© 2004 Institute for Healthcare Improvement The Model for Improvement A Method to Test, Implement,...

© 2004 Institute for Healthcare Improvement

The Model for Improvement

A Method to Test, Implement, and Spread Change Ideas for Improving Care for People

Living with HIV and AIDS


Objectives

List the three improvement questionsDescribe the PDSA CycleIdentify one tip to improve:

Use of aims Use of measures PDSA cycles Team practice


Introduction (15 minutes)

Name Where you work What you doExpectations for the session

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

© 2004 Institute for Healthcare ImprovementThe Model for Improvement was developed by Associates in Process Improvement.


First Question

What are we trying to accomplish?AIM content:

Explicit statement Specific actionsStretch goals

AIM characteristics:Time specificMeasurableDefine participants


Example

The clinic will improve care of HIV/AIDS

patients by making changes in the following

areas: self–management and adherence

support; decision support for clinicians;

clinical information systems; delivery system

design; community linkages; and leadership.

Focusing on education, prevention, and early

intervention, our goals include:


Example

80% of patients with at least one visit every 3 months

85% of patients with documented medication education/adherence counseling

90% of applicable patients with PCP/MAC prophylaxis


AIM Tip #1

Achieve agreement and write the aim clearly


AIM Tip #2

Include numerical goals


AIM Tip #3

Set stretch goals


AIM Tip #4

Avoid aim drift


AIM Tip #5

Be prepared to refocus the aim


Pairs Discussion (10 minutes)

With a partner, discuss your experience with aim statements. What has worked? What has not worked? (3 minutes)

Next, join another pair. Briefly share the highlights of both discussions. Then develop a few tips you would give regarding the development and use of aim statements. (4 minutes)

Last, be prepared to tell the large group one of these tips. (3 minutes)


Second Question

How will we know that a change is an 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


A Family of Measures

Outcome measures

Process measures

Balance measures


Outcome Measures

Measures of the customer or patient


Process Measures

Measures of the workings of the system


Balance Measures

Measures of the other parts of the system


Measurement: Types and Time

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S DD SP A

DATA

Process

Measures

Harm

Outcome Measures


Tips for Measurement #1

Plot data over time Tracking a few key measures over time is the single most powerful tool a team can use.

% Patients with a Visit in Past Three Months



The perfect is the enemy of the good.



Sampling



Integrate measurement into the daily routine



Use both words and numbers


Third Question

What changes can we make that will result in improvement?


Change Concept

While all changes

do not lead to improvement,

all improvement requires change


Change Ideas

Changes to improve care for people living with HIV disease

http://www.IHI.org/IHI/ Topics/HIVAIDS/ HIVDiseaseGeneral/ Changes/


Reflect Back To … (10 minutes total)

The project of which you are most proud, something you were involved with that really improved the situation for patients or for staff. It comes readily to mind because it was/is important to you.


Reflect Back To …

Make a few notes in answer to these questions: What was the project? Who was involved? What changes were made that resulted in an

improvement? What did you learn?


Reflect Back To …

Turn to someone at your table, preferably someone you don’t know or have not yet spoken with.

Introduce yourselves and share your stories.


Debrief

What happened? Collaborative

learning Networking Good ideas ready

for change


What is the PDSA Cycle?

Act

• What 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 data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data


Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S DD SP ALearning fro

m Data

Very small scale test

Follow-up tests

Wide-scale tests of change

Implementation of change


Why Test?

Increase degree of beliefDocument expectations Minimize resistanceLearn and adapt Evaluate costs and side effects


Start Small and Do More

Use of flowsheet will improve care

to known standards

Improved Decision Support

A PS D

APS

D

A PS D

D SP A

DATA

D SP A

Cycle 1A: Adapt Clinic X Standard’s based flow sheet and test with one of Joanne’s patients

Cycle 1B: Revise flowsheet and test with Dr. Burton’s patients next Monday

Cycle 1C: Present refined flowsheet to all 3 clinicians and document feedback

Cycle 1D: Revise and test flowsheet with all patients for one week

Cycle 1E: Implement and monitor the standards


PDSA Tip #1: Scale Down

YearsQuartersMonthsWeeksDaysHoursMinutes

“Drop 2”


PDSA Tip #2: “Oneness”


A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

S D

A P

S D

D S

P A

A P

S D

AP

S D

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

Community Resources

Self-Manage-ment Support

Delivery System Design

Clinical Information Systems

A P

S D

AP

SD

A P

S D

D S

P A

LeadershipDecision Support

PDSA Tip #3: Changes in Parallel


MODEL FOR IMPROVEMENT

Objective for this PDSA Cycle

DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.

DATE:____CYCLE:____

PLAN:QUESTIONS:

PREDICTIONS:

PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE

PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE

PDS

A

STUDY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.

ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.

PDSA Tip #4



PDSA Tip #5

Current Situation Resistant Indifferent Ready

Low Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small Scale Test



Cost of failure small


Very Small Scale Test Small

Scale Test

High Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small Scale Test Small

Scale TestLarge Scale Test

Cost of failure small

Small Scale Test

Large Scale Test

Implement


Ideas for Change (10 minutes)

At your table, develop a small PDSA cycle based on one of the good ideas you heard from our sharing a few minutes ago.

Use the grid from Tip #5 to determine and justify the size of your cycle.


Teams

“A team is a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable.”

--Jon R. Katzenbach


Teams

Team CompositionSystemTechnicalDay-to-day


Team Practice: Tip #1

Team TimeHuddles



Simplify Team ReportsGood bullets; not paragraphsSmaller, more frequent? Other ideas?



Ask forgiveness,

not permission



Learning

with

others


Closing

The Model for ImprovementList the three improvement questionsDescribe the PDSA CycleIdentify a method (tip) to improve:

Use of aimsUse of measuresPDSA cyclesTeam practice


Web Resources

http://www.IHI.org/IHI/Improvement/ ImprovementMethods provides information on improvement methods, strategies, and changes


References

Deming WE. Out of the Crisis. Cambridge, Massachusetts: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1982.

Deming WE. The New Economics. Cambridge, Massachusetts: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1993.

Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco, California: Jossey-Bass; 1996.

© 2004 Institute for Healthcare Improvement The Model for Improvement A Method to Test, Implement,...

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