1. Improvement Forum    A webinar series for QI Managers, Nurse Leaders and others supporting healthcare improvement in Wisconsin’s hospitals    April 2012

2. Are you ready to improve faster?    Our Topic for April 2012    Stephanie Sobczak, QI Manager Tom Kaster, QI Coordinator Wisconsin Hospital Association

3. Today’s Agenda 3 Objective: Reviewing tools and approaches to accelerate implementation of interventions. Content Sharing – The current pace of improvement in healthcare – The need for acceleration – Re-thinking approaches Resources Discussion Questions

4. In the news…. 4

5. Question Polling: What do you think the rate of improvement is in American hospitals? A.More than 50% per year B.At least 20% per year C.About 10% per year D. Less than 3% per year Disclaimer information here… 5

6. The Pace of Improvement 6 Source: “AHRQ National Healthcare Quality Report, 2008,” Agency for Healthcare Research and Quality. Last accessed: September 13, 2010.Agency for Healthcare Research and Quality

7. The Key Question Why does it take so long to adopt a new practice when the evidence is clear? And how are we going to achieve this……. 7

8. The 40/20 Goal Disclaimer information here… 8 Keep patients from getting injured or sicker. Reduce preventable hospital-acquired conditions by 40%. 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years. Help patients heal without complication. Reduce all hospital readmissions by 20%. 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

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10. What does this mean for Wisconsin Nationally 10 ~5,008 Hospitals in US 138 Hospitals in WI ~ XXXX Beds 60,000 lives saved/3 years 1.6 million patients will recover from illness without a preventable re-hospitalization within 30 days of discharge. 1.8 million fewer injuries to patients. Wisconsin 550 lives saved/year 16,500 fewer injuries/year 15,000 re- admissions/year >99 Beds 8 Lives (over 3 years) 26-99 Beds 3 Lives <26 Beds 1 Live

11. What does this mean for Wisconsin Nationally 11 ~5,008 Hospitals in US 138 Hospitals in WI ~ XXXX Beds 60,000 lives saved/3 years 4 patient lives 1.6 million patients will recover from illness without a preventable re-hospitalization within 30 days of discharge. 1.8 million fewer injuries to patients. One Hospital 120 fewer injures 105 preventable re-admissions >99 Beds 8 Lives (over 3 years) 26-99 Beds 3 Lives <26 Beds 1 Live

12. By Hospital Over 3 years: >99 Beds will save 8 Lives 26-99 Beds will save 3 Lives <26 Beds will save 1 Live that otherwise might have been harmed. Disclaimer information here… 12

13. Myths about Improvement 1)If you give people the facts, they will change. 2)If you create a new policy or rule, people will follow them 3)The same message works with everyone 4)Everyone engages at the same time 5)Every new approach should be implemented in the same way Disclaimer information here… 13

14. The Why? Why does it take so long to adopt an evidence based practice? Some reasons, and solutions…. Disclaimer information here… 14

15. Knowing doesn’t mean changing 15 Add info on 17 year adoption gap

16. Health care is very complex 16

17. Make it meaningful Healthcare is complex, change is constant So it is even more important to help people see what they can impact, personally, in their day to day work. Keep it simple, make it “doable”, slow down. Disclaimer information here… 17

18. Assess readiness to change 18

19. Engage the Engaged Disclaimer information here… 19 Non-Engaging Methods Starting with an entire department Relying on evidence only Getting “buy-in” Trying to convince a laggard first Utilizing an early adopter who has little credibility Engaging Methods Seeking champions who are opinion leaders (they may not have a formal title) Starting small on a project with a few key participants Spread after early adopters work out most of the bugs through tests of change Use early adopter peers as spokespersons for spread

20. “What can you get done by next Tuesday?” Dr. Don Berwick Founder, Institute for Healthcare Improvement Former Administrator of CMS Don’t wait to do something Disclaimer information here… 20

21. Obstacles to rapid improvement Some factors that get in the way of speedy improvement Reliance on the STP Unintentional Bottlenecks “Not enough time” Premature Implementation 21

22. Reliance on the “same ten people” 22 STP Do you have a core group of people that serve on many teams? Do they get “burned out”? Do new staff know how to get involved in improvement efforts? Is it clear that improvement is everyone’s job?

23. The Bottleneck Effect 23 OB Events Pressure Ulcers Pressure Ulcers 23 Readmissions CAUTI Adverse Drug Events VTE CLABSI Surgical Infection Surgical Infection VAP Safety Culture A lot to work on over here Few people to lead QI over here

24. Addressing these two issues Can QI Leaders serve in an oversight role rather than running teams? Can more front line staff be involved? Do teams understand their accountability? Is the improvement skill set adequate? 24 “Many hands make light work”

25. Not Enough Time Disclaimer information here… 25 Pat Rutherford of IHI: “ The longer I work in this field, the more I’m convinced that real improvement won’t happen unless our nurses and clinicians can stop doing dumb stuff.”

26. Where can you “find time”? Disclaimer information here… 26 One nurse’s movements within 1 hour Opportunity for improved workflow

27. How to address this? Examine where staff are stuck in “non-value” added time: Looking for information Looking for equipment Looking for supplies Looking for or waiting for other staff Excessive documentation Time spent waiting for meds or labs Disclaimer information here… 27

28. What to do “Lean” the care environment – apply 5S Leverage new EMR functions Redesign the work flow between staff Disclaimer information here… 28

29. Leaping into Implementation “Just do It” is very tempting. It seems like it’s efficient It assumes that each unit works in the same way. It assumes that staff will change their behavior without experience. 29 Policy Book

30. Premature Implementation Perverse Outcomes: Partial adherence to the “new way” Out right resistance – after the P&P is adopted Slipping back into old processes over time No time to measure/prove the improvement Moving on to the next thing too soon = REWORK! Disclaimer information here… 30

31. Be systematic & consistent How an intervention is adopted should be consistent and repeatable Staff can focus on the learning the new content or skill, rather than how something is implemented. BUT what you design (to encourage adoption to happen) can be adapted within the PDSA cycle. 31

32. Aims Measurement Change ideas Testing ideas before implementing changes

33. Discussion What have you found helps speed the pace of improvement in your hospital? 33

34. In summary: Accelerating Improvement 34 3. By engaging more front-line staff in adopting new practices 6. By actively sustaining the improvements through measuring, monitoring and oversight 4. By slowing down to involve more people in tests of change 2. By allowing natural leaders to lead 1. By being systematic in the overall approach 5. By providing absolute clarity on the team’s accountability

35. Resources Understanding Resistance: http://www.focusedperformance.com/articles/resistanceslides.pdf IHI’s Gap Analysis Tool: http://www.ihi.org/offerings/Initiatives/Improvemaphospitals/Documents/IHIGapAnalysis.pdf 35 Readiness assessment example

36. Questions and Answers    What can we learn from each other?    Stephanie Sobczak, MS, MBA Manager QI, Wisconsin Hospital Association Next Month’s Topic: Assessing Evidence Based Practice