Opening Plenary: Overview of the Science of Improvement

Opening Plenary:Overview of the Science of Improvement Wednesday, August 21, 2013 Prepared and Presented by Robert Lloyd, PhD Institute for Healthcare Improvement Faculty

Plenary Session Objectives • To provide a high-level overview of the Science of Improvement: • Deming’s System of Profound Knowledge • The Model for Improvement (MFI) • The role of the PDSA cycle • The Sequence of Improvement • To provide an overview of four HACs that will serve as the content referents for these sessions 2

ExerciseScience of Improvement Self-Assessment This self-assessment is designed to help quality facilitators gain a better understanding of where they personally stand with respect to understanding and explaining the key components of the Science of Improvement (SOI). What would your reaction be if you had to explain the PDSA cycle to your colleagues, develop change concepts or describe how to build measures? You may not be asked to do all of the things listed below in the near future but, if you are facilitating a QI team or expect to achieve the HEN goals, sooner or later these questions will be posed. How will you deal with them? The place to start is to be honest with yourself and see how much you know about QI concepts and methods. Once you have had this period of self-reflection, you will be ready to develop a learning plan for yourself and those on your improvement team. Use the following Response Scale. Select the one response which best captures your opinion. 1 I could teach this topic to others! 2 I could do this by myself right now but would not want to teach it! 3 I could do this but I would have to study first! 4 I could do this with a little help from my friends! 5 I'm not sure I could do this! 6 I'd have to call in an outside expert! Source: R. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators. Jones & Bartlett Publishers, 2004: 301-304.

Exercise: Measurement Self-AssessmentSource: R. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators.Jones & Bartlett Publishers, 2004: 301-304.

Subject Matter Knowledge Subject Matter Knowledge:Knowledge basic to the things we do in life. Professional knowledge. Two Types Of Knowledge… Science of Improvement Knowledge:The interplay of the theories of systems, variation, knowledge, and psychology. SOI Knowledge

Knowledge For Improvement Improvement occurs when we learn how to combine subject matter knowledge and the science of improvement in creative ways to develop effective ideas for change. Subject Matter Knowledge Improvement SOI Knowledge

"One need not be eminent in any part of profound knowledge in order to understand it and to apply it. The various segments of the system of profound knowledge cannot be separated. They interact with each other. For example knowledge about psychology is incomplete without knowledge of variation." W. E. Deming, The New Economics for Industry, Government, Education. MIT, 1993

The Lens of Profound Knowledge Appreciation of a system “The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.” (Deming, Out of the Crisis) It provides an opportunity for dialogue and learning! Theory of Knowledge QI Human Behavior Understanding Variation Aim or Values

The Lens of Profound Knowledge Appreciation of a system “The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.” (Deming, Out of the Crisis) It provides an opportunity for dialogue and learning! Theory of Knowledge QI Human Behavior TRACK 2 FOCUS Understanding Variation Aim or Values

What insights might be obtained by looking through the Lens of Profound Knowledge? • Appreciation for a System • Interdependence, dynamism • World is not deterministic • Optimization, interactions • System must have an aim • Whole is greater than sum of the parts • Human Behavior • Interaction between people • Intrinsic motivation, movement • Beliefs, assumptions • Will to change • Theory of Knowledge • Prediction • Learning from theory, experience • Operational definitions • PDSA for learning and improvement • Understanding Variation • Variation is to be expected • Common or special causes • Ranking, tampering • Potential mistakes

A Model for Learning and Change When you combine the 3 questions with the… …the Model for Improvement. PDSA cycle, you get… Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2nd edition, 2009

A Model for Learning and Change When you combine the 3 questions with the… TRACK 1 FOCUS …the Model for Improvement. PDSA cycle, you get… Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2nd edition, 2009

The Shewhart Cycle for Learning and Improvement Act – Adopt the change, abandon it or run through the cycle again. Plan – plan a change or test aimed at improvement. Act Plan Study Do Do – Carry out the change or test (preferably on a small scale). Study – Examine the results. What did we learn? What went wrong? (Deming, 1993)

You do PDSAs every day!

What will happen if we try something different? What’s next? The PDSA Cycle For Learning And Improvement Did it work? Let’s try it!

Act Plan Study Do • You run PDSAs throughout the entire Sequence of Improvement Make part of routine operations Sustaining improvements and Spreading changes to other locations Test under a variety of conditions Implementing a change Testing a change Theory and Prediction Developing a change

The Primary Drivers of Improvement Having the Will(desire) to change the current state to one that is better Will Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas DevelopingIdeas that will contribute to making processes and outcome better QI Execution Ideas

Will (to change) Ideas Execution Low Medium High Low Medium High Low Medium High Key Components* Self-Assessment How prepared is your Organization? *All three components MUST be viewed together. Focusing on one or even two of the components will guarantee suboptimized performance. Systems thinking lies at the heart of CQI!

Clinical Topics Update: Falls, Pressure Ulcers, Venous Thromboembolism (VTE), Adverse Drug Events (ADE) Cheryl Ruble, RN, MS, CNS, CCRN Kim Werkmeister, RN, BA Improvement Advisor, Cynosure Health

Where are we now with Falls? As of 8/5/13, 12.28% reduction (weighted) has been achieved. What is our goal? Sustainment of percent reduction for 60 percent or more hospitals in Falls and continued work on interventions to achieve 40 percent reduction.

Challenges and Change Concepts for Falls • Accurate data submission • Fall AND injury risk assessment • Implementation patient specific interventions to prevent injury • Develop supporting processes such as purposeful rounding, hand-off communications, or post HAPU huddles

Where are we now with Pressure Ulcers? As of 8/5/13, 17.52% reduction (weighted) has been achieved. What is our goal? Sustainment of percent reduction for 60 percent or more hospitals in Pressure Ulcers and continued work on interventions to achieve 40 percent reduction.

Where are we now with VTE? As of 8/5/13, 16.76% reduction (weighted) has been achieved. What is our goal? Sustainment of percent reduction for 60 percent or more hospitals in VTE and continued work on interventions to achieve 40 percent reduction.

Challenges and Change Concepts for VTE • Accurate data submission • Risk-based prophylaxis • Risk assessment for every patient • Standard work in every area of the hospital

Where are we now with ADE? Excessive Anticoagulation with Warfarin – Inpatients No percent reduction as of 8/5/13 Hypoglycemia in inpatients receiving insulin 26.49% reduction as of 8/5/13 What is our goal? 577 additional hospitals to submit data on the ADE topic. Currently have 333 hospitals (24%) submitting as of 8/5/13. Provide interventions to assist hospitals with a focus on the top two HEN measures.

Challenges and Change Concepts for ADE • Volume of data submission • Choice of data measures • Pharmacist-driven protocols to prevent events related to hypoglycemia and hypercoagulation • Standardized protocols in all areas of the hospital

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Opening Plenary: Overview of the Science of Improvement