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Quality Improvement The Model for Improvement, PDSA Cycles, and Accelerating Improvement Heather Maciejewski BEACON Quality Improvement Coordinator Ohio Chapter, AAP
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Quality Improvement The Model for Improvement, PDSA Cycles, and Accelerating Improvement

Mar 19, 2016

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Quality Improvement The Model for Improvement, PDSA Cycles, and Accelerating Improvement. Heather Maciejewski BEACON Quality Improvement Coordinator Ohio Chapter, AAP. Session Objectives. To describe the components of the Model for Improvement - PowerPoint PPT Presentation
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Page 1: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Quality Improvement

The Model for Improvement, PDSA Cycles, and

Accelerating ImprovementHeather Maciejewski

BEACON Quality Improvement CoordinatorOhio Chapter, AAP

Page 2: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Session Objectives• To describe the components of the

Model for Improvement• To identify measures and goals for your

participation in EASE• To develop a clear plan for your team

to test a change idea• To identify future tests of change

Page 3: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

QUALITY IMPROVEMENT STRUCTURE, APPROACH AND ROADMAP

Page 4: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Structure is Based on Institute for Healthcare Improvement (IHI)

Breakthrough SeriesSelect a Quality Improvement

Topic

Conduct Expert Meeting

Planning Group

(Experts)

Participants (YOU!)

Learning Session

Action Period Calls

Develop Framework and Changes

Holding the Gains

Spread and Dissemination

Supports:• Experts • Learning Session• Action Period Calls• Telephone• Email• Monthly Reports• Monthly Data

Page 5: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Approach is Based on The Model for Improvement

Model for ImprovementWhat are we trying to

accomplish?How will we know that a

change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

Page 6: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Key Driver Diagram

SMART AIMKEY DRIVERS

INTERVENTIONS

By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position on random weekly audits.

A “safe sleep” position includes: • Sleeping in his/her own crib• Alone in the crib• Laying on his/her back

GLOBAL AIM

Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.

• Safety Videos/Edutainment System (Franklin County/CPSC/NICHD)

• Take-home magnets • Brochures • Safe Sleep posters

Nursing Education

• CHEX Quality Board Tips • Nurse champions/RN care partners• Scripting for – and with – parents • Safe Sleep “Cheat Sheet”

• Sleep sacks • Safe Sleep Policy developed• Assess hospital policy on clothing allowed

for patients• Mattresses on beds need evaluated• Potentially use fitted sheets on beds

Multi-Disciplinary (PCA, OT/PT) Education

Physician Education

Parent/Caregiver Education

Management of Environment

• Grand Rounds• Hospital pediatricians web module

Medical Directors: Sarah Denny, MD and Michael Gittelman, MDPrincipal Investigator: Jamie Macklin, MD

Updated: April 3, 2014

Key Driver Diagram adapted from Nationwide Children’s Hospital

Page 7: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

THE MODEL FOR IMPROVEMENT

Page 8: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Model for ImprovementWhat are we trying to

accomplish?How will we know that a

change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

Part 1:Answers

these three questions

Part 2:Guides

change to see if there

is an improvemen

t

The Model for Improvement

Page 9: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Model for ImprovementWhat are we trying to

accomplish?How will we know that a

change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

Part 1:Answers

these three questions

Part 2:Guides

change to see if there

is an improvemen

t

Set Aims

Establish Measures

Select Changes

Test the Changes

The Model for Improvement

Page 10: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

Aim

Page 11: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Aim Statements• Provides a focused rationale and

vision for what your team plans to accomplish

• Are SMARTS: Specific M: MeasurableA: Action-OrientedR: Relevant/Realistic T: Timely

Page 12: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Key Driver Diagram

SMART AIMKEY DRIVERS

INTERVENTIONS

By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position on random weekly audits.

A “safe sleep” position includes: • Sleeping in his/her own crib• Alone in the crib• Laying on his/her back

GLOBAL AIM

Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.

• Safety Videos/Edutainment System (Franklin County/CPSC/NICHD)

• Take-home magnets • Brochures • Safe Sleep posters

Nursing Education

• CHEX Quality Board Tips • Nurse champions/RN care partners• Scripting for – and with – parents • Safe Sleep “Cheat Sheet”

• Sleep sacks • Safe Sleep Policy developed• Assess hospital policy on clothing allowed

for patients• Mattresses on beds need evaluated• Potentially use fitted sheets on beds

Multi-Disciplinary (PCA, OT/PT) Education

Physician Education

Parent/Caregiver Education

Management of Environment

• Grand Rounds• Hospital pediatricians web module

Medical Directors: Sarah Denny, MD and Michael Gittelman, MDPrincipal Investigator: Jamie Macklin, MD

Updated: April 3, 2014

Key Driver Diagram adapted from Nationwide Children’s Hospital

Page 13: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Global vs. Specific Aim Statements

Education and Sleep Environment (EASE): The Injury Prevention Learning Collaborative with

Hospitalists

• Global Aim: Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.

Page 14: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Global vs. Specific Aim Statements

• Specific Aim: By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position during random weekly audits.– A “safe sleep” position includes a child who is:

• Sleeping in his/her own crib• Sleeping alone in the crib• Laying on his/her back

Page 15: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

Measures

Page 16: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Why do we measure?Measures facilitate learning and are not for judgment or comparison

– Recognize areas for improvement – define the gap between where we are and where we need to be

– Provide feedback as a means to evaluate– are the changes we’re making having the desired impact?

– Characterize the robustness of change – how does our system respond to the changes we’ve made?

Page 17: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Process vs. Outcome Measures

• Process measures: represents the workings of the system

• Proportion of patients with hemoglobin A1c levels measured at least twice within the past year

• Proportion of children with asthma who receive asthma management plan

• Outcome measures: represents the voice of the customer or patient

• Reduction in BMI percentile• Hospitalizations or ED visits due to asthma• Patient satisfaction with time to getting an

appointment

Page 18: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

EASE MeasuresEASE process measures include:• > 90% of patients 1 year of age and

younger will leave the hospital with information on safe sleep practices

• Each hospital will show that > 90% of children ≤ 1 year of age will be in “safe sleep” position (own crib, nothing in crib and on back) on random weekly audits by the end of the 12-month project – This is a bundled measure of all three items

for a safe sleep position

Page 19: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

Ideas/ Changes

Page 20: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Plan

DoStudy

Act

The Improvement GuideAssociates in Process Improvement

P-D-S-A Cycle

Page 21: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

PLAN – DO – STUDY – ACT CYCLES

Page 22: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The PDSA CycleFour Steps: Plan, Do, Study, Act

Also known as:• Shewhart Cycle• Deming Cycle• Learning and

Improvement Cycle

Act Plan

Study Do

The Improvement GuideAssociates in Process Improvement

Page 23: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Use PDSA Test Cycles for:• Testing or adapting a change

idea– May answer a question related to the

aim• Implementing a change• Spreading the changes to the

rest of the system

Page 24: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Why Test?• Force us to think small• Increases your belief that the change

will result in improvement• Opportunity for learning without

impacting performance• Help teams adapt good ideas to their

specific situation

The Improvement GuideAssociates in Process Improvement

Page 25: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The PDSA Cycle

Act Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study Do

Page 26: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

• Do initial cycles on smallest scale possible– Think baby steps…a “cycle of one” usually

best• “Failures” are good learning

opportunities; can be better than “Successes”

• As move to implementation, test under as many conditions as possible– Think about factors that could lead to

breakdowns, supports needed, “naysayers”– Different providers; different days of the

week; different patient populations, etc.

Key Points for PDSA Cycles

Page 27: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Key Points for PDSA Cycles• Do initial cycles on smallest scale and

within shortest timeframe possible- Think baby steps…a “cycle of one” usually

best Years Quarters Months Weeks Days Hours Minutes

Drop down “two levels” to plan Test Cycle!

Page 28: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The PDSA Cycle

Act Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study Do• Carry out the plan• Document problems and unexpected observations

Page 29: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The PDSA Cycle

Act Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations

Page 30: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

The PDSA Cycle

Act• What changes are to be made?• Next cycle?

Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations

Page 31: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Common PDSA Pitfalls1. Testing changes where link to overall aim or

key driver is unclear2. Failing to make a prediction before testing

the change 3. Failing to execute the whole cycle

– Plan, Plan, Plan-D-S-A (too much planning, not enough doing)

– P-Do, Do, Do-S-A (too much doing, not enough studying)

Page 32: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Common PDSA Pitfalls4. Not learning from “failures”5. Lack of detailed execution plan6. Failure to think ahead a few cycles

Page 33: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement
Page 34: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

PDSA WORKSHEET

PLAN: Briefly describe the test:

Provide maps for the delivery drivers to ensure they know the delivery location, and can make it on time How will you know that the change is an improvement?

Drivers will deliver pizzas on time without getting lost What driver does the change impact?

Getting to delivery location efficiently What do you predict will happen? The maps will help get drivers to their destination efficiently PLAN

List the tasks necessary to complete this test (what)

Person responsible

(who) When Where 1. Customer calls in order; person answering phone confirms address

Order Taker Jan. 2nd Clifton Location

2. Address is given to Manager Joe

Order Taker Jan. 2nd Clifton Location

3. Map is created for delivery address

Manager Joe Jan. 2nd Clifton Location

4. Map is given to delivery driver

Manager Joe Jan. 2nd Clifton Location

5. Delivery driver follows map to address

Delivery Driver Jan. 2nd Clifton Location

6. Delivery driver reports back on getting lost/not getting lost, and time it takes for pizza to be delivered

Delivery Driver

Jan. 2nd Clifton Location

Plan for collection of data: Delivery drivers will keep a log of time they leave the store to the time they arrive at the delivery address; this information will be sent to Manager Joe.

DO: Test the changes. Was the cycle carried out as planned? X Yes No Record data and observations. 100% of deliveries were made without drivers getting lost What did you observe that was not part of our plan? Day drivers ran into more traffic than expected. STUDY: Did the results match your predictions? XYes No Compare the result of your test to your previous performance: Less drivers were lost because of the maps. What did you learn? Maps are useful for delivery drivers ACT: Decide to Adopt, Adapt, or Abandon.

Adapt: Improve the change and continue testing plan. Plans/changes for next test: Provide maps for all shifts, not just day drivers Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability

Abandon: Discard this change idea and try a different one

Team Name: Best Pizza Delivery Team Date of test: January 2nd Test Completion Date: January 5th Overall team/project aim: Deliver pizzas within 30 minutes

What is the objective of the test? Reduce the number of late deliveries due to drivers getting lost

Do

Study Act

Plan

Page 35: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

PDSA Cycle Ramps: Sequential Building of Knowledge

Best PracticeEvidenceHunchesTheoriesTestable Ideas

Changes That Result in

Improvement

A PS D

APS

D

A PS D

D SP ADATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

The Improvement GuideAssociates in Process Improvement

Successive tests of a change build knowledge AND create

a ramp to improvement

Page 36: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Example of Accelerating Improvement

TEST 1What: Provide mapsWho (population): Day driversWhere: Clifton locationWhen: From 1/2 to 1/5Who Executes: Mgr. JoeResults: Nobody got lost

TEST 2What: Provide mapsWho (population): all shiftsWhere: Clifton locationWhen: From 1/6 to 1/13Who Executes: Mgr. JoeResults: Nobody got lost but deliveries took longer & some drivers had difficulty using the map

TEST 3What: Mapquest DirectionsWho (population): Day driversWhere: Clifton locationWhen: From 1/14 to 1/17Who Executes: Mgr. JoeResults: Nobody got lost, directions easier than map but printing out & sorting directions takes time

TEST 4What: Mapquest DirectionsWho (population): all shiftsWhere: Clifton locationWhen: From 1/17 to 1/24Who Executes: Mgr. JoeResults: Nobody got lost, directions easier than map, but printing and sorting directions still took time; suggested telephone answerer device plan for printing/sorting maps for drivers

Do

StudyAct

Plan

Do

Study

Act

Plan

Do

Study

Act

Plan

Do

StudyAct

Plan

Page 37: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

“All improvements requires change, but not every change is improvement.”

The Improvement Guide, 2009

Page 38: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

Quality Improvement Videos

• The Model for Improvement: http://www.youtube.com/watch?v=SCYghxtioIY

• PDSA Cycles: http://www.youtube.com/watch?v=_-ceS9Ta820&feature=youtu.be

Page 39: Quality Improvement  The  Model for  Improvement,  PDSA Cycles, and  Accelerating Improvement

ReferencesFuller, S. (2010). Model for Improvement. PowerPoint slides

Griffin, F. (2004). The PDSA Cycle Testing and Implementing Changes. Retrieved from: www.njha.com/qualityinstitute/pdf/628200432756PM63.ppt · PPT file

Langley, G., Moen, R., Nolan, K. , Nolan T., Norman, Provost, L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd edition. Jossey-Bass Publishers., San Francisco.

Moen, R. and Norman, C. (2010). Circling back clearing up myths about the Deming cycle and seeing how it keeps evolving. Retrieved from www.qualityprogress. com

NHS Institute for Innovation and Improvement. Quality and Service Improvement Tools: PDSA. Retrieved fromhttp://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html

Provost, L., Murray, S. (2011). The Health Care Data Guide: Learning from data for Improvement. Jossey-Bass Publishers., San Francisco.

Society of Hospital Medicine. Plan-Do- Study- Act. Retrieved from: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/Plan_study.cfm

The Model for Improvement National Primary Care Development Team (2004). Retrieved from: www.npdt.org