August 21 st Track One Virtual Meeting Prepared and Presented by Institute for Healthcare Improvement Faculty Sue Gullo, Director Jane Taylor, Improvement.

August 21st Track One Virtual MeetingPrepared and Presented by

Institute for Healthcare Improvement Faculty

Sue Gullo, DirectorJane Taylor, Improvement Advisor

Session Objectives

Objectives:(1) Review and discuss the Lens of Profound

Knowledge and its related four components (2) Discuss the change concepts and ideas

developed for selected HACs(3) Describe the data collection strategies and

the variation that lives within your data.

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Source: Langley, J. et al, The Improvement Guide, Jossey-Bass

Publishers, 2nd edition, 2009

A Model for Learning and Change

The Shewhart Cycle for Learning and Improvement

Act Plan

Study Do

Act – Adopt the change, abandon it or run through the cycle again.

Plan – plan a change or test aimed at improvement.

Study – Examine the results. What did we learn? What went wrong?

Do – Carry out the change or test (preferably on a small scale).

(Deming, 1993)

Useful Ways to Develop Changes- OS

Critical thinking about the current system1

Sometimes, simply reflecting on problems within a system can generate some good ideas for change. If you make a flow chart of your current process, it may be possible to identify parts of the system that aren’t working or are needlessly complex. Another way to go about critical thinking is to gather and analyze data on the way your system currently works—for example, how you are communicating with people about the meeting—which can then help you identify problems and develop changes to address them.

Benchmarking Comparing your own process to “best practice” can help you identify where your own system falls short.

Take the patient’s perspectiveWhen you see the care system from a patient’s perspective, you’ll see opportunities for improvement that might not be apparent as a caregiver. Is it too loud when you’re trying to sleep? Do bright lights give you a headache? Do you have to wait too long to get your test results? Patient shadowing and interviewing are useful techniques when coming up with good ideas to change.

Useful Ways to Develop Changes- OS

Creative thinking1

Where do new ideas come from? You can spark creative thinking in various ways, including simply taking the time to do this sort of thinking; exposing yourself to situations (such as taking the role of a patient) that can spark new ideas; identifying the boundaries that limit the changes you can make and then finding ways to dismantle those boundaries; and temporarily considering unrealistic goals that can prompt you to break out of your old way of thinking.

Using Change Concepts

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Using Change Concepts to Come Up with Ideas-OS

• A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change.

• After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. If they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.

Guidance for Testing a Change Concept

• A test of change should answer a specific question!

• A test of change requires a theory and a prediction!

• Test on a small scale and collect data over time.

• Build knowledge sequentially with multiple PDSA cycles for each change idea.

• Include a wide range of conditions in the sequence of tests.

• Don’t confuse a task with a test!

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To Be Considered a Real Test

• Test was planned, including a plan for collecting data

• Plan was carried out and data were collected

• Time was set aside to analyze data and study the results

• Action was based on what was learned

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The PDSA Cycle For Learning And ImprovementPlan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

What will happen if we

try something different?

Let’s try it!Did it work?

What’s next?

Linking PDSA Cycles - Tips for Doing It Right

• Linking small tests of change helps ensure buy-in from all the people involved.

Think Ahead You already know you’ll want to do multiple tests. So make your life easier by planning for it. Think a couple of cycles ahead, testing over a wide range of conditions and collecting useful data from each test to guide the next one.

Start Small Keep it simple at the beginning. Scale down the size of the test (for instance, start with just a few patients in one location). Test with volunteers and don’t try to get consensus from everyone in the organization before starting.

Get Started Don’t wait around! Ask, “What change can we test by next Tuesday?”

Hunches Theories

Ideas

Changes That Result in

Improvement

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sequential building of knowledge under a wide range

of conditions

Spreading

AP D

S

AP

D SA

PDS

A P

DS

Sustaining the gains

Repeated Use of the PDSA Cycle for Testing

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Hunches Theories

Ideas

Changes That Result in

Improvement

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sequential building of knowledge under a wide range

of conditions

Spreading

AP D

S

AP

D SA

PDS

A P

DS

Sustaining the gains

Repeated Use of the PDSA Cycle for Testing- Falls

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PDSA Tests- FallsHunch/Theory

Very Small Scale Test

Follow Up Tests

Wide-Scale Tests of Change

Implementation

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Hunches Theories

Ideas

Changes That Result in

Improvement

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sequential building of knowledge under a wide range

of conditions

Spreading

AP D

S

AP

D SA

PDS

A P

DS

Sustaining the gains

Repeated Use of the PDSA Cycle for Testing- HAPU

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PDSA Tests- HAPUHunch/Theory

Very Small Scale Test

Follow Up Tests

Wide-Scale Tests of Change

Implementation

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Appropriate Scope for next PDSA CycleCurrent Situation Resistant Indifferent Ready

Low Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small Scale Test

Very Small Scale Test

Very Small Scale Test

Cost of failure small

Very Small Scale Test

Very Small Scale Test Small Scale

Test

High Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small Scale Test Small Scale

TestLarge Scale Test

Cost of failure small

Small Scale Test

Large Scale Test

Implement

• Be sure to distinguish the reason: – Change was not executed – Change was executed, but not effective

• If the prediction was wrong – not a failure!– Change was executed but did not result in improvement– Local improvement did not impact the secondary driver or

outcome– In either case, we’ve improved our understanding of the system!

Failed Test…Now What?

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The Sequence of Improvement

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

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Appreciation of a system

Understanding Variation

Theory of Knowledge

Human Behavior

A

im or V

alues

The Lens of Profound Knowledge

QI

“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!

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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

Understanding Variation• Variation is to be expected• Common or special causes• Ranking, tampering• Potential mistakes

Theory of Knowledge• Prediction• Learning from theory, experience• Operational definitions • PDSA for learning and

improvement

Human Behavior• Interaction between people• Intrinsic motivation,

movement• Beliefs, assumptions • Will to change