Corner Stone: The Improvement Model

Debbie Barnard, MSc, CPHQ January 30, 2013

AcknowledgementMy thanks to the IHI and API as without them

and the materials they share at IHI.org the pages of this presentation would be blank

What is this session all about?• Know the theory

– State the three fundamental questions that are the basis of the Model for Improvement:

– Identify the processes that make up the Plan-Do-Study-Act (PDSA) cycle;

• Understand how to apply the theory and– Describe how an improvement team can use the model to make

changes in a real-world setting• Being able to share that knowledge in a way that

empowers the learner to make the knowledge their own

Foundation forBreakthrough Improvement

• Will to do what it takes to change to a new system– “own the problem” and leadership support to

improvement.• Ideas on which to base the design of the new system

– don’t recreate the wheel, rather learn from the success of others

• Execution of the ideas– use proven quality methods to test and measure.

Source: IHI.org

The Model for Improvement: Your Engine for Change

IHI.org

Source: The Improvement Guide, API

Aim

Measures

Changes

Execution

What are you trying to accomplish?

• Do you know exactly what you are trying to do

• Do you have clearly defined aims/objectives?

• How good do you want to be by when?

Source: NHS Scotland – Science of Improvement Learning Sessions (The Improvement Guide by API)

PrimaryDriversOutcome

SecondaryDrivers

Ideas for ProcessChanges

AIM:A New

ME!

Calories In

Limit dailyintake

TrackCalories

CaloriesOut

Substitutelow calorie

foods

Avoidalcohol

Work out 5days

Bike towork

PlanMeals

Drink H2ONot Soda

drives

drives

drives

drives

drives

drives

drives

drives

• Weight• BMI• Body Fat• Waist size

• Daily caloriecount

• Exercisecalorie count

• Days betweenworkouts

• Avg drinks/week

• Runningcalorie total

• % ofopportunitiesused

• Sodas/week

• Meals off-plan/week

• Avg cal/day

Exercise

Fidgiting

HackySack inoffice

Percent of dayson bike

Etc...

Our Teaching SampleUnderstanding the System for Weight Loss with Measures

Source: Richard Scoville, Ph.D.

AIM: How much by when?

How will you know that change results in improvement ?

• Do you have a balanced set of measures (process outcome and balancing measures) in place that will enable you track progress towards your goal?

Source: NHS Scotland – Science of Improvement Learning Sessions (The Improvement Guide by API)

PrimaryDriversOutcome

SecondaryDrivers

Ideas for ProcessChanges

AIM:A New

ME!

Calories In

Limit dailyintake

TrackCalories

CaloriesOut

Substitutelow calorie

foods

Avoidalcohol

Work out 5days

Bike towork

PlanMeals

Drink H2ONot Soda

drives

drives

drives

drives

drives

drives

drives

drives

• Weight• BMI• Body Fat• Waist size

• Daily caloriecount

• Exercisecalorie count

• Days betweenworkouts

• Avg drinks/week

• Runningcalorie total

• % ofopportunitiesused

• Sodas/week

• Meals off-plan/week

• Avg cal/day

Exercise

Fidgiting

HackySack inoffice

Percent of dayson bike

Etc...

Our Teaching SampleUnderstanding the System for Weight Loss with Measures

Source: Richard Scoville, Ph.D.

Measures: What d

oes succe

ss

look like?

What Changes Can We Make That Will Result in Improvement?

• What have others done? • What hunches do we have? • What can we learn as we go along?• Principles:

– Everything goes– Think outside the box– Borrow from other disciplines or organizations– Use established change packages

Source: NHS Scotland – Science of Improvement Learning Sessions (The Improvement Guide by API)

PrimaryDriversOutcome

SecondaryDrivers

Ideas for ProcessChanges

AIM:A New

ME!

Calories In

Limit dailyintake

TrackCalories

CaloriesOut

Substitutelow calorie

foods

Avoidalcohol

Work out 5days

Bike towork

PlanMeals

Drink H2ONot Soda

drives

drives

drives

drives

drives

drives

drives

drives

• Weight• BMI• Body Fat• Waist size

• Daily caloriecount

• Exercisecalorie count

• Days betweenworkouts

• Avg drinks/week

• Runningcalorie total

• % ofopportunitiesused

• Sodas/week

• Meals off-plan/week

• Avg cal/day

Exercise

Fidgiting

HackySack inoffice

Percent of dayson bike

Etc...

Our Teaching SampleUnderstanding the System for Weight Loss with Measures

Source: Richard Scoville, Ph.D.

Action Plan Clearly Defined

ActWhat changes

are to be made?Next cycle?

Plan

Objective, questions and predictions (why)

Plan to carry out the cycle (who, what, where, when)

Study Complete the

analysis of the dataCompare data to

predictionsSummarize

what was learned

DoCarry out the planDocument problemsand unexpectedobservationsBegin analysis of the data

The PDSA Cycle for Learning and Improvement

Source: NHS Scotland – Science of Improvement Learning Sessions (The Improvement Guide by API)

Repeated use of the PDSA cycle

Accumulating in

formatio

n and knowledge

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

Testing andrefining ideas

Implementing newprocedures & systems- sustaining change

Brightidea!

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

How is the methodology applied?

Source: NHS Scotland – Science of Improvement Learning Sessions (The Improvement Guide by API)

Source: IHI.org

Methodology applied to the Frontline e.g. Improving ED Services

Testin

g and a

dapta

tion

A P

S D

A PS D

A P

S D

D SP A

A P

S D

A PS D

A P

S D

D SP A

A P

S D

A PS D

A P

S D

D SP A

A P

S D

A PS D

A P

S D

D SP A

1. Triage 2. Diagnostic Testing

3. Fast TrackPatients

4. Capacity /Demand

Change IdeasSource: NHS Scotland – Science of Improvement Learning Sessions (The Improvement Guide by API)

What do you say when, you are asked – testing why????

• To learn whether the change will result in an improvement

• To predict the amount of improvement possible• To learn how to adapt the change to different

environments• To understand the costs and impact of change• To reduce resistance

© 2004 Institute for Healthcare Improvement

Measurement for Learning and Process Improvement

Measurement for

Research

Purpose To bring new knowledge into daily practice

To discover new knowledge

Tests Many sequential, observable tests

One large "blind" test

Biases Stabilize the biases from test to test

Control for as many biases as possible

Data Gather "just enough" data to learn and complete another cycle

Gather as much data as possible, "just in case"

Duration "Small tests of significant changes" accelerates the rate of improvement

Can take long periods of time to obtain results

Practice:“Make the Invisible, Visible”

Simulation/Other Resources• Teaching the Model for Improvement: (Airplane Game) Training

Guide available at http://www.nahq.org/uploads/apps/files/PDSA%20Simulation%20Training%20Guide.pdf

• Langley GL, 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.

• The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org)

• www.IHI.org

Thank YouQuestions/Discussion