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HRET HIIN Virtual Event: Foundations for Change Fellowship

Sustaining Improvement

Wednesday, October 18, 201711:00 – 12:00 p.m. CT

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Welcome and Introductions

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Mallory Bender, Program Manager, HRET

Agenda

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11:00-11:05 Welcome and Introduction Mallory Bender, HRET

11:05-11:15 Action Period Discussion• Watch: Is There a Secret to Sustaining Improvements?• Read: IHI’s Sustaining Improvement White Paper• Review: Seven Spreadly Sins

Kathy Duncan, IHI

11:15-11:35 Can We Facilitate Adoption? • Identify stages of adoption and identify attributes that facilitate adoption • Describe activities that support implementing, sustaining, and spreading

changes

Kathy Duncan, IHI Lauren Macy, IHI

11:35-11:45 Sustainability Framework • Recognize key drivers of sustainability• Identify opportunities to assure drivers of sustainability are present in

improvement in which you play a part

Kathy Duncan, IHILauren Macy, IHI

11:45-11:55 Action Period Assignment • Complete Self Assessment • Complete and email your project summary report to HIIN@aha.org before

Friday (10/20)• Invite your manager to join us for the Nov. 8th Celebration call • Invite any colleagues that you may know of that would benefit from the QI

fellowships beginning in January 2018

Kathy Duncan, IHI

11:55-12:00 Bring it Home Mallory Bender, HRET

Foundations for Change Scheduled Sessions

January 18 – The Case for Improvement

May 10 – Multiple Cycles, Multiple Tests

February 1 – Take your Aim – What are We Trying to Accomplish?

June 14 – Manage Time and Attention

February 15 – What Changes Can We Make That Will Result in

Improvement?

July 12 – Be the Coach

March 1 – Map Your Course August 9 – Treasure Chest: Shadowing a Patient

March 15 – How Will We Know That a Change is an Improvement?

September 13 – Identify and Spread Improvement

March 29 – Empower Teams to Engage in Improvement

October 18 – Sustaining Improvement

April 12 – Know Yourself, Know Others

November 8 – Celebration!

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What has been your biggest “aha” moment or key learning during the fellowship?

Quality Improvement does not have to be so complicated. Start small, and go from there.Things do not move as fast as you think they do. People have different priorities.…I realized I couldn't run this race alone.….. getting a true understanding of what quality improvement is. To make a change you have to start small, and you do not need all the answers before you start to implement programs.

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What has been your biggest “aha” moment or key learning during the fellowship?

....how to accomplish a small test of change before you invest a lot of time and effort to a process that may or may NOT work. …quality improvement does not have to be complicated. Start with small changes and go from there.As someone who is new to the Quality area of nursing, the biggest "aha" moment for me has been how complex and detailed the change process is -- PDSA cycles, driver diagrams, data -- and how to use the use the different tools. Even though this fellowship has been very informative, I still feel like I have much to learn

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Assignment

• Review: Poster "Seven Spreadly Sins"• Watch: Is There a Secret to Sustaining

Improvements?• Read: Sustaining Improvement White Paper

Just a note…….Project Summary Review Due October 20

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“Adoption” is a powerful word

What does the word adoption mean to you?

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AdoptionCan We (I) Facilitate Adoption?

Utilize a sequence of activities that guide the development, test period,

and implementation of an improvement

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Create Adoption Mechanisms

• Engage leadership• Build a communication plan • Identify and utilize existing networks and social

systems • Foster a culture of urgency and persistence

Moving Adopters from Decision to Action

• Information about the changes• Mentors, coaches, or experts to get answers to

questions• Connections with peers• Feedback • Accountability for results• Encouragement and support from leaders

Adoption is a SOCIAL thing!

A better idea…

…communicated through a social network…

…over time

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Stages of Adoption

1. Awareness2. Persuasion3. Decision4. Implementation5. Confirmation

Prochaska J, Norcross J, Diclemente C. In Search of How People Change, American Psychologist, September, 1992.

Can We Facilitate Adoption? Yes!

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Relative Advantage Simple Trialable Compatible Observable

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

Grounding in the Model for Improvement

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“Everyone in healthcare should have two jobs: to do the work,

and to improve the work.” Paul Batalden, MD

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

The Sequence of Improvement

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Tools to change a system: Joseph Juran’s Trilogy

Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999

Quality Planning: Understand needs

of the customer

Quality Improvement:

Improve the Work

Quality Control: Manage the Work

Tools to change a system: Joseph Juran’s Trilogy

Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999

Quality Planning: Understand needs

of the customer

Quality Improvement:

Improve the work

Quality Control: Manage the Work

Management system is organized to anticipate and detect defects,

maintain stable operations, respond to abnormalities

Tools to change a system: Joseph Juran’s Trilogy

Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999

Quality Planning: Understand needs

of the customer

Quality Improvement: Improve the work

Management system mounts coordinated projects to improve

process capability

Quality Control: Manage the work

Tools to change a system: Joseph Juran’s Trilogy

Source: Juran J, Godfrey AB, eds. Juran’s Quality Handbook: Fifth Edition. New York: McGraw-Hill, 1999

Quality Planning: Understand needs of the customer

Establish a culture of high performance management. Positive trust relationship encourages and sustains frontline staff

engagement in QC and QI

Quality Improvement:

Improve the work

Quality Control: Manage the work

How do Leading Organizations Sustain Changes?

• All 10 systems conducted their front-line operations in strikingly similar ways

• Specifics varied regarding execution

• Consistent presence of a central actor, the front-line unit manager

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Focus on Front-line Management

It’s About Paying AttentionOur research and testing has led us to conclude:

“The key to sustaining improvement is to focus on the daily work of frontline managers, supported by high-

performance management system that prescribes standard tasks and responsibilities for managers at all

levels of the organization.”

Improvement alone is not enough. 24

Source: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)

Source: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)

S1: Standardization

S2: Accountability

S3: Visual Management

*S4: Problem Solving

*S5: Escalation

*S6: Integration

S7: Prioritization

S8: Assimilation

S9: Implementation

S10: Policy

S11: Feedback

S12: Transparency

S13: Trust

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The Secondary Drivers seem like a great “checklist” for Sustainability

Drivers of Sustained Improvement

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Aim – Improve and sustain

improvement performance

Quality Control

Standardization

Accountability

Visual Management

Problem Solving

Escalation

Integration

Quality Improvement

Culture of High Performance Management

Standardization

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What Standardization Is What Standardization Is Not

• Standard work for roles within the unit and at every organizational level

• Agreed to and developed with staff input

• Clarifies; a set of mutuallyexclusive tasks and responsibilities

• A completely comprehensive cookbook for how everything is done

• A set of parameters that constrain action and make the work harder to do

Do you have standardized processes?

How do you know? 29

Quick Check-in

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• Ask five people to describe a process• Do you get five different answers? • How much consistency is there?

Accountability

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Develop standard

work

Introduce standard

work

Observe standard

work

Record observations,

surface opportunities

Sustaining changes that work: Moving to standard work

Visual Management

• Links together other drivers• Integrated into daily huddles

to provide frame of reference

• Provides insight into observation of standard processes (accountability)

• Lists current improvement efforts and supports problem solving

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Problem-solving

• Examples of problem-solving methods and skills– Model for

Improvement– Lean Methods– Root Cause Analysis

• Supports all activities in the system– Management methods

introduced via PDSA cycles (huddles)

– Without problem-solving, management system surfaces problems that go without solutions

– Solving problems surfaced keeps staff engaged

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Integration• ‘Vertical’ Integration across levels of management

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Role Exemplary practicesSenior Leader

Senior walk rounds, enterprise visual management board

Middle Manager

Focus on accountability, observation of standard work horizontally and vertically; regular coaching of frontline staff on problem-solving escalation

Front line Comprehensive focus on standard work, rhythm of daily huddles to surface and solveproblems and prioritize improvements

Escalation (verb)

• Meaning: to increase in intensity, magnitude, etc.,• There must be a path to escalation• Staff must know what it is• The path to escalation must not fail

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Escalation

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Operationalizing the Model

• Standard work for managers • Accountability • Visual Management • Problem-solving and escalation • Integration • Escalation

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Operationalizing the Model• Standard work for managers

– Anchored by daily huddles • Accountability

– Regular review of safety standard work• Visual Management

– Visual management boards• Problem-solving and escalation

– Introducing standard problem-solving policies and education• Integration

– Tracking standard work across the organization and engaging top-level leadership

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Quality Improvement (Overlapping)

Aim – Improve and sustain

improvement performance

Quality Control

QualityImprovement

Problem Solving

Escalation

Integration

Prioritization

Assimilation

Implementation

Culture of High Performance Management

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Prioritization

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• Prioritization is a skill. Learn it. Practice it. Verbalize it.

• Assure that the aim is clear – so priorities are based on strategic goals.

• Assure staff understands aims and boundaries.

Assimilation

• Assimilation - Works very well to get new employees oriented to the process that you want right off the bat. They have no preconceived ideas, and it’s easy to get them in the habit.

Makes the "older" staff want to do it as well because the "newbies" aren't going to show

them up.

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Implementation

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Hunches Theories

Ideas

A PS D

A PS D

Investigation Demonstration Implementation

Unless changes are integrated into "daily work", changes will not stick. E.g. job descriptions and job training following current best known methods, link to supervision, etc.

Implement – Make a change a permanent part of the day to day operation of the system

Kevin Little, PhD, Informing Ecological Design, LLC ”

Operationalizing the Model

• Prioritization • Assimilation• Implementation

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Operationalizing the Model• Prioritization

– Understand the boundaries. Allow those closest to the issue to prioritize next steps

• Assimilation– Assure reliable process for new staff to know

how you ‘do work’

• Implementation– Implement a process such as bedside rounds,

methodically, assuring adaptations are appropriate

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Culture of High Performance Management (Overlapping)

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Aim – Improve and sustain

improvement performance

Quality Control

QualityImprovement

Culture of High

Performance Management

Problem-Solving

Escalation

Integration

Policy

Feedback

Transparency

Trust

Policy

• Make sure that policies are in line with current improvement projects

• Purposeful simplification of policies – Think 5• Rotate responsibilities• Remember the 80/20 rule

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Feedback

• Yes it matters, it especially matters to you and from you

• Near Misses are richLeaders: 1. Stop Talking2. Listen (you’re getting

feedback)

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Transparency and Trust

Tell. The. Truth.The more staff understands what you are trying to accomplish, the more they are willing to reach for higher goals. (Never met a clinician who didn't want to provide good, quality care.)

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Operationalizing the Model

• Policy• Feedback• Transparency• Trust

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Operationalizing the Model• Policy- Rotate responsibilities. Keep it simple. Does it make

sense?• Feedback- When rounding, reach out to several staff,

complementing the work demonstrated on the Visual Board; Know the NP, Environmental and administrative secretaries.

• Transparency- Visual board can be a place for bed huddles, safety huddles, etc. – so that info is right in front of you. Find something nice to say – acknowledge the good with all. Discuss the opportunities with leaders only.

• Trust- Earn it. Get back to them. Email outcomes. Do what you say. Eat in the cafeteria 3x week.

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Action Period Assignment

• Complete Self Assessment • Complete and email your project summary

report to HIIN@aha.org before Friday (10/20)! • Invite your manager to join us for the Nov. 8th

Celebration call • Invite any colleagues that you may know of

that would benefit from the QI fellowships beginning in January 2018

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Project Summary Template

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Project Summary due: October 20th

Celebrate!

• NOVEMBER 8! • Invite your Friends

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Bring It Home

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Mallory Bender, Program Manager, HRET

Submission and Other Items

• Please send your final project to hiin@aha.orgby October 20, COB.

• TELL YOUR FRIENDS! We’ll start again in January.

• We will be sending out a final survey in the next week or so, so keep your eyes peeled!

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THANK YOU!

Next call: Wednesday, November 8, 201711:00 – 12:00 pm CT

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