Pave Your Path These presenters have nothing to disclose Pave Your Path: Improvement Science & Helpful Techniques Cory Sevin, RN, MSN, NP Director, IHI Jane Taylor, EdD Improvement Advisory May 21, 2013 Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-032217A
Presenters 2 Jane Taylor, EdD Improvement Advisor, IHI Cory Sevin, RN, MSN, NP Director, IHI Angie Young, RN Quality Assurance Nurse Tenova Home Care
Objectives for Today 3 Putting it all together Describe the underpinnings of improvement science- Theory of Profound Knowledge (Edward Deming) Describe what a process is Identify how process maps make system processes visible Describe observation as a learning tool Questions for presenters - type in questions during the presentation in the chat box.
Agenda 4 Welcome and overview Reflections on homework Using the Model for Improvement-Putting it all together: Tennova Health Tools to use: process mapping and observation Wrap Up
Recommended Homework Put it all together-complete the Aim Worksheet Post Reflect-what did you learn? What are your questions?
6 What Does This Look Like in Real Life? Aim Measures (aka Dashboard) Change Concepts Change Concepts, Key Changes & Key Activities Change Ideas
Problem Needing Improvement 7 Tennova Health Care noticed a small but regular pattern of missing labs and coumadin management. Concern for patient safety and adherence to the patient s care plan motivated them to improve the processes.
What s the Problem? 8 Review of missed labs and follow-up revealed: INR orders being missed (due to scheduling errors or physician offices drawing and not calling HHC with the new POC) MD office not calling back with follow-up orders in a timely fashion Orders being faxed by physician offices afterhours and on the weekends Multiple Nurses being involved in the follow-up process INR s were mixed in with all the other labs to be drawn.
Putting it all Together- Tennova Health Care 9 Aim: Coumadin Therapy Patients will receive follow-up INR results and any changes in the POC within 24 hours. Outcome measure could be: Adverse Event Report Near Miss: Emergent care for improper medication administration and medicine side effects OASIS M2430 Process measures: Time to notify MD of critical lab values Percent INR labs and/or follow-up missed Balancing Measures could be: Time new process takes to complete Partner satisfaction with process
Changes 10 Know all patients on an anti-coagulant medication-one nurse, one log Leverage IT to assist in identifying other patients on anticoagulant therapy Use of flow sheet. Track what INR labs are due each day to help ensure plan of care was followed and each patient receives a follow-up call related to their individualized care. Orders: Include an effective date when orders are put in. For example: Obtain in 1 week, effective 5/29/13 Tracking monthly until stable X 3 months, then will move to quarterly tracking to assure sustainability
Minutes Minutes to Convey to MD Critical Labs 11 12.0 Minutes to Get Critical Lab Values 10.0 8.0 6.0 Minutes 4.0 2.0 0.0 1 2 3 4 Quarters
Tennova Home Care: Anti-Coagulant Therapy Following the Plan Of Care Percentage 100 95 90 85 80 75 Jan. 2013 (86%) Feb. 2013 (86%) 3/1/2013 (100%)
Knowledge for Improvement Subject matter Knowledge Appreciation of a system Theory of Knowledge Psychology Understanding Variation Knowledge for Improvement
How do we get anything done? Process Inspect Wait Administrative Move
What s a Work Process? 15 A work process is made up of steps, tasks or activities and has a beginning and an end Key concepts: Input the materials, equipment, information, people, money, or environmental conditions needed to carry out the process Output the product or service that is created by the process; that which is handed off to the customer
Flow Mapping Example Brushing Your Teeth 16 Open toothpaste Wet toothbrush Apply paste to brush Brush teeth Turn off light Put away paste and brush Rinse mouth Rinse brush
Value Analysis using the Brown Paper Mapping Approach Shows the Big Picture Describes a process as it works today; an as-is model High touch, low-tech Identifies strengths and opportunities Captures the complexity and disconnects of key operational issues Identifies outside areas involved in the process (e.g. exam table paper or brown wrapping paper)
More Detailed Steps Determine the Boundaries List the steps Sequence the steps Draw appropriate symbols Check for completeness Finalize the current process map Complete the Quality Audit Apply waste analysis to identify bottlenecks, waste and improvements Test your changes Redesign new system and document in the form of policies and procedures
Why observe? Insight into process, experience of others.
Stand where the work is done long enough and you will figure out what needs to be done. attributed to Taiichi Ohno
OBSERVATION RECORD Date/Time: Type of Observation: Observer: Initials of Staff Member Observed: P o s i tion: Time Location Activity/Connection/Pathway Interacted with-- Other:
Medication Reconciliation Process Map Review Med List with Patient/Family Understanding All consistent Discrepancies Noted Provide updated list to patient (agency policy, include in PHR if utilized Clinically Significant- Contact MD within 1 calendar day Other Issues to Resolve Able to reach and MD resolve Unable to reach MD Unable to Obtain Meds Patient/ Family Starts with what patients actually taking, then: discharge med list, herbal remedies, trial medications, over-the counter medications, old medications, and physicianadministered medications such as injections. Contact other MD associated with pt. Contact Hospitalist/ DC MD Contact MD Director of Home Care Agency Lack of Money Agency Policy: Program in place Social Work Referral Emergency Funds available in community Cannot Physically Obtain Meds Taxi voucher to have delivered Use of pharmacy that delivers Community Programs Program with hospital to send home with x days supply
Resources for Improvement 23 www.ihi.org Search for improvement methods
The Domestic Lean Goddess 24 Cute short video to demonstrate using PDSA Cycle related to getting the family out the door on time in the morning Available on the HHQI website on the Pave Your Path page
Thank you 25