disene proyectos colaborativos - Organización para la Excelencia

Palancas del Liderazgo y
Proyectos Colaborativos
Cartagena, Junio 2012
Pedro Delgado
Executive Director
Institute for Healthcare Improvement
¿Por qué existimos?
“Entre la atención de salud que
tenemos y la atención que
podríamos tener no hay sólo una
brecha, hay un abismo.”
- Institute of Medicine, Atravesando el Abismo de la Calidad,
2001
Saber...hacer: el “Know-Do” gap
Las Brechas son…
…el resultado de sistemas y procesos no
diseñados de acuerdo a la necesidad**
“Todo sistema está perfectamente diseñado
para lograr exactamente los resultados que
logra”
-Paul Batalden, MD
Rediseño de procesos
Evaluación
www.ihi.org
Executive Quality Academy
White Papers
Necesidad de apalancamiento
• Mejoras en una unidad, para una
‘condicion’…
• No hemos aprendido como obtener
resultados medibles, en corto
tiempo, en muchas ‘condiciones’
para la organizacion entera
Donde esta su organización?
Ambition to Improve Quality
Transformed
organization with
high levels of
quality, safety and
patient satisfaction
everywhere
Islands of excellence
within sea of ordinary
quality and safety
New islands appear,
others go, but no
overall real change
Ordinary Quality
1999
2009
2019
Antecedentes (puntos palanca)
• Lideres bajo presion hacia la
consecucion de resultados
• Observacion y reflexion:
─Pursuing Perfection, 100K Lives, 5M
Lives, IMPACT, IHI/CDC study,
fieldwork, PFCC
• Sintetizacion
• No es una receta magica
Siete puntos de palanca:
para conseguir resultados sistemicos…
1.
2.
3.
4.
5.
6.
7.
Establecimiento de metas sistémicas y seguimiento
de su desarrollo en los niveles mas altos de
gobernabilidad
Construcción de una estrategia implementable para
conseguir los resultados, y seguimiento de su
ejecución a nivel ejecutivo
Canalización de atención hacia las metas sistémicas
Invita a los pacientes y sus familias a ser parte del
equipo!
Involucración del ‘CFO’ en la consecución de las
metas
Involucración de doctores, enfermeras y empleados
Desarrollo de la capacidad para mejorar necesaria
para conseguir las metas
Canalización de la atención
white ball.avi
A Typical Quality Report: “Our Rate of Central Line
Bloodstream Infections Compares Well to Other Hospitals”
The same data, shown another way
The best in
the world
Mind the Gap
15
16
14
12
11
12
11
9
10
8
6
Number of
patients who
got a central
line infection
in our hospital
each quarter.
4
What is being
achieved by the
best in the world
2
0
2007 Q1
Q2
Q3
Q4
2008 Q1
Why eliminate the denominator?
• You don’t need denominators to
compare yourself to yourself, or to the
theoretical ideal, over time
• Denominators add measurement error
• Denominators add measurement waste
• Denominators delay feedback
• Denominators make the problem
abstract, rather than personal
Building Backbone
From………………………To
• Central line infections per
1000 Line Hrs
• Surgical Site Infections/100
cases
• Rate of readmissions
• Harm events per 1000
patient days
• National ranking for
evidence-based medicine
delivery
• # Patients who get
bloodstream infections
• # Patients infected in
surgery
• # Patients readmitted
• # Patients seriously harmed
each month
• # Patients who get defective
care each month
Baseline SSER, Calendar Year 2008, 46 Events
John B.
9/06/2008
Delay in Dx
Shirley H.
12/23/08
Post Proced Death
Florita H.
7/03/2008
Delay in Tx
Wade W.
7/16/2008
Delay in Tx
Baby Boy S.
8/1/2008
Wrong Pt. Procedure
Jimmy P.
Joann E.
7/07/2008
Andrea M.
Nancy H.
9/23/2008
Fall
6/24/2008
6/18/2008
Wrong Site Surgery
Wrong Procedure
Med Error
Alvin G.
Teodur C.
Baby Girl V.
Kyle W.
1/29/08,
2/12/2008
8/17/2008
5/12/2008
9/13/2008
Delay in Tx
Fall
Mother’s Delay in Tx
Delay in Tx
Tamika M
4/21/2008
Med Error
Ursula H.
2/12/2008
Fall
Nicole H.
8/12/2008
Post-proced Cx
Ms. L.
2/14/2008
Delay in Tx
Karen G.
Sandra M.
8/5/2008
12/10/2008
Proced Cx/Delay in Tx
Post Procedure Death
Robert S.
10/13/2008
Fall
Mary D.
3/9/2008
Med Error
Eugene B.
10/27/2008, 10/28/2008
Med Error, Fall
Virginia L.
8/12/2008
Delay in Tx
Chantal E.
6/26/2008
Inapprop Touching
Kathy W.
12/16/2008
Post Proced Loss
of Function
Helene C.
9/5/2008
Fall
Gary B.
6/13/2008
Fall
Lester J.
9/5/2008
Fall
Baby Boy G.
3/25/2008
Med Error
Cynthia M.
10/27/2008
Med Error
Nicole S.
1/4/2008
Delay in Dx
Cynthia K.
11/10/2008
Delay in Tx
Lorena W.
11/10/2008
Post Procedure Death
Joseph R.
9/08/2008
Delay in Dx.
Regina D.
12/9/2008
Wrong Site Surgery
Margaret H.
2/6/2008
Med Error
Lance D.
10/30/2008
Delay in Tx
Dale W.
Priscilla W.
10/12/2008
8/30/2008
Med Error
Delay in Tx
Robert B.
12/2/2008
Post Procedure Death
Calvin P.
4/4/2008
Med Error
Mary C.
12/19/2008
Fall
Gwendolyn P.
10/28/2008
Wrong Implant
Douglas T.
10/18/2008
Med Error
24 Patients & Events – Jan-Dec,2009 vs 46 Total for 2008
Loueene D.
9/23/09
Fall
Beverly S.
2/4/09
Med Error
Robert D.
5/12/09
Post Procedure Death
Edward R.
4/23/09
Wrong Side Procedure
Dorothy R.
1/28/09
Delay In Treatment
Monroe K.
5/18/09
Post Procedure Death
Juanita A.
5/14/09
Delay In Treatment
Michael F.
8/20/09
Retained foreign object
Brenda R.
10/14/09
Delay In Treatment
Peggy P.
7/1/09
Burn
Karen C.
9/28/09
Delay In Treatment
James H.
10/25/09
Post Procedure Death
Lilliam C.
4/3/09
Retained foreign object
47% Reduction SSER from Dec. 08 Baseline
48% Reduction in # of events year to year
Donna S.
6/4/09
Retained foreign object
Yoland C.
7/7/09
Delay in Treatment
Jerry Y.
11/7/09
Fall
Alma M.
11/6/09
Fall
Johnny B.
11/9/09
Fall
Willie B.
11/5/09
Med Error
Sharenda W.
2/15/09
Med Error
Helen C.
11/4/09
Delay In Treatment
Pauline M.
11/2/09
Fall
Scott G.
9/5/09
Delay in Treatment
Ronnie D.
11/3/09
Delay in Treatment
2010
Lois R.
4/16/10
Surgical Fire
Sylvia L.
3/31/10
Delay In Dx
Frank S.
2/22/10
Surgery Cx
Mary B.
5/22/10
Post Procedure Cx
Lamar A.
6/3/10
Med Error
Bruce C.
5/25/10
Delay In Dx
Marilyn C.
1/21/10
Med Error
Ruby B.
5/30/10
Fall
Doyle L.
7/22/10
Med Error
Transparency...
• Pushes internal performance
• Sustains Will through distractions of
─Financial challenges
─Leadership changes
─New mandates
Why go transparent?
• If you look bad…
─There’s little risk that patients will leave you or
sue you, just because of the data
─Your own staff will pay great attention to the
data
─There’s a high likelihood that your
performance will improve, quickly
─Your performance data are going to be public,
anyway, sooner or later
CMS Hospital Quality Alliance program: “Improving Care
Through Information”
Transparency: What it looks like
• “Days since a child was last harmed.”
• “This is our surgical site infection rate. We aren’t
that proud of some of these numbers, frankly.
We’re working on getting better, and we are
asking all the hospitals in the city to publish their
rates, and then let’s all learn how to get better.”
• “We’re posting all of our data on quality , safety
and patient satisfaction results in the waiting
rooms, break rooms, cafeteria, web site…so that
everyone will know how we’re doing, whether it’s
good, bad or ugly.”
Desarrollo de capacidades
Framework:
Leadership for Improvement
1. Set Direction: Mission, Vision and Strategy
Make the future attractive PULL
PUSH Make the status quo uncomfortable
3. Build Will
•
•
•
•
•
•
•
4. Generate Ideas
Plan for Improvement
Set Aims/Allocate Resources
Measure System Performance
Provide Encouragement
Make Financial Linkages
Learn Subject Matter
Work on the Larger System
• Read and Scan Widely, Learn from
other Industries & Disciplines
• Benchmark to Find Ideas
• Listen to Customers
• Invest in Research & Development
• Manage Knowledge
• Understand Organization as a
System
5. Execute Change
• Use Model for Improvement for
Design and Redesign
• Review and Guide Key Initiatives
• Spread Ideas
• Communicate results
• Sustain improved levels of
performance
2. Establish the Foundation
• Reframe Operating Values
• Build Improvement Capability
24 specific components
• Personal Preparation
• Choose and Align the Senior Team
• Build Relationships
• Develop Future Leaders
Execution Framework
Achieve
strategic
goals
Provide leaders for
large system projects
Spread
and sustain
Manage local
improvement
Provide day-to-day
leaders for micro systems
ENVIRONMENT
Build
Capability
INFRASTRUCTURE
Seven Leverage Points
1.
2.
3.
4.
5.
6.
Set specific system-level aims and oversee their
achievement at the highest levels of governance.
Build an executable strategy to achieve the aims, and
oversee the execution at the highest levels of
administration.
Channel attention to system-level aims and measures
Get patients and families on your team!
Engage the CFO in achieving the aims
Engage physicians in achieving the aims
7. Build the improvement capability necessary
to achieve the aims
Questions for Discussion
Discuss at your tables how will you
develop capabilities
• Everyone or a few?
• What is the sequence of development?
• What methods are effective?
What Improvement Skills are
Needed for Each Role?
Everyone
(Staff,
Supervisors,
UBT lead
triad)
Change
Agents
(Middle
Managers,
Stewards,
project leads)
Operational
Leaders
(Executives)
Experts
•
•
•
•
•
•
•
•
•
•
Setting goals and
measures
Identifying
problems
Mapping process
Testing change
Simple waste
reduction
Simple
standardization
Team behaviors
•
•
•
•
•
•
•
•
•
Setting goals and measures
Identifying problems
Mapping process
Sequencing tests of change
Simple understanding
variation
Implementation and spread
Simple waste reduction
Simple standardization
•
•
•
•
Setting direction and big
goals
Execution leadership
Portfolio selection and
management
Managing oversight of
improvement
Being a champion and
sponsor
Understanding variation
to lead
Managing
implementation and
spread
•
•
•
•
Analysis,
prioritization of
portfolios
Deep statistical
process control
Deep improvement
methods
Leadership team
advisory re portfolio
selection, process
Effective plans for
implementation and
spread
Development of…
• Executives
• Managers
• Supervisors and workers
• Internal advisors
Misión del IHI Open School
“Desarrollar las destrezas en calidad y
seguridad del paciente de la próxima
generación de profesionales de la salud a
nivel mundial”
Cursos Disponibles
Visita http://app.ihi.org/lms/home.aspx/spanish
Mejora de la Calidad
•
•
•
•
Fundamentos de la Mejora
El Modelo de Mejora: Su Maquina del Cambio
Midiendo la Mejora
Uniendo todo: ¿Cómo Funciona la Mejora de la Calidad en un Escenario Real de
Atención Sanitaria?
• El Lado Humano de la Mejora de la Calidad
Seguridad del Paciente
•
•
•
•
•
•
Fundamentos de Seguridad de Paciente
Factores Humanos y Seguridad
Trabajo en Equipo y Comunicaciones
Analisis de la Causa Raiz y del Sistema
Comunicacion con el Paciente luego de un Evento Adverso
Introducción a la Cultura de la Seguridad
Liderazgo
• Asi que Quieres ser un Lider en la Atencion Sanitaria
IHI Open School
Contenido
Comunidad
Aprendizaje
Experiencia
l
Capítulos del IHI Open School
402
Capitul
os
En 46 estados de EEUU
Capitulos Internacionales en 53 paises
Developing Improvement Skills in
Senior Executives
Stages of Development
Noriaki Kano
Stage 1 Discovery
• Visit with executives who have been
successful
• Develop system measures
• Site visits and study tours
• Pay attention to quality data, and local
and national benchmarks.
─ http://www.ihi.org/IHI/Results/WhitePapers/WholeSystemMeasuresWhitePaper.htm
• Focus on the meaning, not just the
measure
Know Where You Are
Measure of
Where to Find it
Benchmarking Details
Benefits
Clinical Quality
Hospital Standardized
Mortality Ratio (HSMR)
Available through IHI, make
requests through [email protected] or
- Risk adjusted
- Free of charge
- Trend over time (1998 - 2006)
find a requests template in
“References”
Patient
Satisfaction
HCAHPS: Survey of Patient
Experience available
through Hospital Compare
http://www.hospitalcompare.
hhs.gov
Focus on the most
comprehensive questions:
- “How do patients rate the
hospital overall?”
- “Would patients recommend the
hospital to friends and family?”
- Publically available
- Trend over time (reported
quarterly)
- Geographic comparisons
(national and state averages)
Cost
Effectiveness
The Dartmouth Atlas of
Health Care
http://www.dartmouthatlas.or
g/
Focus On:
- Total Medicare reimbursements
per enrollee during the last two
years of life (2001 - 2005)
- Hospital Care Intensity (HCI)
Index
- Publically available
- Geographic comparisons
(national, state, hospital referral
region)
- Numerous additional measures
available
Financial
Security
Bond Ratings (3 sources):
http://www.moodys.com ,
http://www.standardandpoor
s.com , and
ht://www.fitchratings.com
- Search for your hospital or
hospital system and compare to
standard ranking of bond strength
- Publically available
- National in scale
- Outside review of financial
stability
Stage 2 Learning
•
•
•
•
Lead internal organizational assessment
Attend to the basics – caring for patients and their families
Minimize quality improvement talk
Build the executive team’s connection to reality
─ Senior team and the front line are on the same page
─ “I asked about the days between . . .”
─ Scripted observational rounding
• Mission / vision alignment activities with the medical staff
─ Succession planning and development for medical staff
• Develop a plan to move the metrics (HSMR – “first we fixed
coding, then HAIs, RRTs, sepsis, palliative care,
intensivists . . .”)
Executive Development
Stage 2
•
•
•
•
•
•
•
•
•
•
•
•
•
One on one
Self development
Find who they admire/respect and connect them
External courses (?)
Personally lead a team/initiative
Integrate measurement into their work and job description
Site visits
Reflection with Journals
Internal review
Lead internal company diagnosis
Teach
Peer mentoring
Mission/Vision alignment activities
Stage 3 Implementation
• Strengthen senior team’s capability for oversight and guidance
─ Track drivers on driver diagrams
─ Stimulate tempo and pace; remove barriers
• Develop capacity in middle management
• Transparency
─ “Shared the data with medical staff and the employees for the first time .
. .”
─ “The Board started to see how we compared to others, and how slowly
we were moving the big dots over time . . .”
• Spread strategy
─ “everything, everywhere”
─ “completeness and coverage”
─ Tracking tool
Stage 4 External Promotion
• Connect with your community about quality
goals and progress
─ Paul Levy’s blog
(http://runningahospital.blogspot.com/)
• Deepen board learning and connections with
quality data
• Share your results
• Join national committees and initiatives
• Host site visits and study tours
Patient and Family Centred
Care
ALWAYS EVENTS®
• The term “Always Events” plays opposite to the
well known patient safety “Never Events”
developed by the National Quality Forum and
adopted by the Centres for Medicare and
Medicaid Services to indicate occurrences that
should never happen in the delivery of
healthcare services
49
Goals of the “Always Events” Initiative
• Raising the bar on both provider and patient
expectations
• Introducing a new organizing principle to help galvanize
action and accountability
• Demonstrating how the concept can be implemented in
practice
• Widely disseminating Always Events strategies for
national replication
• Energizing and expanding the movement toward a more
patient- and family-centered healthcare system
50
Always Events
• Communication: The interactions and exchange of
information between patients and providers, as well as
among the team of providers responsible for a patient’s
care, must involve the patient in an appropriate patientcentered way, and
• Care transitions: Patients need an appropriate level of
communication when moving from one provider or health
care setting to another (for example, from primary care
doctor to specialist, from hospital to home, long term
care or rehabilitation facility, and emergency department
to inpatient unit).
51
Always Events 2
• Significant: Patients have identified the experience as
important;
• Evidence-based: The experience is known to be related
to the optimal care of and respect for the patient;
• Measurable: The experience is specific enough that it
is possible to accurately and reliably determine whether
or not it occurred; and
• Affordable: The experience can be achieved by any
organization without substantial renovations, capital
expenditures or the purchase of new equipment or
technology.
52
Table Exercise
• Four areas of concern are:
─COMMUNICATION
─PRIVACY
─PERSONAL CARE
─NUTRITION
• On your table discuss what you as a patient
or carer for a family member would expect
to “always happen” in these areas.
• 10 minutes discussion
53
Implementación
ANALISIS DEL SISTEMA
La “Brecha”
BUENAS IDEAS
(De adentro, de
afuera)
P
IMPLEMENTACION
A
CICLOS DE
PRUEBAS
PEQUENAS CON
CONOCIMIENTO
LOCAL
E
EXITO / SOSTENIBILIDAD
H
¿Qué intentamos lograr?
Cuando
combina las 3
preguntas
con …
¿Cómo sabremos que un
cambio es una mejora?
¿Qué cambios podemos hacer
para obtener mejoras?
El ciclo PHEA:
con él
logramos…
Actuar
Planificar
Estudiar
Hacer
…el modelo de IHI
para el
mejoramiento
El Modelo de Mejoramiento (Langley et al, 1996)
1. Que estamos tratando de
lograr / conseguir?
2. Como sabremos que el cambio
escogido resulta en mejora?
3.Que cambios podemos hacer que
van a resultar en mejora?
Establece tu meta
Cualquier mejoria requiere un
establecimiento de metas. La meta debe
especificar claramente el tiempo y ser
medible; tambien debe especificar la
poblacion de pacientesa que va a ser
afectada
Establece tus medidas
Utiliza medidas cuantificables para definir
si un cambio especifico realmente resulta
en mejoria.
Selecciona los cambios
Toda mejoria requiere cambios, pero no
todos los cambios resultan en mejoria.
Como consecuencia, organizaciones deben
identificar los cambios que mas
probablemente van a resultar en mejoria
Prueba los cambios
El ciclo PHEA te ayudara a probar los
cambios en tu entorno, planificandolo,
haciendolo, observando los resultados y el
proceso y actuando como consecuencia de
los aprendido. Este es un metodo cientifico
para el aprendizaje orientado a la accion
PHEA
Teoria
#
Distancia
Prediccion
140
120
2
3 dobleces
daran
distancia
Distancia: 4m
Direccion: 2
La direccion
de
lanzamiento
(brazo),
desde arriba,
dara
distancia
Distancia: 7m
Direccion: 3
100
Seconds
1
80
X
x
60
X
40
x
20
10
1
2
3
4
5
6
5
6
PDSA
Direccion
3
4
5
3 – Siempre derecho
2 – Algunas curvas
1 – Un desastre…se cae de inmediato
Accuracy
3
2
x
x
3
4
X
1
x
6
1
2
PDSA
PDSA
Theory
#
Time
Prediction
140
X
120
Head to toe
T: 130
A: 2
2
100
Second
s
1
80
60
40
20
3
10
1
2
3
4
4
5
6
4
5
6
PDSA
Accuracy
5
6
3 – All pieces on Sam & positioned
correctly
2 – All pieces on Sam, but one or more is
out of place
1 – One or more pieces are not on Sam.
Accuracy
3
2
1
X
1
2
PDSA
3
El poder de una meta
compartida, ambiciosa
Y una visión sistémica, asociada a
la meta principal a las metas
conductivas
Primary Drivers Secondary Drivers
Perder 15
Kilos en 6
meses (al 20
de Diciembre
2012)
Correr un mini
triatlon…
Diciembre
2012
Programa Escoces de
THE
Seguridad
del
COMMONWEALTH
FUND (2008-2013)
Paciente
Diagrama de Drivers
Disminuir la
mortalidad y los
eventos adversos
hospitalarios en
Escocia
Drivers Primarios
Medidas del
Gobierno Escocés
(Prioridad
Estratégica SP)
Adhesión de
Comites Ejecutivos Seguridad es Clave
Prioridad Estratégica
Drivers Secundarios
Líderes Nacionales adhieren abiertamente a las
metas del PESP, el fracaso no es una opción
- Tiempo y espacio establecidos para lograr
mejoras (no un target:objetivo fijo)
-Los Colegios Reales ayudan a nivel oficial
-Seguridad es un elemento de todo programa
-Estrategia de desarrollo (Consejo Nacional)
-Fuerte acuerdo sobre una serie de resultados y
mediciones
-Calidad -seguridad comprenden 25% de la agenda
--Desarrollo de infrastructura que soporta la mejora
continua y la medición
-Metas de mejora claras en el plan estratégico
Lograr resultados
(deliver) del
programa
-Segmentación de hospitales , enfoque
customizado
-Trabajo con IST, QIS y HES para desarrollar un
enfoque de mejora unificado.
-Apoyo a los CE de todo el país
-Difundir nuevas estrategias de atención
Construir una
Infrastructura
Sustentable para el
Mejoramiento
-Desarrollar expertos en imp. métodos, coaching
-Sistema de medición nacional, análisis cultural
-Trabajo de seguridad migra a agencias espec.
-Programas de training desarrollados en Escocia
- Trabajo con IST, QIS y HES para desarrollar
un enfoque unificado de mejora
Alinear PESP
con el Programa
Nacional de Calidad
y las Mediciones
-Align aims and measures with national
programmes
-Develop a portfolio and execution
model
-Build connection to safety in national
work
-Define within clinical governance
Logrando la meta
Una teoria de como cambiar el sistema
Efecto
Conduce a
Causa
Meta
Articulating Theory:
The “Driver” Model for Reducing Surgical
Harm
OUTCOME
DRIVERS
DESIGN CHANGES
Patient prep.
1. Antibiotics
2. Temp>37C
3. Skin prep.
Reduction in
Surgical Harm
Care Practices
OR Environment
1.Surgical pause
2. Beta blockade
3.Glucose control
1. Teamwork
2. Briefings
Drivers
Secondary Drivers
Appropriate Use of Intensive
Hospital Services (ICU care)
Hospital Care
Identification of Patient
Severity and Wishes with
Respect to End of Life Care
Timely Referral to Palliative
Care and Hospice Options
Appropriate
Utilization of
Resources at the
End of Life
Utilization Measures
(Last
Six Months of Life)
•Hospital Days
•ICU days
•Physician Visits
Identification of Provider
Responsible for Coordination
Coordination of Care
Handoff management
Execution of a Shared Treatment
Plan (for All Providers and
Patient and Family)
Assist Patient and Family to
Establish Goals and Intentions
Patient and Family Support
Preparation of Family
Caregivers to Cope with
Exacerbation
24 Hour Access to Appropriate
Services
Provider Supply
Availability of Providers
Availability of Resources
Mortality Reduction Driver Diagram
Primary Drivers
Reduce
mortality
by 12%
this year
Secondary Drivers
Leadership
Analysis of mortality causes
2x2 review of last 50 patient deaths
Global Trigger Tool review of patient deaths in boxes 3
and 4
Board review on mortality
Communication
between caregivers
Standardization of patient handoffs
SBAR training for clinical staff & physicians
Multi-disciplinary rounds
Identification of attending physician for all patients
High risk patient care
Implement birth bundles
Identification of high risk patients on admission and
during assessments
Rapid Response Team
Increased nursing and physician care
Hospitalists
Intensive/Critical care
Multi-disciplinary rounds
Daily goal sheets
Ventilator bundle
Glycemic control
Remote monitoring of patients
Intensivists
Prevention
Influenza vaccine status of pneumonia patients
Community partnerships to promote care that prevents
critical illness
Eliminate falls with harm
Eliminate pressure ulcers
Sistema Colaborativo:
todos enseñan, todos aprenden
Participantes
Selección
del tema
Grupo de
Planificación
Trabajo de
preparación
Desarrollar el
marco y los
cambios
P
A
P
D
A
S
SA 1
D
S
SA 2
SA 3Publicaciones,
eventos para
compartir
aprendizaje, etc
The IHI Breakthrough Series
Un método de mejora que se basa
en la extensión y adaptación de los
conocimientos existentes en
lugares múltiples para lograr un
objetivo común.
The IHI Breakthrough Series Is Not:
• La investigación para el conocimiento clínico
nuevo
• Un solo valor (solo equipo) se centran
• Pequeños cambios en los sistemas
existentes
• Un proyecto de evaluación comparativa
• Un trabajo de consultoría
IHI Breakthrough Series
(6 to 18 Months Time Frame)
Select
Topic
Participants (10-100 Teams)
(Develop
Mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
A
D
A
S
LS 1
Dissemination
P
P
D
A
S
LS 2
AP1
AP2
D
S
LS 3
AP3*
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
Visits
Sponsors
Publications,
Congress. etc.
Phone Conferences
Assessments
Monthly Team Reports
Holding
the Gains
*AP3 –continue
reporting data as
needed to
document success
Learning Session Objectives
Learning Session 1
Get Ideas
Learning Session 2
Get Methods
Get More Ideas
Get Started
Get Better at Methods
Get a “Stride”
Test all
changes
on small
scale
Action Period 1
Learning Session 3
Celebrate Successes
Get ready to Sustain
and Spread
Test &
implement all
changes
Action Period 2
Overview of the BTS
Trabajo previo
• Comience con un buen soporte líder de alto rango. Formar un equipo piloto y
elaborar una declaración de propósito y enfoque para el trabajo del equipo.
Comienza la recolección de datos útiles. Prepare el panel de historia para LS1
Sesión 1
• Obtener ideas para mejorar. Refina objetivo y las medidas. Desarrollar planes
para pruebas de los cambios para AP1. Comienza a colaborar.
Acción (Período 1)
• Poner a prueba los cambios y obtener retroalimentación de los resultados.
Establecer los informes mensuales. Obtener el apoyo de la colaboración.
• aprendizaje
Sesión 2
• Más ideas para el cambio. Una comprensión más profunda de las pruebas y
puesta en práctica. Superar las barreras. Más colaboración.
IHI Breakthrough Series
(6 to 18 Months Time Frame)
Select
Topic
Participants (10-100 Teams)
(Develop
Mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
A
D
A
S
LS 1
Dissemination
P
P
D
A
S
LS 2
AP1
AP2
D
S
LS 3
AP3*
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
Visits
Sponsors
Publications,
Congress. etc.
Phone Conferences
Assessments
Monthly Team Reports
Holding
the Gains
*AP3 –continue
reporting data as
needed to
document success
…continuación
Acción (Periodo 2)
• Probar los cambios en todas las áreas del paquete sobre el cambio.
Colaborar con los colegas.
• "Convertirse en profesores."
• Comience a hablar más allá de los planes de proyecto piloto.
Sesión 3
• Celebra los resultados. Plan para las ganancias por tenencia y difusión.
Más ideas para el cambio. Desarrollar planes detallados para la función
del equipo en expansión.
Acción (Período 3)
• Continuar con las pruebas y la aplicación del resto de paquete de
cambios. Supervisar las medidas para sostener los logros alcanzados.
Participar en la propagación.
‘Los esenciales’
• Buen tema
• Contenido Técnico:
─Carta de Colaboración
─Cambio del paquete
─Sistema de Medición
• Modelo para la Mejora
• Atención a la estructura:
─Sesiones de aprendizaje y períodos de acción
Seleccion del tema IHI BTS
• La brecha entre la ciencia y la práctica
• Ejemplos de un mejor rendimiento existen
• Un buen "caso de negocio" existe
Berwick DM. Eleven worthy aims for clinical leadership of health system
reform. JAMA 1994; 272: 797-802.
Enfermedades Crónicas
Disease
Parameter
Typical
Best
Diabetes
HbA1c
30% < 8
70% < 8
Asthma
Symptom free
days
<50%
>80%
CHF
Hospital
readmits
>10%/mo
<3%/mo
Depression
Follow-up
<50%
>80%
CVD
LDL< 100mg/dl
<50%
>70%
Cuando estamos listos para hacer una
BTS Collaborative?
Successful changes
Alto
Grado de
creencia
que los
cambios
resultaran
en mejora
Comienzo:
moderado a
alto
Moderado
Unsuccessful
proposed changes
Bajo
Prototipo
Piloto
Al menos 1
o 2 ejemplos
Al menos 8-10
ejemplos
Adopta &
Disemina
Carta de navegación (Charter)
• Un documento para describir y poner en
marcha la colaboración; el establecimiento
de una visión común para el trabajo,
incluyendo:
• Planteamiento del problema, la brecha, con la
declaración de la misión de negocio para la
mejora
• Las metas específicas ... mejorar los
resultados, reducir los costos
• Expectativas ... IHI, las organizaciones
Collaborative Charter:
Reducing Readmissions by Improving Transitions in
Care
Statement of Need
• James, a 68-year-old man, lives at home with Martha,
his wife of 48 years. He was admitted to the hospital with
shortness of breath and diagnosed with pneumonia and
underlying onset of heart failure. He and Martha were
provided with instructions about new medications and
diet before discharge and asked to see his physician in
the office in two weeks. A few days after returning home,
Martha reminded James to schedule his visit to the
physician’s office, but James had difficulty reaching the
scheduler. Finally, he was able to set up a visit for three
weeks later.
Mission
• The mission of this Collaborative is to
bring together patients, cross-continuum
care providers, and other stakeholders
from participating organizations to reduce
readmissions and to increase patient and
family satisfaction with transitions in and
coordination of care. The Collaborative
will be led by faculty and staff from the
Institute for Healthcare Improvement.
Goals
The overall aim of the Collaborative is for participating
hospitals to achieve a breakthrough in the transitions in
care for their patients by September 2010. The specific
goals are:
• Decrease all cause 30-day readmissions in participating
hospitals by 50 percent
• Ninety-five percent or more of patients in participating
hospitals report that hospital staff talked with them about
help needed when they left the hospital; and
• Ninety-five percent or more of patients in participating
hospitals report they got information in writing about
symptoms or health problems to look for after leaving the
hospitals.
Expectations of IHI and of Participating
Organizations
The Institute for Healthcare Improvement and the Collaborative
faculty will:
• Provide a designated IHI Director and Project Manager, in addition
to faculty who have expertise in the subject matter and in
improvement methods….etc.
Participating organizations are expected to:
• Select two medical or surgical units for the front-line improvement
work and a Day-to-Day Leader to drive the work of the front-line
teams. With the support of the Day-to-Day Leader these pilots units
will:
─ Conduct tests of the recommended changes in each of the four areas to
improve transitions home
─ After successful testing and adaption, implement the changes in each
unit.
─ Actively participate on Collaborative conference calls and WebEx
sessions to share learning and results…etc.
Collaborative Charter
• A document to describe and to launch the
collaborative, establishing a common vision for
the work, including:
Problem statement, gap, mission statement with
business case for the improvement
Specific goals…improve outcomes, reduce costs
Expectations...IHI, organizations
Use for marketing, for setting expectations with
the participants, keeping project on track
Measurement System
• The key measures that will be used to
track improvement in the Collaborative
• Definitions of data elements
• Data collection strategies
Used for prework and for Learning Session 1
Building a Measurement System
• Attributes
─Small number (<8) of key measures that refer
to the Collaborative goals
─Together describe a great system of care
Include Outcome, Process and Balancing
measures
─Ideally – clearly defined for common data
collection and reporting (but not necessary)
Measurement System: Unplanned Readmissions
Measure Name Statistic
% CHF Patient
Discharges with
% of Congestive Heart Failure Patient Discharges
with Readmission Within 30 Days
Readmission
Patient and Family
Satisfaction with
Transition
Receiver Satisfaction
with Transition
Teach Back Patient
Education Success
% of HF patients and family caregivers who rate
their satisfaction with discharge planning or the
transition home at the highest level
% of receivers (home health providers, nursing
homes, rehabilitation units) who rate their satisfaction
with the amount of patient information and patient
and family self-activation related to HF patient
transitions home at the highest level
% of time HF patients can Teach Back 75
percent or more of the content related to the
transition home and self-management of heart
failure
Change Package
• The key content for the Collaborative
• A listing of the essential changes needed to get
results
• Ideas with “a pedigree”—either evidence in the
literature or from credible expert opinion
• Organized
─ From broader change concept….to specific
changes…to examples of first tests to try
─ Sequenced…what to work on first, etc.
• This is the heart of the Collaborative and is
needed for Learning Session #1
Portion of Change Package for
Unplanned Readmissions
1.
Enhanced Admission Assessment for PostDischarge Needs
•
Include family caregivers and community providers (e.g., home
health nurses, primary care physicians, HF clinic nurses, etc.) as
full partners in standardized assessment, discharge planning, and
predicting home-going needs.
Reconcile medications upon admission.
Initiate a standard plan of care based on the results of the
assessment.
•
•
2. Enhanced Teaching and Learning
•
•
•
Identify the learner(s) on admission (i.e., the patient and family
caregivers).
Redesign the patient education process to improve patient and
family caregiver understanding of self-care.
Use Teach Back daily in the hospital and during follow-up calls to
assess the patient’s and family caregivers’ understanding of
discharge instructions and ability to do self-care.
The Model for Improvement
When you
combine
the 3
questions
with the…
PDSA
cycle, you
get…
What are we trying to
Accomplish?
How will we know that a
change is an improvement?
What change can we
make that will result in
improvement?
Act
Plan
Study
Do
…the Model
for
Improvement.
The PDSA Cycle for
Learning and Improvement
Act
What changes
are to be made?
Next cycle?
Study
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
Plan
Objective, questions
and predictions (why)
Plan to carry out the
cycle (who, what,
where, when)
Do
Carry out the plan
Document problems
and unexpected
observations
Begin analysis of
the data
Repeated Use of the Cycle
Changes That
Result in
Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
A P
S D
A P
S D
Hunches
Theories
Ideas
Source: Improvement Guide, p 10
Principles for Effective Teaching and
Learning
• Acknowledge the knowledge/expertise in the room
• Define “What’s in it for me” from the participants’
perspective, and be specific
• Respect diverse talents and ways of learning
• Develop interactive learning methods
• Provide opportunities for learners to practice new
knowledge, skills and attitudes
• Encourage contact between participants and
director/faculty
Adapted from Chickering and Gamson, “Seven Principles of Effective
Teaching in Undergraduate Education.”
Types of Learning at Learning
Sessions
Types of Learning/Instruction at LS1
Plenary
Breakout
Team Meeting
Collaborating
Action Period Goals
• This is the time of maximal learning
• Goals:
─Support teams in their improvement work
─Build collaboration and shared learning
─Assess collaboration and progress
Action Period Tools
•
•
•
•
•
First Tests
Conference calls
Listserv
Extranet
Monthly Senior Leader reports
Learning from the BTS:
Project Progress Assessment Scale
0.5 - Intent to Participate
1.0 - Charter and team established
1.5 - Planning for the project has begun
2.0 - Activity, but no changes
2.5 - Changes tested, but no improvement
3.0 - Modest improvement
3.5 - Improvement
4.0 - Significant improvement
4.5 - Sustainable improvement
5.0 - Outstanding sustainable results
Relationship Between Factor Ratings
and % 4’s in BTS (2004)
%4's vs total factor ratings
Seven Factors Rated 15 (Score of 21 = Middle
100
90
ratings of factor)
80
• Focused topic
70
percent 4's
•Great Change Package
• Measures that Work
•Results focused chair,
faculty
• Leverage Early
Adopters
• Teams are motivated
•Individualized support
Best 9 performing BTS’s
60
50
40
Worst 9 performing BTS’s
30
20
10
0
15
17
19
21
23
25
27
29
= 3 Collaboratives
Total R atings on 7 Factors
31
33
35
IHI Experience: Factors that Contribute to
Success in Project Set-up
• Ripe topic with at least moderate degree of belief that theory will
lead to improvement
• Use of clear Charter for recruiting teams
─ Clear numeric breakthrough goals
─ Clear expectations
• Teams have will and resources
─ Aim is customized and aligns with org. strategy
─ Team composition is appropriate
─ Team resources appropriate
─ Day-to-day team leader with adequate time
• Sponsors involved
• Change ideas with a pedigree (Change Package developed from
ideas supplied by experts in the topic)
─ Ideas most powerful
─ Ideas sequenced
IHI Experience: Factors that Contribute to
Success in Project Execution
• Action Oriented: Use of Model for Improvement-lots of testing
• Measurement system that connects testing to tracking progress
─ Each team has goals with measures to match
─ Required monthly reporting with measurement tracked
monthly
• Great Learning sessions
• Robust Action Periods
─ Good communication system (listserv/extranet/ great calls)
• Oversight
─ Tracking progress, participation, connecting teams, fostering
shared learning
• A culture is established with specific values:
• Everybody learns, everybody teaches
• A sense of “family” and support
• Urgency-need results now!
Project Progress Assessment Scale
0.5 - Intent to Participate
1.0 - Charter and team established
1.5 - Planning for the project has begun
2.0 - Activity, but no changes
2.5 - Changes tested, but no improvement
3.0 - Modest improvement
3.5 - Improvement
4.0 - Significant improvement
4.5 - Sustainable improvement
5.0 - Outstanding sustainable results
Assessing Progress on a
BTS: Family of Measures
20
5.0
Average Assessment by Month
90
Number of teams
4.5
15
80
4.0
Comparison BTS
3.5
10
70
Comparison BTS
60
50
3.0
40
2.5
5
Percent o f T eams R at ed 4 o r A b o ve
100
% 4 or higher
A sse ssments fo r C urrent M o nth
30
2.0
0
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
10
1.0
0
A ss essment
Percent o f T eams R ep o rt ing
50
40
30
20
10
0
Dec
Feb
Apr
Jun
LS1
LS1 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
100
90
80
70
60
LS1
20
1.5
Aug
Oct
Percent o f T eams Sub mit t ing D at a
100
90
80
70
60
50
40
30
20
10
0
Dec
Feb
Apr
Jun
Aug
Oct
Percent o f T ea ms o n co nfere nce
100
C a lls
90
80
70
60
50
40
30
20
10
0
LS1
Dec
Feb
Apr
Jun
Aug
Oct
LS1
Dec
Feb
A pr
Jun
A ug
Oct
IHI Breakthrough Series
(6 to 18 Months Time Frame)
Select
Topic
Participants (10-100 Teams)
(Develop
Mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
A
D
A
S
LS 1
Dissemination
P
P
D
A
S
LS 2
AP1
AP2
D
S
LS 3
AP3*
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
Visits
Sponsors
Publications,
Congress. etc.
Phone Conferences
Assessments
Monthly Team Reports
Holding
the Gains
*AP3 –continue
reporting data as
needed to
document success
For Additional Information
The Breakthrough Series: IHI’s Collaborative Model for
Achieving Breakthrough Improvement. IHI Innovation
Series white paper. Boston: Institute for Healthcare
Improvement; 2003. (Free download)
http://www.ihi.org/IHI/Results/WhitePapers/
IHI’s Breakthrough Series College – intensive three day
program offered annually
http://www.ihi.org/IHI/Programs/ProfessionalDevelopment/
References
Chin MH, et al. Improving Diabetes Care in Midwest Community Health Centers With the
Health Disparities Collaborative. Diabetes Care 2004;27:2-8.
Cretin S, Shortell SM, Keeler EB. An Evaluation of Collaborative Interventions to
Improve Chronic Illness Care: Framework and Study Design. Evaluation Review
2004; 28(1):28-51.
Landon BE, et al. Effects of a Quality Improvement Collaborative on the Outcome of Care
of Patients with HIV Infection: The EQHIV Study. Ann Intern Med 2004;140:887-896.
Nembhard IM., Learning and Improving in Quality Improvement Collaboratives: Which
Collaborative Features Do Participants Value Most? HSR: Health Services Research,
2009 (44:2, Part I): 359-378.
Ovretveit J., Bate P., Cleary P., Cretin S., Gustafson D., McInnes K., McLeod H.,
Molfenter T., Plsek P., Robert G., Shortell S., Wilson T. Quality collaboratives:
lessons from research. Quality and Safety in Health Care 2002; 11(4):345-351.
Schonlau M. et al. Evaluation of a Quality Improvement Collaborative in Asthma Care:
Does it Improve Processes and Outcomes of Care? Annals of Family Medicine
2005;3:200-208.
Wilson T., Berwick DM., Cleary PD. What Do Collaborative Improvement Projects Do?
Experience from Seven Countries. Joint Commission Journal on Quality and Safety
2003; 29(2):85-93.
Gracias
• Pedro Delgado, Executive Director
Institute for Healthcare Improvement
20 University Road, 7th Floor
Cambridge, MA
[email protected]