1. Model for Improvement and Tests of Change Denise Remus, PhD, RN Improvement Advisor, Cynosure Health / HRET HEN

2. 2 40/20 Goal  Adverse Drug Events (ADE)  Injuries from Falls and Immobility  Central Line-Associated Blood Stream Infections (CLABSI)  Catheter-Associated Urinary Tract Infection (CAUTI)  Ventilator Associated Pneumonia (VAP)  Venous Thromboembolism (VTE)  Pressure Ulcers  Safe Surgery / Surgical Site Infections  Obstetrical Harm  Readmissions Reduce Harm by 40% and Reduce Readmissions by 20%

3. 3 Drive Improvement Faster Science of improvement Accountability Structure change Document progress Be fearless, take risks, be wiling to fail

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5. 5 One day Alice came to a fork in the road and saw a Cheshire Cat. “Which road do I take?” she asked. His response was a question “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat “it doesn’t matter.” Lewis Carroll

6. 6 Aim Statements What are we trying to accomplish? Communicate expectations Measurable (how good?) Time specific (by when?) Define the specific population (s) (who?) Clear, concise and unambiguous

7. 7 WHAT? HOW MUCH? WHERE? BY WHEN? Aim Statement WHO?

8. 8 Aim Statement Example VTE: At St. Luke’s Hospital, we will reduce hospital- acquired VTE for all inpatients by 40% by December 31, 2013. What: Hospital-acquired VTE Where: St. Luke’s Hospital Who: All inpatients By When: December 31, 2013 How Much: By 40%

9. 9 Measure

10. 10 Select Measures For each clinical topic, must report data for at least 1 Process Measure and 1 Outcome Measure

11. 11 Measures

12. 12 Reduce Harm Improve Processes Where is your Greatest Opportunity to?

13. 13 Consider... What are you already measuring? What are you planning to measure? 1.Identify existing measures 2.Are they in the HRET HEN Encyclopedia of Measures? 3.If not, user-defined measure option

14. 14 VTE Example – Potential Measures Process Measures: – ICU VTE Prophylaxis (JC VTE-2) – VTE Discharge Instructions (JC VTE-5) Outcome Measures: – Potentially Preventable VTE (JC VTE-6) – Post-op PE or DVT (All Adults) (AHRQ PSI 12)

15. 15 Does your organization have an aim statement? Which process and outcome measures will you report?

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18. The PDSA Cycle “What will happen if we try something different?” “Let’s try it!” “Did it work?” “What’s next? ”

19. The Sequence for Improvement 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

20. Repeated Use of the PDSA Cycle for Testing Changes That Result in Improvement Hunches Theories Ideas 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

21. Guidelines For Testing Change Do not try to get buy-in, consensus Be innovative to make the test feasible Collect useful data during each test Test over a wide range of conditions Do not try to get buy-in, consensus Be innovative to make the test feasible Collect useful data during each test Test over a wide range of conditions

22. Guidelines For Testing Change Fail early, fail often What can we do by next Tuesday? Pick willing volunteers AIM big, but test small Steal shamelessly Fail early, fail often What can we do by next Tuesday? Pick willing volunteers AIM big, but test small Steal shamelessly

23. Remember to... Adapt Adopt Abandon Adapt Adopt Abandon

24. Common Traps Plan Do, Plan Do Do Act, Do Act No testing, only data collection No ramps of tests, random PDSAs Undisciplined PDSAs, no documentation No prediction – what are we going to learn? Beware of Cycles longer than 30 days Plan Do, Plan Do Do Act, Do Act No testing, only data collection No ramps of tests, random PDSAs Undisciplined PDSAs, no documentation No prediction – what are we going to learn? Beware of Cycles longer than 30 days

25. 25 Tips for Testing Use a form to document your test. Scale down – think “Drop Two.” Oneness Know the situation in your organization.

26. 26 Value of “Failed” Tests Do something. If it works, do more of it. If it doesn't, do something else. Franklin D. Roosevelt Do something. If it works, do more of it. If it doesn't, do something else. Franklin D. Roosevelt Learning Accelerate development Innovation

27. 27 Failed Test…Now What? 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!

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29. 29 What are you going to test? What do you need to conduct the test? Who will be involved in the test? How will you educate & inform the participant(s)? Where will the test occur? When will the test occur? How will you know if you’ve been successful? Rapid Cycle Test of Change

30. 30 Rapid Cycle Test of Change

31. 31 Improvement Project Worksheet

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