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Effective Design & Sustained Quality Improvement
IDEAS Alumni Event
October 13, 2015
2:30 pm -4:30 pm
Health Quality OntarioThe provincial advisor on the quality of health care in Ontario
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The provincial advisor on the quality
of health care in Ontario
www.HQOntario.ca
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Welcome (Everyone introduce themselves)
Alumni facilitating today’s workshop:
Betty Ann Knutson – Golden Plough Lodge
Stephanie Pearsall – Halton Healthcare
Carol Bennett – Guelph General Hospital
Dr. Val Mueller – Guelph General Hospital
Shannon Maier – Guelph General Hospital
HQO facilitating today’s workshop:
Dave Zago
Tracy Lee
Joe Mauti
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Presenter Disclosures
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• No relationships with commercial interests
• No financial support
• No in-kind support
• No known conflict of interest
• No plan to mitigate potential bias as none are known
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Learning Objectives
After active engagement in this workshop, participants will be better
able to:
• Describe the key questions necessary to designing and sustaining
quality improvement:
– What is the problem? Why is this a problem?
– What can we do differently and how will we know it is better?
– How can we sustain our improvements?
• Demonstrate use of key QI tools to inform each question.
• Describe the importance of adaptive leadership and leading
culture change to support improvement.
• Design an improvement initiative to meet a priority and know what
resources are available to support you.
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www.ideasontario.ca 5
Model for Improvement
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www.ideasontario.ca 6
Something is Wrong Here…
• A 32 year old woman with a previous vaginal delivery
• She is term, at 40 weeks but is tired of being pregnant,
feeling uncomfortable. She asks her doctor for an induction
for “postdates”
• physician documents “wants induction, knows risks.” Team
receives orders for induction, no discussion regarding
rationale.
• Induction started in the
morning, some progression
and an epidural for pain
relief
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But we could do something
about this…
• In the afternoon there is concern about the baby’s
wellbeing and induction is halted for a short time and
restarted
• By later in the day labour begins but baby continues to
deteriorate, evidence of stress
• Patient rushed for stat caesarean section, chaotic
delivery as anesthesia busy in OR and back up has to be
called in
• Baby admitted to NICU
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Initial Data
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And here is how….
Our Aim Statement:
• By the end of the IDEAS 5 month program a process will
be implemented that guides collaborative decision-
making between women, their care providers and the
Maternal Newborn team to reduce the percentage of
postdate inductions occurring before 41 weeks, to less
than the benchmarked 5%.
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Historical Perspectives
• Focus in news media regarding “off label” use of
antipsychotic medication for the management of
dementia without inclusion of diagnosis of “psychosis”
• Incidence of antipsychotic medication at Golden Plough
Lodge quoted as 52.1 % ( from CIHI data base) as
compared to provincial average of 30%
• Recognition that quality of life of people who suffer from
dementia is improved with the judicious use of
antipsychotic medication
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AIM
Our Aim Statement:
• By December 2014, there will be a 50%
reduction in the administration of PRN
antipsychotic medications in a specialized care
unit (Blacklock Cottage)
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Project Charter
Title: Scope/Boundaries:
Team
Executive Sponsor
Team Lead
Process Owner
Improvement Advisor
Team Members
Problem Statement:
Aim Statement:
Measures:
Root Causes of the Problem: Change Ideas:
Anticipated Barriers and Mitigation Strategies: Anticipated Timeline
Key Milestones:
Resources Required: Signatures: Executive Sponsor: _______________________________
Process Owner: __________________________________
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5W2H Method
5W and 2H Response
5 W
What is the problem? Describe it in a single
sentence, so that others will be able to
understand what you mean.
The problem is…
Why is it a problem? What is the pain? This is a problem because…
Where do we encounter the problem? We encounter the problem at (Location) (Time)
when (Specific circumstance)…
Who is impacted? This impacts: (Staff) by…, (Patients) by…,
(Other providers) by … (others) by…
When did we first encounter the problem? We first encountered this problem…
2H
How did we know there was a problem? The symptoms of this problem are…
How often do we encounter this problem? We encounter this problem (x) times and each
encounter is (this big). The problem is getting
(better/worse).
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When starting an improvement initiative it is important to step back and reflect on your current
situation. Use the 5W2H questions below to ensure you have uncovered all key information that is
contributing to the problem area of focus. .
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What are YOU trying to accomplish?
TABLE WORK
Take 5 minutes:
Write your own problem statement and aim statement using the Project Charter
template in your kit.
Take 10 minutes:
Share your draft problem and aim statements with each other at the table.
Listen/ask for clarification.
This is NOT a problem solving exercise. It is a problem definition exercise (problem
statement) with an identification of a better future state (aim statement).
Take 3 minutes: Edit/revise your problem and aim statements.
WHOLE GROUP WORK
Be prepared to share 1 or 2 examples of a problem statement and aim statement.
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Model for Improvement
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Family of Measures
Outcome
• Measures ofwhat youtrying toachieve
Process
• Measuresactivities, tasks,
processes
Balancing
• Measures of other parts of thesystem as we affect processes
and outcomes
• May measure unintendedconsequences
How many measures is the “right” number?
Criteria for Measures
Clearly Defined
Aligned
• Aim
Comparative Data
/Benchmarking
• Internal
• External
Actionable
• Can you influence it
Reasonable
Measurement
Properties
• Reliable
• Valid
• Sensitive to change
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Family of Measures
• Outcome Measure: Reduce the outcome to 5% of
elective postdate inductions delivered before 41 weeks
• Process Measure:
– Discussion regarding the booked inductions at daily morning
huddles
– The percentage of patients that were booked using the induction
referral booking process
– The percentage of huddles that occur with the interdisciplinary
team members to discuss booked inductions
– Percentage of patients that receive education
– Percentage of staff that receive education
– Percentage of patients having an induction with a Bishop’s score
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Family of Measures
Outcome Measure & Key Process Measures
• % reduction in PRN antipsychotic medication for
escalating responsive behaviours
• % increase in confidence of staff to deal with responsive
behaviours through the use of Gentle Persuasive
Approach (GPA)
• Increase in utilization of “white board” as a means of
communication between shifts related to responsive
behaviours
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Family of Measures
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How will YOU know that your
change is an improvement? TABLE WORK
Take 5 minutes:
• Identify and write out one outcome measure and one balance
measure that ties to your aim
Take 5 minutes:
Share your draft measures with each other at the table. Listen/ask for
clarification.
WHOLE GROUP WORK
Be prepared to share 1 or 2 examples.
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The Operational Worksheet
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Model for Improvement
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Root Cause Tools
Common Tools
- 5 Whys
- Process Map
- Stakeholder Analysis
- Driver Diagram
- Fishbone
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Driver Diagram
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Fishbone
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How to Create a Driver
Diagram
1. Clarify your aim statement
2. Identify change ideas and concepts
statement around the structure,
process and norms.
3. Group and organize ideas under
themes (primary drivers).
4. Draw, review and revise.
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Driver Diagram
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Fishbone
Effect
Patients Providers
Places/Equipment Policies/Processes
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What changes can you make to lead
to improvement?TABLE WORK
Take 15 minutes:
• Draft a Driver Diagram
• Draft a Fishbone Diagram
• List 2-5 change ideas from your diagram(s) that you could focus
an early test for improvement and add to your Project Charter
WHOLE GROUP WORK
Be prepared to share 1 or 2 examples.
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BREAK
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Model for Improvement(Dave)
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HIGHLY ADOPTABLE IMPROVEMENT
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Changes
• Key change ideas identified:
– What are your key change ideas
– Standardize method of defining expected date of delivery
– Induction checklist
– Process for referral and booking
– Daily huddles
– Develop and distribute standardized patient information
regarding induction process
– Ensure data integrity
• Tests of change using PDSA
– PDSAs included referral process, standardized EDD
determination, patient information, huddles
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What we have learned:
Adaptive Leadership
• Our challenge was to address the gap between the way things were and
achieving:
– Improved health of our population (mothers and babies)
– Enhanced patient experience
– Reduce total cost of care (LOS, NICU admission etc.)
• With staff education we faced some fear, distress, avoidance and realized
people were facing loss
• How we faced these challenges with adaptive leadership
– Actively listened, let people vent their frustrations, expressed our
curiosity, allowed for disagreement and debate
– Difficult conversations
– Dialogue, tried to change at a pace that was tolerable for staff
– Emotional conviction
– Seeking to understand
– Focusing on supporters, keeping those progressive people engaged
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What we have learned: Highly
Adoptable Improvement
• Factors that were moderate or high risk:
– New booking process (referral form faxed to triage)
– EDD
– Change in practice regarding booking inductions on other
physicians call schedules and relying on colleagues for follow-up
fetal health surveillance (i.e.. U/S, NST)
– Some aspects of booking after 41 weeks seemed harder for
providers
• Countermeasures
– Made changes to form based on feedback for sustainability
– Tried to eliminate double documentation
– Focus on benefits of not having to book all of your own patients
on your own call day (flexibility in scheduling and booked c/s)
– Dialogue regarding plan and fetal health surveillance with triage
visits at 41 weeks
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What we have learned: Data
• It is hard to be statisticians AND clinicians, but
we have learned you need elements of both to be
effective in quality improvement initiatives and in
monitoring practices in terms of patient safety
• Keep it simple
– Quick repeated PDSAs
• Involve all the stakeholders in the collection and
use of data, gaining multiple perspectives
• At the initiation of every project focus on
leadership, strategy, stakeholders, and
measurement
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Run Chart
Fishbone & driver diagram completed
Huddle attendance monitored
PDSA – Booking Form
PDSA Referral form
Staff & Clinician education
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Changes
• Selection of Gentle Persuasive Approach (GPA) to manage
responsive behaviours that may be disturbing, disruptive and/or
potentially harmful to other residents, and/or care partners e.g. staff,
families, volunteers
• Emphasis on the use of GPA as a non-pharmalogical intervention in
managing escalating behaviours before use of PRN pharmalogical
interventions ( specifically antipsychotic drugs, such as Haldol,
Seroquel and Risperdal)
• Improved communication between shifts regarding interventions
useful in redirecting escalating responsive behaviours
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Results/Impact
PDSA on Usage of “Whiteboard” between Shifts
• 5 PDSA’s done from first cycle until present
• Purpose of the “whiteboard” has altered from first cycle
• Intention initially was to alert all staff to responsive behaviours
between shifts; staff were to add yellow sticky notes as to
successful interventions they used with specific residents
• Currently the whiteboard is being used to pass on strategies to
mitigate specific behaviours(s) using GPA
• Challenges:
• consistent use of the whiteboard between shifts
• utilization of the whiteboard by other staff than nursing e.g. dietary,
life enrichment, housekeeping and keeping information on
strategies current
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Overall Challenges
• Learning that RAI-MDS data was not giving us what we needed for
CQI purposes
• Differences in interpretation e.g. “moods and behaviours” versus
“behaviours” as related to “restiveness to care” in RAI-MDS
• Necessity to do data compilation manually e.g. PRN antipsychotic
medication per resident, date and type used
• Introduction of Point of Care documentation has caused PSW
workload to increase; time to document equals &/or more than 60
minutes per shift
• Revert to use of PRN antipsychotic medication to managing
escalating responsive behaviours rather than spending the time to
intervene with GPA
• Ongoing challenge of balancing “task based” workload with time
necessary to do GPA interventions
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Overall Learning
• Use of Whiteboard appears to be effective as a tool for communication
between shifts when used as indicated
• Initial assessment of the use of Gentle Persuasive Approach has appeared
to have had an impact on the administration of PRN antipsychotic
medications; staff are more apt to use GPA as first intervention for
escalating behaviours; appears that use of PRN antipsychotic medication is
“last choice”, rather than ”first choice”
• The importance of examining the data related to PRN antipsychotic
medication in conjunction with the responsive behaviours and developing
strategies to reduce and/or redirect the behaviours(s) seems promising
when conducted with all key players e.g. physician, pharmacist, NP, RPN,
PSW, Life Enrichment staff, Registered Staff (RN/RPN)
• Introduction of Nurse Practitioner has proven to be invaluable for team
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Sustainability
• Continue to collect and analyze data on Blacklock
Cottage
• Continue to meet as a “team” to review strategies for
mitigating responsive behaviours and examining data for
relationships; “equal voice, equal opportunity to influence
plan of care”
• Recognition of “best choice” for intervention for resident
involves all partners at the table: re-examination of how
we conduct 6 week Admission Care Conference and
Annual Care Conference ( future CQI)
• Use of whiteboard throughout Golden Plough Lodge
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Run Chart
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Culture Transformation
“If you want to make enemies, try to change
something”
By Woodrow Wilson
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Town Hall
• Based on what you have worked on today, what
are the adaptive challenges you expect in your
improvement?
• What leadership strategies can you use to
mitigate these?
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Closing
• Tools and Resources: http://shareideas.ca/
• Highly Adoptable Improvement Model
http://www.highlyadoptableqi.com/index.html
• Reflect upon day
• Rough copy of Project Charter
• Evaluation
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