Segmentation in Reliability Design (Application of the Christensen Model)

1. Segmentation in Reliability Design(Application of the Christensen Model) Roger Resar April 2006

2. Building of Descriptive • Researcher must pass through it in order to develop more advance theory • Consists of three steps • Observation • Classification • Defining relationships Clay Christensen Harvard Business Review

3. Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statements of association Categorization based on attributes of phenomena Anomalies will need to be observed Observe describe and measure the phenomena Descriptive Theory

4. Reliability Descriptive Theory 3 Tier approach when applied to radiology interpretations in the ED achieved a high level of reliability Nolan et al JAMA

5. Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statements of association Categorization based on attributes of phenomena Anomalies will need to be observed Observe describe and measure the phenomena Descriptive Theory

6. Current IHI Normative Theory To Achieve a 10-2 Level Reliability Based on work by the IHI innovation team, some hospitals in the Pursuing Perfection and P4P work, and publications by Nolan et al, a three tier approach has been taught as a methodology when applied to CMS conditions can achieve 10-2 performance. (All or none measurement)

7. Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statements of causality Categorization of the circumstances in which we might find ourselves Anomalies will need to be observed Observe describe and measure the phenomena Normative Theory

8. Reliability Community Observations When the Current Normative Theory is Used • When the 3 tier model is applied to the broad CMS measures few hospitals are able to consistently achieve the 10-2 goal • Those hospitals achieving the10-2 goal for all measures within a CMS condition commonly accomplish this with manpower and a very high level of vigilance • Within a given condition when successful 10-2 performance occurs on a single measure a good three tier strategy can be observed (although commonly a deliberate 3 tier strategy was not as much designed as discovered)

9. Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability Statement of Causality We ought to apply the 3 tier approach to the CMS conditions Anomalies Observed • Using 3 tier design to the CMS conditions approach 10-2 not consistently observed • Individual measures within conditions achieved 10-2 with obvious 3 tier design • Segments of the population achieve 10-2 in all or none measures 10-2 Performance will be observed when the 3 tier approach is used on the CMS conditions Current Normative Theory

10. Anomalies Observed • Certain measures of the CMS conditions achieve 10-2 level of reliability. When studied the 3 tier design is commonly used not as a deliberate strategy, but as a haphazard design. • Whenever applied to the broad CMS condition hospitals have difficulties • Teams can predictably take certain segments of the population or certain measures and can achieve a 10-2 level of reliability

11. Examples of Anomalies • Smoking cessation, pneumovax or flu shots when taken on as a hospital wide measure reaches greater than an 10-2 performance. • Timed measures such as antibiotic administration or time to a heart catheterization laboratory reaches 10-2 levels of performance • Certain segments of the population attain 10-2 reliability (admissions from the ED with a known diagnosis of CAP)

12. New Theory Based on Anomalies The work on the CMS conditions can achieve a 10-2 level of performance if appropriate segments are identified and each segment is designed using the 3 tier approach if necessary

13. Dividing the CMS conditions into appropriate segments and applying the 3 tier design will achieve 10-2 for the whole condition Preliminary statement of causality Segments based on admission route, time of first case, responsible area are useful in design for 10-2 performance Observing the current reliability community suggests certain anomalies that draw questions to the 3 tier design for conditions. Observations the segments appear to be more reliable in design New Descriptive Theory

14. Using the 3 Tier approach to the design on the segments of the condition and or measures will achieve 10-2 reliability in the whole Statement of Causality We ought to apply the 3 tier approach to the CMS conditions using a segmental approach Anomalies will need to be observed 10-2 Performance will be observed when the 3 tier approach is used on the appropriate segments of the CMS conditions New Normative Theory

15. Why Segments • Allows for control of some variables • Defines the boundaries around which expectations can be formed • More likely to test the validity of the design rather than confront barriers • Fosters a deeper understanding of the design complexity required • Forces understanding of the differences between segments as design strategies • Permits design beyond the disease • Allows the formation of more predictable timelines

16. Applying Segments to the Normative Model • The current work on reliability will stress the concept of segment definition tied to process and outcome measures • Segment definition and relationships to improvement will be driven by a design table • Observations of anomalies will be part of future community work to refine the normative theory

17. Design Table for Segment Theory Improvement Work

18. Finding your first segment • The segment must represent a reasonable volume • The segment should have clear cut defined boundaries • The segment should have willing participants so the barrier of agreeing is not a problem • The segment should allow for key articulated variables or barriers to be neutralized

19. Using the Design Table for CAP Planning Using Segments

20. Using the Design Table for CAP Planning Using Segments

21. Next Steps • Identify your first segment (If you have a first segment what is your level of reliability) • Confirm that your segment has the key requirements for segmental definition and design • Fill out the segment flow sheet and the design table • Local customization will develop the structure changes and process changes • The segments will vary depending on organization size • Anomalies from the segmental design need to be studied to authenticate the new normative theory