1. Segmentation in Reliability Design (Application of the Christensen Model)
Roger Resar
April 2006

2. Building of Descriptive
Researcher must pass through it in order to develop more advance theory
Consists of three steps
Observation
Classification
Defining relationships
Clay Christensen Harvard Business Review

3. Anomalies will need to be observed
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Statements of association
Categorization based on attributes of phenomena
Anomalies will need to be observed
Observe describe and measure the phenomena
Descriptive Theory

4. Reliability Descriptive Theory
3 Tier approach when applied to radiology interpretations in the ED achieved a high level of reliability
Nolan et al JAMA

5. Anomalies will need to be observed
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Statements of association
Categorization based on attributes of phenomena
Anomalies will need to be observed
Observe describe and measure the phenomena
Descriptive Theory

6. Current IHI Normative Theory To Achieve a 10-2 Level Reliability
Based on work by the IHI innovation team, some hospitals in the Pursuing Perfection and P4P work, and publications by Nolan et al, a three tier approach has been taught as a methodology when applied to CMS conditions can achieve 10-2 performance. (All or none measurement)

7. Anomalies will need to be observed
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Statements of causality
Categorization of the circumstances in which we might find ourselves
Anomalies will need to be observed
Observe describe and measure the phenomena
Normative Theory

8. Reliability Community Observations When the Current Normative Theory is Used
When the 3 tier model is applied to the broad CMS measures few hospitals are able to consistently achieve the 10-2 goal
Those hospitals achieving the10-2 goal for all measures within a CMS condition commonly accomplish this with manpower and a very high level of vigilance
Within a given condition when successful 10-2 performance occurs on a single measure a good three tier strategy can be observed (although commonly a deliberate 3 tier strategy was not as much designed as discovered)

9. Current Normative Theory
Using the 3 Tier approach to the design of the CMS conditions will consistently achieve a 10-2 level of reliability
Statement of Causality
We ought to apply the 3 tier approach to the CMS conditions
Anomalies Observed
Using 3 tier design to the CMS conditions approach 10-2 not consistently observed
Individual measures within conditions achieved 10-2 with obvious 3 tier design
Segments of the population achieve 10-2 in all or none measures
10-2 Performance will be observed when the 3 tier approach is used on the CMS conditions
Current Normative Theory

10. Anomalies Observed
Certain measures of the CMS conditions achieve 10-2 level of reliability. When studied the 3 tier design is commonly used not as a deliberate strategy, but as a haphazard design.
Whenever applied to the broad CMS condition hospitals have difficulties
Teams can predictably take certain segments of the population or certain measures and can achieve a 10-2 level of reliability

11. Examples of Anomalies
Smoking cessation, pneumovax or flu shots when taken on as a hospital wide measure reaches greater than an 10-2 performance.
Timed measures such as antibiotic administration or time to a heart catheterization laboratory reaches 10-2 levels of performance
Certain segments of the population attain 10-2 reliability (admissions from the ED with a known diagnosis of CAP)

12. New Theory Based on Anomalies
The work on the CMS conditions can achieve a 10-2 level of performance if appropriate segments are identified and each segment is designed using the 3 tier approach if necessary

13. New Descriptive Theory
Dividing the CMS conditions into appropriate segments and applying the 3 tier design will achieve 10-2 for the whole condition
Preliminary statement of causality
Segments based on admission route, time of first case, responsible area are useful in design for 10-2 performance
Observing the current reliability community suggests certain anomalies that draw questions to the 3 tier design for conditions. Observations the segments appear to be more reliable in design
New Descriptive Theory

14. Anomalies will need to be observed
Using the 3 Tier approach to the design on the segments of the condition and or measures will achieve 10-2 reliability in the whole
Statement of Causality
We ought to apply the 3 tier approach to the CMS conditions using a segmental approach
Anomalies will need to be observed
10-2 Performance will be observed when the 3 tier approach is used on the appropriate segments of the CMS conditions
New Normative Theory

15. Why Segments Allows for control of some variables
Defines the boundaries around which expectations can be formed
More likely to test the validity of the design rather than confront barriers
Fosters a deeper understanding of the design complexity required
Forces understanding of the differences between segments as design strategies
Permits design beyond the disease
Allows the formation of more predictable timelines

16. Applying Segments to the Normative Model
The current work on reliability will stress the concept of segment definition tied to process and outcome measures
Segment definition and relationships to improvement will be driven by a design table
Observations of anomalies will be part of future community work to refine the normative theory

17. Design Table for Segment Theory Improvement Work
Strategy Change/Rule
Structure Change
Process Change

18. Finding your first segment
The segment must represent a reasonable volume
The segment should have clear cut defined boundaries
The segment should have willing participants so the barrier of agreeing is not a problem
The segment should allow for key articulated variables or barriers to be neutralized

19. Using the Design Table for CAP Planning Using Segments
Strategy Change/Rule
Structure Change
Process Change
Patients admitted to the hospital through the ED with a diagnosis of CAP
An organizational policy is developed to split the responsibility for the CAP measures to attain a combined 10-2 performance
Smaoking,Pneumovax measures will be handled on the admitting floor as an institution wide protocol
Timed strategy with a 3 hour call will be expected for the ED physicians on presumed CAP
ED develops a unique protocol for all patients with a presumed diagnosis of CAP when admitted to the ED
Hospital wide smoking cessation and immunization protocols are developed with appropriate training and support and applies to all patients admitted to the hospital
ED sets up a 4 hour timeline from arrival to the ED with required antibiotic decision at 3 hours
ED process in place. Feed back to the ED on the oxygenation, cultures, and antibiotic measures done on concurrently based on sampling
Detailed processes set up out side of the ED and monitored by a responsible entity for smoking, pneumovax etc. Feedback to responsible entity
Presumptive diagnosis at admission to ED starts a ED protocol with timer to accomplish 4 hours antibiotic. Feedback on time defects

20. Using the Design Table for CAP Planning Using Segments
Strategy Change/Rule
Structure Change
Process Change
Patients admitted to the hospital through the ED with a diagnosis of CAP
See previous slide
Patients admitted to the hospital with a challenging diagnosis which includes CAP and results in CAP being diagnosed later
Patients with a possible diagnosis of CAP are monitored until a final decision is made
Institutional agreement on the 4 hour rule starts when the diagnosis is made on the floor (even though for reporting this is a defect).
Method developed to determine when a final diagnosis is made and how to communicate back to the required measures for CAP and subsequent baseline performance of the CAP measures.
Feed back to the units responsible for care of the challenging diagnosis on performance done concurrently by sampling
Patients admitted directly to the floor with a diagnosis of CAP
All admitting diagnoses are required to be screened for certain key diagnoses with notification of the unit this is a key diagnosis
A CAP diagnosis on any unit requires a baseline performance of the CAP measures.
Feed back of performance to each unit
Any patient discharged when key measures have not been performed
Institutional policy that defects which still might be mitigated require a recovery.
Resources made available to contact patients and correct the correctable defects
Key processes to describe how mitigation will actually occur. Scripts to be developed. Feedback on follow-up reliability .

21. Next Steps
Identify your first segment (If you have a first segment what is your level of reliability)
Confirm that your segment has the key requirements for segmental definition and design
Fill out the segment flow sheet and the design table
Local customization will develop the structure changes and process changes
The segments will vary depending on organization size
Anomalies from the segmental design need to be studied to authenticate the new normative theory