Barb Boushon, Mike Davies, MD Mark Murray and Associates 916-441-3070 Murraytant@msn.com

1. The Process Improvement Model: Aims, Measures, Tests/Changes and Teams Barb Boushon, Mike Davies, MD Mark Murray and Associates 916-441-3070 Murraytant@msn.com

2. Why Change Strategies Often Don’t Work • Lots of planning then lots of implementing • Analysis paralysis • Lack of consensus on problem and solution • Implemention vs. test • Risky change process

3. Why Change Strategies Often Don’t Work • Pushing one solution/idea • One person’s perspective • How do we know it works? • Lack of agreement • Ignores context/circumstances

4. Improvement Involves “Experimentation” • Setting aims/goals • Generating ideas • Testing • Measuring progress • Reflection

5. Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

6. AIMS What are we trying to accomplish?

7. Aims What is an Aim? • Statement of Intention “What are we trying to accomplish?” • Aligned with strategic goals • Based on data • Stated clearly using numeric goals • Involves senior leaders

8. Aims and Goals Goal: Improve hospital flow by reducing delays within and between departments Aims: • Reduce the input delay • Reduce the throughput delay • Reduce the output delay

9. The Patient Journey: Inputs; Throughput; Output Wait for MD ER Visit Decision to admit to admit Length of stay on unit Decision to Discharge to discharge Length of stay in in nursing home ER Throughput ER Input ER Output Beds Output Beds Throughput NH Throughput Beds Input NH Input

10. Sample Input Aims • Within 12 months, 100% of patients seeking care in the ED will see the MD within 15 minutes of their arrival. • Within 12 months, 100% of surgeries will begin at the scheduled time • Within 12 months, 100% of lab specimens will be collected within 20 minutes of the order being received within the department • Within 12 months, the time from receiving the order for CT to patient receiving the CT will be reduced by 25% from xx minutes to xx minutes.

11. Sample Throughput Aims • Within 12 months, the average cycle time in the ED will be reduced from xx minutes to 45 minutes  • Within 12 months the average cycle time for surgery will be reduced by 25% from xx minutes to xx minutes  • Within 12 months, the average process time for a xx (lab) will be reduced from xx minutes to xx minutes • Within 12 months, the average length of stay for xx unit will be reduced by xx% from xx hours to xx hours

12. Sample Output Aim • Within 12 months 100% of patients will be admitted to the receiving unit within 30 minutes of notification from ER (or OR, or PACU, or ICU)

13. MEASURES How will we know that a change is an improvement?

14. Measures Measures: How will we know a change is an improvement? • Baseline measures • Plot data over time. • Focus on simple measures directly related to aim • Sampling • Integrate measurement into daily work. • Create simple annotated run graphs.

15. CT Exams

16. Measures • Delay • Input • Throughput • Output • Demand (and variation) • Supply • Activity • Satisfaction • Defects • No-shows • Internal and external diversions • Readmission rate

17. “Kinds” of Data • Judgment • Research • Performance appraisal • “do something TO you” • Improvement • Process improvement efforts • “do something WITH you”

18. Flow Mapping • Record each process step on a separate piece of sticky paper • Put the steps in the right order • Record who is responsible for each step • Add forgotten steps • Agree to all of above • Analyze

19. Flow Mapping Example Apply paste to brush Brush teeth Open toothpaste Wet toothbrush Turn off light Put away paste and brush Rinse mouth Rinse brush

20. Changes and Tests What changes can we make that will result in an improvement?

21. Tests and Changes How will you reach your aim? • Testing changes • With likelihood of success • For re-assurance in environment • Adopting successful strategies based on your tests.

22. Flow of Work Change Principles • Balance upstream and downstream demand and supply for all services • Eliminate any backlogs of work • Reduce the queues from one entity to the other • Develop contingency plans to address demand or supply variation

23. Flow of Work Change Principles • Reduce demand • Identify and manage each supply constraint • Synchronize the work • Predict and anticipate needs • Optimize environment: equipment, staff and space

24. Tests and Changes Tests: Cycles for Learning and Improvement • Rapid Cycles • Multiple tests of multiple changes • Testing vs. implementation

25. How to Implement a Change High Successful Change Belief that change will result in improvement Still Needs Further Testing Unsuccessful Change Low Implementing Developing Testing From Lloyd Provost

26. Model for Improvement What are we trying to accomplish? How will we know thata change is an improvement? What change can we make that will result in improvement? A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Ideas Very Small Scale Test Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

27. PDSA Cycles • Are Not Plans! • Are small in scale • Thinking months – think weeks; thinking weeks – think days; thinking days – think hours • Thinking facility – think unit; thinking unit – think teams; thinking teams, think ONE team • Thinking all patients – think a type of patient; thinking a type of patient, think a sample; thinking sample then 3-5 may be enough

28. P A D S P A P D A S P A D P S A P A D S D S D P S A P A P A D S S A D P S A D P A S S A P A Balance Demand And Supply S A Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996 Decrease Appt. Types Decrease Demand

29. Summary • Keep focused on Aim – Measure – Change • Changes are “small experiments” • Experiment wisely – PSDA • Learn from small changes over wide conditions before implementing widely • Get started and keep going

30. Model for Improvement • Aim: What are we trying to accomplish? • Measurement:How will we know that a change is an improvement? • What Changescan we make that will result in an improvement? • Cycle for Learning • and • Improvement ACT PLAN STUDY DO Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

31. Teams

32. Important Questions • What is our current team number and composition? • Are we clear about our mission and goals? • Are we working together as smoothly and efficiently as we could? • Are we providing high quality care for our patients? • Is working with this team any fun? • Do we get the job done well?

33. What are the Attributes of a Team? • Proactive vs. reactive • Communicative vs. isolated • Accountable to each other, and to the patient • Use measures for feedback • Delivers safe and high quality care

34. Attributes continued……. • Cross-trained versus territorial • Integrated versus separated • Continuous flow versus flow based on urgency • All staff work to highest level of training, experience, and licensure

35. Role • Test and implement changes • Measure and record pertinent data • Communicate (successes and unintended consequences)

36. Profile • Willing to be involved in the process • Interested in the issues • Ready to participate in discussion and test changes • Possess knowledge related to the process

37. Membership • Senior department leader(s) • Clinical team physician leader • Day-to-day leadership • Technical experts

38. Senior Dept. Leader • Department’s sponsor for the Hospital Flow Improvement Initiative • Authority to institute change • Authority to allocate the time and resources necessary to achieve the team’s aim

39. Physician Leader • Good working relationship with colleagues and with the day-to-day leader(s) • Interested in driving change in the system/department and will be a champion for the work • Opinion leader in the department (individuals sought out for advice who are not afraid to test change)

40. Day-to Day Leader • Critical driving force of the project, assuring that tests of change are implemented and overseeing data collection • Understands not only the details of the system, but also the various effects of making change(s) in the system • Able to work effectively with the physician champion(s)

41. Day-to-Day Leader (cont.) • Team’s “key contact” for the initiative • Responsible for coordinating communications between the department team and the Steering Team • Organize team meetings, assist with completion of agreed-upon tasks, assure follow-thru with assignments, and facilitate communication

42. Technical Expert(s) • Knows the department well and understands the various processes and tasks of care • Understands the processes/tasks of entry into the department • Understands the care processes within the department • Understands the processes/task of how the patient leaves the department

43. Meetings • Schedules • Tasks • Effective meetings

44. Effective Meetings • Develop a plan or purpose ahead of time • Use agendas • Start and end on time • Review aim at each meeting • Take minutes • Review progress

45. Effective Meetings (cont.) • Manage discussion • Deal with difficult meetings or individuals • Celebrate • Close the meeting • Address environmental issues

46. Teams Teamwork! ICU ED Beds Outside OR Diagnostics

47. Team Meeting 1 Objective 1: To refine and finalize your aims for this collaborative. Objective 2: To refine team membership Process: • Select a recorder and a reporter. • Refine and record your aims • Input delay • Throughput delay • Output delay • Refine your team • Prepare to report back.