1. Opening Plenary: Overview of the Science of Improvement Prepared and Presented by Robert Lloyd, PhD Institute for Healthcare Improvement Faculty Wednesday, August 21, 2013 1

2. Plenary Session Objectives To provide a high-level overview of the Science of Improvement: – Deming’s System of Profound Knowledge – The Model for Improvement (MFI) – The role of the PDSA cycle – The Sequence of Improvement To provide an overview of four HACs that will serve as the content referents for these sessions 2

3. Exercise Science of Improvement Self-Assessment This self-assessment is designed to help quality facilitators gain a better understanding of where they personally stand with respect to understanding and explaining the key components of the Science of Improvement (SOI). What would your reaction be if you had to explain the PDSA cycle to your colleagues, develop change concepts or describe how to build measures? You may not be asked to do all of the things listed below in the near future but, if you are facilitating a QI team or expect to achieve the HEN goals, sooner or later these questions will be posed. How will you deal with them? The place to start is to be honest with yourself and see how much you know about QI concepts and methods. Once you have had this period of self-reflection, you will be ready to develop a learning plan for yourself and those on your improvement team. Use the following Response Scale. Select the one response which best captures your opinion. 1I could teach this topic to others! 2I could do this by myself right now but would not want to teach it! 3I could do this but I would have to study first! 4I could do this with a little help from my friends! 5I'm not sure I could do this! 6I'd have to call in an outside expert! Source: R. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators. Jones & Bartlett Publishers, 2004: 301-304.

4. Exercise: Measurement Self-Assessment Source: R. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators. Jones & Bartlett Publishers, 2004: 301-304. Measurement Topic or Skill Response Scale 123456 Build clear aim statements for our work (How good? By when?) Establish appropriate goals for a project Move a team from concepts to appropriate measures Develop process, outcome and balancing measures Build a clear and unambiguous operational definition for each measure Develop and implement data collection strategies Identify specific changes and ideas that we can test Set up and run PDSA tests Explain the sequence of improvement (testing, implementing and spreading) and apply it to the team’s work

5. 5 Science of Improvement Knowledge: The interplay of the theories of systems, variation, knowledge, and psychology. Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge. SOI Knowledge Subject Matter Knowledge Two Types Of Knowledge…

6. 6 SOI Knowledge Subject Matter Knowledge Improvement occurs when we learn how to combine subject matter knowledge and the science of improvement in creative ways to develop effective ideas for change. Improvement Knowledge For Improvement

7. 7 W. E. Deming, The New Economics for Industry, Government, Education. MIT, 1993 "One need not be eminent in any part of profound knowledge in order to understand it and to apply it. The various segments of the system of profound knowledge cannot be separated. They interact with each other. For example knowledge about psychology is incomplete without knowledge of variation."

8. 8 Appreciation of a system Understanding Variation Theory of Knowledge Aim or Values The Lens of Profound Knowledge “ 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! QI Human Behavior

9. 9 Appreciation of a system Understanding Variation Theory of Knowledge Aim or Values The Lens of Profound Knowledge “ 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! QI Human Behavior TRACK 2 FOCUS

10. 10 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

11. Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2 nd edition, 2009 A Model for Learning and Change When you combine the 3 questions with the… … the Model for Improvement. PDSA cycle, you get…

12. Source: Langley, J. et al, The Improvement Guide, Jossey-Bass Publishers, 2 nd edition, 2009 A Model for Learning and Change When you combine the 3 questions with the… … the Model for Improvement. PDSA cycle, you get… TRACK 1 FOCUS

13. ActPlan StudyDo Act – Adopt the change, abandon it or run through the cycle again. Plan – plan a change or test aimed at improvement. Study – Examine the results. What did we learn? What went wrong? Do – Carry out the change or test (preferably on a small scale). (Deming, 1993) The Shewhart Cycle for Learning and Improvement

14. You do PDSAs every day! 14

15. You do PDSAs every day! 15

16. You do PDSAs every day! 16

17. You do PDSAs every day! 17

18. You do PDSAs every day! 18

19. You do PDSAs every day! 19

20. You do PDSAs every day! 20

21. 21 What will happen if we try something different? Let’s try it! Did it work? What’s next? The PDSA Cycle For Learning And Improvement

22. Sustaining improvements and Spreading changes to other locations Developing a change Implementing a change Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations You run PDSAs throughout the entire Sequence of Improvement

23. The Primary Drivers of Improvement Will Ideas Execution Having the Will (desire) to change the current state to one that is better Developing Ideas that will contribute to making processes and outcome better Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas QI

24. Key Components* Self-Assessment Will (to change) Ideas Execution Low Medium High * All three components MUST be viewed together. Focusing on one or even two of the components will guarantee suboptimized performance. Systems thinking lies at the heart of CQI! How prepared is your Organization?

25. Clinical Topics Update: Falls, Pressure Ulcers, Venous Thromboembolism (VTE), Adverse Drug Events (ADE) Cheryl Ruble, RN, MS, CNS, CCRN Kim Werkmeister, RN, BA Improvement Advisor, Cynosure Health

26. Where are we now with Falls? As of 8/5/13, 12.28% reduction (weighted) has been achieved. What is our goal? Sustainment of percent reduction for 60 percent or more hospitals in Falls and continued work on interventions to achieve 40 percent reduction.

27. Falls Outcomes Data Falls With or Without Injury (NSC-4) Falls With Injury (minor or greater) (NSC-5) # hospitals reporting831476 # hospitals eligible for measure1416 % eligible hospitals59%34% Benchmark2.150.50 # hospitals met benchmark last 3 months293271 % hospitals met benchmark last 3 months21%19% # hospitals at zero last 3 months86184 % hospitals at zero last 3 month6%13% Meeting 30-6-60 goalNo

28. Challenges and Change Concepts for Falls Accurate data submission Fall AND injury risk assessment Implementation patient specific interventions to prevent injury Develop supporting processes such as purposeful rounding, hand-off communications, or post HAPU huddles

29. Where are we now with Pressure Ulcers? As of 8/5/13, 17.52% reduction (weighted) has been achieved. What is our goal? Sustainment of percent reduction for 60 percent or more hospitals in Pressure Ulcers and continued work on interventions to achieve 40 percent reduction.

30. Pressure Ulcer Outcomes Data Patient with at least One Stage II or Greater Nosocomial Pressure Ulcers (NSC-2) Pressure Ulcer (MCR FFS) (CMS HAC) # hospitals reporting399367 # hospitals eligible for measure1416 % eligible hospitals28%26% Benchmark1.980.00 # hospitals met benchmark last 3 months3750 % hospitals met benchmark last 3 months26%0% # hospitals at zero last 3 months2370 % hospitals at zero last 3 month17%0% Meeting 30-6-60 goalNo

31. Challenges and Change Concepts for Pressure Ulcers Accurate data submission Head to toe risk & skin assessment Develop and implement an individual plan of care Address moisture, shear, and friction Develop supporting processes such as purposeful rounding, hand-off communications, or post HAPU huddles

32. Where are we now with VTE? As of 8/5/13, 16.76% reduction (weighted) has been achieved. What is our goal? Sustainment of percent reduction for 60 percent or more hospitals in VTE and continued work on interventions to achieve 40 percent reduction.

33. VTE Outcomes Data Potentially Preventable VTE (VTE-6) Post Op PE or DVT (AHRQ PSI 12) # hospitals reporting330364 # hospitals eligible for measure1416 % eligible hospitals23%26% Benchmark0.160.56 # hospitals met benchmark last 3 months73198 % hospitals met benchmark last 3 months5%14% # hospitals at zero last 3 months72134 % hospitals at zero last 3 month5%9% Meeting 30-6-60 goalNo

34. Challenges and Change Concepts for VTE Accurate data submission Risk-based prophylaxis Risk assessment for every patient Standard work in every area of the hospital

35. Where are we now with ADE? Excessive Anticoagulation with Warfarin – Inpatients No percent reduction as of 8/5/13 Hypoglycemia in inpatients receiving insulin 26.49% reduction as of 8/5/13 What is our goal? 577 additional hospitals to submit data on the ADE topic. Currently have 333 hospitals (24%) submitting as of 8/5/13. Provide interventions to assist hospitals with a focus on the top two HEN measures.

36. ADE Outcomes Data Excessive anticoagulation with warfarin Hypoglycemia in patients receiving insulin # hospitals reporting209102 # hospitals eligible for measure1416 % eligible hospitals15%7% Benchmark0.000.07 # hospitals met benchmark last 3 months7969 % hospitals met benchmark last 3 months6%5% # hospitals at zero last 3 months7940 % hospitals at zero last 3 month6%3% Meeting 30-6-60 goalNo

37. Challenges and Change Concepts for ADE Volume of data submission Choice of data measures Pharmacist-driven protocols to prevent events related to hypoglycemia and hypercoagulation Standardized protocols in all areas of the hospital

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