The Model for Improvement Dannie Currie SIA for the SHN Atlantic Node

Model For Improvement * A simple yet powerful tool for accelerating improvement The model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

Model For Improvement * The model has two parts: Three fundamental questions, Used to establish AIM; MEASURES, AND CHANGE IDEAS. The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of change to determine if the change is an improvement. *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP **The Plan-Do-Study-Act cycle was developed by W. E. Deming

Model For Improvement Action Oriented Trial and Learning Leadership

Aim What are you going to do? How much? By when?

Bold Aim, Firm Deadlines Align aim with strategic goals of the organization Write a clear and concise statement of aim Make the target for improvement bold and unambiguous Include deadline Include scope, boundaries, constraints and anything else that is needed to keep the team focused

Bold Aim, Firm Deadlines “Some is not a number. Soon is not a time” Donald Berwick, MD Institute for Healthcare Improvement

Measures Three Main Types : Outcome Measures Process Measures Balancing Measures

Model For Improvement Outcome measures: Are driven by the specific objectives identified in the AIM statement, e.g. # of medication discrepancies Are understood from the consumer’s perspective eg. Reduced discrepancies Process measures Indicate whether a specific change is having the intended effect, e.g. % of residents with a BPMH on admission Indicate if process changes are leading to improvements

Model For Improvement Balancing measures: Are related measures to understand the impact of changes on the broader system, e.g resident/staff satisfaction They can be the other effects of planned changes e.g. Increased admission time; decreased rework

Measures Choose 2-6 measures that are useful and manageable Should be operationally defined e.g. rework Should be integrated into clinical documentation Include a balanced set of measures to avoid sub-optimization Purpose is for learning not judgment

Measures Outcome; Process; Balancing ? Mean number of undocumented intentional discrepancies Mean number of unintentional discrepancies Percentage of LTC residents reconciled on admission Other

Change Concept 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 combing these change concepts with knowledge about the specific work can help generate ideas for tests of change. PDSAs are used to test the specific ideas. Change concepts are usually at a high level of abstraction, but evoke multiple ideas for a specific process. Examples: Reduce handoffs Consider all parties as part of the same system Improve work flow Eliminate waste Berwick, Boushon,& Roessner, 2007

Aim: Assure customers do not leave bank cards behind Change Concept Aim: Assure customers do not leave bank cards behind

Aim: Assure customers do not leave bank cards behind Change Concept Idea: Beeping sound Concept: Use reminders Aim: Assure customers do not leave bank cards behind Idea: Beeping sound

Change Concept Voice reminders Electric shock Siren Concept: Aim: Assure customers do not leave bank cards behind Idea: Beeping sound Concept: Use reminders Electric shock Voice reminders Siren Based on Edward DeBono’s Concept Fan

Change Ideas Change Package Getting Started Kits Creative and Critical thinking Hunches Best practices Asking process users and subject matter experts for ideas Community of Practice Insight from research and benchmarking

Change While all changes do not lead to improvement, all improvement requires change. Berwick, Boushon,& Roessner, 2007

Rapid Cycle Change Cycle- A structured trial of a process change. Plan- a specific planning phase Do- a time to try the change and observe what happens Study- an analysis of the results of the trial Act- devising next steps based on analysis One PDSA cycle should lead to the Plan of a subsequent cycle. Berwick, Boushon,& Roessner, 2007

Moving From Testing to Implementing Changes Result in Improvement A P S D Learning From Data A P S D Implementation of Change A P S D Wide Scale tests of change A P S D Follow up tests Change Ideas Very Small test

Rapid Cycle Change Initiation of Rapid Cycle tests is dependent on getting the first test of change started Do Not try to Perfect the change then implement…consider your work a masterpiece in progress Failure is a great Opportunity to plan to do better next time… Frequency of Testing determines the speed of the process improvement ie daily testing = improvement in weeks; weekly = improvement in 3-4 months

Model for improvement Act Plan Study Do Aims Measurement Change Ideas What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Aims Measurement Change Ideas Act Plan Study Do Trial & Learning Langley, Nolan et al 1996

Acknowledgements Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/GausModelforImprovement.htm?TabId=2 Harris, B. (2007). Change Concepts. Murray, M (2006). “Small Steps, Big Changes” workshop. Reasear, R. (2007). Institute for Healthcare Improvement “Designing Reliability Into Healthcare Processes: Based on the work of the Institute for Healthcare Improvement Innovation”