August 21 st Track One Virtual Meeting Prepared and Presented by Institute for Healthcare Improvement Faculty Sue Gullo, Director Jane Taylor, Improvement Advisor 1

Session Objectives Objectives: 1.Describe in-depth the Lens of Profound Knowledge 2.Identify change concepts 3.Develop a plan for testing changes 4.Discuss change concepts and testing in the context of Falls and HAPU’s 5.Use the Lens of Profound Knowledge to identify what is working and what needs improvement from a system perspective 6.Work with faculty to develop organizational PDSA’s 2

Goal of the next 7 Sessions- Spring Sessions-focused on knowledge and measurement. Fall Sessions- learning by doing. We are going to operationalize what we know works. Knowledge does not equal action, and knowledge does not equal improvement. – Reporting does not equal improvement! Learning by doing equals results! 3

For real change to be designed.. Complete Pre-work- Open School Modules and Video “Building Skills in Data Collection and Understanding Variation” – QI 102 Lesson 4:Developing Changes – QI 102 Lesson 5: Testing Changes Print plenary session slides- we will refer to them during our track. Have data on hand that relates to Immobility- HAPU and Falls specifically. Improvement Fellows-bring a Clinical Buddy to the sessions. This would be a person who you can partner with from a clinical unit to test, collect and post data, and drive change. Have handouts printed and ready to use Be ready to change your world! Homework will be described at the end of the session and it will be in collaboration with a clinical buddy you have identified.

Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2 nd edition, 2009 A Model for Learning and Change

6 Change Concepts The Improvement Guide contains an Appendix (Appendix A: A Resource Guide to Change Concepts) that describes in detail how 72 change concepts can be used to create ideas for testing.

Useful Ways to Develop Changes- OS Critical thinking about the current system 1 Sometimes, simply reflecting on problems within a system can generate some good ideas for change. If you make a flow chart of your current process, it may be possible to identify parts of the system that aren’t working or are needlessly complex. Another way to go about critical thinking is to gather and analyze data on the way your system currently works—for example, how you are communicating with people about the meeting—which can then help you identify problems and develop changes to address them. Benchmarking Comparing your own process to “best practice” can help you identify where your own system falls short. Take the patient’s perspective When you see the care system from a patient’s perspective, you’ll see opportunities for improvement that might not be apparent as a caregiver. Is it too loud when you’re trying to sleep? Do bright lights give you a headache? Do you have to wait too long to get your test results? Patient shadowing and interviewing are useful techniques when coming up with good ideas to change.

Useful Ways to Develop Changes- OS Creative thinking 1 Where do new ideas come from? You can spark creative thinking in various ways, including simply taking the time to do this sort of thinking; exposing yourself to situations (such as taking the role of a patient) that can spark new ideas; identifying the boundaries that limit the changes you can make and then finding ways to dismantle those boundaries; and temporarily considering unrealistic goals that can prompt you to break out of your old way of thinking. Using Change Concepts 8

Using Change Concepts to Come Up with Ideas- OS A change concept is 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 combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change. After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. If they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.

Guidance for Testing a Change Concept A test of change should answer a specific question! A test of change requires a theory and a prediction! Test on a small scale and collect data over time. Build knowledge sequentially with multiple PDSA cycles for each change idea. Include a wide range of conditions in the sequence of tests. Don’t confuse a task with a test! 11

To Be Considered a Real Test Test was planned, including a plan for collecting data Plan was carried out and data were collected Time was set aside to analyze data and study the results Action was based on what was learned 12

13 The PDSA Cycle For Learning And Improvement What will happen if we try something different? Let’s try it! Did it work? What’s next?

Linking PDSA Cycles - Tips for Doing It Right Linking small tests of change helps ensure buy-in from all the people involved. Think Ahead You already know you’ll want to do multiple tests. So make your life easier by planning for it. Think a couple of cycles ahead, testing over a wide range of conditions and collecting useful data from each test to guide the next one. Start Small Keep it simple at the beginning. Scale down the size of the test (for instance, start with just a few patients in one location). Test with volunteers and don’t try to get consensus from everyone in the organization before starting. Get Started Don’t wait around! Ask, “What change can we test by next Tuesday?”

Hunches Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains Repeated Use of the PDSA Cycle for Testing 15

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PDSA Tests- Falls Hunch/ Theory Very Small Scale Test Follow Up Tests Wide-Scale Tests of Change Implementation Operational definition of a round is not standard Ask 5 people to define the process for hourly rounding If we do hourly rounding, we will prevent falls (manage variation- CC; eliminate waste, doing tasks in parallel, delighting the customer) One patient, one day 1-3-5; All patients one day Documentation, prompting, tools All patients for one week After I have identified barriers and tested my way through the barriers 17

Appropriate Scope for next PDSA Cycle Current Situation ResistantIndifferentReady Low Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Very Small Scale Test Small Scale Test High Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Small Scale Test Large Scale Test Cost of failure small Small Scale Test Large Scale Test Implement

Hunches Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains Repeated Use of the PDSA Cycle for Testing- Falls 19

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PDSA Tests- HAPU Hunch/ Theory Very Small Scale Test Follow Up Tests Wide-Scale Tests of Change Implementation If we hourly round, we can reposition. One patient one day 1-3-5; All patients one day Documentation, prompting, tools All patients for one week After I have identified barriers and tested my way through the barriers What data will you collect? 21

Appropriate Scope for next PDSA Cycle Current Situation ResistantIndifferentReady Low Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Very Small Scale Test Small Scale Test High Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Small Scale Test Large Scale Test Cost of failure small Small Scale Test Large Scale Test Implement

Hunches Theories Ideas Changes That Result in Improvement DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains Repeated Use of the PDSA Cycle for Testing- HAPU 23

Be sure to distinguish the reason: – Change was not executed – Change was executed, but not effective If the prediction was wrong – not a failure! – Change was executed but did not result in improvement – Local improvement did not impact the secondary driver or outcome – In either case, we’ve improved our understanding of the system! Failed Test…Now What? 24

Worksheet- AIM Statement 25

Exercise: Aim Statement Our focus will be on Pressure Ulcers and Falls. So, take a few minutes and evaluate your current Aim Statements. Review them for clarity, performance expectations, and completion date. If you have started work on a new HAC or are revising your work plan, take this opportunity to create new Aim Statements or modify existing ones. Use the Aim Statement Worksheet to create or revisit your an Aim Statement. 26

Aim Statement Worksheet HAC name: Aim statement (What’s the problem? Why is it important? What are we going to do about it?) How good? By when? 27

Exercise Plan Your First (next) PDSA Use your Aim Statement, Driver Diagram, Measurement Plan Worksheet and your Developing Ideas for Change Worksheet as reference materials for this exercise. Select one idea from your Developing Ideas for Change Worksheet as an initial test of change. Complete the Plan section of the PDSA Worksheet Get feedback on your work from others at your table and be prepared to report your plan to the class. 28

PDSA Worksheet Use this to document individual tests. Remember: It’s not a test if you don’t actually change some aspect of the process! 29

30 Appreciation of a system Understanding Variation Theory of Knowledge Human Behavior Aim or Values The Lens of Profound Knowledge QI “ 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!

31 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

Profound Knowledge Worksheet Appreciation for a System Human Behavior Theory of Knowledge Understanding Variation 32

Prep for September 11th What process measures tell you where you need to go? 33

Implementation Checklist (Source: Langley, J. et. al. The Improvement Guide, page 136) 34

Collect daily process measures on a run chart Quality Buddy and Clinical Buddy meet daily to plot and discuss the data. Process measures – Percentage of patients assessed on admission (locally defined) Your choice- falls or pressure ulcers – Percentage of patients at risk re-assessed daily Continue on your pressure ulcer or fall choice above 35

For September 11th Participants are expected to complete the following IHI Open School Modules prior to the September 11 th session: QI 103 Lesson 1: Measurement Fundamentals QI 103 Lesson 2: Displaying Data 36