queri 2008 meeting 081210 - health services research needed social engineering ... business...

1

Connecting Researchwith Patient Care

Implementing Research:Lessons Learned from Improving ClinicalPerformance Measures

Peter Woodbridge, MD, MBA 1, 2,Heather Woodward-Hagg 3, Linda

Williams MD 4,Dawn Bravata 4,TeresaDamush 4, Laurie Plue 4, Penny Butler 5

1 Nebraska Western Iowa VA HCS, 2 University ofNebraska College of Public Health, 3 VA HSRD Centeron Implementing Evidence Based Practice, 4 StrokeQUERI, 5 Roudebush VAMC

Introduction

Objective Enrich the dialogue on implementation science

by providing a different perspective

Expose QUERI implementers to an empiricmodel for effecting improvement

Perspective The Goal: Operationalize Research

Implementation science provides guidance But must be adapted for context

Brutally pragmatic about the literature Impact, not understanding, is the measure of value

2


I have built it.Why did they not come?

A Story

You are an ACOS for Ambulatory Care

You have 210 employees (MD, RN, HT)

You are responsible for ensuring that 43,000 uniqueveterans have timely access to 50 monitored clinics Those veterans make 270,000 clinic visits in a year

You are responsible for ensuring that “the clinicsmeet all nationally monitored performancemeasures.” There are Approximately121 clinical performance measures

Approximately 30 access measures

that are tracked for 50 clinics

A young investigator comes to youwith his new stroke screening protocolthat his research shows will benefitpatients

What do you do?

a) Express your regrets saying thatyou would like to help but you donot have capacity due to competingpriorities

b) Say you will put it in the projectqueue and do nothing as the crisisde jeur consumes your time

c) Get right on it and have itimplemented in 30 days

An Alternate Ending:

The young investigator volunteers tofacilitate implementation

What do you think is the likelihood ofadoption?

3

Dougherty, D. and Conway, P.H. (2008, May). "The '3T's' road mapto transform US health care." Journal of the American MedicalAssociation 299(19), pp. 2319-2321

“Health services researchmust evolve from

generating clinical efficacyknowledge to creatingclinical effectiveness

knowledge”

~ Carolyn Clancy, Director, AHRQ atVA HSRD meeting. 2/2008

Our Hypothesis

To shorten the implementationinterval, clinical investigators must“own” their findings and get into themud of quality improvement

Lean Concept:

“Gemba” – where the truth canbe found;” the place wherevalue is added; the shop floor

4

Action Research and LeanHealthcare Change Facilitation

Action Research* Directed at

improving safety,quality, access, etc.(“value”)

Plan, Act, Observe,Reflect (PAOR)

Involvement Vs. “extractive”

Goal: achievechange and“understanding”

Change Facilitation Directed at

improving safety,quality, access, etc.(“value”)

Plan, Do, Study,Act (PDSA)

Gemba Vs. “managing”

Goal: achievechange and“improvement”

* Dick, B. (2002) Action research: action and research [On Lline]. Availableat http://www.scu.edu.au/schools/gcm/ar/arp/aandr.html, accessed 12/7/2008

The Right Stuff:Investigators as Change Facilitators

Existing attributes Passion for topic

(ownership)

Data driven(empiric)

Analytical(deductive)

Hypothesisgeneration(experimentalist)

Project manager

Skills needed Social Engineering Change facilitation

Organizational &group dynamics

Processimprovementmethods (LeanHealthcare)

5

Lean Healthcare

A framework for organizationalimprovement derived from:

Lean (and six sigma)

Complexity science

Business management theory andpractice

Organizational development theory andpractice

Lean Healthcare

Grounded in four useful mental models:

Reppening QI Model

The Value Improvement “Stool”

Rapid Cycle Change PDSA

Stacey Complexity Diagram

With emphasis on practical tools andmethods

Tailored to the “complexity” of the specificinitiative

6

11

Reppenning QI Model

ProcessReliability

Errosion inReliability

Investment inReliability

ActualPerformance

PerformanceGap

DesiredPerformance

Time Spent onImprovement

+

+

-

+

Time SpentWorking

+

Pressure todo work

+

+

Work Harder

Pressure toImprove

Capability+

+

Work Smarter

* Repenning, N. and J. Sterman (2001)., California Management Review, 43, 4: 64-88

DELAY

Value = (Safety + Quality + Access + Service) / Cost

LeanHealthcare

ImprovementModel

Key enabling elements:• Microsystems• √ N• Structure

7

Rapid Cycle Change (RCC) PDSA

Make many small scale, hypothesisdriven, testable changes using PDSA

Those that seem to work, test inincreasingly larger settings

Plan an improvement

Do – Test the improvement

Study the effects byanalyzing data

Act upon this information(adopt, adapt, abandon) Adapted from Kim Voss

14

The Stacey Matrix:Reliability, Variability & Complexity

Anarchy(RandomChaos)

Far fromAgreement

Close toAgreement

Close toCertainty

Far fromCertainty

Com

plexity

(Dynam

icSystem

s;

Deterministic

Chaos)

Rational(Linear)Systems

The Impactof

Variabilityon SystemComplexity V

aria

bility

Rel

iabi

lity

Adapted from Ralph Stacey“Complexity and Creativity in

Organizations”

Technical

So

cia

l

8

Effectiveness of Lean HealthcareImprovement

Aggregate Quality Ranking

103

2

34

27

2922

16

113

114

122

112

84

6456

0

20

40

60

80

100

120

140

07 Q2 07 Q3 07 Q4 08 Q1 08 Q2 08 Q3 08 Q4

Nati

on

al

Ran

kin

g

VAMC #1Implementation

VAMC #2Implementation

VA Quality Aggregate is theoverall average of the individualrankings of 67 evidence-based,clinically significant, preventiveand chronic disease performancemeasures (includes HEDIS andORYX)

Implementation Outside VA(2005-2007)*

* Woodward-Hagg, H., Doebbeling, B , Workman-Germann, J., Flanagan, M., Scachitti, S., Suskovich, D., Corum, C.,(2008) Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption,AHRQ Advances in Patient Safety: New Directions and Alternative Approaches

9


Challenges to Implementing EBP (andResearch)

“To avoid getting stuck inmud, you need to

understand its properties”

~ NOAA file photo

Challenges: “Complexity”

ClinicalGuidelines

Specia

ltyDis

char

ge

Primary CareNew Patient

CommunicatePurpose ofAppointment

Transportaion

Access

Primary Care

Specialty Care

Access Management

Roudebush VA Medical Center1/27/2006

Recall List

Clinic VisitCheckout

Centraliz

ed

Check-in

AppointmentNotification

Research happens incontrolled

environments

Clinical care happensin complex

environments

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Challenges: Process vs.Professionalism

Systems Engineering Adaptive Systems

Simple

“Follow aRecipe”

PatientCheck-in

LinearDefined

Few Steps

Standardized

Complicated

“Flying anAirplane”

Scheduling aConsult

Non-linearDefinable

Many Steps

RigidAdherence to

Protocols

Complex

“Raising aChild”

Patient Care

Uniqueness

ExperienceHelps

Chaotic

“Emergency”

Emergency

Unpredictable

SpeedImprovisation

Industry vs. Craft Paradox

Adapted from Brenda Zimmerman, 2002

Challenges: Diversity ofOrganizational Perspectives

Macro Senior leadership

Vision and Strategic Direction

Meso Midlevel managers and supervisors

Policies and Procedures

Micro Frontline staff

Processes

- Nelson, et al Quality by Design

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21

Case Study: HypertensionPolicy v. Process

Performance Measure:

Hypertension) BP =<140/90

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb

-06

Mar

-06

Apr

-05

May

-06

Jun-

06

Jul-0

6

Aug

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb

-07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7

Aug

-07

Monthly RateFYTD 06 Running CumFY'07 Target (75%)FYTD 07 Running Cum

Action:

-Clinical pharmacists w ill be utilized for medication management follow ing established protocols

-Essential to get data base w hich w ould prov ide the prov iders w ith monthly data of patients w ith elevated BP; w hat % are controlled:

w hat % are on diuretic; Dr. Walsh to ask new data group if this is av ailable data

-Determine if clinical reminder has protocol use of diuretic Dr. Pratt/Dr. Suelzer to meet w ith all primary care prov iders in May

-A Rapid Process Improv ement w ill be done May 21st for rapid cycle changes

2006 Performance “Policy” RP

IW

Interventions:

Provider & clinic specific data

PharmD manage new HTN

Return to RN Q 3 weeks

Intervention:

Monthly review of data

“Work harder”

Interventions:

Standardized work

Checkout reminder

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Case Study: MedicationManagement

After a hiatus of one year, a medical centerresumes weekly tracers

Review of the tracer data reveals asignificant problem with medicationmanagement (unsecured medications,missing meds, outdated medications, etc.)

The medical center uses de-centralizedmedication servers in patient’s rooms

What should leadership do?

A) Instruct the pharmacy to lock upall medications in Pyxis machines

B) Educate the nursing staff as tomedical center policy andprocedures regarding medicationmanagement

C) Charter a LSS PI team to addressprocess issues (work smarter)

D) Charge a containment team to finda quick (work harder) fix

Containment Team Outcome:

10 fold decrease in medicationmanagement errors in 2 weeks

Containment Team Discoveries:

Unreliable processes and systems work arounds

Charter an RPIW to look atmedication management on oneward (microsystem)

Other wards to adapt / adopt

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The Incubators of Improvement:Clinical Microsystems

Microsystems are the building blocks of hospitals

It is where: Care is made

Quality, safety, reliability, efficiency and innovation is made

Staff morale and patient satisfaction is made

Hospital quality = sum of the quality of its microsystems

Therefore, the job of every person in each microsystemto: Care for their patients

And, to improve care

“A small group of people that work together toprovide care to discrete subgroup of patients”

- Nelson, et al Quality by Design

The Key to Improvement

Create an organizational culture of“experimentalists” that strive continuously, intheir microsystems, to reduce processambiguity and workarounds so as to improvesafety, effectiveness, patient-centeredness,timeliness, efficiency and equity

“What sets companies like Toyota apart is nottheir portfolio of existing solutions but their abilityto generate new ones repeatedly”

– S. Spears

The Common Ground forResearch and Patient Care

13


Overcoming the Challenges

Goa

l-drive

n

Pro

cess

es

Care

Managem

ent

Guidelines

Nurses

Adm

inis

trat

ors

Discover Common Purpose

Patient Safety

Quality*

Evidence

*But what doesquality mean?

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Discover Common Purpose

Reduce hassles and waste

What is waste?

How can we tackle it?

“Physicians need time to listen, examine, think,explain, interpret, and comfort (value adding).Activities that take time away are waste. Healthcareorganizations need to improve flow and identify andeliminate time stealers.” ~ p. 5

Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. IHI InnovationSeries white paper. Cambridge, MA: Institute for HealthcareImprovement; 2007

Lean Basics

A generic process managementphilosophy directed at smoothing flowand eliminating waste

Although rooted in manufacturing(Toyota), extensively adapted to serviceindustries including healthcare

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Lean Concepts

Value

Value is determined by the “customer” (patients;ordering provider; the person we serve)

Waste

Anything that does not add value from thecustomer’s perspective

Value stream

The actions (and waste) taken to create value

What is Waste?

Mura – unevenness indemand

Muri – overburdeningpeople or equipment

Muda – process stepsthat do not add value

NonNon--value adding, resourcevalue adding, resourceconsuming activitiesconsuming activities

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Overburdening and Errors

Nurse overloading leads to 24% of allsentinel events

For each patient over optimumpatient-to nurse staffing ratio, the 30day mortality rate increases by 7%

Aiken L.H., et al.: Hospital nurse staffing and patientmortality, nurse burnout, and job dissatisfaction. JAMA288:1987–1993, Oct. 23, 2002.

Eugene Litvak, PhD, IHI MHO Course

Artificial Overburdening

NWI FY 06

Number of Discharges and Admissions by Time of Day

-

100

200

300

400

500

600

700

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Time of Day

When does thepharmacy delivermedications?

Admissions

Discharges

Changing to 7 PM not onlysmoothes work but eliminatesrework for pharmacy

Under current state, pharmacypulling meds before residentsfinish rounds

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Bar Code Medication AdministrationBypassing: A Case Study

The Evidence: IOM – Medication errors 7,000 deaths annually

FDA – Barcodes 500,000 in adverse medicationevents over 20 years

VA – 3.7% of IP medication administrations are “FiveRights” violations (VA data)

Only 1.2-7.7% of adverse events and medication errorsare reported (Vicente, 2003)

BCMA reduces medication errors by: 86% ( Johnson, et al, 2002)

71% (Puckett, 1995)

BCMA introduced in VA to reduce medication errorsin 1999

Current State Analysis: Bypassing is endemic

• At one VA:

• 94 incidents since 10/2002

• 10/13 aggregate RCA related to BCMA

• VA Study*:

• BCMA bypassed 47% of time on acute patient wards

• BCMA bypassed 92% of time on long-term care wards

* Rogers, Patterson, Render, Woods, Cook, Ebright, VAGetting at Patient Safety (GAPS) Center

Prior Interventions at one VA:

• Wristband printers replaced

• Increased number of laptops

• CAC-BCMA Coordinator created and filled

• Missed Medication and PRN Reports (autoprint)

• LR/NS Bolus stocked on floors

• No more D5W on floors

• Removed barcodes from patient labels

• I-Carts

Problem Persists; Lean Healthcare RPIWChartered

BCMA Bypass Analysis

Nurses spend about 10% of their timein direct patient contact.

For the most part, the remainder isspent on what I call “hunting andgathering” (Heinrich, 2005)

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35

14 minutes in the life of a Pharmacy Tech

Med/Isolation Carts – CurrentState

19

BCMA Cart – Post 5S Mock-up

Place forWater Jug

Place for IVBags

LaminatedInstructions

CommonSupplies

BCMA Cart – Post 5S

IV Drawer

20

RPIW Baseline / Outcomes Data

318Total time to pass meds to onepatient

310Totals log-ins per patient medpass

1.03.3Number of attempts before medpass complete for one patient

33181Distance traveled to pass meds toone patient

Post-RPIW

Baseline

Time saved for other patient care activities = 15 min x 100ADC x 3 shifts x 365 = 27,375 hours per year (~16 FTE)


Lean Healthcare:Leadership, Ownership & Structure

21


LeanHealthcare

ImprovementModel


42

Why Leadership?

“To introduce any new article offood among seamen, let it beever so much for their good,requires both the example andthe authority of theCommander”

-James Cook, 1780

Berwick, JAMA (2003) 289:1969

22

43

Why Leadership?

JCAHO 2006 Root Cause Analysis of Sentinel Events

11%

13%

18%

18%

31%

32%

33%

34%

42%

49%

51%

65%

0% 20% 40% 60% 80% 100%

Continuum of care

Staffing

Care planning

Organizational culture

Availability of information

Orientation / training

Competency

Envrionment

Procedural compliance

Leadership

Patient assessment

Communication

In almost 1/2 of sentinelevents, a breakdown inleadership contributed tothe failure

Leadership and Ownership:The NWI Way Leadership Initiative

We are all leaders North Platte Canteen*

We are all owners Take ownership for what

you do

We all create value The lens by which all our

activities are examined

NWI Way

* Greene, B “Once Upon a Town” Perennial, 2003

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45

Lean Healthcare Ownership Roles

Sponsor Senior leader

Macro-perspective

Management GuidanceTeam (MGT) Mid-level managers

Meso-perspective

“Policy”

Owner “Eye on the ball”

Micro-perspective

Improvement Team Understand process

“In the mud”

LH Change Facilitator “In the boat” with the

team

Help teams see theproblem

Provides just-in-timetraining and assistance

Measurement Specialist Team member

Administrative Support Team member

Consultants & Stakeholders Perspective

PerformanceMeasure Datanot meeting

target

CharterManagement

Team

Obtain ProcessLevel Data

DefineProject Scope

CharterPAT

Weekly meetingsto develop/test/implement

5 RCCs/month

Scope/Complexityof process?

CharterRPIW

Process/System

Redesign

PeriodicFeedbackTo EMT/

PerformanceMeasure

Board

PeriodicFeedbackTo EMT/

PerformanceMeasure

Board

PerformanceMeasureReviewBoard

Lean Improvement Cycle

24

47

Using Lean Healthcare to AddressComplexity


Far fromAgreement

Close toAgreement

Close toCertainty

Far fromCertainty

Complexity

(Dynam

icSystem

s;

Determ

inisticChaos)


Adapted from Ralph Stacey“Complexity and Creativity in

Organizations”


Far fromAgreement

Close toAgreement

Close toCertainty

Far fromCertainty

Com

plexity

(Dynamic

Systems;

Deterministic

Chaos)


NegotiatedSystems

EvolvingSystems

(RCC PDSA)

So

cia

l

48

Matching Intensity of Effort toInitiative Complexity

5 RCC PDSA Within a clinical

microsystem

Microsystem is capable

Fast Start Project Defined charter

Little analysis required

Motivated team

Rapid ProcessImprovementWorkshop (RPIW) Defined charter

Many RCC PDSA

A lot of progress likelyin one week

100 Day Project Analysis required

Ambiguous charter

Follows DMAIC

25

49

5 RCC PDSA

5 RCC PDSA per month Responsibility of Owner,

MGT, and Sponsor

Indentify 5 improvementideas to test each month

Use small tests of change

Test each idea forquantifiable impact

No charter “Improvement” is charter

Success depends on Motivated team

Capable team

Use when there is good“agreement” but weakevidence as to best practice

50

Fast Start Project

One day “mini-blitz”followed by weeklymeetings First day:

Process map

Isolate problems

Identify RCC PDSA

Up to 6 weeks Analyze results RCC

PDSA

Additional RCC PDSA

Has charter

Progress tracked atmonthly milestonemeetings

Best used for “simple”problems that may requirea structured environmentfor “negotiation”

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51

Rapid Process ImprovementWorkshop (RPIW)

Weeklong (40 hour)event + 90 day weeklyfollow-up Combine education and

improvement

Highly structured

Day 1-2 analysis VOC & PD

Process map

Isolate problems

Day 3-5 RCC PDSA 20-30 small tests of

change in one week

Best used for“complicated” but welldefined problems

52

100 Day Project

Advanced Lean Based on DEDISS cycle

Define Evaluate Design Implement Spread Sustain

3 hour meetings weeklyfor 8 weeks followed by1 hour meetings for 6weeks

Just in time training ofteam

Formal “go / no-go”milestones

Often requires valuestream mapping

Use for “complex”problems May spin off other

project teams

27

53

Systems Engineering

Systems EngineeringProject Uses engineering tools

to analyze problemsand simulate solutions

Formal project planwith defined milestones

Formal “go / no-go”milestones

Solutions often rest onimproving humanperformance (humanfactors and cognitiveengineering)

Use for “chaotic”problems Separate deterministic

from random chaos

Coaching and Lean HealthcareChange Facilitation

Give a man a fish and he will eat fora day. Teach a man to fish and hewill eat for a lifetime. ~Confucius

But to teach, you must get inthe boat!!

28


Lean Healthcare:Creating Improvement Capability


LeanHealthcare

ImprovementModel


29

Lean Improvement

Define theProblem

EvaluateCurrent State

IdentifyOperational

Barriers

ImproveSystems

SustainabilityStrategy

Project Charter

Process Map

Check Sheet

Process ObservationWorksheet

Spaghetti Diagram

Waste Worksheet

Lean Tools

Process ControlPlan

Adapted with permission: LSSHC

Lean Improvement

Define theProblem


IdentifyOperational

Barriers

ImproveSystems


Project Charter

Process Map

Check Sheet


Spaghetti Diagram

Waste Worksheet

Lean Tools

Process ControlPlan


30

PatientArrives

At Radiology

Patientescorted tooutpatientradiology

ClerkAssigns

Patient toRegistrar

PatientPre-

registered?

Clerk RequestsID and Medical

Card

Not EnoughEscorts

PatientArrives

at RegistrationDesk

RegistrarEnterspatient

informationinto system

Not EnoughRegistrars

Patient WaitTimes

Yes

No

“Kapowie”

Courtesy LSSHC

Outpatient RegistrationCurrent State Process Map

Process Flow Diagram

Square = steps, one per sticky

Square at angle = branch

Stars = ambiguities, workarounds

Flowers = ideas for solvingAt High Level

31

Voice of the Customers

Select Key Process Customers:

Customers that are important to theproject success

Customers that are not adequatelyrepresented within the teammembership.

By permission: LSSHC

“Customers” are anyoneimpacted by the process

Voice of the CustomerInterviews

What do you like about our services(Strengths)?

What do you think needs improvement(Weaknesses)?

What Opportunities do you feel we couldtake advantage of?

What could potentially Threaten oursuccess?

Let the Customer Talk - Listen Carefully -Record Responses

By permission: LSSHC

32

Identify the “Positive Deviants”

Positive deviants are the successful outliers They are the individuals that get it right when

others fail

Learn from the positive deviants Analyze their success Use their practices to identify process

improvements

Make positive deviant activities visible toothers in the group Healthcare workers are “learners” They learn best from peers

Observe the ProcessGather Process Data

33

Process Observation WorksheetExample

Process Observation Worksheet

Process: Patient check-in

Step # Description Distance

Clock

Time

Task

Time

Wait

Time Observations

0:00

1 Patient arrives 0:10 0:10

2 Clerk requests ID 0:13 0:03

3 Patient registered (Y/N) N

3A Patient sent to HBU 575 0:15 0:02

3B HBU registers patient 0:47 0:32 0:20

4 Appointment (Y/N) 575 N

4A Make walk-in appointment 0:50 0:03

5 Check patient in 0:52 0:02

6 Patient sent to waiting room 100 0:56 0:04

Enter time that stepwas completed.

Distance traveledIn steps

Task time calculatedlater…

Check-sheet Example

Project Name: MRSA

Output Metric: Handwashing

Date / Time Unit Room #

Followed

handwashing

protocol

Reason for Non-

compliance Comment

5/18/2007 5E 124 Yes

5/18/2007 5E 126 No

Non-cleanser in

dispenser

5/18/2007 5S 148 No

Nurse carrying

items; no place to

put down

34

Spaghetti DiagramClinic 5 Room Turnover Project

Exa

mR

oo

m

Exa

mR

oo

m

Exa

mR

oo

m

Exa

mR

oo

m

“6+ Miles per Day”

Lean Improvement

Define theProblem


IdentifyOperational

Barriers

ImproveSystems


Project Charter

Process Map

Check Sheet


Spaghetti Diagram

Waste Worksheet

Lean Tools

Process ControlPlan


35

Lean & RCC PDSA

Many SmallTests of Change

Start Smalland Evolve to

Full Scale

Basic Lean Tools

Apply Lean Tools to reduce oreliminate waste

5S

Visual Controls

Visual Workplace rules

Workstation Design

Setup Reduction

36

5S Workplace Organization

Five “S”

Sort

Simplify (Set inorder)

Standardize

Sweep (Shine)

Sustain (SelfControl)

NOT

Scrounge

Steal

Stash

Scramble

Search

From Virginia Mason

37

From Virginia Mason

Pittsburg VA –Equipment Room

BEFORE

BenefitsBenefits

Clean equipment =pathogen vector

Saves frustration, searching

Freed up $20K-worth ofunused equipment for useelsewhere

IV Pumps(4)

Always Plugged In

AFTER

Whiteboardindicateslocation

38


Lean Healthcare:Sustainability and Spread


LH ValueImprovement

Model


39


Sustainability

“The first rule of sustainability isto align with natural forces, or at

least not try to defy them.”~Paul Hawken

Lean Improvement

Define theProblem


IdentifyOperational

Barriers

ImproveSystems


Project Charter

Process Map

Check Sheet


Spaghetti Diagram

Waste Worksheet

Lean Tools

Process ControlPlan


40

79

VAP Bundle Implementation

What does this processlook like at week 15?

80

Whathappened?

Sustainability

Woodward-Hagg, H., El-Harit, J., Vanni, C., Scott, P., (2007). Application of Lean Six Sigma Techniques to Reduce Workload Impact DuringImplementation of Patient Care Bundles within Critical Care – A Case Study. Proceedings of the 2007 American Society for Engineering EducationIndiana/Illinois Section Conference, Indianapolis, IN, March 2007.

Whathappened?

41

81

Multiple factorsimpacting sustainability

ProcessReliability

Errosion inReliability

Investment inReliability

ActualPerformance

PerformanceGap

DesiredPerformance

Time Spent onImprovement

+

+

-

+

Time SpentWorking

+

Pressure todo work

+

+

Work Harder

Pressure toImprove

Capability+

+

Work Smarter

ImproveReliability

ImproveClinician Effectiveness

of “Work Smarter” Loop

TimelyIdentification of

PerformanceGaps

ReduceReliabilityErosion

delay

ImproveStaff Engagement

In the Initiative

AlignIncentive Systems

Courtesy: HeatherWoodward-Hagg


Spread

42

Berwick’s rules for Change inHealthcare

Find Sound Innovations

Find and support Innovators

Invest in Early Adopters

Make early adopter activityobservable

Trust and enable reinvention

Create ‘slack’ for change

Berwick, JAMA (2003) 289:1969

Factors that Determine Spread(and Sustainability)

Innovation attributes

Relative advantage

Compatibility

Complexity / Simplicity

Trialability

Observability

Communication

The “Early Adopter” Opinion Leader

Berwick, JAMA (2003) 289:1969

43

Staff Engagement /Communication:

Don’t make changes:

Without soliciting staff feedback

Without soliciting MGT and sponsorfeedback

Be transparent:

Demonstrate mock-ups widely

Share data

The team serves those not in the room!!


Lean Healthcare:Measurement

44


LH ValueImprovement

Model


Information Triangle

Decisions

Data

Information

Knowledge

Data: symbols, facts, numbers

Data that has been processed giving itmeaning by way of relational connection

Justified, true, andbelieved Information

Purdy & Giaeidi, VEHU 303 (2007)

45

Chartology: What is the data tryingto tell us?

Data as presentedto NASA

From Edward Tufte, Visual Explanations: Images and Quantities, Evidence andNarrative, Graphics Press (February 1997)

What is the probability thatthe Challenger boosterrockets will suffer a O-ringfailure if the launchtemperature is 28oF?

Challenger data re-plotted

What is the probability that theChallenger booster rockets willsuffer a O-ring failure if thelaunch temperature is 28oF?

From Edward Tufte, Visual Explanations: Images and Quantities, Evidence andNarrative, Graphics Press (February 1997)

Our Data Challenges:

1) To see the story that the data is tryingto tell us

2) To share that story with others in ameaningful way

46

91

Case Study: Colon CancerScreening

A LSS Fast Start project is chartered toaddress the medical center’s failingColon Cancer Screening performancemeasures

The medical center does not doscreening colonoscopies!!!

92

Problemwith Returns

Problemwith

Screening

Additional Analysis:

If not returned in 2weeks, not returned


Weak process – relianceon providers to writeorders; poor reminders;variance

What does the data tell us?

Metperformancemeasure

Somebody isDoing Screening

Colonoscopy


Co-managed carepatients

47


SR, ACA, ACA2, LSS, IE, LH:What’s in a name?

“Potato, potahto, Tomato, tomahto,

Let's call the whole thing off”

~ Louis Armstrong

It’s a Toolbox!

48


Parting Words

“Courage and perseverance havea magical talisman, before whichdifficulties disappear andobstacles vanish into air. "~ John Quincy Adams

An Emergent Model forImprovement

Is there a welldefined policy?

Is there anawareness gap?

Is this a design /development project?

Policy DevelopmentProject(MGT)

Employee EducationProject(LRM)

Lean Design Team(MGT)

Is thereorganizationalcommitment*?

Formal(DEDISS) Project

Not a project!!

Yes

No

Yes

Yes

No

No

No

Yes

* Organizational Commitment:A willingness to free up 8-10front line staff for 50 hours eachto fix the process

Is this a crisis?Containment Team

(MGT)Yes

No

49

Improvement Life Cycle

Define

Evaluate

Design

Implement

Spread

Sustain

Quantify the problemSet goal: Specific, Measurable,Achievable, Relevant, Time-bound(SMART)

Current State Analysis: Processmaps, constraint identification,barriers, etc.

Brainstorm solutionsPlan RCC PDSA small tests ofchange (how to measure impact)

Conduct small tests of changeWhat was impact?Adopt, Adapt, Abandon

Go from small tests of change toexpanded tests and full scaleimplementation (training, policies,etc.)

Plan for “erosion”Identify “critical to quality” stepsSet action limit measuresDefine contingency plan

The Lean Six SigmaDMAIC cycle adapted

for healthcare

An Improvement Challenge to theResearch Community

CoachingExtracting

DataDocumenting

Problems

EngagingGeneratingInformation

AnticipatingFailures

TransformingCreating

KnowledgePredicting

Vulnerabilities

EffecterActivities

AnalyticalActivities

AfferentActivities

C

ap

ab

ilit

yE

vo

luti

on

50

Questions?

Contact information:

[email protected]

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queri 2008 meeting 081210 - health services research needed social engineering ... business...

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