From Ideas to Action: Practical Tips for Making Improvements Dr Donald Campbell Clinical Epidemiology & Health Service EvaluationUnit

Improvements n the will to make the change n the ideas to make the change n the execution of the ideas Commitment to measurement and reporting

Topics n Aims, Measures, Changes n The Model for Improvement and the PDSA Cycle n Collecting and Displaying Data

The Breakthrough Collaborative n Brings together multiple sites with common aims n Working to spread and adapt existing knowledge è not developing new knowledge

Fundamental Questions for Improvement n What is the aim? n What will be measured to know the aim has been achieved? n What are the changes?

Aims focused on delays n Patient Satisfaction n Clinical n Operational

Measures n The key measures should operationalize the aim –LOS for admitted, discharge, and fast track –Clinical improvements –Patient satisfaction scores n Collect data on sub-components of the system judiciously - ie, only if it is necessary

Changes n Based on your aims, identify the key changes in need of development/improvement in your system n Solicit input from others when you return to your organization

Median Time to Antibiotics Administration Anne Arundel Medical Center

Time To Analgesia Royal Melbourne Hospital Excessive workload

ED Median Total Length of Stay St Elsewhere’s Medical Center Week

Median Time From Bed Requested to Patient Upstairs District General Hospital

Percent Left Without Seeing Doctor (1999) Royal King Arthur Hospital

Some Things to Consider When Making Improvements n Multiple PDSA Cycles (and time) are usually needed to adapt a change n Pay attention to detail n Measurement - useful not perfect n Promote the project n Overcoming barriers to achieving success n Hold the gains

Model for Improvement ActPlan StudyDo What is the aim? What will be measured to know the aim has been achieved? What are the changes?

Model for Improvement ActPlan StudyDo What are we trying to accomplish? How will we know that a change is improvement? What change can we make that will result in improvement?

Use of Data Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA 1a 1b 1c 1d Median LOS for Admitted Patients Week 1. “quick-look” x-rays 3. Bed ahead 2. Work-up done on floor

Useful Measurement n Data directly related to aims n Data collected in cycles to determine the effect of a particular change n Qualitative data to assist in refining a change n narrow bandwidth & stay on the money

Collecting Data n Use purposive sampling to conserve resources - Sample data daily for Fast Track, Main ED, Admitted - Summarize data weekly using the median to lessen the effect of outliers - To calculate Total LOS, use a weighted average of the medians n Integrate measurement into the daily routine

Collecting Data n Use sampling to conserve resources - Sample data daily for Fast Track, Main ED, Admitted - Summarize data weekly using the median to lessen the effect of outliers - To calculate Total LOS, use a weighted average of the medians n Integrate measurement into the daily routine

Operationalising Data Collection - some examples n Time to analgesia –pen/paper stuck on narcotics safe –pain scale at triage n Fast track –identify on computer (or manually on assigned cubicle) n Ottawa ankle rules –aide memoire at triage and/or in cubicles

Length of Stay for Main ED Discharged Patients n =1 per week Avg=180, SD=50 Avg=135, SD=35

Median Length of Stay for Main ED Discharged Patients n=14 per week

Median Length of Stay for Main ED Discharged Patients n=28 per week

Median Length of Stay for Main ED Discharged Patients n=300 per week

Example of a Data Collection Form Weekly Medians: Total LOS_________ ED LOS__________ Adm LOS_________ Fast Track_________

From the Wisconsin State Journal Half Still Under Median Despite the increase, union officials said about half the league’s players still earned less than the league-wide median of $75,000.

Understanding Demand Emergency Department Demand by Day Average Number of Patients per Hour Day

Understanding Demand Enhancing the understanding Average Number of Patients per Hour n What about recording pts/hour by hour of the day? n What about pts/hour by day of the week?

Emergency Department Demand by Hour Average Number of Patients per Hour Hour of the Day

Good Visual Display of Data? Attending MDS Do Work-up Outside ED

n Goal for pneumonia: –administer antibiotics to 95 % of patients w/in 60 mins of arrival to ED n Impact of early antibiotic administration: –decreased mortality/decreased length of stay/reduced costs Pneumonia March-June 1998

Some Tips for Designing Good Graphics n Eliminate ink that does not add information n Show the data n Make good use of space - Scale the graph so the data eventually encompasses most of the graphing area - Include information about multiple characteristics on the same graph or use multiple graphs on the same page n Integrate words with the data

Improving LOS for Admitted Patients from the ED Bed ahead Individual responsible for bed control Quick-look x-rays 2/16/98 3/16 4/13 5/11 6/8 7/6 Week

The Key: Holding the Gains n Document processes and adhere to standards n Pay attention to orientation and training n Assign ownership n Use measurement and audits The test: if you aren’t measuring you aren’t really trying!

Bibliography Berwick D. A primer on leading the improvement of systems. BMJ 1996; 312: Berwick D, Nolan T. Physicians as leaders in improving health care: a new series in Annals of Internal Medicine. Ann Intern Med. 1998; 128: Brock W, Nolan K, Nolan T. Pragmatic science: accelerating the improvement of critical care. New Horizons 1998; 6: Cook T, Campbell D. Quasi-Experimentation. (Boston: Houghton Mifflin 1979) Langley J, Nolan K, Nolan T, Provost L.. The Improvement Guide. (San Francisco: Jossey-Bass 1996) Lundberg G, Wennberg J. Editorial: a new proposal adn a call to action. JAMA 1997; 278: Rodgers E. Diffusion of Innovations. (New York: The Free Press Tufte, E., The Visual Display of Quantitative Information, (Cheshire, CT:Graphics Press,1983)