GHA Hospital Engagement Network HAC Learning Collaborative
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Transcript of GHA Hospital Engagement Network HAC Learning Collaborative
GHA Hospital Engagement Network
HAC Learning Collaborative
Webinar ~ September 19, 2012Webinar ~ September 19, 2012
Kelley Dotson, GHAKelley Dotson, GHAFreya Gilbert, Hughston HospitalFreya Gilbert, Hughston Hospital
Meryl Montgomery, MCCGMeryl Montgomery, MCCG
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Follow-Up from 8/28 Evaluations
• Technical Issues with Webinar– Screen and volume– Transcript with handouts– View the presenters
• Webinar Material Availability– Agenda emailed with links– Materials posted to GHA website
• Participation in Sharing and Learning– Allow participant to submit questions/requests prior to webinar– Open forum during webinar to allow sharing– Small group meetings with similar hospitals– Subscribe to the list serve at HealthcareCommunities.org (exchange info-
EBP, Examples)
• Application of Reliability Concepts– Hospitals examples through presentations– Open forum for exchange of information
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
• Review concepts of the Reliability Theory used at specific hospitals
• Discuss improvement work for reliable design concepts
• Share struggles and ideas related to using concepts of the Reliability Theory
Learning Objectives
Reliability Theory Concepts in Practice
Med Rec - Hughston Hospital
Freya Gilbert, RNAdministrative Director of
Quality & Clinical PracticeHughston Hospital
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Analyzing Testing & ImplementingQuestion the Connection
Key Question Your Evaluation
Is the connection between goals and processes clear? (Failure to connect process measures to outcome goals makes no sense!)
Medication Reconciliation-We learned to have an overall measurable goal and then to develop short term goals and objectives. Finding some objectives that we could reach quickly. Accomplishing quick wins starts the momentum and facilitates engagement from the front line staff.
Is the design strategy primarily vigilance and hard work?
Has some degree of segmentation been used to test?
Is standard work with testing been part of the design?
Is a design methodology being used?
Are small tests of change being used in a rapid cycle?
Is data collection rapid enough?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Analyzing Testing & ImplementingQuestion the Design
StrategyKey Question Your EvaluationIs the connection between goals and process clear?
Is the design strategy primarily vigilance and hard work? (Am I guilty of using hard work and vigilance as my only strategy)
Hard work is involved with any project but a focused on drilling down to processes to simplify. Process flow chart completed on steps for admitting patient at each point. Looked at differences and planned on ways to standardize process. Stratagy was to motivate front line staff by involving them in each step of the improvement process. Ask about their needs and thoughts for improvement.
Has some degree of segmentation been used to test?
Is standard work with testing been part of the design?
Is a design methodology being used?
Are small tests of change being used in a rapid cycle?
Is data collection rapid enough?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
How to Measure Human Factor
How to Measure the Human Factor Human
Factor Tests of Study the Design Process
Identify Human Factor Tests of Change &
Resulting Defects
Develop Process to Resolve Defects
Performance Rate = LESS than 95%
Performance Rate = 95% or GREATER
Processes are varied, optional, & dependent upon human factor•Common equipment•Standard order sheets •Personal check lists•Written policies/procedures •Multiple choice protocols
Processes are standard, routine, & instigate human factor•Decision aids•Prompters•Standard defaults •Hard stops•Redundant processes
Compliance feedback shared without solutions = “Work harder” next time
Good Intent to Comply + Vigilance & Hard Work Process Failure Invited Performance NOT Sustained
Habits, patterns, & schedules used in the process design to enhance compliance
Human Factors (at least 25%) + Reliability Science
Process Failure Prevented, Identified, Mitigated Performance Sustained
Education and training to provide information to increase awareness with NO standard process specified
Education and training provides information to increase knowledge with processes specified, articulated, & tested
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Analyzing Testing & ImplementingQuestion SEGMENTATION
Key Question Your EvaluationIs the connection between goals and process clear?
Is the design strategy primarily vigilance and hard work? (Am I guilty of using hard work and vigilance as my only strategy)
Has some degree of segmentation been used to test?
Yes. We looked at each step of our medication reconciliation process by admission type & location. Focus was placed on obtaining the initial medication history.
Is standard work with testing been part of the design?
Is a design methodology being used?
Are small tests of change being used in a rapid cycle?
Is data collection rapid enough?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Segmentation-Enables control of some variables -Defines boundaries success of
sequential expectations-Tests validity rather than addressing the barriers -Forces understanding of the
differences among segment -Fosters deeper understanding of design complexity -Allows the formation of predictable timelines
• Finding the FIRST Segment– MUST represent a reasonable volume– Should have clearly defined boundaries– Involve willing participants to avoid barrier of agreeing– Allows neutralization of key variables or barriers– Establishes a design theme
• Identifying OTHER Segments– Total segment topics not to exceed 4-5– Segment follows design theme (type of admission, physician,
etc.)
– Segments differ by a distinct design feature– Adjustment of the initial segment division as the design
develops– Segments cover the population involved in the topic
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Testing & ImplementingQuestion STANDARDIZATION vs STANDARD
WORK
Key Question Your EvaluationIs the connection between goals and process clear?
Is the design strategy primarily vigilance and hard work? (Am I guilty of using hard work and vigilance as my only strategy)
Has some degree of segmentation been used to test?
Is standard work with testing been part of the design?
Yes. We analyzed a specific step in a process to determine working, identified possible failures and an improvement goal, and then standardized process for all admitting units, and continue to test.
Is a design methodology being used?
Are small tests of change being used in a rapid cycle?
Is data collection rapid enough?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Standardization - Standard Work
*KEY LEARNING POINT*
A standardized process design using knowledge of human factors & acceptable science is superior to varied processes
•Allows training of new employees & enables testing of current employees•Provide the appropriate infrastructure (the how, what, where, who & when)
– The “what” we are standardizing is based on scientific evidence• Initial standardized protocol requires little time when testing a very small scale• Changes to the protocol in the initial stages should be required and encouraged
– The “how” is based on systems knowledge and does not require scientific evidence• Defects are studied and used to redesign the process
Successful description of a process by 5 front line process users likely to achieve 95% performance
& to sustain the performance over time
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Key Question Your EvaluationIs the connection between goals and process clear?
Is the design strategy primarily vigilance and hard work? (Am I guilty of using hard work and vigilance as my only strategy)
Has some degree of segmentation been used to test?
Is standard work with testing been part of the design?
Is a design methodology being used? Lean Six Sigma, Plan Do Check Act Tools used were audit form, walk through of process on each unit, flow chart each unit, FMEA, analysis of results, run charts
Are small tests of change being used in a rapid cycle?
Is data collection rapid enough?
Analyzing Testing & Implementing
Question the DESIGN METHODOLOGY
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Three Step Design for Reliability
Steps Techniques1. Prevent initial failure by standardizing
the process to achieve 80%a. Identify the process to standardize
b. Segment the population to test the design for anomalies
2. Identify failures in step 1 and apply an
action to achieve 80% for these failures
a. Utilize a robust concept to make visible failures from step 1 after step 1 has achieved 80% reliability
b. Once the failure is identified, apply an action to mitigate the failure
3. In either step 1 and/or step 2 detect the
failures and use the knowledge from
analysis of the failures to redesign
a. Identify common failures
b. Develop a method to measure & study failures
c. Utilize knowledge of common failures to redesign either step 1 or step 2
Points to Remember- Perfection is the enemy of DESIGN - Constant testing of observed defects- The design is designed by the people who use the design - Segmentation tests the design
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Analyzing Testing & ImplementingQuestion the SMALL, RAPID CYCLE
TESTSKey Question Your EvaluationIs the connection between goals and process clear?
Is the design strategy primarily vigilance and hard work?
Has some degree of segmentation been used to test?
Is standard work with testing been part of the design?
Is a design methodology being used?
Are small tests of change being used in a rapid cycle?
Yes. Data analysis was shifted from the quality department to all members of the team to determine compliance or non-compliance with indicators. This shift enabled the care providers to identify issues from a perspective broader than the focus. When identified, issues would be solved by implementing and testing change or added to the “parking lot” for review at a later time. Collaboration between departments to discuss tests was very beneficial (PACU and Rehabilitation staff).
Is data collection rapid enough?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
How to Evaluate
• Are testing cycles being used on an acceptable basis?
• Are huddles occurring after the tests for quick redesign?
• Are records being kept of the tests?• Do all team members have test
responsibilities?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Analyzing Testing & ImplementingQuestion COLLECTION &
MEASUREMENT
Key Question Your Evaluation
Is the connection between goals and process clear?
Is the design strategy primarily vigilance and hard work? (Am I guilty of using hard work and vigilance as my only strategy)
Has some degree of segmentation been used to test?
Is standard work with testing been part of the design?
Is a design methodology being used?
Are small tests of change being used in a rapid cycle?
Is data collection rapid enough? Yes. Initially, every 2 weeks, and then monthly . Each unit involved obtained & reviewed 10 med rec forms. If a problem was identified went to specific unit and asked staff the questions to identify barriers.
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Design Measurement = Process Measures
Using Failure Modes in Process ReDesign •Assess defects in the current design (Process Failure)•Prioritize failure modes in terms of overall affect on the reliability of the process•Establish process measures based on the prioritized failure modes
– Incorporate established measurement into the INITIAL design– Evaluate process improvement using small samples over time
Using Measurement to Evaluate Design / ReDesign (Process Measures)•Data collected by the team using established process measures•Data collection strictly follows a define tempo / schedule•Data can initially be collected for segments
PROCESS Measurement vs OUTCOME Measurement•Process measures are collected by the primary team
– Process Measure Goals set at 95% (10-2)•Outcome measures are NOT collected by the primary team
– Outcome measures goals set at 0 / 100%
Reliability Theory Concepts in Practice:
HITTING THE WALL - MCCG
Meryl Montgomery, RN, MSNNursing QI Coordinator, Magnet Program
Director
Medical Center of Central Georgia
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**Key Question** What do we do when the team just seems stuck?
•Use the 7 Question Analysis •Check the rules of engagement•Use the spread analysis
Testing Implementation and Spread
Hitting the Wall
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Outcome
Goals
Key
Drivers
2009
Processes
Decrease pressure ulcers
Provide high quality care using processes based on EBP.
- Best practices bundle- Standardization of supplies / devices-Staged surface replacement-Shift assessments-EMR prompted interventions, embedded EBP
HITTING THE WALLPROCESSES TO IMPROVE OUTCOMES
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Outcome
Goals
Key
Drivers
2010
Processes
Decrease pressure ulcers
Provide high quality care using processes based on EBP.
- Critical care specific bundle- NSIC (Nurse Sensitive
Indicator Champion) model- Patient partnership and
education- PAR stock- Mandatory education and
shadowing WOCN- Competency evaluation in sim
lab- Proactive turn clock- Engage procedural units- Monitor leading and lagging
indicators
HITTING THE WALLMore Processes to Improve Outcomes
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PROCESSES - EBP Bundle
Offload pressure with surfaces
Avoid shearing: slides and lifts
Focus on vulnerable times Heel protectors
Body aligner/ wedge Ear, ETT protectors
Other device-specific strategies Chair cushions
Single cloth pad for incontinence No-diapers or plastic
Clean and dry Barrier cream and cleanser
Nutrition POA assessment
Turn q 2 hours Risk assessment each shift
Prevention on admission Sacral pads
Patient/family education HOB<30 degrees
Focus on mobility Out of bed when possible
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
LOTS of processes, hard work and diligence
Outcome
Goals
Key
Drivers
2011
Processes
Decrease pressure ulcers
Provide high quality care using processes based on EBP.
Integrate with falls and Safe Patient Handling: focus on immobility and offloading- SIMPLIFYUpdate bundle for best practicesResearch100% inpatient surfacesDevice-specific bundlesMonthly prevalence for units >5%
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Results: Leading Indicator: use of prevention strategies
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HAPU vs. POA- going in the right direction
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HAPU prevalence rates 3Q10-2Q12
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Stepping Back to Move Beyond the Wall
Review the 7 Questions to Analyze Testing & Implementing
Key Question Your Evaluation
Is the connection between goals & process clear?
√ Connecting goals and EBP processes?
Is the design strategy primarily vigilance and hard work?
OOPS- hard work- re-educate (“nag”). Vigilance- audit (“snitch”)
Has some degree of segmentation been used to test?
SOME- pilot sacral pads in critical care
Is standard work with testing been part of the design?
SOME- however, lack of clarity among care providers
Is a design methodology being used? √ design methodology used?
Are small tests of change being used in a rapid cycle?
SOME- inconsistent.
Is data collection rapid enough? SOME- prevalence quarterly- not enough to test for changes
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Hitting THE WALL in 2012
• Sustain HAPU rate just under <5%• Prevention strategy utilization >70%• Underperform compared to >500 beds and Magnet
hospitals• Focus on education, expectation, engagement,
encouragement, RCA, report out• Join GHA HEN HAC- RCA, process flow, small tests
of changeStepping back- where we are with reliable process design strategies?
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Stepping Back to Move Beyond the Wall
Review the Rules of Engagement
Engage (adaptive)
How does this make the world a better
place?
Educate (technical)
What do we need to know?
Execute (adaptive)
What do we need to do? What can we do
with our resources and culture?
Evaluate (technical)
How do we know we improved safety?
Senior leaders
Staff
Team leaders
Engage Team Members Using the 4 E’s2
www.ahrq.gov/cusptoolkit/2assembleteam/assembleteam.pptx
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Stepping Back to Move Beyond the WallReview the Stages of Engagement
Engagement: “To involve oneself or become occupied; to participate fully and deeply”
Active support of the project
Engaged
Apathy
Aversion
Uninvolved
www.ahrq.gov/cusptoolkit/2assembleteam/assembleteam.pptx
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Stepping Back to Move Beyond the WallKey Questions To Analyze Spread
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Stepping Back to Move Beyond the WallUtilize the Spread Analysis
IHI Science of Improvement Tools•A Framework for Spread: From Local Improvements to System-Wide Change
• A key factor in closing the gap between best practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas.
•Spread Planner • The Spread Planner is a set of questions designed to assist
organizations in identifying the key actions they can take to turn a local success into a system-wide improvement.
http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSpreadingChanges.aspx
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Outcome Goals Key Drivers Current Processes
Decrease
pressure ulcers
A3 Learning from defects/ PDCA Weekly executive rounding
Redundancy - Admission checklist to begin- Immobility/ offload process- Standard work for both RN and CT, but
need clear WWWWHWW- 4 eyes on all admissions
IV5 Interview 5 RN and 5 CT in critical care and med surg to assess reliability of prevention bundle
1x4 NSIC complete tool to monitor prevention aspects for 1 unit, 1 pt, 1 shift•Findings track to barrier busting, addressing human factors•Ex. Hunting and gathering supplies- increased PAR stock
Standard work Turn Team
Moving past the “nag and snitch”*climbing over & going around THE
WALL
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BEFORE attempting the MOVE…What have others done when you hit the wall?
• Present– Stepping back to move forward– EXCHANGE ideas
• Future– Ideas implemented– Beyond the WALL
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Exchange Ideas to Prevent HACsFalls – Med Rec – Pressure Ulcers - VTEs
Possible Topics for Discussion among Participants•Tips for doing Small Tests using “1”•Results from Data Collection/Analysis•Successful interventions for each HAC•Beneficial Tools and/or Frameworks •Evidence Based Practice (EBP) guides/tools•Supportive research findings•Policy / Procedure development
**Remember to email questions/requests to [email protected] if
preference is to anonymously initiate a discussion**
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
To-Do List
• Submit process data• Collect data using the worksheet
• Email data to [email protected]• Current collection should be the 3rd month of process data collection
and submission
• Complete the electronic evaluation
• Remember…complete & send the sign-in sheet if listening to the recording
• Join the Georgia HEN Community of Practice on the HealthcareCommunities.org website• List Serve is excellent way for hospitals to share information
• List serve is excellent way for HEN to provide information
Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.
Keep the Drum Beat Keep the Drum Beat Going.Going.
Educational TELNET/Webinars
Next Telnet/Webinar
•3rd Wednesday every month•October 17, 2012•11:00 am – 12:00 pm