Transcript Driver Diagram - FHA Physician Quality and Safety

Driver Diagram Examples
Includes template and definitions
Driver Diagram Definitions:
• A Driver Diagram is an improvement tool used to organize theories and
ideas in an improvement effort. It displays visually, our theory about
why things are the way they are and/or potential areas we can leverage
to change the status quo. The driver diagram is often used to scope or
size a project and to clarify the plan for reaching the aim.
• Primary Drivers: major processes, operating rules, or structures that will
contribute to moving towards the aim
• Secondary Drivers: elements or portions of the primary drivers. The
secondary drivers are system components necessary in order to impact
primary drivers, and thus reach project aim.
• Specific changes /Change concepts: Specific changes are concrete
actionable ideas to take to testing. Change concepts are broad
concepts (e.g. move steps in the process closer together) that are not
yet specific enough to be actionable but which will be used to generate
specific ideas for change.
– Note: measures can be indicated on the DD as it becomes more mature.
Driver Diagram
Primary Drivers
AIM
D1
D2
D3
D4
D5
Secondary Drivers
Specific Ideas to Test or
Change Concepts
Driver Diagram
Primary Drivers
Secondary Drivers
Document decisions
Correct
indications
AIM
Identify failures
Specific Ideas to Test or
Change Concepts
Standardize order forms
Daily huddles
Hardwired process
Reduce CAUTI by
30% compared to
the 2010 baseline by
August 31, 2013
Daily reviews
Effective infection
control
Teamwork
Script rounds/daily huddles
Communication
Involve pts/caregivers
Hand hygiene
Visible reminders for aseptic technique
Sterile technique
Assemble insertion kits
Collection bag positioning
Educate ancillary staff
Sample collection
Prompt removal
Outcome measures
Reduce reactheterization
- # CAUTI
-
Rate/1000
catheter days
Engaged leaders
Process measures (from
Primary & Secondary Drivers)
Balancing Measure(s)
Make post-op removal the default option
Develop contingency plans for retention
Failures “front of mind”
Attention to improvements
Report CAUTIs monthly
-
% urinary catheters removed
POD 1 or 2
Present patient stories
-
% meeting insertion criteria
Leadership reality rounding
-
% assessed for ongoing
Pt satisfaction
Employee
satisfaction
Forcing functions
need
Make results visible on units
John W. Young, MBA RN
National Association of Public Hospitals and Health System
Ann Brown, Wave 23
Improving Colon Cancer Screening at Internal Medicine Faculty Practice
Specific Changes:
Primary Drivers:
Secondary Drivers:
Aim
Decrease
•Waiting time
between referral and
colonoscopy
•Waiting time for
results of
colonoscopy
Increase
• Colon cancer
screening rates
• Direct colonoscopy
referrals through
EMR
• Results of colon
cancer screening in
EMR
Calie Santana, Wave 21
Identify
patients who
should have
colon cancer
screening and
have not
received it
Increase
access to
colonoscopie
s
• Link colonoscopy
database with EMR for
automatic result reporting
into the flowsheet
Preventive care EMR
flowsheet (individual patients
@ each visit)
Whole panel performance
reports
Use Direct colonoscopy
Navigators (facilitated
communication, preps,
directions, scheduling)
Referral to Direct colonoscopy
from inside the EMR
Facilitate
delivery of
evidencebased care
in colon
cancer
screening
Communication/care
coordination between GI and
referring PCP (f/u interval,
pathology findings)
•Generate bimonthly
reports of colon cancer
screening rates and
actions taken by providers
and work toward goal rate
of 80%
•
Create a referral form
for Direct colonoscopy in
the EMR
• Create a benchmark for
time from referral to
colonoscopy schedule
(access to test), and time
from referral to Navigator
completed all necessary
steps (efficiency of
program) and work
towards benchmark goal
• Review current
workflowof result
communication in the EMR
• Develop workflow that
minimizes data entry by
9-22-07
referring provider
IHI
Improve Severe Sepsis Care and Reduce Sepsis Mortality
Primary Drivers:
Desired
Outcomes:
Decrease
•Mortality
•Complications
•Costs
•LOS
Improve
•Sepsis/Severe
Sepsis Bundle
Compliance
• Early
recognition of
severe
sepsis/septic
shock
•Recognizable,
reliable language
standards for
sepsis care
Identify severe
sepsis early in
ED patients
Secondary Drivers:
Uniform Sepsis Screening/Sepsis
Screening tool
Education/communication to
frontline staff
Provide
appropriate,
reliable and
timely care to
patients with
sepsis/severe
sepsis using
evidence-based
therapies
Coordination of
treatment
services
Sepsis Algorithm and Standard
Order Set
Bundle elements:
Antibiotics within 180 mins and
after blood cultures
Serum lactate w/in 30 min
Fluid challenge eligibility/delivery
Contingency team for 1st 24 hours
of sepsis trigger
Organized team methodology for
patient care transitions
Create team
process to
support sepsis
therapies
Josephine Melchione, Wave 21
Pharmacy
Caregiver communication
Lab
Specific Changes:
??
Primary Drivers
Knowledge of
medications
Secondary Drivers
Discussing medication
benefits and side effects
Eliciting concerns and
questions
Effective
communication
Communication aids for
aphasic patients
Change Concepts
Specific Change Ideas
Focus on the outcome to a customer
Script to aid discussion
Listen to customers
Shared decision making
model
Reach agreement on expectations
Coach customers to use a
product/service
Optimize level of inspection
Involve carers
Medication
compliance in
stroke patients
by 50%
Medication Delivery
System
Use reminders
For those with cognitive
impairment
For those with functional
limitations
Use differentiation
Use constraints
Use affordances
Patient choice
Coordination of care
Asan Akpan, Wave 21
SALT assessment of identify
best means of
communication
Patient/carer satisfaction
and experience of
medication discussions and
usage
Aim
Improve
Document decision of
patient/carer
Standardization
Incorporate into weekly
MDT meeting
Desensitize
Ensure medications dose,
frequency, route and
patient decisions stated
on discharge letter to GP
Improve predictions
Develop contingency plans
Manage uncertainty, not task
Match amount to need
Follow up compliance
check(need to decide OPD,
telephone call, home visit,
questionnaire, etc)
Documentation of how
medications will be taken
and delivered
Document in case notes
Document in discharge letter
to GP
Driver Diagram for Reducing In-Patient Falls
Aim
Reduce Inpatient
Falls on 4Cand
6WReduce falls to
<3.5/1000 patient
days and reduce
moderate or higher
harm from falls to
<0.1/1000 patient
days
Outcome Measures
-Patient days between falls
-Patient days between a
harmful fall
-The rate of falls per 1000
patient days
-The rate of harmful falls
per 1000 patient days
-$ revenue loss avoided due
to fall reduction
Adapted from Gavin
Sells, NHS Scotland,
Wave 24 2011/2012
Used with permission.
Primary Drivers
Reliable
Assessment
Process Measure
% Pts with falls risk
assessment every 8 hrs.
Reliable
Care
Process Measure
% of patients with evidence of
hourly rounding
Patient and
Family
Centered
Care
Process Measure: % Pts
who can verbalize their
role in fall prevention
Patient
Condition
Secondary Drivers
Good/reliable tools for
assessment
Staff trained and know how to
use assessment tools
Timely assessment
Specific Changes to
Test
Staff awareness/education
Falls noticed board/story
board
Care plans are easy to use
Fallsafe Care Bundle
Care plans regularly updated
Use of pressure pads
Appropriate level of
monitoring/supervision of
patients
Willingness of patient and carers
to cooperate
cctv or mirrors in corridors
Use of sitters for some
patients
Physical strength/stability
Mental health
Frailty
Slipper socks
Patient understanding of their
own abilities
New signs on doors easier
to read
Patient understanding of their
own abilities
Driver Diagram: Improving Outcomes for High-Risk and Critically Ill Patients
Specific Changes:
Primary Drivers:
Secondary Drivers:
Identify &
rescue
worsening
patients
Desired
Outcomes:
Decrease
Provide
appropriate,
reliable and
timely care to
high-risk and
critically ill
patients using
evidencebased
therapies
•Mortality
•Complications
•Costs
Improve
•Satisfaction
Create highly
effective multidisciplinary
team
Integrate
patient &
family into care
so they receive
care they want
Rapid Response System
Early Warning System
Protocols and Standing Orders
Bundles
Care planning
Reliable communication
Family involvement
Clarification of wishes
End of life care
Consistent care delivery
Flow
Driver Diagram
IG: PP. 286,412,429
Develop an
infrastructure
that promotes
quality care
See next page
Leadership
Financial Stewardship
Example:
Another way to
organize change
package:
Driver Diagram
Primary Driver
P1. Identify &
rescue
worsening
patients
Secondary Driver
S1. Rapid response system
Key Change Concepts
Implement a Rapid Response Team
Perfect triggering
Perfect responding
Perfect evaluation
S2. Early warning systems
Use objective measures to assess disease severity
Create a process for use of scoring tools
Improve identification of severe sepsis
P2. Provide
appropriate,
reliable and
timely care to
high-risk &
S3. Protocols and Standing
Order Sets
Develop weaning protocol
Specific change ideas
Standardize call criteria
Define response team members (including a
sponsor)
Establish protocols/guidelines
Educate units about when and how to call
Create process to gather data about calls
Use steering committee for development
and on-going testing oversight
Review call criteria effectiveness
Test/Add an Early Warning System
Review missed opportunities (e.g.
unscheduled transfers to ICU)
Work towards "goal" call rate
Develop discipline-specific criteria for team
members
Review team performance in three spheres:
care provided, response time, and caller
satisfaction
Develop tool box to be brought to activations
(examples: i-stat, IV tubing, lab tubes, BP
cuff, documentation form)
Do case review
Track response time
Review overall process to evaluate need to
improve
Develop data tool for tracking
Test a measurement tool such as MEWS
Use an overall bed-board to assess layout of
unit
Create rules for when to call RN, MD, and
activate system
Apply the Evaluation for Severe Sepsis
Screening Tool in clinical areas such as the
ED, wards, and ICU
Have nurses and Rapid Response Team
complete severe sepsis screening
Pre-extubation worksheet