Numbers Make the World Go Round: Using Data to Drive Change May 25th, 2012

1. Numbers Make the World Go Round: Using Data to Drive Change May 25th, 2012 Presented by: T. Rollefstad SIA Safer Healthcare Now!, CPSI

2. We’ve got the data so now what? Session One

3. Where are we At and Where are we Going? Morning Afternoon Session 3 Understand when to move from testing to implementation Create a plan for next steps Session 4 Explore in dialogue, several topics relevant to making change Session 1 • Describe some methods to drill into the data for a focus • Identify some next steps to use data for action • Learn a method for making rapid change Session 2 • Learn to apply a method for rapid change • Understand how to build knowledge from testing

4. The improvement process Project mission Project team Ongoing monitoring Outcome Future plans Project Phase • Conceptual flow of process • Customer Grid • Data • Fishbone • Pareto chart • Run charts • SPC charts Sustaining Improvement Phase 1 1 month 5 Diagnostic Phase Annotated run chart SPC charts Impact Phase 2 4 3 Intervention Phase A 2 months P S D S D 2 months S Plan a change Do it in a small test Study its effects Act on the result P A A A D A S P P S P D D Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) 63% have recruited a team 68% have selected a focus 45-50% have completed a charter and begun testing

6. Diving into the Issues What questions & methods did you use in trying to drill into your data to find a focus? How did you choose the team members to work with you? How did you gain support for your work?

7. Getting MORE information Table Talk – Pick ONE Debrief Share with the table next to you: • What questions & methods did you use in trying to drill into your data to find a focus? • How did you choose the team members to work with you? • How did you gain support for your work?

8. 1. Project Phase • “getting organized” • decide on process that needs improving • form teams • write an aim statement • consider appropriate measures

9. AIM Statements • Should be SMART Specific Measureable Appropriate Result oriented Time scheduled To reduce the rate of infections in joint replacement surgery to less than 1% within 12 months

10. 2. Diagnostic Phase • Collect evidence and diagnose problem • Determine the cause • Use tools to identify and organize information

11. Tools: identify and organize • process flow chart • brainstorming • patient focus group • nominal group technique • tally chart • observation

12. Organize information • Affinity diagram • Pareto chart • Histogram • Graphs of current data-run and statistical process control charts (SPC) • Huddles • Cause and effect diagram

13. Pareto Chart Observations

14. 3. Intervention PhaseModel for Improvement What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement? ACT PLAN STUDY DO Langley, Nolan, Nolan Norman & Provost 1999

15. Test Cycles Act Plan • Objective • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned • Carry out the plan • Document problems • and unexpected • observations • Gather key • data

16. How BIG shall we go?

17. PDSA cycle PDSA cycles – single test D S Changes that result in improvement S A P A A D P S P A P D S D Hunches, theories and ideas Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

18. Act Plan Study Do From Improvement to Spread Spreading a change to other locations Make part of routine operations Test under a variety of conditions Implementing a change Testing a change Theory and Prediction Developing a change Robert Lloyd

19. Fast Forward PDSA Session Two

20. Pareto Chart Observations

21. Catheters in too long: Ideas to try • Include catheter necessity in daily nursing assessments & shift change • Develop nursing protocols to allow removal if criteria met • Implement automatic stop orders for 48-72 hrs after insertion • Place reminders (stickers) in patient order sheets requiring continuation of catheter order • Use alerts in computerized ordering systems to indicate presence of a catheter & require documentation for continued need How-To-Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: IHI; 2011. (Available at www,ihi.org)

22. Test Cycles Act Plan • Objective • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned • Carry out the plan • Document problems • and unexpected • observations • Gather key • data

25. Huddle Group in the Fish Bowl Instructions: • Choose an idea to test • Complete the questions for the PDSA planning on the flip chart • Discuss result in terms of your unit • Record answers to the Study of that result • Record the answers to the Act – change, adopt, abandon?

26. Observer Group Outer Ring Instructions: • Was the prediction clear? • Was the plan clear? W5 • What did you learn in the study? • How would you modify the test?

27. Catheters in too long: Ideas to try • Include catheter necessity in daily nursing assessments & shift change • Develop nursing protocols to allow removal if criteria met • Implement automatic stop orders for 48-72 hrs after insertion • Place reminders (stickers) in patient order sheets requiring continuation of catheter order • Use alerts in computerized ordering systems to indicate presence of a catheter & require documentation for continued need How-To-Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: IHI; 2011. (Available at www,ihi.org)

28. Fish Bowl Debrief #1 What struck you about the planning portion? How did the teams study the “do” observations? What might you measure? How might you change this test?

29. Six Outer Ring volunteers for next fishbowl

30. Observer Group Outer Ring Instructions: • Was the prediction clear? • Was the plan clear? W5 • What did you learn in the study? • How would you modify the test?

31. Fish Bowl Debrief #2 What struck you about the planning portion? How did the teams build on their learning? What might you measure? How might this testing work in your area?

32. Moving from Testing to Implementation Session Three

33. Act Plan Study Do From Improvement to Spread Spreading a change to other locations Make part of routine operations Test under a variety of conditions Implementing a change Testing a change Theory and Prediction Developing a change Robert Lloyd

36. CHAT Power of Testing CLAVARDER

37. Develop, Test and Implement A successful change High Degree of belief that the change will result in improvement Change still needs further testing. There is a risk of implementing at this stage. Moderate Unsuccessful proposed change Low Testing a Change Cycle 1, 2, 3… Developing a Change Implementing a Change Source: Langley, et al. The Improvement Guide

38. Testing and Implementation Similarities: • PDSA cycles • Building knowledge • Predictions • Data Differences: • Testing is temporary, implementation is permanent • Support processes • Expectations of failure • Social impacts and resistance • Balancing measures

39. IMAGINE 1 YEAR FROM NOW What does fully implemented look like?

40. 4. Impact and Implementation • Measure impact of changes/interventions • Record the results • Revise the interventions • Monitor impact Impact and implementation phase • Annotated run chart • SPC charts • Other graphs Measure impact Implement the changes Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

41. 5. Sustaining Improvement • Once an intervention has been introduced, the intervention and any improvements need to be sustained. • This may involve: • Standardization of existing systems and processes • Documentation of policies, procedures, protocols and guidelines • Measurement and review of interventions to ensure that change becomes part of ‘standard’ practice • Training and education of staff Sustaining Improvement Phase Sustain the gains • Standardization • Documentation • Measurement • Training Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

43. Leading Your Change Planning your next steps

44. Work Plan Exercise • Take 30 min to document your next steps and tests using the work sheet provided • Report out one of your planned next steps or tests

45. Tanis Rollefstad, RN, BN, MACT candidate Safety & Improvement Advisor SHN, CPSI Tanis.rollefstad@hqca.ca