That variability . . Similar if you take all deaths or other diseases.Public domain
You have heard a little about the Model for Improvement and the PDSA Cycle. You can use plan, do, study, act (PDSA) cycles to test an idea by temporarily trialling a change and assessing its impact. Often in a healthcare setting new ideas are can be introduced without sufficient testing. This next game is just a way of introducing the PDSA cycle – limited time, but I hope that it will give you a feel for this process The game has a long history. Its application and learning was identified by: Lloyd Provost, Associates for Process Improvement – The Improvement Guide (statistician)You will begin to:Know how to develop theories of change and how to design tests of these theoriesUnderstand to use results of tests to design new tests and reflect on what learnedBegin to appreciate the roles that on going data collection and documentation play in carrying out PDSA cycles
PDSA Cycle:Components: plan, do study and actPLAN: agree the change to be tested or implemented.DO: carry out the test or change and measure the impact documentSTUDY: study data before and after the change and reflect on what was learnt.ACT: plan the next change cycle (amending the original idea if it was not successful) or plan implementation of successful ideas.Test first on a really small scale – one clinic, one patient, one day – this minimises the risk of time and money and is safer and less disruptive for patients and staff. Increase the numbers as the idea is refined. Test with people who are willing and happy to innovate. Only implement the idea when you are confident that you have considered and tested all the possible ways of achieving the change.
You need to set up your movements so that you only have one marker remaining in the timealloted(say after test, that you can also measure time taken each test)Get into teams at your tables:REMEMBER YOUR OBJECTIVEYou have 1 minute to:Open your M and MsCover all circles, but one, in the triangle. Does not matter which circle you leave freePlan for your first testRecord on the sheet your theoryYou have 1 minute from now to carry out your first test(3min 46 secs)
After cycle one ask:Teams for the number of counters left only on flip chartMove onto cycle 2:Again, give them 1 minute to plan next theory and 1 minute to carry outAt end of time:Ask for teams’ results – was any one team better, had they improved? Are we going to make assumptions on one data point?One team if they had a plan – perhaps ask team that had the least counters left (what did you do, what was your theory, prediction, data collection)Did you think your carried out a PDSA cycle? Need to carry out all parts of this cycleDid you record moves?Did they test out a different hypothesis after first cycleDid they communicate with anyone else (could bring in operational definitions in this case; were not told they could, but didn’t ask)Did they allocate roles, observation, one person to move counters etc (ie try under different conditions)Did you do it more than once in the time allotted – another measureAnd so on …
LESSONS:You need to plan, document and analyseLook at best practice, carry out your own tests – rapid tests of changeCan also do multiple pdsas to move forwardWe can be good at planning, but not so good at analysing and acting on those results to make changesJust to get you into the way of thinking of testing changes using pdsa cycle.You will also be able to identify how better to do the PDSAs over time
MLS13 QI Workshop
Questions to be answered today• How do we define Quality in healthcare?• What is Quality Improvement?• HOW CAN WE IMPROVE QUALITY?• How can we ensure that "change" is really animprovement?• What tools and approaches can we use to promotesuccessful improvement/change?
The safety paradox Healthcare staff are: Highly trained & motivated Committed to their patients Use sophisticated technology Errors are common and patients are frequentlyharmed
Potentially an average of 7,300 patients per year per trust suffer an adverseevent …Double Decker bus seats 73 people…100 bus loads of patients per year per trust …Nearly 2 bus loads per week per trustSafety in Acute Hospitals
Adverse Events• Due to healthcare management rather than to the underlying disease• May or may not be preventable• Effect 8-12% of hospitalised patients (one or more adverse events)• Older people are particularly vulnerable• Voluntary reporting systems are poor at measuring adverse events butuseful for learning about vulnerabilities
Epidemiology of harmStudy Authors Date of admissions Number of hospitaladmissionsAdverse event rate(% admissions)Harvard Medical PracticeStudy (HMPS)Brennan et al, 1991;Leape et al, 19911984 30195 3.7Utah-Colorado Study(UTCOS)Thomas et al, 2000 1992 14052 2.9Quality in Australian HealthCare Study(QAHCS)Wilson et al, 1995 1992 14179 16.6** United Kingdom Vincent et al, 2001 1999 1014 10.8 **Denmark Schioler et al, 2001 1998 1097 9.0New Zealand Davis et al, 2002 1998 6579 11.2Canada Baker et al, 2004 ???? 3745 7.5France Michel et al, 2007 2004 8754 6.6% per 1000 daysadmission** United Kingdom Sari et al, 2007 2004 1006 8.7 **Spain Aranaz-Andre et al, 2008 2005 5624 8.4The Netherlands Zegers et al, 2009 2006 7926 5.7Sweden Soop et al, 2009 2006 1967 12.3
Clinical information available in hospital outpatientclinics Prescribing for hospital inpatient Equipment availability in the operating theatre Equipment available for inserting peripheralintravenous lines
Process MappingStroke: assessment, imaging, thrombolysis Patient telephones 999 Ambulance arrives at home Ambulance leaves home Paramedics pre-alert stroke team Hospital Registration Bed in Resusitation Area
Process Mapping Nursing Staff IV placement ECG Monitor Hook up Vital signs monitoring Blood glucose Blood tests Weight estimate
Process Mapping Clinical Assessment History Medication Allergies Identification Of Witness Time of Onset/when last well Witness difficult to locate?
Process Mapping Clinical Assessment NIHSS Neurological Examination Lab samples - FBP/ PT/UE Transport of blood to labs
Process Mapping Imaging Bed to CT Scanner Disconnect monitor CT Scan CT Report Transport from CT – Stroke Unit Reconnect Monitor
Process Mapping Drug Preparation Calculate dose Prepare TpA Give bolus Start Infusion
Bundle of Care Parallel v Serial Process for clinical assessment ED Doctor History Meds/Allergies Order CT Scan Medical Registrar NIHSS Stroke Scale – on-line training Neuro Examination
Bundle of Care Nursing staff in Ed asked to defer ECG Medical staff reminded to stay with patient and assistwith transport of patient to CT Scanner Near Patient testing Training of Reception staff in recognition of strokesymptoms MD check list – responsiblity of nursing staff- ed andstroke,responsibilty of medical staff Ed and medicalregistrar.
MedianGoal0204060801001201401601802001234567891011121314151617181920212223242526272829313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081BundleDoor to needle time (within 60 mins)
Act• What changes are tobe made?• Next cycle?Study• Complete analysis of data• Compare data to predictions• Summarise what was learnedDo• Carry out the plan• Document problems andunexpected observations• begin analysis of dataPlan• Objective• Questions and predictions(why?)• Plan to carry out the cycle• Plan for data collection
To Be Considered a PDSA Cycle The test or observation was planned(including a plan for collecting data) The plan was attempted Time was set aside to analyze the dataand study the results Action was rationally based on what waslearned
The M&M Challenge Aim – to be left as few M&Ms aspossible at the end (?only 1) Measure – number of M&Ms leftOperational definitions: DO NOT EAT THE M&Ms Leave one blank circle on game sheet Jump one marker over another andremove marker that is jumped over Each round lasts 1 minute21365410987
STEP 1: PlanObjective: To test (another)approach to removing pegsPredictions: Will we leavefewer pegs?Plan: Who, what, record movesSTEP 2: Do• Carry out the plan• Record moves• Note problems or changesto planSTEP 3: Study• Compare data to predictions• Summarise what was learned• Update the team’s theory(approach)STEP 4: Act• Does our approachleave 1 peg?• If not what new ideasshould we test on nextcycle?PDSA FOR THEPEG (M&M) GAME
Safety brings its own dangersThe price of safety is chronic unease‘First of all, I was not in a position to challenge on the basisof my limited experience of this type of treatment. Second, Iwas an SHO (junior doctor) and did what I was told to do bythe Registrar. He was supervising me and I assumed he hadthe knowledge to know what was being done. Dr M.was employed as a registrar ... in a centre for excellenceand I did not intend to challenge him’.
Reliability of ward care (1) How well do you understand the goals of care forthis patient today? (2) How well do you understand what work needs to beaccomplished to get this patient to the next level ofcare? Less than 10% of nurses or doctors could answer thesequestionsPronovost et al, 2003
Six things all TrustBoards should do Setting Aims: Set a specific aim to reduce harm this year – a publiccommitment to measurable quality improvement Getting Data and Hearing Stories: Review progress toward safercare as the first agenda item at every board meeting, grounded intransparency, and putting a “human face” on harm data. Establishing and Monitoring System-Level Measures: Identify asmall group of organization-wide “roll-up” measures of patient); keepup to and make transparent to the entire organszation and users. Changing the Environment, Policies, and Culture: Commit to anenvironment that is respectful, fair, and just – for all those touched byavoidable harm/poor outcomes. Learning… Starting with the Board: Learn how “best in the world”boards work to reduce harm. Expect such training for all staff. Establishing Executive Accountability: Oversee the execution ofharm reduction plan; include executive team accountability.
Reflect on yourown experiences of health care . . .What was good?What was bad?What made you angry?What upset you?
“To the typical physician, my illness is aroutine incident in his rounds while for meit’s the crisis of my life. I would feel better if Ihad a doctor who at least perceived thisincongruity. I just wish he would give me hiswhole mind just once, be bonded with mefor a brief space, survey my soul as well asmy flesh, to get at my illness, for each man isill in his own way.”Anatole Broyard
The A B C Dof dignity-conserving careChochinov BMJ 2007; 335: 184-187ABCD
Chochinov BMJ 2007; 335: 184-187ttitude How would I feel if I was this patient? Inappropriate assumptions?- poor quality of life; ageism; social acceptability; malingering;Is my attitude towards the patient biased by my ownexperiences, anxieties, or fears?Does my attitude towards being a healthcare provider helpor hinder an empathic professional relationships withpatients?People who are treated like they no longer matter will actand feel like they no longer matterA
ehaviourBChochinov BMJ 2007; 335: 184-187 Respect Small acts of kindness- simple comfort measures; acknowledging a photo; Permission to examine Acknowledge inconvenience and discomfort Discussion after patient dressed Good communication skills“You, as a person, are worthy of my care and attention”
ompassionCChochinov BMJ 2007; 335: 184-187 Extending care beyond the intellectual level Developed and shaped by life experience Something that we feel Awareness of suffering and a wish to relieve it Non-physical communication
ialogueDChochinov BMJ 2007; 335: 184-187 Formal psychotherapeutic approaches Getting to know the patient- hobbies; family; beliefs; previous exposure to illness; what isimportant in their life Acknowledging fear, distress Identifying significant others who can support