Introduction to the rapid improvement model plus
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Introduction to the Rapid Improvement Model Plus. Simple Tools for Workflow Redesign. Workshop Objectives. By the end of this module, you will be able to: Discuss the three fundamental questions used in rapid improvement so you can quickly begin work on performance improvement

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Introduction to the rapid improvement model plus

Introduction to the Rapid Improvement Model Plus

Simple Tools for Workflow Redesign


Workshop objectives

Workshop Objectives

  • By the end of this module, you will be able to:

    • Discuss the three fundamental questions used in rapid improvement so you can quickly begin work on performance improvement

    • Create a process flow that allows you to understand where you need to start your improvement work

    • Identify sources of waste in your processes

    • Create a data collection plan

    • Apply the Plan-Do-Study-Act (PDSA) cycle so teams know when and how to use it for rapid improvement


Section i assess develop a process flow map

Section I:Assess – Develop a Process Flow Map


Rapid improvement model

Rapid Improvement Model

What are we trying to

accomplish?

How will we know that a

change is an improvement?

What change can we make that

will result in improvement?

Act

Plan

Study

Do

Model for Improvement developed by

Associates in Process Improvement

( http://www.apiweb.org)


Why do rapid improvement

Why do rapid improvement?

  • Engage your team to improve processes affecting patient care experiences and your team’s work experience

  • Achieve big gains from small rapid tests of change

  • Eliminate time wasting and dangerous work-arounds

  • Engage team members in improving work processes

  • Accomplish your department’s goals

  • Improve your department’s performance


What could be improved where you work

What could be improved where you work?

  • Patient Satisfaction

  • Employee Satisfaction

  • Safety

  • Clinical outcomes

  • Under, over, or misuse of procedures, medications etc.

  • Attendance

  • Excessive costs/waste

  • Inefficiency

  • Wait times or delays

  • Unexplained variation

  • Multiple processes

  • Errors

  • Rework

  • Work-arounds


Rim has a specific scope

RIM has a specific scope

With RIM you would not attempt to address the following issues as part of your improvement plan …

  • Staffing and FTE issues exclusively

  • Performance management issues

  • Compliance or legal issues

  • Any agreements addressed in Local Union contracts and the National Agreement


What s wrong with this picture

What’s wrong with this picture?


Assess what is the current process

Assess: What is the current process?

  • Begin with a quick “walk through” of the entire process, to get a sense of the flow and sequence of steps. “Pin yourself to the problem” as if you were the staff or patient.

  • Go back and gather information at each step (data, stories, etc.)

  • Follow along the actual pathways of material and information yourself

  • Collect relevant current-state information while “working through” using a data collection tool

  • Map the whole process yourself (or as a team), even if several people/departments are involved and multiple hand-offs occur

The point of mapping is NOT the map.

It is understanding the flow of information and material.


Assess where do problems occur

Assess: Where do problems occur?

Member

identified

for screening

Member contacted for appointment

Appointment for mammogram scheduled

Co-pays collected

Do not

collect co-pay

Do not

identify

people needing

screening

Mammogram completed

Mammogram

read

Member contacted with results

Do the results

warrant

follow-up

care?

no

Timely turn

around in

calling member

yes

Team agrees

this is the biggest opportunity

Follow-up care scheduled as needed

  • Focus on one area in a process


Workshop exercise and report out

Workshop Exercise and Report Out

  • Draw a process map for an area you want to improve

  • Use no more than 5 – 6 major steps

  • Identify where the failures occur

  • Brainstorm the most critical 1 – 2 failures that need to be improved

  • Keep a list of all points that need improvement


Section ii assess identify your goal for improvement

Section II:Assess – Identify Your Goal for Improvement


Identify your goal for improvement

Identify Your Goal for Improvement

What are we trying to

accomplish?

How will we know that a

change is an improvement?

What change can we make that

will result in improvement?

Act

Plan

Study

Do

Model for Improvement developed by

Associates in Process Improvement

( http://www.apiweb.org)


Question 1 what are we trying to accomplish

Question 1: What are we trying to accomplish?

What could be improved in your area?

Goal statements are S.M.A.R.T. and are the first steps you and your team will take:

S

Specific including the target population

M

Measurable

A

Attainable

R

Realistic

T

Time bound


Goal statement steps and examples

Goal Statement Steps and Examples

What could be improved in your area?

  • Brainstorm what could be improved, review the process map

  • Review current data if available and departmental goals

  • Write a Goal statement for one improvement your team wants to try

  • Good examples of Goal statements:

    • Inpatient: reduce ventilator-associated infections by 25% in the ICU West within 10 months.

    • Outpatient: Increase by 25% the annual testing of HgbA1C in diagnosed diabetes in the South City Clinic within 6 months.

    • Non-clinical: Improve staff satisfaction service scores by 5% in the registration department in the next 6 months.


Exercise and report out

Exercise and Report Out

At your table, using the flip chart:

  • Work on creating a Goal statement for an improvement project in your area

  • Make sure it follows the SMART principle


Let s assess your goal statement

Let’s Assess Your Goal Statement

Goal content

  • Explicit overarching description

  • Specific actions or focus

  • Goals

    Goal characteristics

  • Time specific

  • Measurable

  • Define participants


Section iii develop measures and plan for data collection

Section III:Develop Measures and Plan for Data Collection


Creating measures for improvement

Creating Measures for Improvement

What are we trying to

accomplish?

How will we know that a

We are here

change is an improvement?

What change can we make that

will result in improvement?

Act

Plan

Study

Do

Model for Improvement developed by

Associates in Process Improvement

( http://www.apiweb.org)


Three types of data

Accountability

Research

Improvement

Reporting Purposes

Specific data

Agencies

State/federal regulators

Beyond Doubt

Lots of data

Prove hypotheses

Statistical

Just Enough to Learn

Limited data

Small samples/tests of

Changes incorporated as needed

Three Types of Data


Three types of measures

Three Types of Measures

Outcome Measures:

  • Voice of the customer or patient

    • How is the system performing? What is the result?

      • Tied directly to goal statements

      • Can be time, clinical outcome, financial, or satisfaction

        Process Measures:

  • Voice of how the process works

    • Are the parts/steps in the system performing reliably as planned?

      Balancing Measures:

  • What happened to the system as we improved outcome and process measures (e.g., high or low volume days)?

    • Looking at a system from different directions/dimensions


  • Examples of non clinical measures

    Examples of Non-Clinical Measures

    Outcome measure

    • Percent change on Employee Satisfaction Scores for two service-related questions

      • Q11: Are you trained to give good service?

      • Q12: Are you supported to give good service?

        Process measure

    • How many registration clerks say they used scripted languages in their customer interactions this week?

      Balance measure(unintended consequences)

    • Member/patient satisfaction scores


    Steps in identifying measures

    Steps in Identifying Measures

    • Identify the high priority process you are working on

    • Develop the process map for workflows and decisions made

    • Define your outcomes: clinical/operational, service, cost

    • Review the process map and ask, “what do we need to know to tell how the process is working?”


    Steps in designing a data collection tool

    Steps in Designing a Data Collection Tool

    • Data collection tool is created and tested by front-line workers

    • Use paper, and test quickly before formalizing

    • Avoid collecting unnecessary data – ask for only what is needed

    • Final form needs to include a definition of measures, what is included and not, and simplifies what needs to be entered


    Simple data collection tool

    Simple Data Collection Tool

    Project level

    information

    (person, place, time)

    Outcomes data

    (by week)

    Identified barriers, leads to more testing ideas

    Process data

    (collected

    by staff during the day)

    Example:


    During testing measurement is

    During Testing, Measurement is:

    • Feedback for your team

    • Information so your team can act rapidly if necessary

    • For improvement and not for judgment, accountability or research

    • Useful rather than perfect

      • Simple, easy data collection while doing your daily work

      • Consider using existing data sources/sampling

    • Timely as a key to learning

    • Tracking data over time using pencil/paper

    • Used to think about every test and its implications


    Motivate staff display data in your department

    Motivate Staff:Display Data in Your Department

    What will tell us whether our changes are improving care and service?


    Workshop exercise developing measures

    Workshop Exercise: Developing Measures

    Scenario:A friend has asked you to consult on a personal improvement project.

    Project Goal:Lose 10 lbs in 6 months

    • Develop measures that can be reported each week

      • 1 Outcome measure

      • 1 Process measure

  • Develop Summary of Measures on your flip chart


  • Exercise determine your project measures

    ExerciseDetermine Your Project Measures


    Section iv identify potential ideas for improvement

    Section IV:Identify Potential Ideas for Improvement


    Focus on planning rapid tests under varying conditions

    Focus on Planning Rapid TestsUnder Varying Conditions

    What are we trying to

    accomplish?

    How will we know that a

    change is an improvement?

    We are here

    What change can we make that will result in improvement?

    Act

    Plan

    Study

    Do

    Model for Improvement developed by

    Associates in Process Improvement

    ( http://www.apiweb.org)


    Identify changes

    Identify Changes

    Determine what will help:

    • Brainstorm ideas

    • Standardize and simplify processes

    • 6S (see online module)

    • Reduce waste, wasted steps

    • Apply best practice or evidence-based practices


    Standardize and simplify

    Standardize and Simplify

    • Standardize

      • Create predictability and consistency. Ways to standardize include:

        • Common equipment

        • Standard order sheets

        • Check lists

        • Reducing number of steps in a process

    • Simplify

      • Eliminate unnecessary complexity

      • Design single way to perform tasks

      • Put supplies near where the work is done


    Standardize why standardize

    StandardizeWhy Standardize?

    Benefits of standardizing

    • Builds a reliable system

    • Supports training and competency testing

    • Everyone can clearly state what their work consists of

    • Allows for the use of best practices

    • Feedback and learning is part of the system for improvement


    Simplify identify what is waste

    SimplifyIdentify What is Waste

    • Searching

      • Nurse cannot find IV pump

      • MA cannot find discharge forms

    • Deciding

      • Nurse is not sure which patient she should see next

      • Physician is looking for time to call patients

    • Travel

      • EVS has to walk to the store room to get frequently used supplies.

    • Transporting

      • Phlebotomist carries a blood sample from the ED to the lab for a common blood test.

      • Patients are not transported from their rooms to radiology for an MRI by the scheduled test time


    Workshop exercise

    Workshop Exercise

    • Look at the issue you identified on your process map.

      • Are there ways to simply or reduce waste in this issue?

      • Brainstorm ideas.


    Section v develop and plan for small tests of change and huddles

    Section V:Develop and Plan for Small Tests of Change and Huddles


    Focus on rapid tests under varying conditions testing ideas

    Focus on Rapid Tests Under Varying Conditions: Testing Ideas

    What are we trying to

    accomplish?

    How will we know that a

    change is an improvement?

    What change can we make that

    will result in improvement?

    Act

    Plan

    Study

    Do

    Model for Improvement developed by

    Associates in Process Improvement

    ( http://www.apiweb.org)


    Why test before implementing

    Why test before implementing?

    • Increase degree of belief that it may work

    • Document expectations and learnings

    • Build a common understanding of what good looks like

    • Evaluate costs and side-effects for changes

    • Explore theories and predictions

    • Test ideas under different conditions

    • Learn and adapt in real time


    Cycle for improvement the pdsa cycle

    Cycle for Improvement:The PDSA Cycle

    Act

    Plan

    - Objective

    - Predictions

    - Plan to carry out the cycle (who, what,where, when)

    - Plan for data collection

    - What changesare to be made?

    - Next cycle?

    Study

    Do

    • - Analyze data

    • Compare resultsto predictions- Summarize what was learned

    - Carry out the plan

    - Documentobservations

    - Record data

    How we test for change.


    Tips for successful testing

    Tips for Successful Testing

    • Develop a plan for PDSAs

      • What, who, When, Where, How

    • Start with small tests – “What can we do Tuesday?” (e.g., 1 MA, 1 MD, 1 patient)

    • Think big – test small

    • Failure is ok – it’s an opportunity to learn

    • Plan multiple PDSA cycles to address “What are we trying to accomplish?”

    • Use huddles to check:

      • What worked, what didn’t and what should we change for our next test?

    • Celebrate success early and often


    Test changes non clinical

    Test Changes: Non-Clinical

    What changes can we make that will

    result in an improvement?

    • Idea:Train one Registration desk staff to use communication tools or scripts like “Acknowledge, Introduce, Duration, Explanation, Thank you” (AIDET)

    • Hunch:Using scripted language helps staff feel more comfortable with how to communicate with patients

    • Test:Tomorrow morning one receptionist will try this with all patients


    Let s try it

    Let’s Try It!

    Complete the following for your team:

    • Idea:

    • Hunch:

    • Test:


    Rapid improvement multiple cycles

    The cycle:

    If there is no improvement, try the cycle again!

    Try another solution/change

    Collect data based on the change

    Pause to plan…what’s your prediction for the next test?

    If there is improvement you can:

    Test in a different shift, area, group

    Decide how to make the change part of daily work

    Select another area in process to improve

    Rapid Improvement: Multiple Cycles

    Data

    Change

    Change

    Act

    Plan

    Data

    Study

    Do


    Introduction to the rapid improvement model plus

    Non-Clinical:

    Teach 1 regular staff

    customer service script with video. Use script for greeting every patient for 1 day

    Teach all regular

    staff the technique

    (wk 2)

    Expand to 2 regular

    staff for 2 days on different shifts

    Expand to all regular

    staff on same shift for 2 days (wk 1)

    P

    P

    P

    P

    P

    A

    A

    A

    A

    A

    S

    S

    S

    S

    S

    D

    D

    D

    D

    D


    Let s try it1

    Let’s Try It!

    Playing the M&M’s Game


    M m s game instructions

    M&M’s Game Instructions

    • Use the PDSA testing cycle concept

    • Use the worksheet with the triangle & circles on it

    • Open your candy. Please don’t eat the candy (yet)

    • Place a candy on 14 of the 15 numbered circles

    • Testing:

      • Remove M&M’s by “jumping” one M&M over

        another and into a blank circle, remove the

        “jumped” M&M (and don’t eat it)

      • Record the number of candies left on the worksheet

      • Objective: one M&M stands alone on the worksheet


    M m s pdsa datasheet

    M&M’S PDSA Datasheet


    Testing debrief what did we learn

    Testing Debrief: What did we learn?

    • Rapidly trying and learning

    • Documenting tests

    • Sharing and learning in a group

    • When solution found – writing steps down

    • There is no one single way to succeed


    The sequence for improvement

    The Sequence for Improvement

    Spread a change to other locations

    Make part of routine operations

    Implement a change

    Test under a variety of conditions

    Test a change

    Act

    Plan

    Theory & Prediction

    Develop a change

    Study

    Do

    to here!

    Don’t go from here …


    Review the rim model

    Review: The RIM Model

    What are we trying to

    accomplish?

    How will we know that a

    change is an improvement?

    What change can we make that

    will result in improvement?

    Act

    Plan

    Study

    Do

    Model for Improvement developed by

    Associates in Process Improvement

    ( http://www.apiweb.org)


    Appendix huddles

    Appendix: Huddles


    What is a huddle

    What is a Huddle?

    • Quick way to check on progress of a test and plan

    • Replaces hourly meetings

    • Speeds up the process of testing towards improvement


    How do you run a huddle

    How do you run a huddle?

    • Discuss the concept of a huddle and explain that it is a tool used for speeding up improvement

    • Agree on a time and place where the huddle will occur

    • Bring the team together

    • Have a clear set of objectives for each huddle

    • Limit huddles to 15 minutes or less


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