1 V. Foundations of QualityKevin DeHority

2 Foundations of Quality ImprovementRapid Cycle QI requires teams to set aims, try out changes, and measure the effects… What are we trying to accomplish? (Aim) How will we know that the change is an improvement? (Measures) What can we do to improve things? (Change)

3 Identify the Problem & State Aim (avoid jumping right to a solution!)The main elements of an effective Aim include… What will improve? When will it improve? How much will it improve? For whom will it improve? Most teams want to jump right in to identify and nominate fixes for the most prominent problems affecting their patients or clients. But this jump start can lock you into misplaced priorities. It is usually better to have your group do some brainstorming and a little research to identify real problems (i.e. patterns of service delivery that create problems for patients and families).

4 Identify the Problem & State Aim (avoid jumping right to a solution!)For example… What will improve? Advance care planning When will it improve? Within 6 months How much will it improve? 85% of patients, up from current estimates of “occasional” For whom will it improve? CHF & COPD Clinic Patients Aim Statement: Within 6 months, 85% of our CHF and COPD patients in our outpatient clinic will have advance care plans completed and documented in their electronic medical record Coming up with an aim is hard to do. You have to clarify your goals, thing how you will measure them, and make it enough of a stretch to be worth doing. Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD)

5 Establish a Good Team Shortcomings in healthcare processes almost always involve multiple people… Organization Leaders Enough clout to insist on the changes you want to test and can help you get needed time and resources Content Expert Clinical knowledge about your problem area and thorough understanding of care processes in your system Few important changes can be implemented by a single person, you need a group to make it happen

6 Establish a Good Team…continuedShortcomings in healthcare processes almost always involve multiple people… Improvement Expert Expertise in improvement methods to help the team implement the QI model Team Leader Drives the project on a day-to-day basis. Understands the details of the system and makes sure work is getting done Few important changes can be implemented by a single person, you need a group to make it happen

7 Important tasks to cover…Who will implement the changes? Who will tell other people about changes to be tried? Who will collect & analyze the data? Who will plot and track changes for a storyboard? Who will keep senior leaders in the loop & informed? Who will run the meetings & keep a to-do list? It is good to ask for a commitment from each team member in which they agree to be involved for the duration of the effort. Role delineation is extremely important.

8 Measuring Your SuccessHow will we know that our change is an improvement? The simplest answer is by measuring our progress How do we know what to measure? The answer lies in our aim statement: implicit in the aim is the way to measure our success

9 Measuring Your SuccessThere are three types of measures: Outcome Measures Seeks an accurate means of assessing directly what you care most about, such as the patient/family experience Process Measures Assesses how your care delivery system is working. Do certain desirable actions happen in the right order at the right time? Adverse Effects Changes that you make in the pattern of care often result in adverse effects. We need to monitor likely or important side effects while keeping surveillance on our overall goals Working on your measures often requires that you go back and sharpen your aim. The major concern with relying only on process measures is whether they are tightly linked to the outcome you really care about. Often teams will measure processes just long enough to be sure that they are working correctly, but they will keep measuring outcomes until they achieve their aim.

10 Measuring Your SuccessExamples of the three measures: Outcome Measure % of CHF/COPD patients with specified treatment decisions documented in their medical records Process Measure % of CHF/COPD patients each month who have a clinic visit with an entry on their medical records documenting ever having a discussion of advance care plans Adverse Effect % of patients who are upset at having these issues raised and who decline the offer to make plans Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD)

11 When choosing a measurement strategy (we suggest the following)Look at what other teams have used Measure outcomes whenever you can Simplify measurement whenever possible (take samples, piggyback on current measurement systems) Start out measuring a few things, & drop if they are too difficult or not informative enough Measure just long enough to be sure that the improvement is in place Working on a measurement plan often teaches you a lot about your aim, at that point, go back and restate the aim so that the aim and measure match (and also end up reflecting what you and your team really want to do). If you have 10 units of effort to put into improvement, save one or two for measurement Too much will make you focus only on data collection, but too little will leave you without insight

12 Identifying & Testing ChangesHow do you identify which changes to make? Look at best practices Brainstorm ideas with your team Perform root cause analysis as a group Keep a list of what has been tried and what is awaiting trial Select changes that you are willing to try right away Be sure that the changes you try would make a difference in your measure & help accomplish your aim With your aim and measures stated, your team needs to decide which changes to try. Of course, some interventions that you think will work may surprise you and behave otherwise (that is why we test!). And remember that it is generally risky to implement a good idea on a large scale until you have it working well in one area with a few patients and staff.

13 Identifying & Testing ChangesDo’s and Don’ts Do start with changes that you can do Do test the idea on a small scale to see if it works Do break down the work into smaller steps to make it less over-whelming Don’t do all the work yourself; delegate to the team and others Don’t spend so much time preparing for large-scale change that you don’t get started quickly (say, by next Tuesday). With your aim and measures stated, your team needs to decide which changes to try. Of course, some interventions that you think will work may surprise you and behave otherwise (that is why we test!). And remember that it is generally risky to implement a good idea on a large scale until you have it working well in one area with a few patients and staff. Good ideas are found everywhere; the challenge is to select the ones that are most worthwhile for you to try in your organization

14 How will I know if an idea will work? PDCA (Plan Do Check Act)Step 1: Plan Decide with your team how you will implement this change on a small scale (plan it step by step) Identify who will do what and when they will accomplish the task Make some predictions about what you expect to happen after the change is implemented Set deadlines for key steps Identify data you will need to see what effect this change has made during the test period Once you have identified changes to try, assess them on a small sample of patients. Testing is a simple step-by-step process to help identify whether or not something is working. If the change does not have a good effect on your outcome, testing will give you some ideas on how to adjust it or whether to try something else. The four steps outlined are the heart of the rapid-cycle QI model.

15 How will I know if an idea will work? PDCA (Plan Do Check Act)Step 2: Do Try it Document problems and unexpected observations Collect and monitor the data Once you have identified changes to try, assess them on a small sample of patients. Testing is a simple step-by-step process to help identify whether or not something is working. If the change does not have a good effect on your outcome, testing will give you some ideas on how to adjust it or whether to try something else. The four steps outlined are the heart of the rapid-cycle QI model.

16 How will I know if an idea will work? PDCA (Plan Do Check Act)Step 3: Check Analyze what happened, look at what the data says about the change Summarize what you learned from the test. Did your data and observations match what you had predicted for this change? If yes, what else happened? If not, then why not? Even failed tests teach teams a great deal about their care system. Once you have identified changes to try, assess them on a small sample of patients. Testing is a simple step-by-step process to help identify whether or not something is working. If the change does not have a good effect on your outcome, testing will give you some ideas on how to adjust it or whether to try something else. The four steps outlined are the heart of the rapid-cycle QI model.

17 How will I know if an idea will work? PDCA (Plan Do Check Act)Step 3: Act By now, you know whether the change you tested is working If it is working... You can plan to standardize and implement on a larger scale If it is not working… Evaluate what happened so as to get ideas on how to modify the change Determine whether to try something else Keep trying until you find what works in your system. Generally, try many small changes, one at a time, rather than gambling on one large change. Let your mantra be, “we are going to give it a try; if it does not work, we will learn something from it”. Remember, measurement tells you what works and what does not. Either way the cycle moves back to step 1 (Plan)

18 Displaying the Data Two primary ways to display your data…Time Series Graphs Collecting and plotting data over time Storyboards Helps you display your project to others Helps the team to understand its own progress Show your results in a simple and structured way to patients, families, senior leaders, other staff, and other organizations

19 Making the Changes StickA few ideas to prevent old practices from taking over… Establish and document the improved processes: procedures, guidelines, order sheets, forms, etc. Revise job descriptions to make sure that someone is responsible for the new processes Assign responsibility to particular people to monitor repeated backsliding – Staff meetings, Leadership Walks Add the new processes to training materials for new staff Tell others in your organization and community about your progress, and make participants proud Share positive feedback from patients and families

20 Spread Learning Think about ways to spread improvement, and plan for how you will do so… Spread what? What will we have that could be worth implementing elsewhere? Spread where? Who would benefit most from our work? Is it another kind of patient or another organization? Spread when? At what point in your project should you begin sharing it with others? When do you know your changes are really improvements, and how will you decide that your ideas are worth trying elsewhere? Based on your answers, you can develop an implementation plan to spread your improvement

21 How to motivate? How to motivate people to take on the process of change… Show evidence Describe the benefits, tell patients’ stories Use your annotated time series to “tell the story” Target influential people and sites Do not try to convince the most resistant people first Build enthusiasm and commitment where you can

22 Final Rules of Thumb Basic pointers to encourage you along the way…What can we do by next Tuesday? Keep it simple, and get it started Set stretch goals that will make it worthwhile Go for the low-hanging fruit by starting with easier projects or in units where staff will be friendly You can only fix what you can measure If we keep doing what we have been doing, we will keep getting what we have been getting. To get something better, we have to start doing something differently

23 Connecting the Importance of Standardized Work with The MOQC Palliative Care Demonstration ProjectJust as our previous ACU Leadership Meeting where we connected VSM and Structured Problem Solving to our E-Prescribe roll out, we are now introducing the importance of Standard Work with E-Prescribe.

24 Standardized Work Critical to Improvement EffortsWithout the basis of Standard Work there is no place for us to make improvements from A common misconception of Standard Work… Is that it robs us of our creativity – however, when implemented correctly the exact opposite is true! When implemented correctly… It enables a flexible workforce Significantly reduces errors Significantly improves efficiency Enables new initiatives to launch with greater success Exact opposite is true because when implemented correctly there is a systematic way to roll out new best standards to the entire group. In the absence of this if someone comes up with a better way we only benefit when that individual is performing the work…by asking everyone to perform the tasks the same way while at the same time encouraging folks to come up with the next best way we begin to really tap into the collective groups creativity.

25 Standard Work Exercise – Individual ActivityWe have learned that one of our patients is in quite a bit of pain, and you naturally want to do something about it This process will be represented by the drawing of a pig (yes, that is right…an oink-oink but very therapeutic pig) Please take the next minute or so to draw your pig on the provided blank piece of paper Upon completion, please hold your pig up for all to see! Some oncology nurses realize that cancer patients were often in pain, despite efforts by medical and nursing staff to relieve it. The nurses wanted to do something about it – but what? Should they identify specific problems in the hospice program, or should they jump right in with ideas that they think will fix things? Should they recruit other people to be on their team?

26 Individual Exercise – Draw the pig on the back side of your handouts & hold up for all to see!Slide stands on it’s own merit.

27 Standard Work Exercise – Individual Activity This exercise helps illustrate the need for developing & training standardized work relative to this process! When developing standardized work, it is important to involve the folks who “do the work” (for instance your work team) For the sake of our exercise we will make the assumption this group worked together to create the standard work for our pig However, Standard Work alone is not enough…people need off-line & OTJ Training for the standards to become 2nd Nature Let’s complete some quick off-line & On The Job training on the agreed to standard work (using the standard work instructions & one of the sheets of grid paper) Hand out the standardized work and a piece of paper with a grid to each person. This will be used for them to re-draw the pig while you train them / walk them through the “standardized work”. If time allowed you would then have them re-draw the pig on their own with the training under their belt and the use of the standardized work, however just let them know this since their won’t be enough time. Have them hold up both their first pig and the latest pig.

28 Standard Work Exercise – Individual ActivityTake a look at the original pig vs. the new standardized pig... Which one looks more like a pig? Which pigs look more alike across the room? The original pigs or the standardized pigs? It appears that our Patient is in much less pain this time!!! We should always improve on the current standard… Re-sequence steps so pen or pencil doesn’t need to lift? More definition to size of nose or ears? Maybe add more grid lines? Remember, Standard Work must be SIMPLE and created by the folks doing the work so it is meaningful in real-time in our areas Slide stands on it’s own merit.

29 MOQC Palliative Care Demonstration Project Change Management Recommended Steps

30 Change Management The following activities are recommended as a part of this collaborative… Visually Display Performance Tracking System in work area Create a visual presence of your goals and metrics Allow folks to be thinking and documenting issues and ideas in between meetings Update Performance Tracking System every 1-2 weeks Create responsibility and cadence for updating the metrics

31 Change Management The following activities are options to facilitate change: Hold Team Meeting around the Performance Tracking System once every two weeks with the following meeting standard work (place date & TM on tracking sheet upon completion) Determine participants and create meeting schedule Review Performance that period relative to your metrics Document specific issues and problems preventing you from meeting your goals Brainstorm specific ideas to experiment with to positively impact the identified problems (Idea Generating Form) Design and Run small change experiments and report out on impact during next team meeting (Idea Generating Form)

32 Change Management The following activities are options to facilitate change: Complete a Leadership Walk in the work area at a minimum every two weeks on alternating weeks from the team meeting (place date, LW, & Initials on Tracking Sheet upon completion) Determine participants and create walk schedule Leaders reinforce process changes Leaders interact with team around the teams’ ideas for improvement Leaders help break down barriers Upload Idea Generating Forms with Summary of Learning on the Palliative Demonstrative Project’s collaborative website Openly share learning with other members of the collaborative through various different forums