Model for Improvement

1. Model for Improvement Carol Haraden, Vice President, Institute for Healthcare Improvement

2. Objectives Distinguish between the aims of spreading innovation and publishing research. Discuss the balance between process and outcome measures. Use the Model for Improvement when planning changes

3. Model for Improvement

4. Aims and Methods Spreading Innovation Aim: Improvement Methods: Test observable Stable bias Just enough data Adaptation of changes Sequential tests Publishing Research Aim: New knowledge Methods: Test blinded Eliminate bias Just in case Fixed hypothesis One large test

5. Continuous, Breakthrough Improvement... P A DATA D S D S P A A S P D P A D S ...results from a series of improvement cycles Changes that result in improvement Hunches, theories, ideas

6. Model for Improvement The Improvement Guide, API

7. Establishing the Team’s Aims • Improvement relies on intention to improve • Senior leaders set & align aim with strategic goals • Middle management understand – and can translate- the project work to the strategic goals • Agreement on aim is critical • Aim should be unambiguous...Clear, specific, numerical, measurable • Strong message in stretch goal • Avoid aim “drift”

8. Do Not Negotiate the Ambition of the Aim Negotiate time to get to the aim Think about using half-lives Remind folks that we will get there through a program of testing and spread Keep the ‘hard red goal line’ on every graph Consider relative versus absolute goal

9. Aims Statements-Outcomes, Process, Relative or Absolute? Surgical Achieve 100% compliance with appropriate selection and timing of prophylactic antibiotic administration Diabetes- Chronic Disease Reduce diabetic patient admissions by 75 percent within 11 months Heart Failure- Outpatient Patients with HF recognize deterioration and call the office within 10 months.

10. Aim Statements-Outcomes, Process, Relative or Absolute? Culture At least 70 percent of board staff surveyed report a positive climate within 1 year

11. Exercise Work together in small groups Choose an improvement effort / topic of common interest & relevance to the group Develop a strong, clear aim statement to guide improvement work on this topic Discuss how you would set the goal in this aim statement

12. The Improvement Guide, API

13. Measurement Guidelines The key measures should clarify the aim and make it tangible Keep it simple: Be careful about over-doing process measures Use a balanced set of measures

14. Seek Usefulness Not Perfection

15. Measurement Clarify the Aims • Example • Aim: Medications are reconciled at transfer for 99% of patients within 1 year • Measure: Number of patients with un-reconciled medications per 100 admissions • Formula: The total number of charts with un-reconciled medications found in a sample of patient records, divided by the total number of patient records reviewed. Multiply the result by 100

16. Measurement Clarify the Aims Example • Aim: Patients on a high risk medication experience a related ADE at the rate of .001% (.999 success) • Measure: Percent of patients receiving a specific high-risk medication with a related ADE • Formula: Total number patients identified as having experienced an ADE related to a specific high-risk drug or class from a sample of patient records, divided by the total number of records in the sample. Multiply the result by 100 to express as a percentage

17. Process Measures Process measures track whether a change has been made (not the outcome) Examples: Percent of times the SEWS is complete and accurate in 100% of sample Percent of pneumonia patients receiving antibiotic before leaving the ED The percent of times patients on a ventilator have VAP bundle complete

18. Exercise Select measures for your aim Is this data currently collected?

19. The Improvement Guide, API

20. Change Concepts

21. Selecting Changes Copy: use the literature, experience of others, hunches and theories: “This is what they did at Dr. Grays. I don’t know if it will work here but let’s see what we can learn from it.” Avoid low impact changes, “Let’s put up a poster.”; “Let’s have an education session.”; “Let’s send out reminders.”

22. Change Concepts #2 22 Avoid technical slow-downs: “We will build a computer programme to do this…” Be strategic: set priorities based on the aim, known problems, and feasibility, “Let’s see if we can get the multi-disciplinary team together for one round.”

23. Bibliography Berwick D. A primer on leading the improvement of systems. BMJ 1996; 312: 619-622. Berwick D, Nolan T. Physicians as leaders in improving health care: a new series in Annals of Internal Medicine. Ann Intern Med. 1998; 128:289-292. Brock W, Nolan K, Nolan T. Pragmatic science: accelerating the improvement of critical care. New Horizons 1998; 6: 61-68. Cook T, Campbell D. Quasi-Experimentation. Boston: Houghton Mifflin 1979. Langley J, Nolan K, Nolan T, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996. Lundberg G, Wennberg J. Editorial: a new proposal and a call to action. JAMA 1997; 278: 1615-1616. Rodgers E., Diffusion of Innovations. New York: The Free Press 1995. Tufte, E., The Visual Display of Quantitative Information, Cheshire, CT, Graphics Press,1983.