1. AMI Virtual Learning Collaborative
Atlantic Node
AMI Virtual Learning Collaborative
Building on LS1-A

2. LS1-A Re-Cap Introduced to WebEx technology
Atlantic Node
LS1-A Re-Cap
Introduced to WebEx technology
Overview of Virtual Learning Collaborative and Expectations
Expert presentation on Thrombolytic Therapy
Process Mapping

3. What Worked Well The content and presentations Sharing by Participants
Atlantic Node
What Worked Well
The content and presentations
Sharing by Participants
Engagement
Use of Examples
Polls/Feedback
Being able to ask questions

4. Atlantic Node
What Worked Well
Being able to participate without travelling is a huge plus
Easy Access/ able to access it almost anywhere, easy to follow
Having presentation from specialist and then being able to apply to our specific practice

5. What Worked Well Hearing while seeing, coordination
Atlantic Node
What Worked Well
Hearing while seeing, coordination
Having interaction with colleagues from the provinces and regions

6. Improvement Opportunities
Atlantic Node
Change Ideas to Test
Post on CoP
2. Include NL time in correspondence
3. Use emoticon to flag issue
Improvement Opportunities
1. Slides and handouts
2. Times listed only as ADT
3. Voice delay and overlap

7. Improvement Opportunities
Atlantic Node
Change Ideas to Test
4. Establish Co-Host role
5. Speak directly into microphone; headset/ hands free
6. Next VLC pre sessions
Improvement Opportunities
4. Passing the ‘Ball’
5. Voice clarity fluctuation
6. WebEx training before Session

8. Atlantic Node
Comments/Questions

9. AMI Virtual Learning Collaborative
Atlantic Node
AMI Virtual Learning Collaborative
The Model for Improvement

10. Measurement *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP
**The Plan-Do-Study-Act cycle was developed by W. E. Deming

11. Overview Measures & Targets Inclusion & Exclusion Criteria
Atlantic Node
Overview
Measures & Targets
Inclusion & Exclusion Criteria
Individual Data Collection Form
Elapsed Time by Patient Worksheet
Measurement Worksheet

12. Atlantic Node
What are Our Measures?
% STEMI or new LBBB who received thrombolytic within 30 minutes of arrival at ED.
% STEMI or new LBBB who received an ECG within 10 minutes of arrival at ED.

13. Atlantic Node
What are our Targets?
90% STEMI or new LBBB receive thrombolytic within 30 minutes of arrival at ED.
90% STEMI or new LBBB receive an ECG within 10 minutes of arrival at ED.

14. Atlantic Node
Why These Measures?
Based on CCORT AMI Indicators (CMAJ 2008: 179: )
Time is muscle (myocardium)
Two measures which are key to timely thrombolysis
We know there is room for improvement

15. Measure 4.0A Lytic Within 30 Minutes of Arrival
Atlantic Node
Measure 4.0A Lytic Within 30 Minutes of Arrival
Denominator
Inclusion:
All STEMI or new LBBB confirmed by ECG
Lytic within 6 hours of arrival at ED
Lytic as primary reperfusion therapy
Exclusion:
Patients with NSTEMI, non-Q wave or subendocardial MIs
Transfers in who received lytics in another acute care facility or ambulance
Under 18 years of age

16. Measure 4.0A Lytic Within 30 Minutes of Arrival
Atlantic Node
Measure 4.0A Lytic Within 30 Minutes of Arrival
Numerator
All those in the denominator who received lytic within 30 minutes of arrival at ED

17. Measure 10.0 ECG Within 10 Minutes of Arrival
Atlantic Node
Measure 10.0 ECG Within 10 Minutes of Arrival
Denominator
Inclusion:
Patients admitted through Emergency with diagnosis of STEMI or new LBBB confirmed by ECG
Exclusion:
Received a lytic in ambulance
Transferred from another acute care facility
Under 18 years of age

18. Measure 10.0 ECG Within 10 Minutes
Atlantic Node
Measure 10.0 ECG Within 10 Minutes
Numerator
All those in the denominator who had an ECG within 10 minutes of arrival at ED
If ECG completed by EMS (pre-hospital) this is considered within 10 minutes of arrival at ED

19. Additional Process Measures
Atlantic Node
Additional Process Measures
Time 1st medical contact to 1st ECG
Time 1st medical contact to arrival at ED
Time diagnostic ECG done to read by MD
Time diagnostic ECG read by MD to thrombolysis

20. Individual Data Collection Form
Atlantic Node
Individual Data Collection Form
Use a data sheet for each month of data submission
Each workbook has 2 worksheets – (1) Individual pt. times & (2) Elapsed time by pt 20

21. Individual Data Collection Form
Atlantic Node
Individual Data Collection Form
Enter name of hospital,
Select Month and Year from drop down box

22. Individual Data Collection Form
Atlantic Node
Individual Data Collection Form
Enter individual pt data as they arrive in ED
MRN = Medical Record Number
- Use identifier of your choice

23. Individual Data Collection Form
Atlantic Node
Individual Data Collection Form
Sequential pt. #
Pt. identifier
optional comments about pt
Enter times in appropriate cols.

24. Individual Data Collection Form
Atlantic Node
Individual Data Collection Form
Notes:
Walk-In (pt.#1) – “1st medical contact” usually same as “Arrived ED”
Transport by Ambulance (pt.#2&#3) – “1st medical contact” occurs before “Arrived ED”
ECG and Lytics in ED (pt.#2) – “1st ECG” after “Arrived ED” and before “Lytics started”
ECG in ambulance and Lytics in ED (pt.#3) – “1st ECG” before “Arrived ED” and “Lytics started”
If ECG and Lytics in ambulance (pt.not shown) – “1st ECG” and “Lytics Started” before “Arrived ED”

25. Elapsed Time by Pt Worksheet
Atlantic Node
Elapsed Time by Pt Worksheet
Automatic calculations
Now on second worksheet = Elapsed Time by Pt.

26. Elapsed Time by Pt Worksheet
Atlantic Node
Elapsed Time by Pt Worksheet
Classification of patient for measure 4.0A
All elapsed times are automatically calculated from data entered on “Individual Times” worksheet

27. Elapsed Time by Pt Worksheet
Atlantic Node
Elapsed Time by Pt Worksheet
Number of teams meeting criteria w/i 30 mins and those not meeting criteria w/I 30 mins

28. Measurement Worksheet
Atlantic Node
Measurement Worksheet
Enter data on “Data Entry Sheet

29. Measurement Worksheet
Atlantic Node
Measurement Worksheet
Enter name of hospital, region and description of patient sample in ‘windows’ outlined in red.

30. Measurement Worksheet
Atlantic Node
Measurement Worksheet
In column for appropriate month and year identify implementation stage and collection method
1. Baseline = 1st month of data submission
2. Full = after reaching goal and holding it for 3 consecutive data submissions
3. Early = everything else.

31. Measurement Worksheet
Atlantic Node
Measurement Worksheet
Enter data from Elapsed Time / Individual Data Collection form in “red” outlined cells for Denominator
Enter data from Elapsed Time / Individual Data Collection form in cell for Numerator

35. Atlantic Node
Contact information
Central Measurement Team
Virginia Flintoft
Alex Titeu

36. 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

37. 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

38. Model For Improvement
Action Oriented
Trial and Learning
Leadership

39. Team Charter Operationalizes the Improvement Model Improvement theory
Project management

40. Team Charter
To ensure a common understanding and focus by making explicit:
AIMS
Measurement targets
Changes
Timelines
Roles and Responsibilities
To communicate effectively with senior leadership and other stakeholders

41. Team Review your system: - Who does the patient see?
- Who is needed to implement?
- Who needs to know about the changes?
- Who supports the changes?
Work with those who will work with you
Each member is a champion in their area

42. Team Core Team Members Ad Hoc
Clinicians providing care i.e. nurses, technicians, therapists, paramedic
Clinical and administrative leaders i.e. Clinical Nurse Specialist, Nurse Manager
Ad Hoc
Physician Champion
Quality Improvement personnel
Clerical Support

43. Roles and Responsibilities
Team Leader
• Completing and clarifying the team charter in a manner that ensures the support of team members and team sponsor.
• Organizing and running effective meetings and maintaining team records ie minutes, correspondence, improvement data
• Facilitating work within the team and ensuring participation at and between meetings
• Communicate about the improvement work with the sponsor, team members, stakeholders and the larger organization.

44. Roles and Responsibilities
Team Members
• Sharing content knowledge, skill and experience
• Communicating and developing a shared understanding within the team of the work process to be improved or changed.
• Testing change ideas within the team and in the real work context
• Leading and supporting coworkers to adapt the new process
• Completing tasks or assignments within and between meetings
• Establishing two-way communication with their colleagues and the team

45. Roles and Responsibilities
Team Sponsor
• Clarifying the improvement mandate and aligning it within the organizations strategic and operational objectives
• Connecting and communicating with appropriate stakeholders
• Allowing time and other resources
• Establishing an accountability mechanism
• Facilitating the work of the team within the larger organization.
• Engaging a team leader and a coach
Initiating the team charter

46. Roles and Responsibilities
Team Coach
• Facilitating the use of improvement tools and techniques
• Monitoring and facilitating healthy team behaviors
• Providing technical expertise and guidance focusing on team process
• Supporting the team leader to plan effective team meetings
• Assisting with measurement for improvement eg data collection, submission, analysis and display

47. Exercise #1
Identify your team members and assign Roles and Responsibilities.

48. Participant Sharing
Team Example

49. AIM
What are you going to do?
How much?
By when?

50. 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

51. Example

52. Write your AIM statement
Exercise #2
Write your AIM statement

53. Participant Sharing
Team Example

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

55. Measures Three Main Types : Outcome Measures Process Measures
Balancing Measures

56. Model For Improvement Outcome measures:
Are driven by the specific objectives identified in the AIM statement, e.g. # decreased 30 Day AMI Mortality Rate
Are understood from the consumer’s perspective eg. Reduced discrepancies
Process measures
Indicate whether a specific change is having the intended effect, e.g. ECG within 10 minutes; lytics door to needle within 30 minutes
Indicate if process changes are leading to improvements

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

58. Measures Measures should be useful and manageable (2-6)
Should be operationally defined e.g. Hospital Arrival = Arrival: The earliest documented time the patient arrived at the hospital; this may differ from the admission time
Should be integrated into clinical documentation
Purpose is for learning not judgment

59. Measures

60. Break & Networking
Please be back in 15 minutes

61. Changes
What Changes can we make that will lead to an improvement?

62. 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

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

64. 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

65. 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

66. 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

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

68. Change Package
What’s in a Change Package?

69. Exercise 3
Using the Change Package select, modify, or add change ideas and record them in your Charter .

70. Break & Networking
Please be back in 15 minutes

71. Getting things moving: Plan, Do, Study,

72. What change will you implement by next Tuesday?
PDSA
What change will you implement by next Tuesday?

73. PDSA Testing 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
Berwick, Boushon,& Roessner, 2007

74. Rapid Cycle Testing
AIM: State your overall goal you would like to reach Example: 90% of eligible patients will have thrombolytic agents administered within 30 minutes of hospital arrival by March 2010
Describe your first (next) test of change
Person Responsible
When to be done
Where to be done
Test Synchronizing clocks, watches and equipment (individual, departmental, and equipment)
John RN
Oct 26/08 ED

75. Plan List the tasks needed to set up this test of change
Person Responsible
When to be done
Where to be done
Identify time ‘data points’ in patient flow thru ED
Audit current clocks and equipment for current time
Audit a sample staff watch time
Design and test a protocol for daily synchronization of clocks, watches and equipment
Arrange a huddle
Complete the “testing” worksheet
Mary RN
Jane Team Lead
Susan Unit Manager
Mary RN with team
John RN
Oct 22-09
Oct
10 am on Oct 23-09
Oct
Sept 12 before 1500h
Here ED
ED Conference Rm
ED Nursing Desk
Conference Rm Med Unit #1

76. Plan Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
Equipment, watches and clocks will need to be adjusted.
The protocol will need refinements
The huddle will identify new change ideas for testing
Self Report Y/N
Discussed and recorded in huddle
Yes/No

77. Completing Test of Change
Do: Describe what actually happened when you ran the test
Most clocks and watches were easily reset but equipment posed more of a challenge because some were off unit at the time..
Study: Describe the measured results and how they compared to the predictions
3 of 5 clocks; 4 of 6 watches; and evry piece of equipment needed the time
Act: Describe what modifications to the plan will be made for next time.
All ED staff, EKG technicians and physicians will be asked to set their time in sync with the clock in the ED trauma room

78. Completing Test of Change
The idea of using huddles, as opposed to the standard one-hour meeting, arose from a need to speed up the work of improvement teams.
Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.
Berwick, Boushon,& Roessner, 2007

79. Rapid Cycle Change As you move thru cycles increase size of the test:
1-5-25
Getting it working well with one;
Test it on five more;
After 25, establish in organization

80. 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

81. PDSA Cycles for Testing
Increase your belief that the change will result in improvement
Opportunity for learning from “failures” without impacting performance
Document how much improvement can be expected from the change

82. PDSA Cycles for Testing
Learn how to adapt the change to conditions in the local environment
Evaluate costs and side-effects of the change
Minimize resistance upon implementation

83. Why Test-Why Not Just Implement??
Sometimes we have an idea but we’re not sure quite how to implement it! Testing can be very useful before implementing. Can avoid a lot of pain. Anyone had any gorilla moments. SSI example! 83

84. Exercise Select a change idea Complete the Plan
Conduct the test in your work setting by NEXT TUESDAY
Complete the Do, Study, Act sections

85. Parallel Ramps Aim Testing ……………….Implementation…….Spread P P D P D S
Focus on Product/Service P D S A P D S A P D S A P D S A
Improve Work Flow
Thrombolytic to eligible
Patients within 30 minutes
of ED arrival P D S A P D S A P D S A
Change the work environment P D S A P D S A P D S A P D S A
Manage variation P D S A P D S A P D S A P D S A
Design System to
avoid mistakes
Testing ……………….Implementation…….Spread

86. 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

87. 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

88. Rapid Cycle Change
Questions?

89. Acknowledgements
Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at:
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”