AMI Virtual Learning Collaborative

1. Atlantic Node AMI Virtual Learning Collaborative Building on LS1-A

2. LS1-A Re-Cap Atlantic Node • Introduced to WebEx technology • Overview of Virtual Learning Collaborative and Expectations • Expert presentation on Thrombolytic Therapy • Process Mapping

3. What Worked Well Atlantic Node • The content and presentations • Sharing by Participants • Engagement • Use of Examples • Polls/Feedback • Being able to ask questions

4. What Worked Well Atlantic Node • Being able to participate without travelling is a huge plus • Easy Access/ able to access it almost anywhere, easy to follow • Having presentation from specialist and then being able to apply to our specific practice

5. What Worked Well Atlantic Node • Hearing while seeing, coordination • Having interaction with colleagues from the provinces and regions

6. Improvement Opportunities 1. Slides and handouts 2. Times listed only as ADT 3. Voice delay and overlap Change Ideas to Test Post on CoP 2. Include NL time in correspondence 3. Use emoticon to flag issue Atlantic Node

7. Improvement Opportunities 4. Passing the ‘Ball’ 5. Voice clarity fluctuation 6. WebEx training before Session Change Ideas to Test 4. Establish Co-Host role 5. Speak directly into microphone; headset/ hands free 6. Next VLC pre sessions Atlantic Node

8. Atlantic Node Comments/Questions

9. Atlantic Node AMI Virtual Learning Collaborative The Model for Improvement

10. Measurement *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

11. Overview Measures & Targets Inclusion & Exclusion Criteria Individual Data Collection Form Elapsed Time by Patient Worksheet Measurement Worksheet Atlantic Node

12. What are OurMeasures? % STEMI or new LBBB who received thrombolytic within 30 minutes of arrival at ED. % STEMI or new LBBB who received an ECG within 10 minutes of arrival at ED. Atlantic Node

13. What are ourTargets? 90% STEMI or new LBBB receive thrombolytic within 30 minutes of arrival at ED. 90% STEMI or new LBBB receive an ECG within 10 minutes of arrival at ED. Atlantic Node

14. Why These Measures? Atlantic Node • Based on CCORT AMI Indicators (CMAJ 2008: 179: 909-15) • Time is muscle (myocardium) • Two measures which are key to timely thrombolysis • We know there is room for improvement

15. Measure 4.0A Lytic Within 30 Minutes of Arrival Denominator Inclusion: All STEMI or new LBBB confirmed by ECG Lytic within 6 hours of arrival at ED Lytic as primary reperfusion therapy Exclusion: Patients with NSTEMI, non-Q wave or subendocardial MIs Transfers in who received lytics in another acute care facility or ambulance Under 18 years of age Atlantic Node

16. Measure 4.0A Lytic Within 30 Minutes of Arrival Numerator All those in the denominator who received lytic within 30 minutes of arrival at ED Atlantic Node

17. Measure 10.0ECG Within 10 Minutes of Arrival Denominator Inclusion: Patients admitted through Emergency with diagnosis of STEMI or new LBBB confirmed by ECG Exclusion: Received a lytic in ambulance Transferred from another acute care facility Under 18 years of age Atlantic Node

18. Measure 10.0ECG Within 10 Minutes Numerator All those in the denominator who had an ECG within 10 minutes of arrival at ED If ECG completed by EMS (pre-hospital) this is considered within 10 minutes of arrival at ED Atlantic Node

19. Additional Process Measures Atlantic Node • Time 1st medical contact to 1st ECG • Time 1st medical contact to arrival at ED • Time diagnostic ECG done to read by MD • Time diagnostic ECG read by MD to thrombolysis

20. Individual Data Collection Form Atlantic Node Use a data sheet for each month of data submission Each workbook has 2 worksheets – (1) Individual pt. times & (2) Elapsed time by pt

21. Individual Data Collection Form Atlantic Node Enter name of hospital, Select Month and Year from drop down box

22. Individual Data Collection Form Atlantic Node Enter individual pt data as they arrive in ED MRN = Medical Record Number - Use identifier of your choice

23. Individual Data Collection Form Atlantic Node Sequential pt. # Pt. identifier optional comments about pt Enter times in appropriate cols.

24. Individual Data Collection Form Atlantic Node • Notes: • Walk-In (pt.#1) – “1st medical contact” usually same as “Arrived ED” • Transport by Ambulance (pt.#2&#3) – “1st medical contact” occurs before “Arrived ED” • ECG and Lytics in ED (pt.#2) – “1st ECG” after “Arrived ED” and before “Lytics started” • ECG in ambulance and Lytics in ED (pt.#3) – “1st ECG” before “Arrived ED” and “Lytics started” • If ECG and Lytics in ambulance (pt.not shown) – “1st ECG” and “Lytics Started” before “Arrived ED”

25. Elapsed Time by Pt Worksheet Atlantic Node Automatic calculations Now on second worksheet = Elapsed Time by Pt.

26. Elapsed Time by Pt Worksheet Atlantic Node Classification of patient for measure 4.0A All elapsed times are automatically calculated from data entered on “Individual Times” worksheet

27. Elapsed Time by Pt Worksheet Atlantic Node Number of teams meeting criteria w/i 30 mins and those not meeting criteria w/I 30 mins

28. Measurement Worksheet Atlantic Node Enter data on “Data Entry Sheet

29. Measurement Worksheet Atlantic Node Enter name of hospital, region and description of patient sample in ‘windows’ outlined in red.

30. Measurement Worksheet Atlantic Node In column for appropriate month and year identify implementation stage and collection method 1. Baseline = 1st month of data submission 2. Full = after reaching goal and holding it for 3 consecutive data submissions 3. Early = everything else.

31. Measurement Worksheet Atlantic Node Enter data from Elapsed Time / Individual Data Collection form in “red” outlined cells for Denominator Enter data from Elapsed Time / Individual Data Collection form in cell for Numerator

35. Contact information Atlantic Node Central Measurement Team Virginia Flintoft virginia.flintoft@utoronto.ca 416-946-8350 Alex Titeu shn.ea@utoronto.ca 416-946-3103

36. Model For Improvement * A simple yet powerful tool for accelerating improvement The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

37. Model For Improvement * • The model has two parts: • Three fundamental questions, • Used to establish AIM; MEASURES, AND CHANGE IDEAS. • The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of change to determine if the change is an improvement. *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

38. Model For Improvement • Action Oriented • Trial and Learning • Leadership

39. Team Charter Operationalizes the Improvement Model • Improvement theory • Project management

40. Team Charter To ensure a common understanding and focus by making explicit: • AIMS • Measurement targets • Changes • Timelines • Roles and Responsibilities To communicate effectively with senior leadership and other stakeholders

41. Team • Review your system: - Who does the patient see? - Who is needed to implement? - Who needs to know about the changes? - Who supports the changes? • Work with those who will work with you • Each member is a champion in their area

42. Team • Core Team Members • Clinicians providing care i.e. nurses, technicians, therapists, paramedic • Clinical and administrative leaders i.e. Clinical Nurse Specialist, Nurse Manager • Ad Hoc • Physician Champion • Quality Improvement personnel • Clerical Support

43. Roles and Responsibilities Team Leader • Completing and clarifying the team charter in a manner that ensures the support of team members and team sponsor. • Organizing and running effective meetings and maintaining team records ie minutes, correspondence, improvement data • Facilitating work within the team and ensuring participation at and between meetings • Communicate about the improvement work with the sponsor, team members, stakeholders and the larger organization.

44. Roles and Responsibilities Team Members • Sharing content knowledge, skill and experience • Communicating and developing a shared understanding within the team of the work process to be improved or changed. • Testing change ideas within the team and in the real work context • Leading and supporting coworkers to adapt the new process • Completing tasks or assignments within and between meetings • Establishing two-way communication with their colleagues and the team

45. Roles and Responsibilities Team Sponsor • Clarifying the improvement mandate and aligning it within the organizations strategic and operational objectives • Connecting and communicating with appropriate stakeholders • Allowing time and other resources • Establishing an accountability mechanism • Facilitating the work of the team within the larger organization. • Engaging a team leader and a coach • Initiating the team charter

46. Roles and Responsibilities Team Coach • Facilitating the use of improvement tools and techniques • Monitoring and facilitating healthy team behaviors • Providing technical expertise and guidance focusing on team process • Supporting the team leader to plan effective team meetings • Assisting with measurement for improvement eg data collection, submission, analysis and display

47. Exercise #1 Identify your team members and assign Roles and Responsibilities.

48. Participant Sharing Team Example

49. AIM • What are you going to do? • How much? • By when?

50. Bold Aim, Firm Deadlines • Align aim with strategic goals of the organization • Write a clear and concise statement of aim • Make the target for improvement bold and unambiguous • Include deadline • Include scope, boundaries, constraints and anything else that is needed to keep the team focused