread ChangePDSA to SDSA and beyond!

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Grace Capreol, CoachKasey Harding – Team Leader

Learning Objectives

● Using a real example of change to define the steps of spreading from PDSA – SDSA● Using specific criteria for determining the potential success of standardization●Outlining a communication strategy for leadership and staff before and during standardization●Defining evaluation measures for standardization●Dissemination of successful standardization

Testing Changes

Standardizing

Spreading

Standardizing to Spreading

SOGI Data Collection Project Outline

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To follow the “best practices” guidelines and recommendations to collect Sexual Orientation and Gender Identity (SOGI) data on all CHC patients over the age of 13, thereby creating an environment of inclusive and affirming

healthcare for all patients.

Goals and Objectives1. Inclusive and affirming environment of care for all patients.

2. Enhanced healthcare services for LGBTQ population3. Targeted healthcare services for at risk populations

4. Improved resources for LGBTQ population5. Staff and patient education opportunities

PDSA 1: Pod

Evaluate & Create

Action Plan

PDSA 3: Expand to

other clinical teams

Timeline for Rollout

Dec. ‘15 Jan ‘16 Feb ‘16

PDSA 2:Time Study

Apr ‘16

Data Review

May ‘16

Survey MonkeyQualitative review

Data Review

Newsletter Article to Agency

Data Review

June ‘16

PDSA 4: SOGI for Peds

Report out to Performance

Improvement (PI)Committee

Training

Training for Microsystem

Team

July ‘16

Data Review

RN/LPNTrainingEHR

Change

Decision on Agency Roll-Out

Playbook

PSA, MA, Provider Training

Agency Go-Live

Data review PI

Committee Meeting

Timeline for Rollout

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Aug ‘16 Sept ‘16 Oct ‘16 Nov ‘16 Dec ‘16 Jan ‘16

System Change

DashboardsNOVO

Site Meetings& Retraining

Internal Resource Page

Published

Data ReviewPI Committee

Meeting

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Improvement Ramp

First Step: What do we aim to achieve?

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Process Map – identify areas for improvement

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Stars indicated every point of contact with a patient where access to SOGI data may be important.

Ex: Patient Registration & Preferred Name

Specific Aim StatementsHow are we measuring success?

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PDSA – Helps keep track of progress toward SDSA

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Predictions – what does your POD expect will happen from this test of change? How are you going to measure those expectations?

First Question to ask yourself

Is the process standardized?

1. Is the process Failure free over time?

Can Your team can count on it not to fail when everyone is doing following the process?

If one person overlooks it, will another catch it? Are there clear specifications and communication? Is the process supported by technology to reduce failure (EHR)?

2. Is there an expectation of No Variation except per Clinical Criteria or Judgement

3. Is the process LEAN with minimal steps in the process?

4. Will you use the standard for developing staff competency and training new employees?

5. Is there a process owner, from Start to Finish?

Is it understood that there can be No Individual Autonomy to Change the Process?Do you have methods for constantly learning and improving a standardized process?

Is the process standardized?

Standard Workflow for CHCI SOGI Collection

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Playbook and Standardized Questionnaire

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Evidence exists from one POD that the standard achieved the desired

result, and should be tried by another POD.

Be sure that a process standard is successful in more than one POD

before undertaking broad “spread”.

Ihi.orgGeisinger Quality Institute

Evidence from first Pod• Pod was able to

increase SOGI collection rates from 0% to over 70% of patients seen in 12 months.

• Team reported low burden to collect & document data

• December marked transition to SDSA

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Ok, we’ve got this great process that is working well for our POD.

How do we know if we are ready to spread our

work?Ihi.orgGeisinger Quality Institute

How Will You Know? A process recognizable by all in the workplace

as “the way we do things” here Five staff members can regularly articulate

the process steps when asked individually to describe

A “miss” (defect) in the process flow can be immediately identified so that it can corrected There is a process in place to identify a failed step in

process There is a communication plan to support correcting

a process defect to all areas Measures clearly indicate that the process is

workingIhi.orgGeisinger Quality Institute

Staff Reaction to Standardization

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“We have heard so much about what was going on in the NB site and were wondering when this would get around to us.”

~MA in Enfield

“I have a daughter who is transgender and I asked her about the training we received and the process we are using. She was very interested in how we would be using the data collected and not just the fact that we collected it. I would like to know more about our long-term goals.” ~ RDH NB

“Everything gets put on the MA’s to do but this is something that feels right to do as an agency. When I heard what the patient response was in the first sites I couldn’t wait for it to move to our site.” ~ MA New London

Data, Data, Data!

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Agency Roll-Out

60% of patients seen within last 12 months

SOGI Collection Rates by Site

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Another way to visualize datato prove the impact to leadership

It is never to early to plan for spread however certain things should be

in place before actually carrying

out the plan.

Ihi.orgGeisinger Quality Institute

“4 Certain Things” 1. The improvement process is a key

strategic initiative of the organization2. It has identified executive and local

leadership3. There exists successful sites that are the

source of the improvement process to be spread

4. There exists evidence that the improvement process results in a desired outcome

A Framework for Spread: From Local Improvement to System-wide Change. 2006 Institute for Improvement Ihi.org

Geisinger Quality Institute

Key Strategic Initiatives:Performance Improvement Plan 2015-2016

UDS Reporting 2016

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LGBTQ Resource Page & Site Champions

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Broad Spread is a BIG deal

Owned by Leaders and Managers

Extensive planning, timetables, communication, leadership expectations, possible infrastructure enhancements, transition to operational responsibilities, follow-up measurement, etc. (Whew!!) Ihi.org

Geisinger Quality Institute

Communication is Key

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Presentation to Agency Wide Performance Improvement Committee with Key Action Items

Outlined

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Use positive patient feedback to sustain momentum!

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Lessons Learned

00/00/00

• Standardization is on-going and the process requires continuous attention.

• Prioritize a true change in agency culture not just process. • Facilitate collaborations with internal departments early in the process

(i.e.: data, business intelligence)• Be prepared for the “hoops” you need to jump through to get to an

agency wide initiative – committee presentations, BOD approval• Patient feedback can invigorate enthusiasm in staff• Training to all levels of staff is arduous but necessary in standardization –

remember to include administration, IT, billing, finance.• Communication to the correct individuals is a key to success. • Recognition for key staff (especially those with increased work load) is

essential• Leadership buy-in can make or break an initiative. • Assign a key point of contact for questions, concerns and suggestions.• Highlight successes often!

Questions/Comments

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Contact Information

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Kasey Harding-Wheeler, Director CKPHardinK@chc1.com

Grace Capreol, Sr. EHR & Health Applications Analyst

CapreoG@chc1.com

Resources

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You can access more playbook documentation and resource guides on the moodle!