Comparing Lean and IHI Quality Improvement Richard Scoville, PhD IHQI Speaker Series February 9, 2015 Richard Scoville, PhD • Improvement Advisor for Institute for Healthcare Improvement Dentaquest Institute Cincinnati Children’s Hospital NHS UK • Adjunct Associate Professor, Dept. Health Policy & Management, UNC Chapel Hill
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Comparing Lean and IHI Quality Improvement · Comparing Lean and IHI Quality Improvement Richard Scoville, PhD IHQI Speaker Series February 9, 2015 ... Model for improvement Multidisciplinary
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Tests for special cause - One data point that falls outside the limits- Eight or more consecutive subgroups above or below the mean- Six points all going up or all going down.- Two out of three consecutive points in either outer third of the limits.
?
Psychology
Psychology deals with the behavior of humans as social actors, their
interactions with one another, and their interactions with the systems of
which they are a part.
“First we build people, then we build cars.”
- Toyota saying
“Drive out fear.”- W. Edwards Deming
“Doh!”- Homer Simpson
Homo Economicus?
• Who are we really?
Are we rational actors who evaluate options carefully and
dispassionately?
Or are our actions driven by appetites, reflexes, and faulty
logic?
Do you use lung protective strategy In ventilating acute lung injury patients?
Audit
2.6%
The Gap between Perception and Practice of Sepsis Therapy. FM Brunkhorst et al. for the German Competence Network Sepsis –Crit Care Med 2008;36(10):2719-25.
Results of A Level 1Reliability Processes.
%
0
20
40
60
80
100
80%
YES
Adhere to Best Practice?
Slide courtesy of Terry Clemmer, MD
Interview
Audit
%
0
20
40
60
80
100
2.6%
80%
67%
9%
46%
18%
79%
31%
The Gap between Perception and
Practice of Sepsis Therapy. FM
Brunkhorst et al. for the German
Competence Network Sepsis – Crit Care
Med 2008;36(10):2719-25.
“Of course we do it every time”
Slide courtesy of Terry Clemmer, MD
‘Heuristics’
• Anchoring
‘Manufacturers suggested retail price’
• Availability
High salience events over-predicted
• Representativeness
Patterns, patterns everywhere
• Optimism
All the children are above average
• Loss Aversion
Losing is worse than not winning
• Status Quo Preference
The ‘whatever’ principle
• The Herd Instinct
‘Everybody’s doing it!’
Thaler, R. and C. Sunstein (2008). Nudge. New York, Penguin.
A Choice Architecture
http://www.youtube.com/watch?v=2lXh2n0aPyw
‘Culture’
Culture =
• Beliefs
Ideas and values that the group accepts as ‘self evident’, ‘reasonable’, ‘right’, ‘just’, etc.
• Rituals
Things we do together: work, play, worship, etc.
• Norms
What’s right? cool? polite? bad? pitiable? disgusting? etc.
To change culture, change behavior; the rest will follow.
P39
Transparency!
An Effective Improvement Culture Requires…
Principles from Social Psychology
Asch: “Collective Conservatism”
• People are likely to conform when they know that other people will observe what they have to say
• Newly formed groups establish beliefs and norms quickly
Gilovich: “Spotlight Effect”
• We tend to believe that others are attending to and care about what we do or believe
Asch, S. E. (1955). "Opinions and Social Pressure." Scientific American 193(5): 31-35.
Gilovich, T., V. Medvec, et al. (2000). "The spotlight effect in social judgment." Journal of Personality and Social Psychology 78(2): 211-222.
Lots of Advice Out There…
One Actually Worth Reading
Theory of Knowledge
The development of practical knowledge of “what works,” grounded in
predictions about the results to be achieved through system changes.
Knowledge is gained through a process of stating a theory, making a
prediction based on the theory, comparing observations with predictions,
and revising or abandoning the theory accordingly.
“If you don’t try, you’ll never know”
The Model for Improvement
“A heuristic for learning from experience and guiding purposeful action.”
The Model for Improvement
• What it’s NOT:�The (entire) IHI-QI approach to
improvement
�A project plan
�Engineering
�A ‘toolkit’
�A collaborative
• What is IS:
“A heuristic for learning from experience and guiding purposeful action.”
• At all levels of scale...
“An algorithm for achieving an aim at any scale”
IHI-QI
Leadership
Statistical process control
Diffusion of innovation
Program Evaluation Measurement
Complex adaptive systems
Decision theory
Theories of motivation
Reliability theory
Social network theory
Regression
Design of experiments
Model for improvement
Multidisciplinary teams
Graphical displays of data
Operational definitions
System Psychology
Learning Variation
Conceptual Frameworks
Control charts
Run charts
Pareto charts
Histograms
Kaizen event
Develop-test-
implement sequence
Gemba walk
RCA
System diagram
Driver diagram
SDIDirected creativity
BTS collaboratives
Value stream map
‘Leading Change’
Situational Awareness
A3 planning
PDSA Forms
Tools and Methods
System Psychology
Learning Variation
Social network
diagrams
Projects
"All Improvement Takes Place Project by Project. There is
no such thing as improvement generally. All improvement
takes place project by project and in no other way.
As used here, “improvement project” means “a chronic
problem scheduled for solution.” Since improvement project
has multiple meanings, the company glossary and training
manuals should
define it.“
–Joseph Juran - Handbook
Planning – Improvement - Control
Select topic and
target system,
population
Identify subject
matter &
improvement
experts
to support the
collaborative
Engage local
partners
Programme
design including
spread strategy
Recruit
participating
teams
Baseline
data
Evaluate,
Publish,
Organize
material for
future projects
support– site visits, phone calls, webniars,
engagement of supervisory managers, faculty
feedback, data interpretation, IT support, etc.
KEY
LS = Learning Session
AP = Action Period
Planning & Preparation
Implementation
Spread Activity
12 – 18 months
LS1 LS2 LS3 LS4 LS5
AP1 AP2 AP3 AP4
Drivers,
changes,
measures
Expert Meeting
BTS Collaborative: A Learning Model
- Xi Jinping
“Avoid going through the motions.”
- W. Edwards Deming
“Without theory, there are no questions; without questions, there is no learning.”
Changes
Patients of the NSLIJ
system with advanced illness reliably receive care that• Is trustworthy
• Aligns with their needs & preferences• Avoids unneeded or undesired tests and
treatments• Engages with patients and families as respected partners in care
• Encourages patient and family responsibility(1)
Measure Concepts:
• Patient/family satisfaction• ICU days in last X months
of life• Acute admissions in last X
months of life: # & LOS• Cost of care in last X months (to payer, system, and family)
P1 The system of care reliably identifies patients with advanced illness
Reliable process for early identification of patients with advanced illness via standard
criteria
Outcomes Primary Drivers Secondary Drivers
P2 Informed patient preferences and hopes are understood by families and clinicians
P3 Services align with patients’ needs and preferences: accessible, appropriate, respectful, coordinated across time and place
Community awareness encourages early self-identification, use of advanced directives
Informed, recurring Conversations (2) occur
at critical times (starting early) and include key elements
Preferences are reliably documented and
communicated multiple ways
Care is continuous across settings, mediated through shared information ( both manual and
Information Technology platform)
Services, advice and facilities available to
patients for appropriate care 24/7
Team provides curative and palliative care
Home /family caregivers are assessed and supported
Care is provided by identified (3) interdisciplinary team, with ‘navigator’ or care
manager for pt/fam, and PCP ‘in drivers seat’
Version 8/13/2013 • Notes (n) in slide notes
P4 Financial and payment arrangements support the aim
Elements & structure of
Conversations: e.g. ‘Presence-
Listening- Planning- Guidance cycle
Supports include:
Call center; clinician/ sw cell
phone
Providers educated and selected
for Conversations
Process to assemble individual
care team and communicate to
pt/fam
Trigger: Norton, The ‘Surprise’
question, multiple
hospitalizations), AIM criteria
Advanced directives, personal health records, electronic sharing
where feasible
Intentional team set up with team
roles clarified and physician control respected per pt. wish
Business models are explicit and include
supporting care and services outside the hospital
Partner with community agencies
for awareness programs &
recruitment
Content Theory
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
2/10/2015 • 56
External Context• Phase 1 and 2 ECC
projects demonstrate
feasibility; continuing
faculty
• Team experience with
prior data procedures
and measures (ECC 2)
• Aggregator prototype
(EDD)
• Anticipated changes in
reimbursement policies
provide motivation for
team participation
• National interest by
dental in medical
disease management
models drive
participation
• Evolving dental
protocols re prevention,
disease management
(CHB protocols)
• Moral imperative re
safety net population
• Private practice
payment model resists
DM approaches
• Evolving roles of dental
providers: team based
care
ECC Phase III – Execution TheoryAIM: Reduce incidence of caries, pain & referrals by participating practices through application of disease management model. Develop content for campaign to follow.
Assumptions• Current delivery, policy & reimbursement models will be restructured.
Inputs
Collaborative teams :
• Senior leadership & alignment with org goals
• QI Team Lead• Clinical champion
• Measurement process for data entry, review, and
use• Experienced teams from
ECC2/EDD• Will to change!
• Dedicated time for QI team
• EDR; Aggregator installation, coding
• No ‘crises’ in play
DQI Team• Experienced faculty from
prior initiatives• Experienced project
team; broad skills• NICHQ project
management • DQI funding to support
faculty & teams• Coaches from ECC2
Materials
• Driver diagram with high degree of confidence
• Project charter, change package, other technical