Rapid Cycle Improvement Tucson Nurses Week May 2012

Transcription

1 Rapid Cycle Improvement Tucson Nurses Week May 2012 Diana Lopez, RN, MSN & Jennifer Qualls, RN, MSN Knowledge Management Carondelet Health Network Page 1

2 Presentation Objectives Define RCI (Rapid Cycle Improvement) Model for Improvement Describe Plan, Do, Study, Act Discuss how to set up RCI teams Review the change process & common barriers & resistance to change Provide 2 examples of RCI Projects & lessons learned Page 2

3 What is RCI? Applying the recurring sequence of PDSA (Plan, Do, Study, Act) in a short period of time to solve a problem or issue facing the team in order to achieve a breakthrough or continuous improvement and realize results more quickly Page 3

4 PDSA Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? Goal Statement Measures What change can we make that will result in improvement? Ideas Act Act Plan Plan Study Study Do Do From: Associates in Process Improvement Page 4

5 Setting a Goal Answers and clarifies What do we want to accomplish? Creates a shared language for communicating to others about the project Facilitates conversations & understanding about the project within your organization Page 5

6 How Do You Know If Your Changes Result in Improvements? MEASURES! Types of Measures: Outcome Measures Have we improved the outcomes for our patients? Are the patients having a better experience? Process Measures Is our work improving outcomes? Balancing Measures What impact is our improvement work having on the rest of the system? Page 6

7 Ideas What changes can we make that will lead to improvement? What will lead us to accomplishing our goal? Page 7

8 Determining if the Change is an Improvement This work focuses on making changes to systems rather than on measurement but measurement plays a critical role. Key measures are required to assess progress toward the aim Specific measures can be used for learning during PDSA cycles Data from the system (including from patients and staff) can be used to focus improvement and refine changes. Page 8

9 The PDSA Cycle for Improvement Act - What changes are to be made? - Next cycle? Study - Complete the analysis of the data - Compare data to predictions - Summarize what was learned Plan - Objective - Questions and predictions (Why?) - Plan to carry out the cycle (who, what, where, when) Do - Carry out the plan - Document problems and unexpected observations - Begin analysis of the data Page 9

10 REPEATED USE OF THE PDSA CYCLE Model 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? Hunches Theories Ideas A P S D Very Small Scale Test Follow-up Tests A P S D Wide-Scale Tests of Change Changes That Result in Improvement Implementation of Change Hold the Gains Knowledge & Experience Rapi d Cycle P R O J E C T D I F F I C Y U L T Y

11 Find Your Champion! Page 11

12 Assemble Your Team Composition Team Leader/ Champion Facilitator Team member(s) Helpful hints Multidisciplinary Assure leadership support Include hands-on expertise & variety of skills (example: bedside nurses) Track progress & celebrate small successes Clarify roles & responsibilities Handle conflict constructively & quickly Maintain core group for consistency Page 12

13 Identify a Problem! 1 Page 13

14 Where do you start? Determine what you want to change Examples: Improve patient satisfaction Improve Core Measure Outcomes Change the work environment Improve work flow Manage time Decrease variation Eliminate wastes Improve systems to eliminate errors Page 14

15 Tools to Use with Rapid Cycle Improvement Brainstorming generating a large number of ideas about factors contributing to the problem or issue Affinity Diagram organizing the ideas from brainstorming into categories/groupings Cause & Effect Diagram (Fishbone) graphic display of ideas related to the problem or issue Generally helps in identifying leverage points Flowchart graphic display of the sequence of events in a process Creating an Actual and Desired flowchart may help in further defining the Rapid Cycle Improvement objective Page 15

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17 Fishbone Diagram Page 17

18 Tips for Success Improvement occurs in small steps Repeated attempts are needed to test and implement new ideas Assess regularly & improve plan as you go Start with changes that are easy to test & likely to be successful Collect and study useful data during each test Failed changes = learning opportunities Test fast, fail fast, adjust fast (Tom Peters) Eventually test over a wide range of conditions Page 18

19 Barriers & Resistance Barrier - Problems with Teams Is your leader available and empowered? Are you meeting weekly? Does everyone know their role and responsibilities? If you have conflicts, who can help to resolve them? Page 19

20 Address Conflicts Early Page 20

21 Barriers & Resistance Barrier - Problems with Resources Suggestions: Keep your team small at first Use volunteers and champions Collect just enough data Set a dedicated meeting time Huddle if needed (15 minutes is all you need!) Involve senior leadership if resources are a problem Page 21

22 Barriers & Resistance Barrier - Resistance : No one thinks there is a problem Take the high ground... We re different Share information and challenge assumptions... It s too difficult Look at others (internally & externally) that have successfully made a change Break ideas for change into small components Present changes as a test - that can be accepted, refined, or abandoned Use just enough data Post results of the small test from the outset as proof that it can happen Engage senior leadership Page 22

23 Adapting to Change Innovators 2.5% Early Adopters 13.5% Early Majority 34% Late Majority 34% Laggards 15% Identify your Early Adopters & engage their help Page 23

24 Barriers & Resistance Barrier - Problems with Ownership Be sure to include all affected areas Collaborate with staff at all levels Involve the people that DO the work Find champions in several disciplines Keep leaders informed and involved Page 24

25 Examples of CHN RCI Projects Glycemic Control: Managing blood sugars in the ICU CAP: Administering the correct antibiotics to pneumonia patients in a timely fashion SCIP: Giving surgery patients correct antibiotic & VTE prophylaxis and removing Foley catheters promptly CHF: Completing discharge education for heart failure patients Infection Control: Improving environmental cleaning in the OR Palliative Care: Providing comfort care to patients at end of life Falls: Preventing patient falls Customer Service: Improving patient satisfaction in the Emergency Center Quality: Decreasing the time it takes to gather Core Measure data Page 25

26 Glycemic Control in the ICU Facility A. Team Members: ICU, lab, pharmacy, IT, and physician members at Facility A. Specific Aim: Of all ICU blood glucose values, 80% or more will be in the optimal range of 60 to 180 mg/dl by Sept 15 th, Measure: % ICU blood glucose values mg/dl Page 26

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28 Facility A Pilot Blood Glucose Range Unit education, Hyperglycemia Audit started Pilot Approved as new Hospital A. order set 10 patient trial, 1:1 RN education D10W removed, pt criteria identified Baseline Period Mean: 77.35%

29 Nurse Call Compliance

30 Barriers and Resistance Facility A, Team leader leaving institution Identify new team leader before current team leader is gone Physicians (hospitalists) resistant to using insulin drips Encourage use by demonstrating reduced hypoglycemia with new orders Define patient population ideal for insulin drip use Revise subq insulin orders Page 30

31 Sustainability Plan Facility A Nursing Education: one-to-one remediation for noncompliance on hyperglycemia audit, reminders at safety briefs before each shift Data Monitoring: blood sugar reports reviewed weekly with team, posted weekly in ICU, reported monthly to administration Coaching: designated coaches on each shift for assistance and reinforcement of education Page 31

32 Glycemic Control Facility B Team Members: ICU, infection prevention, and physician members at Facility B. Specific Aim: For ICU patients undergoing cardiothoracic surgery, 80% or more of their blood glucose values will be in the optimal range of 60 to 180 mg/dl by Sept 15 th, Measure: % ICU blood glucose values mg/dl for ICU patients undergoing cardiothoracic surgery Page 32

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34 Optimal Blood Glucose Range Facility B Auditing resumed Unit education completed, new protocol implemented

35 CHVI Blood Glucose Check Compliance Data Auditing stopped for protocol revision Concurrent, 100% auditing began Auditing resumed

36 Barriers and Resistance Facility B. Maintain high level of compliance while reducing audit frequency Continue to engage glycemic coaches Continue providing feedback (data) to staff Educate new RNs on insulin drip protocol Include in unit orientation before RN s first shift Glycemic coaches provide guidance during first few shifts to ensure understanding Page 36

37 Sustainability Plan Facility B Nursing Education: one-to-one remediation for noncompliance on insulin drip audit, insulin drip education update quarterly Data Monitoring: compliance reports reviewed monthly with team, posted biweekly in ICU, reported biweekly to administration Coaching: designated coaches on each shift for assistance and reinforcement of education Page 37

38 Lessons Learned Buy-in from physicians as well as nurses is key Anticipating and planning for barriers will help with implementation in the long run Obtaining accurate, timely data can be an unforeseen barrier Page 38

39 Community Acquired Pneumonia Antibiotic Selection Leverage Point: Physician use of pneumonia order sets Test of Change: Improve ease of access to order sets. Weekly feed back of order set use to CMO & physician champions. Robust review of charts that fall out for antibiotic selection by physician peers. Antibiotic in 6 Hours Leverage Point: Delay in identification of pneumonia patients entering the EC to the administration of antibiotic Test of Change: Weekly feedback to managers & nursing staff on antibiotic administered within 6 hours. Education & 1:1 counseling to nursing staff as needed. Page 39

40 Specific Aim & Measures AIM - 100% of Community Acquired Pneumonia patients will have appropriate selection & timely administration of antibiotics by September 15, 2011 Measures - Percentage of pneumonia patients with appropriate selection & timely administration of antibiotics Page 40

41 Team members From Two Facilities Infectious disease physician Primary care physicians Emergency department physicians Staff nurses Nurse managers Pneumonia core measure abstractors Pharmacist IT representative Page 41

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44 Baseline Data Hospital A. Best Practice = 94.8% (Dec 2011)

45 Hosp A. Antibiotic Selection = 100% (Dec 2011) Hosp A. Antibiotic in 6 Hours = 100% (Dec 2011)

46 Baseline Data Hospital B. Best Practice = 100% (Dec 2011)

47 Hosp B. Antibiotic Selection = 100% (Dec 2011) Hosp B. Antibiotic in 6 hr = 100% (Dec 2011)

48 Hospital A. Percent of Patients in Whom CAP Order Sets are Used (weekly) Emergency Center Use Admissions Use Meaningful Use Began Data not collected after 8/2011

49 Hosp B. Percent of Patients in Whom CAP Order Sets are Used (weekly) Emergency Center Use Admissions Use Initiated Robust Review of Fallouts 4/18/11 Meaningful Use Began 7/4/11

50 Ease of Access to Pneumonia Order Set for Physicians Place ICON on all hospital computer desktops for easier access to order sets (Completed Sept 2011) Improve listing of order sets Page 50

51 Barriers and Resistance EC Providers & Admitting Physicians Barriers: Physicians do not like using preprinted cook book order sets. They report there are barriers to locating order sets on line. Solution: Provide evidence via data demonstrating the use of order sets improves patient outcomes Provide education & coaching Remove barriers for locating electronic orders Page 51

52 Barriers and Resistance EC Nursing Staff & Unit Nursing Staff Barriers: Nurses worry about additional tasks but value change when they understand the benefits. Solution: Improve communication through timely feedback of information & data Provide education & coaching Web based training CE packet Page 52

53 Sustainability Education For physicians, nurses, & unit clerks on how to access preprinted order sets & components of core measures. Data Monitoring Monthly reporting of physician use of preprinted order sets. Reported to CMO s Weekly report to nursing departments on compliance with antibiotics within 6 hours Coaching 1:1 Coaching for all physician or nurses involved in fallouts Page 53

54 Pneumonia STATS: How Are We Doing? Hospital A For the week of September 26, 2011 Goal is 100%

55 Lessons Learned Getting someone to collect data is a challenge Weekly feedback to all nursing staff & managers 1:1 follow-up for fallouts by physicians & nursing managers Recognizing early adopters & shining stars Celebrating small victories Page 55

56 Questions? Page 56

57 References Kendrick, K. et al. Implementing projects using the rapid cycle approach; JONA; 3/2010; 20 (3): Valente, S. Rapid cycle change projects improve quality care; Journal of Nursing Care Quality; 4/2010; 26 (1) ASQ Quality Press; The public health quality improvement handbook; Berwick DM. A primer on leading the improvement of systems.bmj. 1996;312(9): Kotter JP. Leading change. Harvard Business Review 2007;85(1): Page 57