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PLAN. DO. ACT. STUDY. Model for Improvement. What are we trying to accomplish?. AIM. What can we change that will result in an improvement?. How will we know that a change is an improvement ?. CHANGE. MEASUREMENT. PDSA –testing a change. MARU. From YouTube.

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Model for improvement

PLAN

DO

ACT

STUDY

Model for Improvement

What are we trying to accomplish?

AIM

What can we change that will result in an improvement?

How will we know that a change is an improvement?

CHANGE

MEASUREMENT


Pdsa testing a change

PDSA –testing a change

MARU

From YouTube

What is Maru trying to achieve?

How many ideas does he try?

Is he successful?

What was the possible negative outcome?


Rapid cycle change

Rapid Cycle Change

PLAN

PLAN

PLAN

PLAN

DO

DO

DO

DO

ACT

ACT

ACT

ACT

STUDY

STUDY

STUDY

STUDY

What are we trying to accomplish?

What can we change that will result in an improvement?

How will we know that a change is an improvement?


Model for improvement

PROBLEM :

AIM of this change:


Model for improvement

Do a PDSA

to solve a problem at home

AIM of this change:


Model for improvement

PROBLEM : unpacking the dishwasher is inefficient

AIM: unpack the dishwasher in a more efficient way

  • Tom to rearrange cupboard today

  • -Mary and Tom to unpack into one cupboard for 4 days

How easy it is to unpack the dishwasher

Put half the cups and half the glasses in the cupboard just above the dishwasher

Mary – it will look horrible and I will hate it

Tom – it will be easy and Mary will like it


Model for improvement

PLAN

DO

ACT

STUDY

Model for Improvement

What are we trying to accomplish?

AIM

What can we change that will result in an improvement?

How will we know that a change is an improvement?

CHANGE

MEASUREMENT


Measurement

Measurement

Outcome measure

Are we getting closer

to our target?


Measurement1

Measurement

Process measure

(Bundle compliance)

Did we use

the whole bundle

in every patient

every time?


Model for improvement

Measurement

Measuring the impact of a change

Was the change

an improvement?


Measuring over time

Measuring over time

  • a volunteer to write

  • a volunteer to measure

  • graph paper


Annotated run chart

Annotated Run Chart

Community Need

Change Made in June

I


Interpreting data what is the story

Interpreting Data: what is the story?

Before (Feb) After (Aug)

I


What is the real story

What is the real story?

Feb

Aug

Feb

Aug

Change Made

Change Made

Feb

Aug

Change Made in June

Feb

Aug

Feb

Aug

Change Made

Change Made

I


Model for improvement

Prevention of Mother to Child Transmission.

A sub-district in a province in SA

Positive PCRs at 6 weeks (target <5%)

Feb 2010 8.2%

Feb 2011 3.2%

Improvement?


Model for improvement

Positive PCRs at 6 weeks (target <5%)

Feb 2010 8.2%

Feb 2011 3.2%

Improvement?


Model for improvement

Run Chart: Rules for Identifying Statistically Significant Change

Median

Median

Shift: 6 points in row on same side of the median Note: A point exactly on the centerline does not cancel or count towards a shift

Rule 2

Rule 1

Trend:5points in row headed in same direction

Note: Ties between two consecutive points don’t cancel or add to a trend

Rule 3

Rule 4

Data line crosses once

Too few runs: total 2 runs

Median

Median 11.4

Astronomical Point: a obviously, even blatantly different value

Note: Every set of data will have a highest and lowest data point. This does not mean the high or low are astronomical

Runs: too few or too many runs

I

Provost and Murray


Run charts

Run Charts

One of the most powerful tools for improvement

Describe a process over time

Shows trends the process is experiencing

Can be used to analyse whether the change was an improvement

Data can be used to drive change


Model for improvement

Outcome measurement

Are we getting to our target?

Was the change an improvement?

How do we measure HAIs?


Model for improvement

Measuring infection rates

Lessons from an ICU


Quality improvement 101

Quality Improvement 101

Problem?


Measuring infection rates

Measuring Infection Rates

  • Total number of infective cases per 1,000 device days:

Total No. of VAP cases

X 1,000

Numerator

Ventilator days

Denominator


Definition of vap

Definition of VAP

“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time orwithin 48hrs before the onset of the infection”

“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltratewith fever /leucocytosis and purulent tracheobronchial secretions”


Overcoming numerator issues

Overcoming Numerator Issues

Numerator

Total No. of VAP cases

Patients with

X 1,000

Ventilator days

Denominator


Overcoming numerator issues diagnosing the hai workbook

Overcoming Numerator Issues – diagnosing the HAI (workbook)

Checklists for

Diagnosing the

HA Infection

used by the

team


Overcoming denominator issues

Overcoming Denominator Issues

At the same time

every day the

Unit manager

counts devices

in use in the ward


Measuring hai

Measuring HAI

Percentages and rates

% (or rate) = Numerator/ denominator

eg

Rate of infection = readmissions for septic caesarian section wounds per week / number of Caesarian Sections performed per week

Rate of infection = Number of VAP / 1000 device days


Safety calendar welsh 1000 lives campaign

Safety CalendarWelsh 1000 lives campaign

I

Developed by Annette Bartley


Welsh patient safety project

Welsh Patient Safety Project


Measuring hai1

Measuring HAI

For measure ‘rare’ events (occur < 10%)

The concept of

‘days between’ infections


Model for improvement

Off the internet, Google pictures


Model for improvement

Off the internet, Google pictures


Model for improvement

Off the internet,

Google pictures


Model for improvement

Off the internet, Google pictures


Maternal deaths malawi

Maternal deaths – Malawi

For the “NO Maternal Death” Campaign

a colorful, laminated A4 paper

that said “Days without a Maternal Death: ______”.

were hung in every Labour Ward

for all (providers, patients and guardians) to see

and the number was filled in daily with a dry erase marker


Days between icecreams

Days between icecreams

25

Days

between

icecream

20

15

10

5

1st

2nd

3rd

4th

5th

Icecream


Days between events infection

Days between events (infection)

25

Days

Between

events

(eg

Infection)

20

15

10

5

1st

2nd

3rd

4th

5th

Sequence of events (eg Infection)


Neonatal deaths malare health centre 5 s alive project ghana

Neonatal deaths – Malare Health Centre, 5’s Alive! Project, Ghana

I


Model for improvement

Measuring rare events and time-between measures.

James Benneyan IHI

I


Model for improvement

ICU: Sequence of VAP infections by date 2010


Model for improvement

Use the tools to

Display the data


Model for improvement

Days

Be-tween

Infection

Sequence of Infections

# Days since

last infection

Date of

infection


Model for improvement

So far we have:

  • Mapped the size of the project in your facility

  • Prioritise a unit and bundle to start with

  • Written an aim


Model for improvement

Now, write down:

  • Your aim

  • Process Measures(Bundle compliance)

  • The outcome measures

    • Rate = numerator/denominator (describe)

    • Days between

    • Welsh Safety Cross calendar

    • Other

  • How you will feedback the data every month to

    • The frontline staff

    • Management

    • Mark with a * areas that you want to strengthen


Improving your outcome measure

Improving your Outcome Measure

1) Numerator

Standardised diagnosis of infection

2) What is the measure for HAI?

Rate = Infection/device day

Days between (CLABSI, VAP, UTI)

Days or cases between SSI

3) Collecting and collating data:

What (definition)/ Where/ How (tools)/ Who/ When

4) Presenting the data:

Format - Safety Cross, Graphs

Feedback/presentation - Management platform


Model for improvement

Note the areas that need strengthening

  • Your aim

  • Process Measures (Bundle compliance)

  • The outcome measures

    • Rate = numerator/denominator (describe)*

    • Days between

    • Welsh Safety calendar*

    • Other

  • How you will feedback the data every month to

    • The frontline staff *

    • Management *

    • * Areas that need strengthening


Model for improvement

Establishing or Improving

your outcome measure/s

  • Select a priority area for improvement

  • resolving it will have a big impact

  • it is under your control to test a change

  • you can start on Monday


Model for improvement

PLAN

DO

ACT

STUDY

Plan a PDSA using the

Model for Improvement

What are we trying to accomplish?

aim

What can we change that will result in an improvement?

How will we know that a change is an improvement?

change

measurement


Model for improvement

PROBLEM :

AIM of this change:

Design a PDSA to improve one of the areas with a *


Model for improvement

PROBLEM : staff aren’t engaged in the project

increase awareness through measurement

AIM

What

When

Where

Who

How

AIM: the Welsh Safety Cross is completed

Staff know what it means

AIM: use the Welsh Safety Cross

Welsh Safety Cross will improve the profile of the project.

Will need to engage staff with colouring it in or they won’t take any notice


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