The Science of Improvement Part 2The Science of Improvement Part 2Dwight EvansThe speaker does not have any relevant financial relationships with any commercial interests

“Science of Improvement”

Basically the Scientific Method:

Measure the current process

Analyze the steps in the process (process

mapping)

Experiments changing the process (RCI)

Measuring the new results (Q and Pt safety)

Analysis: accept (incorporate into your

processes) or reject the change studied

“Science of Improvement” Characteristics

Team-based

Must follow chosen “Method” for S of I

Value People/Respect/Communicate

Lean: Eliminate non-value added steps

Maximize every staff members’ potential through “standard

work”

A Learning Culture: Relentless reflection, CQI, Pursuit of

excellence

Commitment to quality and patient safety/ Mindfulness

“Improving my work is my work”: the people who Do the work

are the best people to IMPROVE the work

1. Clear Aims for Improvement Improvement is not an accident! To get improvement – You have to start

by declaring your intent to do so: Aim [SMART]

The Aim must be BOLD Project leaders must be very savvy in

negotiating these goals Bias towards Action (try something now

rather than later) Must have a very Pragmatic mindset (theory

is boring, but practical ideas are helpful)

2. Team-Based Improvement

Successful Teams Learn and Use the Methods of the “Science of Improvement” They follow instructions!

The Team: Does its own measurement Measures its progress frequently Plots its measurements graphically Posts the graphs in the area where the

improvement is happening

3. Build Infrastructure Paradox: Teams working in resource poor

areas excel in creating local infrastructure. Why? Being resource poor nurtures

cleverness and innovation A relationship between resource availability

and willingness to change Does it take a “burning platform” to motivate

people to change? Leadership role: unleash latent talent to

make a productive change in system

4. Alter the Political Environment

Successful improvement efforts comes from teams that are Agile in handling the political context in which they work “Manage Well” in keeping projects

going despite shifting political winds and changing administrative staff members

Successful teams do it with balance, gracefulness, wisdom in a long-term time frame (stability)

Model for Improvement - ReviewModel for Improvement - Review

The seeming SimplicitySimplicity of the Model for Improvement contradicts its sophistication; breakthrough in performance depends on four simple steps: Set Aims Define Measures / Mapping the Process Find promising ideas for Change Test these ideas in real work setting

[PDSA] with multiple “RCI”

What are we trying toaccomplish?

change is an improvement?

What changes can we make that will result in the

improvements that we seek ?

Model for improvement

Act Plan

Study Do

change principles

testing ideas before implementing changes

goals and aims

measuresHow will we know that a

Trystorming

• Rapid Tests of Change (RCI = Multiple PDSA cycles)

• PDSA SDSA

Revised conceptual model of plan–do–study–act (PDSA) methodology.4.

Ogrinc G , and Shojania K G BMJ Qual Saf 2014;23:265-267

S of I Process curve…..S of I Process curve…..

Morale

Denial

Anger

Understanding

Learning

Continuous improvement

Despair

Fun?

Lost

Clues

Emotionalevent

timeA few months

FearAngerShame

“Success is how far you bounce when you hit bottom”

[Learn from your failures!] *Patton

New Healthcare Rules for the 21New Healthcare Rules for the 21stst CenturyCentury

Old Rules:

1. Care is based on visits

2. Professional Autonomy drives variability

3. Professionals control care

4. Information is in a closed record

New Rules:1. Care is based on

continuous healing relationships

2. Care is customized according to patient needs and values

3. The patient is the source of control

4. Knowledge is shared and information flows freely

New Healthcare Rules for the 21New Healthcare Rules for the 21stst CenturyCentury

Old Rules:

5. Decision-making is based on

training and experience

6. Do no harm is an individual

responsibility

7. Secrecy is necessary

8. The system reacts to needs

New Rules:

5. Decision making is

evidence-based

6. Patient Safety is a system

property

7. Transparency is necessary

8. Needs are anticipated

New Healthcare Rules for the 21New Healthcare Rules for the 21stst CenturyCentury

Old Rules:

9. Cost Reduction is sought

10. Preference is given to professional roles over the system

New Rules:

9. Waste is continuously decreased

10. Cooperation among clinicians is a priority

A Transformative Model

Current:

Disease oriented

Find it, fix it

Biomedical interventions

Reactive

Sporadic

Individual left to enact

Physician-directed

Whole Person Care:

Health oriented

Identify risk, minimize it

Whole person approaches

Proactive

Lifelong planning

Support in implementation

Team/Partnership-based

Comprehensive HealthCareCoordinated with local churches’

mission Centers of Influence

Medical aspect: Integrated primary care with specialty care

Mt. 4: 23

Health Ministry’s Vision

Patient-centered care Training to change the focus Efficient delivery of care

Continuous Relationship Engagement vs an encounter

Science of Improvement: Quality Patient Safety

Health Ministry’s Vision

Team care (not group care) High performing teams operating at the top

end of every member’s license /capability Thus, each HC facility is

A learning organization

Core concepts: Shared decision making Sustained [patient –clinician]relationships Inter-professional collaboration

Health Ministry’s Vision

First Step Acknowledge that we all have limited

Time Finances Space

Therefore, HealthCare facilities must invent new ways of applying, and using their existing resources to meet patient needs

“It’s not what you have, but what you do with what you have”

J. Schumpeter

Second Step

Develop A HealthCare culture marked by innovation that values: Patient Safety Understanding Risk Redesigning Systems Improving care based on data Engaging patients while honoring

their preferences

Why are people so anxious to proclaim: “Let me be the devil’s advocate” ? A devil’s advocate is an idea killer

Why not an Angel’s Advocate? An Angel’s Advocate knows that identifying

a problem takes no particular genius, However, discovering issues and then

working collaboratively to develop solutions however does

Angel’s Vs. Devil’s Advocate

Innovation

“Always be bad at something you are passionate about”

What does this mean? Always be a beginner at something Always be in love with what you are

beginning

What then is “Science of Improvement”? [Quality and Pt. Safety][Quality and Pt. Safety]

Quality is a way of thinking about work

Quality is how you approach work every day for yourself personally and for those you serve

Quality is not about a staff title or using the latest catchy phrase

Take Home Message

Quality and Patient Safety are not compulsory … Neither is survival.*

Quality measurement will be progressively more focused on outcome measures

Boards and Senior leadership must spend significant time reviewing quality and safety issues Know your “metrics” and act on them

*with apologies to W. Edwards Deming

“All Teach,

All Learn!”

InvitationInvitation

Think about the “Science of Improvement principles presented

Try using these ideas and methods in your daily work Start now; do what makes sense to you

Master at least one Improvement methodology; refine it with your good judgment, hard work, and intelligent adaptation of them to the conditions that shape your world

Celebrate your successes and share what you have learned with others – invite them to do what you have done!

“I don’t know what your destiny will

be, but one thing I know, the only

ones among you who will be really

happy are those who have sought

and found how to serve”

Albert Schweitzer

Science of Improvement Themes:

Soon is not a Time!

Some is not a Number!

Hope is not a Plan!

Caring is not Whole Person Care! Compassion without science is well-intentioned kindness; it needs

to be combined with evidence-based medicine and evidence-based HC management

“The Science of Improvement”Is Creating a culture of continuous quality improvement and a “Just Culture”

Improving my work is my work• Every employee has two jobs:

• Their “job description”• Improving how the do their “job”