EXECUTION - IHIapp.ihi.org/.../Event-2539/Document-3846/Execution.pdf · 2014. 10. 17. ·...
Transcript of EXECUTION - IHIapp.ihi.org/.../Event-2539/Document-3846/Execution.pdf · 2014. 10. 17. ·...
EXECUTION
October 24, 2014
Real Time Demand Capacity (RTDC) Approach
Identify
Barriers to
Accomplishing
Plans
Focused
Improvements
on Barriers
Real-Time
Matching of
Capacity to
Demand
Shift/Add
Capacity to
Address Large
Mismatches
Copyright © 2013 Institute for Healthcare Improvement
Months: 3 6 9 12 24
. . . .
Larger
Improvement
Projects . . . .
Execution \Ex`e*cu"tion\, n
The act of doing something successfully; using knowledge as distinguished from merely possessing it
Source: Webster's Revised Unabridged Dictionary
By Definition
Objectives
Share some thoughts on disciplines that can
assist in execution
Increase your ability to make improvements in
patient flow
Execution:
A Portfolio of Disciplines
1. Testing and implementation
2. Project management
3. Change management
Testing - trying and adapting ideas to learn what
works in your system
Implementation - making a change a permanent
part of the day to day operation of the system
Testing versus Implementation
Testing to Implementation:Multiple Plan-Do-Study-Act (PDSA) Cycles
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Small Scale Test
Follow-up Tests
Wide-Scale Tests
Implementation
of Change
A P
S D
A P
S D
A Few Tips for Testing
Scale down the size of the initial test of a change (# of patients, staff, units, time period). Learn from any failed tests.
Use multiple PDSA cycles to increase the scale and test over a wider range of conditions.
Set a good tempo for testing
Small scale = Small change
Implementation Strategies to Hold the Gains: A Checklist
Document the standard process and audit it periodically
Make changes to job descriptions as necessary
Assign ownership
Use measurement over time
10
UPMC: Some Standards for RTDC
Daily (M-F) unit bed huddles are required prior to bed meeting
Daily (M-F) bed meeting is mandatory
Each unit is required to submit a prediction sheet (RTDC Management Form) daily; predictions & plans must be documented in writing on the prediction sheet
After the meeting, discharges (potential & confirmed) must be reconciled every 2 hrs minimum by the unit secretary
Nursing leadership presence is required at each bed meeting
Evaluating Results
Note from a Flow Team on the results of
their work:
We improved our “ED LOS for admitted patients”
from 5.1 hours in July to 4.5 hours in August.
Time Series Design
Mar Apr May June July Aug
5.15.2
5.0
4.8
4.6
4.4
4.2
4.5
ED LOS (hrs) for Admitted Patients
13
UPMC Shadyside:
Median ED LOS for Admitted Patients
Execution:
A Portfolio of Disciplines
1.Testing and implementation
2. Project management
3. Change management
Hope is not a plan….
neither is
If only we could….
Some Suggestions on Managing a Project
Designate a Day-to-Day Leader (Project Manager)
Document the work plan: who, what, by when
(Set tempo: 30-60-90 day cycles)
17
To DoWorking
WellPlan (activities and tests -include
who and what)
By
When
1. Start a discharge list by
unit each day
- Flow Team to develop a format for
discharge list and discuss the proposed
process with 3South and 4North
- Kathy to oversee tests of list
11/14
11/17
2. Establish a daily Unit
Bed Huddle to finalize the
discharge list
3. Provide daily feedback
on actual discharges
Step #1: Predict Capacity (available beds plus discharges by unit)
RTDC Work Plan
Some Suggestions on Managing a Project
Designate a Day-to-Day Leader (Project Manager)
Document the work plan: who, what, by when
(Set tempo: 30-60-90 day cycles)
Create a review process to understand if “what,
by when” happened
Keep focused on the goals
Execution:
A Portfolio of Disciplines
1. Testing and implementation
2. Project management
3. Change management
Addressing the people side of change
Prochaska’s Stages of Change
Pre-contemplation
Contemplation
Decision
**Action
Maintenance
Selling an Idea
Needed:
1. A volunteer with a good idea
2. A group of potential adopters
Attributes of an Idea that Facilitate Adoption
Relative Advantage
Simple Trialable Compatible Observable
Adopter Categories
Innovators
Early
Adopters
Early
Majority
Late
Majority
Laggards
2.5% 13.5% 34% 34% 16%
Source: Rogers, 1995
UPMC Mercy
The People Side of Change
The Balancing Act
How do we Engage Staff?
Deliver the message at every possible forum
- not only the how but the why
Shared Governance Committees
Ancillary Department staff meetings
Charge Nurse orientation classes
Resident noon conference
Grand Rounds
Executive Leadership Meetings
How do we Engage Staff?
Establish “what’s in it for me”
Charge RN….as the “Air Traffic Controller” you have a clear map, focused work
Patient Placement….no longer the burden to manage the entire house
ED RN…no longer the need to board patients for extended time
Evening staff RN….no longer the 3 - 7 crunch of 10 patients out & 10 patients in
Daylight staff RN….I’ll be that evening staff nurse soon
How do we Engage Staff?
Show staff that administratively you are supporting them
Provide easy escalation routes when they run into barriers
Put a face to their escalation path
Senior Leadership presence at the Bed Meetings
Leadership presence intermittently at Unit Huddles
How do we Engage Staff?
Give staff daily feedback & recognitionDaily results, what went well yesterday – where are our opportunities
Never create a punitive environment
Give monthly achievement awards, no matter how small
Pizza, bagels, Chex mix, chocolate all work!!
There will be those days….be there for them
Engage the early adoptersCreate apostles & take them on the road
Maintaining Momentum
• As a leader, don’t lose your focus
• Report consistent results/metrics
• Show the effects of work house-wide
• Positive feedback from senior leadership
• Keep the next goal always on the horizon and
visible
Going from Good to Great
Will
Ideas
Execution
References
Berwick D. A primer on leading the improvement of systems. BMJ
1996; 312: 619-622.
Cook T, Campbell D. Quasi-Experimentation. (Boston: Houghton Mifflin
1979)
Langley J, Moen, R, Nolan K, Nolan T, Norman, C, Provost L. The
Improvement Guide. 2nd Edition (San Francisco: Jossey-Bass 2009)
Tufte, E., The Visual Display of Quantitative Information, (Cheshire,
CT:Graphics Press,1983)
References
Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.
Block, P. Flawless Consulting: A Guide to Getting Your Expertise Used. 2nd Edition, Hoboken, NJ: Wiley Inc., 1999.
Heifetz, R. Leadership without Easy Answers.Cambridge, MA: Harvard Press, 1994.
Kotler P., Roberto E. Social Marketing: Strategies for Changing Public Behavior. New York, NY: Free Press, 1989.
Prochaska J., Norcross J. Diclemente C. In Search of How People Change, American Psychologist. September, 1992.
Rogers, E. Diffusion of Innovations. New York, NY: The Free Press, 1995.