Change for the Better in Your Facility

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Change for the Better in Your Facility
Change for the Better in Your Facility:
some helpful frameworks
Susanne Salem-Schatz
MA Coalition for the Prevention of Medical Errors
HealthCare Quality Initiatives
Sharon Benjamin, Ph.D.
Alchemy
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Objectives
The participant will be able to:
•
Identify at least 2 adaptive strategies for
engaging front line staff in improvement
initiatives
• Understand and recognize technical vs.
adaptive challenges and have some initial ideas
on what strategies to use in each situation
• Describe at least 2 features of the quality
improvement framework
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So Far You Have Heard



Why it is important not to use antibiotics
unless absolutely necessary;
How the high prevalence of asymptomatic
bacteriuria in the elderly can lead to
unnecessary antibiotic use;
Expert recommendations for when to test and
when to treat a suspected UTI;
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I’m Convinced…



Much of what we heard today is not as widely
understood as it should be.
Long-standing and habitual practices can
actually harm the people we are trying to help.
Changing practices about urine testing and
treatment of the elderly is very reasonable.
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Time for Change

Seems like it should be easy



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Now we know better
We intend to make a change
We are sure others will follow suit when we share what we
have learned.
Not so fast!



Change can be hard and good intentions are not enough.
Not all change is the same
Different people need different reasons to change
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Good News: We Can Help You
Make Successful Change
We offer tools and strategies to improve your
chances of success, and
Proven organizational approaches to practice
improvement
►
►
Engagement strategies for finding better ideas
A quality improvement framework
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Two Kinds of Problems
Require Different Change Approaches
Technical problems have right answers!
These solutions usually get mandated by
leadership.
Problems that require people to change their
behavior, or organizations to change their
culture, require flexible solutions than emerge
from engaging everyone.
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Technical Change
Technical challenges are problems that melt in
the face of evidence about how to improve
outcomes.
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Toyota helped make the assembly of cars vastly
more efficient and profitable.
Giving possible heart attack
victims aspirin improves
mortality.
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Technical Problems
Are often permanently solved as research and evidence accumulate
about the best ways to do things.
New technology often opens the door to solving stubborn
problems.
Technical problems have right answers that can be universally
applied and are usually mandated by leaders.
Technical problems usually have COMPLICATED solutions such
as new technology, processes and procedures.
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But Not All Problems Are
Technical
There is a category of problem that resists permanent solution
because they relate to people and their decisions and behavior.
Such as what to do when you notice a change in a resident’s health
or mental status.
Knowing what to do requires critical thinking not a checklist.
Treating this kind of problem as a technical problem leads to
confusion, frustration, resignation and cynicism.
One size doesn’t fit all!
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We Often Get Confused And Try Technical
Solutions for Nontechnical Problems
≠
What works in technical situations often doesn’t work with challenges that
relate to human behavior.
We need solutions that ADAPT to human needs.
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Problems & Opportunities
Awareness Iceberg
4%
known to
top leaders
9%
known to
middle managers
74%
known to
supervisors
100%
Action
unleashed @
the front line
known to
the front line &
customers
Yoshida, S., (1989) Quality improvement and TQC management at Calsonic in Japan and Overseas,
Paper presented at the Second International Quality Symposium, Mexico.
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Including Front Line Staff


Engages the very people “whose behavior needs
to change to solve the problem” to identify
existing solutions from within
Front line engagement & ownership can:
elicit good ideas that account for day to day
realities
suppress the “immune rejection response”
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Over and over we discovered
staff who had better
practices. And staff helped
develop even better ideas….
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Harrington staff step up the fight
against hospital acquired infections
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What You Can Do


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Expand the circle of your conversation
Don’t rely solely on education
ASK about their experience


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What do they know about the problem?
What would they like to know?
What keeps them doing the right thing 100% of
the time?
What ideas do they have that might help?
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Organize Your Learning with Quality
Improvement Tools and Strategies
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The Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make
that will result in improvement?
Act
Plan
Study
Do
Setting Aims
Establishing Measures
Selecting Changes
W. Edwards Deming
*2001 Associates in Process Improvement
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Model for Improvement in Action
100% of residents with treated UTI will meet criteria
for urine testing
•Proportion of reviewed UTI cases that meet
program criteria
•Rates of urine culture, UTI, CDI
•Educate
all staff and engage them in identifying and
•
testing practice change solutions
•Use decision support tools
•Review cases daily; share results monthly
Act
Plan
Study
Do
Aim
Measures
Changes
*2001 Associates in Process Improvement
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Act Plan
Study
PDSA: Small Tests of Change
Do
Plan:
•
•
•
•
•
•
1 small change to test
Predict what will happen
Decide on what data to
evaluate test
Do:
•
Study
Run the test
Document problems and
observations
Organize your data
•
•
Analyze your data
Compare results to your
predictions
Summarize what you have
learned
Act
•
Decide what to do next
•
More testing?
•
Try something else?
•
Finalize the change?
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Some Tips For Testing


Small tests of change
Rule of 1
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Test over a short period of time
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1 patient/resident – 1 staff person – 1 day
If they say weeks, think days
If they say days, think hours
PDSA Worksheet to plan your test

Call for help!
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Planning your Changes
(in your handouts)
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Using the model for improvement to prevent
transmission of CDI: How Franciscan Hospital for
Children makes it work.
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Improve Communication of Current Precautions
Status: Cycle 1
PLAN:
•Standardize
location of signage
•Store precautions
signage in
convenient location
near/with PPE
ACT:
•Reduce size of
signs; magnetize
signs to attach to
door frame
•Reconsider
signage storage
options
DO:
CHECK:
•Sign holders too big for
available space to
accommodate 4 signs per
room
•Sign fit well in holders;
concern sign holders will
break from continual
expansion to remove/replace
signs
•Installed sign
holder outside room
•Stored one of each
precaution signs in
each sign holder
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Improve Communication of Current Precautions
Status: Cycle 2
PLAN:
•Reduce sign size;
magnetize
•Store extra signs in
folder attached to
precautions cart
DO:
•Created 4”X3” print
area
•Printed on magnetic
sheets
•Placed on metal door
frame
•Attached plastic folder
to cart; filled with one
of each precautions
signs
ACT:
•Investigate smaller
other sign holders
•Create signs to fit
CHECK:
•Sign was easily
knocked off frame.
•Signs were too small.
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Aim: Improve Communication of Current Precautions Status
Improved
adherence to
current
precautions
AP
SD
Cycle 1E: Implement sign
holders for all rooms
Cycle 1D: Educate clinical, ancillary,
and support staff on new signage
AP
SD
Delays in
precautions
implementation
Cycle 1C:Increase size, post in plastic sign
holder, test on one room get feedback
Cycle 1B:Reduce size, magnetize for doorframe
placement. Test on one room get feedback.
Cycle 1A: Standardize precautions signage location, test
on one room, and get feedback
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Collaborative Results 2012-2013
(N=17)
45.0
41.3
28%
40.0
35.0
29.8
30.0
37%
25.0
17.7
20.0
15.0
10.0
5.0
47%
Baseline Period*
Prevention Activity Period**
11.1
2.8 1.6
0.0
Facility CDI
Rate
Facility UTI
Rate
Urine Culture
Rate
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2012-2013 (N=14)
% of UTI meeting criteria for signs & symptoms
80.00%
70.00%
72%
60.00%
50.00%
40.00%
30.00%
38%
20.00%
10.00%
0.00%
30

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