Transcript (RIM) for LA training non kp staff 9-16-11

Introduction to the
Rapid Improvement
Model Plus
Simple Tools for
Workflow Redesign
Workshop Objectives
• By the end of this module, you will be able to:
 Discuss the three fundamental questions used in rapid
improvement so you can quickly begin work on
performance improvement
 Create a process flow that allows you to understand
where you need to start your improvement work
 Identify sources of waste in your processes
 Create a data collection plan
 Apply the Plan-Do-Study-Act (PDSA) cycle so teams
know when and how to use it for rapid improvement
2
Section I:
Assess – Develop a
Process Flow Map
Rapid Improvement Model
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?
A P
TA
DA
Act
Plan
P
D
S D
Do
D S
P A
A
S
A P
Study
S D
Implementation
of Change
Wide-Scale
Tests of Change
Follow-up
Tests
Very Small
Scale Test
Model for Improvement developed by
Associates in Process Improvement
( http://www.apiweb.org)
4
Changes That
Result in
Improvement
Why do rapid improvement?
• Engage your team to improve processes affecting
patient care experiences and your team’s work
experience
• Achieve big gains from small rapid tests of change
• Eliminate time wasting and dangerous work-arounds
• Engage team members in improving work processes
• Accomplish your department’s goals
• Improve your department’s performance
5
What could be improved where
you work?
1. Patient Satisfaction
8.
Inefficiency
2. Employee Satisfaction
9.
Wait times or delays
3. Safety
10. Unexplained variation
4. Clinical outcomes
11. Multiple processes
5. Under, over, or misuse of
procedures, medications etc. 12. Errors
6. Attendance
13. Rework
7. Excessive costs/waste
14. Work-arounds
6
RIM has a specific scope
With RIM you would not attempt to address the
following issues as part of your improvement
plan …
•
Staffing and FTE issues exclusively
•
Performance management issues
•
Compliance or legal issues
•
Any agreements addressed in Local Union
contracts and the National Agreement
7
What’s wrong with this
picture?
8
Assess: What is the current
process?
• Begin with a quick “walk through” of the entire process, to get a
sense of the flow and sequence of steps. “Pin yourself to the
problem” as if you were the staff or patient.
• Go back and gather information at each step (data, stories,
etc.)
• Follow along the actual pathways of material and information
yourself
• Collect relevant current-state information while “working
through” using a data collection tool
• Map the whole process yourself (or as a team), even if several
people/departments are involved and multiple hand-offs occur
The point of mapping is NOT the map.
It is understanding the flow of information and material.
9
Assess: Where do problems
occur?
• Focus on one area in a process
Member
identified
for screening
Member contacted for
appointment
Appointment for
mammogram
scheduled
Co-pays collected
Do not
collect co-pay
Do not
identify
people needing
screening
Mammogram
completed
Mammogram
read
Member contacted
with results
Timely turn
around in
calling member
Team agrees
this is the biggest opportunity
10
Do the results
warrant
follow-up
care?
yes
Follow-up care
scheduled as needed
no
Workshop Exercise and
Report Out
• Draw a process map for an area you want to
improve
• Use no more than 5 – 6 major steps
• Identify where the failures occur
• Brainstorm the most critical 1 – 2 failures that
need to be improved
• Keep a list of all points that need
improvement
11
Section II:
Assess – Identify Your
Goal for Improvement
Identify Your Goal for
Improvement
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?
A P
A
AT
D
Act
A
Plan
P
S
D
A P
S D
Study
Do
S D
D S
P A
Implementation
of Change
Wide-Scale
Tests of Change
Follow-up
Tests
Very Small
Scale Test
Model for Improvement developed by
Associates in Process Improvement
( http://www.apiweb.org)
13
Changes That
Result in
Improvement
Question 1: What are we trying
to accomplish?
What could be improved in your area?
Goal statements are S.M.A.R.T. and are the first
steps you and your team will take:
S
M
A
R
T
14
Specific including the target population
Measurable
Attainable
Realistic
Time bound
Goal Statement Steps and
Examples
What could be improved in your area?
• Brainstorm what could be improved, review the process map
• Review current data if available and departmental goals
• Write a Goal statement for one improvement your team
wants to try
• Good examples of Goal statements:
 Inpatient: reduce ventilator-associated infections by 25% in the ICU
West within 10 months.
 Outpatient: Increase by 25% the annual testing of HgbA1C in
diagnosed diabetes in the South City Clinic within 6 months.
 Non-clinical: Improve staff satisfaction service scores by 5% in the
registration department in the next 6 months.
15
Exercise and Report Out
At your table, using the flip chart:
• Work on creating a Goal statement for an
improvement project in your area
• Make sure it follows the SMART principle
16
Let’s Assess Your Goal
Statement
Goal content
 Explicit overarching description
 Specific actions or focus
 Goals
Goal characteristics
 Time specific
 Measurable
 Define participants
17
Section III:
Develop Measures and
Plan for Data
Collection
Creating Measures for
Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
We are here
A P
What change can we make that
will result in improvement?
TA
A
D
S D
D S
P A
A
P
S
Act
Plan
D
A P
S D
Study
Do
Implementation
of Change
Wide-Scale
Tests of Change
Follow-up
Tests
Very Small
Scale Test
Model for Improvement developed by
Associates in Process Improvement
( http://www.apiweb.org)
19
Changes That
Result in
Improvement
Three Types of Data
Accountability
Reporting Purposes
 Specific data
 Agencies
 State/federal regulators
Research
Beyond Doubt
 Lots of data
 Prove hypotheses
 Statistical
Improvement
Just Enough to Learn
 Limited data
 Small samples/tests of
 Changes incorporated as needed
20
Three Types of Measures
Outcome Measures:
• Voice of the customer or patient
 How is the system performing? What is the result?
 Tied directly to goal statements
 Can be time, clinical outcome, financial, or satisfaction
Process Measures:
• Voice of how the process works
 Are the parts/steps in the system performing reliably as planned?
Balancing Measures:
• What happened to the system as we improved outcome
and process measures (e.g., high or low volume days)?
 Looking at a system from different directions/dimensions
21
Examples of Non-Clinical
Measures
Outcome measure
• Percent change on Employee Satisfaction Scores for
two service-related questions
 Q11: Are you trained to give good service?
 Q12: Are you supported to give good service?
Process measure
• How many registration clerks say they used scripted
languages in their customer interactions this week?
Balance measure (unintended consequences)
• Member/patient satisfaction scores
22
Steps in Identifying Measures
• Identify the high priority process you are
working on
• Develop the process map for workflows and
decisions made
• Define your outcomes: clinical/operational,
service, cost
• Review the process map and ask, “what do
we need to know to tell how the process is
working?”
23
Steps in Designing a Data
Collection Tool
• Data collection tool is created and tested by
front-line workers
• Use paper, and test quickly before formalizing
• Avoid collecting unnecessary data – ask for
only what is needed
• Final form needs to include a definition of
measures, what is included and not, and
simplifies what needs to be entered
24
Simple Data Collection Tool
Example:
Project level
information
(person, place,
time)
Outcomes
data
(by week)
Identified
barriers, leads
to more testing
ideas
25
Process data
(collected
by staff during
the day)
During Testing, Measurement
is:
• Feedback for your team
• Information so your team can act rapidly if necessary
• For improvement and not for judgment, accountability
or research
• Useful rather than perfect
 Simple, easy data collection while doing your daily work
 Consider using existing data sources/sampling
• Timely as a key to learning
• Tracking data over time using pencil/paper
• Used to think about every test and its implications
26
Motivate Staff:
Display Data in Your Department
What will tell us whether our changes are improving care and service?
Percentage Patients who reduce # of meds
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
Months
27
10 11 12 13 14 15 16
Workshop Exercise:
Developing Measures
Scenario: A friend has asked you to consult on
a personal improvement project.
Project Goal: Lose 10 lbs in 6 months
• Develop measures that can be reported each week

1 Outcome measure

1 Process measure
• Develop Summary of Measures on your flip chart
28
Exercise
Determine Your Project Measures
Type of Measure
Outcome Measure
Process Measure
29
Name of the
Measure
Define
How the Data
will be Collected
Section IV:
Identify Potential
Ideas for
Improvement
Focus on Planning Rapid Tests
Under Varying Conditions
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?
We are here
TA
DA
A
P
S
D
Act
Study
Plan
Do
A P
S D
Follow-up
Tests
Very Small
Scale Test
Model for Improvement developed by
Associates in Process Improvement
( http://www.apiweb.org)
31
A P
S D
D S
P A
Changes That
Result in
Improvement
Implementation
of Change
Wide-Scale
Tests of Change
Identify Changes
Determine what will help:
• Brainstorm ideas
• Standardize and simplify processes
• 6S (see online module)
• Reduce waste, wasted steps
• Apply best practice or evidence-based practices
32
Standardize and Simplify
• Standardize
 Create predictability and consistency. Ways to
standardize include:
•
•
•
•
Common equipment
Standard order sheets
Check lists
Reducing number of steps in a process
• Simplify
 Eliminate unnecessary complexity
 Design single way to perform tasks
 Put supplies near where the work is done
33
Standardize
Why Standardize?
Benefits of standardizing
• Builds a reliable system
• Supports training and competency testing
• Everyone can clearly state what their work
consists of
• Allows for the use of best practices
• Feedback and learning is part of the system
for improvement
34
Simplify
Identify What is Waste
• Searching
 Nurse cannot find IV pump
 MA cannot find discharge forms
• Deciding
 Nurse is not sure which patient she should see next
 Physician is looking for time to call patients
• Travel
 EVS has to walk to the store room to get frequently used supplies.
• Transporting
 Phlebotomist carries a blood sample from the ED to the lab for a
common blood test.
 Patients are not transported from their rooms to radiology for an
MRI by the scheduled test time
35
Workshop Exercise
• Look at the issue you identified on your
process map.
 Are there ways to simply or reduce waste in
this issue?
 Brainstorm ideas.
36
Section V:
Develop and Plan for
Small Tests of
Change and Huddles
Focus on Rapid Tests Under
Varying Conditions: Testing Ideas
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?
A P
TA
DA
Act
Plan
P
D
S D
Do
D S
P A
A
S
A P
Study
S D
Implementation
of Change
Wide-Scale
Tests of Change
Follow-up
Tests
Very Small
Scale Test
Model for Improvement developed by
Associates in Process Improvement
( http://www.apiweb.org)
38
Changes That
Result in
Improvement
Why test before implementing?
• Increase degree of belief that it may work
• Document expectations and learnings
• Build a common understanding of what good
looks like
• Evaluate costs and side-effects for changes
• Explore theories and predictions
• Test ideas under different conditions
• Learn and adapt in real time
39
Cycle for Improvement:
The PDSA Cycle
How we test for
change.
Act
- What changes
are to be made?
- Next cycle?
Study
- Analyze data
- Compare results
to predictions
- Summarize
what was learned
40
Plan
- Objective
- Predictions
- Plan to carry out the
cycle (who, what,
where, when)
- Plan for data collection
Do
- Carry out the plan
- Document
observations
- Record data
Tips for Successful Testing
• Develop a plan for PDSAs
 What, who, When, Where, How
• Start with small tests – “What can we do Tuesday?”
(e.g., 1 MA, 1 MD, 1 patient)
• Think big – test small
• Failure is ok – it’s an opportunity to learn
• Plan multiple PDSA cycles to address “What are we
trying to accomplish?”
• Use huddles to check:
 What worked, what didn’t and what should we change for
our next test?
• Celebrate success early and often
41
Test Changes: Non-Clinical
What changes can we make that will
result in an improvement?
• Idea:
Train one Registration desk staff to use
communication tools or scripts like
“Acknowledge, Introduce, Duration,
Explanation, Thank you” (AIDET)
• Hunch:
Using scripted language helps staff feel
more comfortable with how to
communicate with patients
• Test:
Tomorrow morning one receptionist will
try this with all patients
42
Let’s Try It!
Complete the following for your team:
• Idea:
• Hunch:
• Test:
43
Rapid Improvement:
Multiple Cycles
The cycle:
If there is no improvement, try the
cycle again!
 Try another solution/change
 Collect data based on the change
Act
Plan
 Pause to plan…what’s your
prediction for the next test?
If there is improvement you can:
Study
Do
 Test in a different shift, area, group
 Decide how to make the change
part of daily work
 Select another area in process to
improve
44
A P
S D
Non-Clinical:
Teach 1 regular staff
customer service script
with video. Use script
for greeting every
patient for 1 day
45
A P
S D
Expand to 2 regular
staff for 2 days on
different shifts
Expand to all
regular
staff on same shift
for 2 days (wk 1)
Teach all regular
staff the technique
(wk 2)
Let’s Try It!
Playing the M&M’s Game
46
M&M’s Game Instructions
• Use the PDSA testing cycle concept
• Use the worksheet with the triangle & circles on it
• Open your candy. Please don’t eat the candy (yet)
1
• Place a candy on 14 of the 15 numbered circles
2
• Testing:
 Remove M&M’s by “jumping” one M&M over
another and into a blank circle, remove the
“jumped” M&M (and don’t eat it)
 Record the number of candies left on the worksheet
 Objective: one M&M stands alone on the worksheet
47
4
7
11
3
8
12
6
5
9
13
10
14
15
M&M’S PDSA Datasheet
48
Testing Debrief:
What did we learn?
• Rapidly trying and learning
• Documenting tests
• Sharing and learning in a group
• When solution found – writing steps down
• There is no one single way to succeed
49
The Sequence for Improvement
Make part
of routine
operations
Test under
a variety of
conditions
Theory &
Prediction
Develop a
change
50
Spread a change to
other locations
to here!
Implement a
change
Test a
change
Don’t go from
here …
Act
Plan
Study
Do
Review: The RIM Model
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?
A P
TA
DA
Act
Plan
P
D
S D
Do
D S
P A
A
S
A P
Study
S D
Implementation
of Change
Wide-Scale
Tests of Change
Follow-up
Tests
Very Small
Scale Test
Model for Improvement developed by
Associates in Process Improvement
( http://www.apiweb.org)
51
Changes That
Result in
Improvement
Appendix: Huddles
What is a Huddle?
• Quick way to check on progress of a
test and plan
• Replaces hourly meetings
• Speeds up the process of testing
towards improvement
53
How do you run a huddle?
• Discuss the concept of a huddle and explain that it is a
tool used for speeding up improvement
• Agree on a time and place where the huddle will occur
• Bring the team together
• Have a clear set of objectives for each huddle
• Limit huddles to 15 minutes or less
54