Rapid Improvement Strategies

Shirley M. Moore, RN, PhD, FAAN

Associate Dean for Research and Professor of Nursing

Case Western Reserve University

Cleveland, OH, USA

Rapid Improvement Strategies

One of the criticisms of CQI is that it can take a long time to plan, test, and evaluate an improvement

Making fast changes lasting and pervasive, rapid improvement strategies speed things up without changing the nature of necessary improvement activities

Objectives

Describe the key focuses of rapid improvement strategies

Compare traditional and rapid improvement strategies

Apply rapid improvement strategies to an improvement initiative

Making rapid improvement work....

Interdisciplinary Systems approach Throw away your hats Take risks Take ownership

As in the use of traditional improvement strategies, to help develop tests and implement changes using rapid improvement strategies, the PDSA cycle is used as a framework for an efficient trial-and-learning methodology

When using rapid improvement strategies, the goal is to speed up cycles, thus making change faster

Plan-Do-Study-Act (PDSA)

Plan--a change, preferably on a small scale

Do--carry out the plan Study--the effects of the change, making

simple measurements Act--on what you learn to plan the next

round of testing

“Trial and Learning”

Small scale tests

Simple measurements

Five steps to speed up change

Wasting time working on the wrong problem

Ineffective Meetings

Planning and not acting

Too much time collecting data

Selling change to others

1. Define the right problem

2. Rapid meetings

3. Rapid plans

4. Rapid data collection

5. Rapid whole system change

Define the Right Problem

Postpone benchmarking when problems are obvious

Waiting for data to clarify problems can delay improvement efforts

Using data you “have” may lead to an inaccurate improvement

Focus benchmarking on a “few problems”

Define the Right Problem

Creates a focus on the “system” and not the staff

Problem statement: “The inability of the ED to initiate antibiotics in a timely manner.”

Problem restated: “Delay in antibiotic administration for pneumonia patients.”

Define the Right Problem

Define the problem in terms of the customers experience, obtain information via: focus groups interviews observations questionnaires

Define the Right Problem

State the problem from different perspectives Problem statements often include the

environment for improvement Increases focus on the team’s scope

Problem statement: “Sixty percent of pneumonia patients get antibiotics in the ED.”

Problem statement: “Forty percent of pneumonia patients do not get antibiotics in the ED.”

Define the Right Problem

State the problem from different perspectives

Team exercise:• Have all team members define the problem• Compare answers to identify the various ways to

approach the problem.

Rapid Meetings

Choose a nonparticipating facilitator• keep group on track and focused• identify team problems

Meet before the meetings • present team focus and agenda to members

for feedback (electronic, telephone, etc)• initiates ideas prior to meetings, increases

interaction and problem-solving

Rapid Meetings

Postpone evaluation of ideas• increases amount and creativity of ideas.• minimizes “group think”

Think it through again• improves teams original decisions• considers all perspectives

Rapid Meetings

Meet between meetings• Electronic feedback on issues (e-mail)--

eliminates evaluation of ideas and minimizes group think

• Allows for “drafts” to be revised, updated and represented

• More meeting time available for approval of action plans, decision making, and finalizing implementation strategies

Plan Rapidly

Start with what “could be” and not “what is”....Ideal system design...Futuring

• Fits solution to system• Generates solutions before understanding constraints,

increasing creativity• Brainstorm ideal solution, then define realistic

improvement approach• Minimizes time spent flowcharting the current

process

Plan Rapidly

Know Your Cast Champions Agents Sponsors Targets

Collect data rapidly

Write outcomes reports before begin data collection, including tables and figure

Collect only data you need Representative surveys of customers Increase speed of data collection by using

numerical and subjective data

Collect data rapidly

Rely on numerical estimates made by process owners• Derive from subjective data based on

observations and feedback• Involve a cross-section of experts involved in

the process• Analyze and display outcomes• Experts discuss and re-estimate outcomes

Rapid Whole-System Changes

Cross-functional teams--interdisciplinary Internal and external experts Unfolding storyboards

• employees follow team progress• understand evolution of change• increase involvement and feedback

Rapid Whole-System Changes

Employees need to feel they are capable of change

Employees are more likely to change when they participated in the decision making process and have organizational support

Top down approach Maintain focus with reminders and updates Focus on early adopters

Strength of Evidence

Beyond reasonable doubt

Preponderance of evidence

Common Sense

Summary

Application of a set of strategies can be employed to speed up the CQI process

Rapid improvement strategies do not bypass the basic steps of the CQI process - they speed up the planning, measurement and PDSA cycle time

Using rapid improvement strategies often means getting rid of old, ritualistic organizational change behaviors

References

Alemi, F., Moore, S. M., Headrick, L., Heckelman, F., Kizys, N., & Neuhauser, D. (1998). Rapid improvement. The Joint Commission Journal on Quality Improvement, 24, 119-129.