Opening Plenary: Overview of the Science of Improvement Prepared and Presented by Robert Lloyd, PhD Institute for Healthcare Improvement Faculty Wednesday,

Opening Plenary:Overview of the Science of Improvement

Prepared and Presented by

Robert Lloyd, PhDInstitute for Healthcare Improvement Faculty

Wednesday, August 21, 2013

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Plenary Session Objectives

• To provide a high-level overview of the Science of Improvement:– Deming’s System of Profound Knowledge– The Model for Improvement (MFI) – The role of the PDSA cycle– The Sequence of Improvement

• To provide an overview of four HACs that will serve as the content referents for these sessions

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ExerciseScience of Improvement Self-Assessment

This self-assessment is designed to help quality facilitators gain a better understanding of where they personally stand with respect to understanding and explaining the key components of the Science of Improvement (SOI). What would your reaction be if you had to explain the PDSA cycle to your colleagues, develop change concepts or describe how to build measures?

You may not be asked to do all of the things listed below in the near future but, if you are facilitating a QI team or expect to achieve the HEN goals, sooner or later these questions will be posed. How will you deal with them?

The place to start is to be honest with yourself and see how much you know about QI concepts and methods. Once you have had this period of self-reflection, you will be ready to develop a learning plan for yourself and those on your improvement team.

Use the following Response Scale. Select the one response which best captures your opinion.1 I could teach this topic to others!2 I could do this by myself right now but would not want to teach it!3 I could do this but I would have to study first!4 I could do this with a little help from my friends!5 I'm not sure I could do this!6 I'd have to call in an outside expert! Source: R. Lloyd, Quality Health Care: A Guide

to Developing and Using Indicators. Jones & Bartlett Publishers, 2004: 301-304.

Exercise: Measurement Self-AssessmentSource: R. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators.

Jones & Bartlett Publishers, 2004: 301-304.

Measurement Topic or SkillResponse Scale

1 2 3 4 5 6

Build clear aim statements for our work (How good? By when?)

Establish appropriate goals for a project Move a team from concepts to appropriate measuresDevelop process, outcome and balancing measuresBuild a clear and unambiguous operational definition for each measureDevelop and implement data collection strategies

Identify specific changes and ideas that we can test

Set up and run PDSA tests

Explain the sequence of improvement (testing, implementing and spreading) and apply it to the team’s work

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Science of Improvement Knowledge: The interplay of the theories of systems, variation, knowledge, and psychology.

Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.

SOI Knowledge

Subject Matter Knowledge

Two Types Of Knowledge…

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SOI Knowledge

Subject Matter Knowledge

Improvement occurs when we learn how to combine subject matter knowledge and the science of

improvement in creative ways to develop effective ideas for change.

Impro

vement

Knowledge For Improvement

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W. E. Deming, The New Economics for Industry, Government, Education. MIT, 1993

"One need not be eminent in any part

of profound knowledge in order to

understand it and to apply it. The

various segments of the system of

profound knowledge cannot be

separated. They interact with each

other. For example knowledge about

psychology is incomplete without

knowledge of variation."

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Appreciation of a system

Understanding Variation

Theory of Knowledge

A

im or V

alues

The Lens of Profound Knowledge

“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!

QI Human Behavior

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Appreciation of a system

Understanding Variation

Theory of Knowledge

A

im or V

alues

The Lens of Profound Knowledge

“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!

QI Human Behavior

TRACK 2

FOCUS

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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

Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2nd edition, 2009

A Model for Learning and Change

When you combine

the 3 questions with the…

…the Model for

Improvement.PDSA cycle,

you get…

Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2nd edition, 2009

A Model for Learning and Change

When you combine

the 3 questions with the…

…the Model for

Improvement.PDSA cycle,

you get…

TRACK 1 FOCUS

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)

The Shewhart Cycle for Learning and Improvement

You do PDSAs every day!

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You do PDSAs every day!

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You do PDSAs every day!

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You do PDSAs every day!

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You do PDSAs every day!

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You do PDSAs every day!

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You do PDSAs every day!

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Plan• 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?

The PDSA Cycle For Learning And 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

You run PDSAs throughout the entire Sequence of Improvement

The Primary Drivers of Improvement

Will

Ideas Execution

Having the Will (desire) to change the current state to one that is better

Developing Ideas that will contribute to making processes and outcome better

Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas

QI

Key Components* Self-Assessment

• Will (to change)• Ideas• Execution

• Low Medium High• Low Medium High• Low Medium High

*All three components MUST be viewed together. Focusing on one or even two of the components will guarantee suboptimized

performance. Systems thinking lies at the heart of CQI!

How prepared is your Organization?

Clinical Topics Update: Falls, Pressure Ulcers, Venous Thromboembolism

(VTE), Adverse Drug Events (ADE) Cheryl Ruble, RN, MS, CNS, CCRN

Kim Werkmeister, RN, BAImprovement Advisor, Cynosure Health

Where are we now with Falls?

As of 8/5/13, 12.28% reduction (weighted) has been achieved.

What is our goal?Sustainment of percent reduction for 60 percent or more hospitals in Falls and continued work on interventions to achieve 40 percent reduction.

Falls Outcomes Data Falls With or Without Injury

(NSC-4)

Falls With Injury

(minor or greater) (NSC-5)

# hospitals reporting 831 476

# hospitals eligible for measure 1416 1416

% eligible hospitals 59% 34%

Benchmark 2.15 0.50

# hospitals met benchmark last 3 months 293 271

% hospitals met benchmark last 3 months 21% 19%

# hospitals at zero last 3 months 86 184

% hospitals at zero last 3 month 6% 13%

Meeting 30-6-60 goal No No

Challenges and Change Concepts for Falls

• Accurate data submission

• Fall AND injury risk assessment

• Implementation patient specific interventions to prevent injury

• Develop supporting processes such as purposeful rounding, hand-off communications, or post HAPU huddles

Where are we now with Pressure Ulcers?

As of 8/5/13, 17.52% reduction (weighted) has been achieved.

What is our goal?Sustainment of percent reduction for 60 percent or more hospitals in Pressure Ulcers and continued work on interventions to achieve 40 percent reduction.

Pressure Ulcer Outcomes Data

Patient with at least One Stage II or Greater

Nosocomial Pressure Ulcers (NSC-2)

Pressure Ulcer (MCR FFS) (CMS HAC)

# hospitals reporting 399 367

# hospitals eligible for measure 1416 1416

% eligible hospitals 28% 26%

Benchmark 1.98 0.00

# hospitals met benchmark last 3 months 375 0

% hospitals met benchmark last 3 months 26% 0%

# hospitals at zero last 3 months 237 0

% hospitals at zero last 3 month 17% 0%

Meeting 30-6-60 goal No No

Challenges and Change Concepts for Pressure Ulcers

• Accurate data submission• Head to toe risk & skin

assessment• Develop and implement an

individual plan of care• Address moisture, shear, and

friction• Develop supporting processes

such as purposeful rounding, hand-off communications, or post HAPU huddles

Where are we now with VTE?

As of 8/5/13, 16.76% reduction (weighted) has been achieved.

What is our goal?Sustainment of percent reduction for 60 percent or more hospitals in VTE and continued work on interventions to achieve 40 percent reduction.

VTE Outcomes Data Potentially Preventable VTE

(VTE-6)

Post Op PE or DVT

(AHRQ PSI 12)

# hospitals reporting 330 364

# hospitals eligible for measure 1416 1416

% eligible hospitals 23% 26%

Benchmark 0.16 0.56

# hospitals met benchmark last 3 months 73 198

% hospitals met benchmark last 3 months 5% 14%

# hospitals at zero last 3 months 72 134

% hospitals at zero last 3 month 5% 9%

Meeting 30-6-60 goal No No

Challenges and Change Concepts for VTE

• Accurate data submission

• Risk-based prophylaxis• Risk assessment for

every patient• Standard work in every

area of the hospital

Where are we now with ADE?

Excessive Anticoagulation with Warfarin – Inpatients No percent reduction as of 8/5/13

Hypoglycemia in inpatients receiving insulin 26.49% reduction as of 8/5/13

What is our goal?577 additional hospitals to submit data on the ADE topic. Currently have 333 hospitals (24%) submitting as of 8/5/13.

Provide interventions to assist hospitals with a focus on the top two HEN measures.

ADE Outcomes Data Excessive anticoagulation with warfarin

Hypoglycemia in patients receiving

insulin

# hospitals reporting 209 102

# hospitals eligible for measure 1416 1416

% eligible hospitals 15% 7%

Benchmark 0.00 0.07

# hospitals met benchmark last 3 months 79 69

% hospitals met benchmark last 3 months 6% 5%

# hospitals at zero last 3 months 79 40

% hospitals at zero last 3 month 6% 3%

Meeting 30-6-60 goal No No

Challenges and Change Concepts for ADE

• Volume of data submission• Choice of data measures• Pharmacist-driven

protocols to prevent events related to hypoglycemia and hypercoagulation

• Standardized protocols in all areas of the hospital

Transition to Tracks

Track 1: Stay logged in to this session

Track 2: Login into Track 2 using the link provided in the chat box or sent directly to your email