Oregon Health Authority Improvement Science in Action: Driver Diagrams & MUSIQ Jonathan Merrell April 30, 2014 Objectives 1. Describe the components and utility of a Driver Diagram 2. Evaluate your Driver Diagram. Identify improvements if applicable API, Inc. All Rights Reserved. S 1
What is a Driver Diagram? A tool for organizing information that displays our theory of what will drive improvement in an improvement project as we seek to answer the first question in the Model for Improvement - What change can we make that will result in improvement? API, Inc. All Rights Reserved. S 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. S 2
A Theory of How to Improve Outcome Primary Drivers Secondary Drivers (processes, norms, structures) Changes S. Driver 1 Change 1 P. Driver Change 2 S. Driver 2 Aim: Expresses stakeholder value! S. Driver 3 Change 3 P. Driver Effect Drives S. Driver 1 Cause S. Driver 2 System for Improving Oral Health Outcome Primary Drivers Secondary Drivers Patient oral health literacy Active, informed families Patient self management Improved diet Improved hygiene Reduce burden of dental disease % pts with new cavitation % pts complaining of pain % of pts with OR Tx Reliable delivery of evidence based preventive & restorative care Community support CHCs, private dentists, pediatricians, PCPs Payers Early, regular risk-based evaluation & guidance Use of conservative procedures Fluoride exposure ART Qualified OR Tx Improved patient access: Dental Home Coordination with PCPs: referrals Team-based care Balancing demand and capacity 3
Driver Diagram Template Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 D3 D4 Measures: (Outcome, Process, Balancing) D5 Driver Diagram: A Primary Tool for QI Driver Diagram to Reduce Surgical Mortality S 4
Format on Extranet--------------------Driver Diagram Early in Project 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 Driver Diagram for Reducing In-Patient Falls Aim Primary Drivers Secondary Drivers Good/reliable tools for Specific Changes to Test Reliable assessment Assessment Staff awareness/education Reliable Care Patient and Family Centered Care Staff trained and know how to use assessment tools Timely assessment Care plans are easy to use Care plans regularly updated Appropriate level of monitoring/supervision of patients Willingness of patient and carers to cooperate Physical strength/stability Mental health Falls noticed board/story board/hiddles Fallsafe Care Bundle Use of pressure pads cctv or mirrors in corridors Use of sitters for some patients Frailty Slipper socks Adapted from Gavin Sells, NHS Scotland, Wave 24 2011/2012 Used with permission. Patient Condition Patient understanding of their own abilities Patient understanding of their own abilities New signs on doors easier to read R More Mature DD Used with Permission: Amy Topel, Wave 21 5
Goal: 50% Reduction in Maternal and Neonatal Deaths 4/17/2014 Malawi Maternal Mortality Elements of Effective Obstetric Care Phase Three: Receipt of Adequate and Appropriate Treatment Family Friendly Care Effective Support Systems Key Drivers Individualized patient focused care Respect and dignity of women maintained throughout care Proactive interpersonal communication Floor Stocks Available Blood Availability Motivated staff Ideas to Test Clinically Excellent Care for Women Prompt ID of Obstructed Labour Prompt ID of need for CEOC Control infection through protocols Timely treatment of bleeding Active management of 3rd stage Prompt recognition and treatment of asphyxia Clinically Excellent Care for Newborns Information Driven Decision Making Routine classification to identify and track risk Prevention, prompt recognition, and treatment of infections/sepsis Safe care to avoid hypothermia & promote b.f. Maternal death and near miss audits Measure patient, guardian, staff satisfaction Regular collection/analysis of key data Accurate and complete patient records Balancing Measures: Patient Satisfaction Physician Satisfaction Staff Satisfaction Throughput Costs Outcomes Access to appointments Waiting times during appointments Process Measures: Continuity Appointment demand Appointment supply No-show rates Appointment cycle time Case load New referrals Physician and Midlevel FTE Learning Structure for Reducing Waits and Delays in the Outpatient Orthopedics Department Key Drivers (Focus Areas) Shape the Demand Match Supply to Demand: Clinic appointments and general radiography Re-design Care Processes Interventions Partnerships between specialty and primary care practices Predicting patient demand Adapt strategies to decrease demand Link and coordinate schedules for office practices and procedures Manage case load and scope of practice Using TPS strategies, design work processes that are reliable, adaptable, and continuously improving Reduce complexity and streamline patient flow Build care teams to maximize the time and expertise of specialists Specific Approaches Work down the backlog Decrease demand for visits Use scheduling system to smooth demand Plan for seasonal events Develop measurement system to manage fluctuations in supply and demand Create contingency plans Input equity Reduce scheduling complexity Service agreements Graduate to referring physician Provide an assessment and recommendations of current outpatient, inpatient, and diagnostic scheduling practices Optimize the care team Predict and anticipate patient needs Reduce complexity Standardize. Treat work as a series of experiments Address problems immediately Disseminate solutions 6
Driver Diagram Catheter Associated Urinary Tract Infections AIM Primary Drivers Correct indications Secondary Drivers Document decisions Identify failures Specific Ideas to Test or Change Concepts Standardize order forms Daily huddles Reduce CAUTI by 30% compared to the 2010 baseline by August 31, 2013 Daily reviews Hardwired process Teamwork Communication Script rounds/daily huddles Involve pts/caregivers Effective infection control Hand hygiene Sterile technique Collection bag positioning Visible reminders for aseptic technique Assemble insertion kits Educate ancillary staff Sample collection Outcome measures - # CAUTI Prompt removal Forcing functions Reduce reactheterization Make post-op removal the default option Develop contingency plans for retention - Rate/1000 catheter days Balancing Measure(s) Pt satisfaction Employee satisfaction Engaged leaders Process measures (from Primary & Secondary Drivers) - % urinary catheters removed POD 1 or 2 - % meeting insertion criteria - % assessed for ongoing need Failures front of mind Attention to improvements John W. Young, MBA RN National Association of Public Hospitals and Health System Report CAUTIs monthly Present patient stories Leadership reality rounding Make results visible on units Ann Brown, Wave 23 7
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 Improving Colon Cancer Screening at Internal Medicine Faculty Practice Primary Drivers: Secondary Drivers: Specific Changes: Identify patients who should have colon cancer screening and have not received it Increase access to colonoscopie s Facilitate delivery of evidencebased care in colon cancer screening 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 Communication/care coordination between GI and referring PCP (f/u interval, pathology findings) Link colonoscopy database with EMR for automatic result reporting into the flowsheet 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 workflow of result communication in the EMR Develop workflow that minimizes data entry by referring provider 9-22-07 IHI Improve Severe Sepsis Care and Reduce Sepsis Mortality Primary Drivers: Secondary Drivers: Specific Changes: 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 Provide appropriate, reliable and timely care to patients with sepsis/severe sepsis using evidence-based therapies Coordination of treatment services Create team process to support sepsis therapies Josephine Melchione, Wave 21 Uniform Sepsis Screening/Sepsis Screening tool Education/communication to frontline staff 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 1 st 24 hours of sepsis trigger Organized team methodology for patient care transitions Pharmacy Caregiver communication Lab?? 8
Primary Drivers Secondary Drivers Change Concepts Specific Change Ideas Knowledge of medications Effective communication Discussing medication benefits and side effects Eliciting concerns and questions Communication aids for aphasic patients Involve carers Focus on the outcome to a customer Listen to customers Reach agreement on expectations Coach customers to use a product/service Optimize level of inspection Script to aid discussion Shared decision making model Document decision of patient/carer SALT assessment of identify best means of communication Aim Improve Medication compliance in stroke patients by 50% Asan Akpan, Wave 21 Medication Delivery System Coordination of care For those with cognitive impairment For those with functional limitations Patient choice Incorporate into weekly MDT meeting Ensure medications dose, frequency, route and patient decisions stated on discharge letter to GP Use reminders Use differentiation Use constraints Use affordances Standardization Desensitize Improve predictions Develop contingency plans Manage uncertainty, not task Match amount to need Patient/carer satisfaction and experience of medication discussions and usage 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: Improving Outcomes for High-Risk and Critically Ill Patients Primary Drivers: Secondary Drivers: Specific Changes: Identify & rescue worsening patients Rapid Response System Early Warning System See next page Desired Outcomes: Decrease Mortality Complications Costs Improve Satisfaction Driver Diagram IG: PP. 286,412,429 Provide appropriate, reliable and timely care to high-risk and critically ill patients using evidence-based therapies Create highly effective multidisciplinary team Integrate patient & family into care so they receive care they want Develop an infrastructure that promotes quality care Protocols and Standing Orders Bundles Care planning Reliable communication Family involvement Clarification of wishes End of life care Consistent care delivery Flow Leadership Financial Stewardship Example: Another way to organize change package: Driver Diagram 9
Primary Driver Secondary Driver Key Change Concepts Specific change ideas P1. Identify & S1. Rapid response system Implement a Rapid Response Team Standardize call criteria rescue worsening Define response team members (including a sponsor) patients 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 Perfect triggering Review call criteria effectiveness Test/Add an Early Warning System Review missed opportunities (e.g. unscheduled transfers to ICU) Work towards "goal" call rate Perfect responding 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 Perfect evaluation Review overall process to evaluate need to improve Develop data tool for tracking S2. Early warning systems Use objective measures to assess disease severity Test a measurement tool such as MEWS Use an overall bed-board to assess layout of unit Create a process for use of scoring tools Create rules for when to call RN, MD, and activate system Improve identification of severe sepsis 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 P2. Provide appropriate, reliable and timely care to high-risk & critically ill S3. Protocols and Standing Order Sets Develop weaning protocol Pre-extubation worksheet Let s Construct A Driver Diagram Re-Design your existing DD or Design a new DD for your project Use the Aim of your Project 1. Work as a team please 2. Use flip chart paper and wall space or use your laptop. 3. Quickly choose a recorder 30 sec. 4. Identify primary and secondary drivers and ideas for change. draw the diagram. (Measures are a bonus!) minutes work time. 5. Each group will share results. 10