Beginners Improvement Skills Workshop January 17 th 2012

1. Beginners Improvement Skills Workshop January 17th 2012

2. Objectives • By then end of the session......... • You will be familiar with the Model for Improvement and the Plan Do Study Act methodology • You will have completed your own PDSA • You will have a plan to begin your improvement work

3. SEPSIS /SEVERE SEPSIS FACTS >37000 DEATH PER YEAR KILLS MORE PATIENTS EACH YEAR THAN MYOCARDIAL INFARCTIONS, AND LUNG,+BREAST+ COLON CANCER

4. STAG Sepsis Management in Scotland • Signs of sepsis < 2 days • 2% of emergency admissions (~5000) • 73% had a EWS • 34% had severe sepsis • 21% blood cultures • 32% IV Antibiotics • 70% IV fluids Scottish Defect Rate was 18-74%

5. VTE – the facts Up to 25,000 deaths each year in England & Wales No reason to believe that Scotland is any better Significant gap in delivery of evidence based interventions

6. The First Law of Improvement Every system is perfectly designed to achieve exactly the results it gets. Peter Senge The Fifth Dimension

7. How do we build a bridge from the science of improvement to the practice of improvement? The Model for Improvement ‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’ Dr Donald M. Berwick Former CEO, Institute for Healthcare Improvement

8. A Model for learning and Change When you combine the 3 questions with the… ……the Model for Improvement. PDSA cycle, you get…… The Improvement Guide, API, 1996

9. 3 Key Questions - the thinking part • What are we trying to achieve? • Know exactly what you are trying to do • Have clear aims and objectives • How will we know that change is an improvement? • Measuring processes and outcomes • What changes can we make that will result in an improvement? • What do we want to test? What can we learn as we go along?

10. Plan Do Study Act - the doing part • A simple tool – used to test out ideas that will improve systems and processes • A structured approach for making small incremental changes to systems • A full cycle for planning, implementing, testing and identifying further changes

11. Developing the team’s Aim Statement Question 1: What are We Trying to Accomplish? 11

12. Check Points in Developing anAim Statement AIM Content Explicit over arching description Specific actions or focus Goals AIM Characteristics Measurable (How good?) Time specific (By when?) Define participants and customers 12

13. Aim Statement Exercise: You Make the Call! 13

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15. Question 2: How Do We Know that a Change is an Improvement? “When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind.” Lord Kelvin, May 3, 1883 “In God we trust.All others bring data.” W. E. Deming

16. D D How Do We Know if a Change is an Improvement???? Improvement is NOT just about measurement However… without measurement you will never be able to answer the Question 16

17. Traditionally why have we measured……? Judgment? Research? Improvement? 17

18. “The Three Faces of Performance Measurement: Improvement, Accountability and Research” “We are increasingly realizing not only how critical measurement is to the quality improvement we seek but also how counterproductive it can be to mix measurement for accountability or research with measurement for improvement.”

19. Improvement vs. ResearchContrast of Complementary Methods Improvement Aim: • Improve practice of health care Methods: • Test observable • Just enough data • Adaptation of the changes • Many sequential tests…… Clinical Research Aim: • Create New clinical knowledge Methods: • Test blinded • Just in case data • Fixed hypotheses • One fixed test

21. Three types of measures Outcome Measures – Directly relates to the overall aim Voice of the customer or patient How is the system performing? What is the result? Process Measures - Voice of the workings of the system. Are the processes that contribute to the aim performing as planned? Balancing Measures –Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)? Balloon Buldge

22. Expectations for Improvement When will my data start to move? • Process measures will start to move first • Outcome measures will most likely lag behind process measures • Balancing measures – just monitoring – not looking for movement (pay attention if there is movement)

23. Topic: Reduce waiting time and increase patient satisfaction in A&E Measure Perspective (O, P, B) P B O P B O P B B % patient receiving discharge materials Patient volume…increase or decrease Total Length of Stay…including wait time Time to registration Staff satisfaction Patient Satisfaction Availability of antibiotics “Left without being seen” (LWBS) Costs…increase or decrease

24. Stages of Facing Reality: • “The data are wrong” • “The data are right, but it’s not a problem” • “The data are right; it is a problem; but it is not my problem.” • “This is my data and I accept the burden of improvement”

25. Engage with the data and Tell the Story!

26. Question 3: What changes can we make that will result in Improvement? • Sepsis • Improve screening • EWS + SIRS • Improve timely treatment • Reliable escalation The Sepsis Six • VTE • Risk assessment • Appropriate treatment • Timely reassessment • Patient involvement SIGN 122

27. Model for Improvement Now, let’s focus on the PDSA part of the MFI and tests of change Source: The Improvement Guide, API

28. Why Test Changes? • To increase the belief that the change will result in improvements in your setting • To learn how to adapt the change to conditions in your setting • To evaluate the costs and “side-effects” of changes • To minimise resistance when spreading the change throughout the organisation

29. The PDSA Cycle for Learning & Improvement What will happen if we try something different? What’s next? Do It !!! Did it work?

30. Guidance for Testing a Change Concept • A test of change should answer a specific question! • A test of change requires a theoryand aprediction! • Test on a small scale and collect data over time. • Build knowledge sequentiallywith multiple PDSA cycles for each change idea. • Include a wide range of conditions in the sequence of tests. • Don’t confuse a taskwith atest!

31. StartSmall ~ 1:3:5:All • 1 patient • 1 day • 1 admission • 1 clinician

32. Move Quickly to Testing Changes • Year • Quarter • Month • Week • Day • Hour “What tests can we completed by next Tuesday?”

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

34. Key Points to Remember! • PDSA’s cannot be too small • One PDSA will almost always lead to another • You can achieve rapid results • They help you to be thorough & systematic • They help you learn from your work • Anyone can use them in any area

35. Your 1st test of change PDSA Worksheet

36. The Value of “Failed” Tests “I did not fail one thousand times; I found one thousand ways how not to make a light bulb.” Thomas Edison

37. PDSA Testing Over to you !!