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Welcome back to the IHI Improvement Coach Professional Development Program Workshop 1Day 3
Welcome back, warm up, questions from day 2
1
Day 2 Debrief
2
Workshop 1: Day 3 Overview
Time Agenda Item
7:00 AM Breakfast available
8:00 AM
9:45 AM Break
• Welcome back, warm up, questions from day 2
• How will we test our change ideas?
• Running real PDSA cycles
• A PDSA exercise
• A case study
• How will we test our change ideas? Planning a PDSA cycle
11:45 AM Lunch
12:45 PM
2:00 PM Break
• Facilitation, part A
• Teamwork and communication: Understanding working styles
• A case study
• Tying it all together
• Day 3 debrief and next steps
4:00 PM Adjourn
3
How do we test our change ideas?
Running Real PDSA Cycles
Day 3
William Peters
February 1st, 2017
Running real PDSA cycles …
Source: Associates for Process Improvement
• Be able to correctly run real PDSA cycles
• Appreciate why it is so critical to ask a question(s) and make a
prediction(s) in the Plan part of a PDSA cycle
• Know the vital task of comparing the data in the Study to the
predictions detailed in the Plan
• Recognize the critical nature that running PDSA cycles, building
knowledge, has on the success of the project and overall
organization
• Appreciate the idea that a failed test is still considered success!
Quality Improvement Fundamentals LLC
5
Running real PDSA cycles …
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
PlanAct
DoStudy
Source: Associates for Process Improvement
Many of these!
The secret? How I know
someone KNOWS PDSA?
“we compare our DATA in the
Study to our PREDICTION(s)
in the Plan”
What is inherent in making a
prediction?
Quality Improvement Fundamentals LLC
6
It is not necessary to change. Survival is
not mandatory. ~W. Edwards Deming
When you are through changing, you are
through. ~Bruce Barton
If nothing ever changed, there'd be no
butterflies. ~Author Unknown
If you want to make enemies, try to change
something. ~Woodrow Wilson(he never met Deming, never learned most people are
open to trying good ideas)
On change …
Quality Improvement Fundamentals LLC
7
DESIGN DESIGN APPROVE
In the conference room
The Typical Approach…
IMPLEMENT
DESIGN DESIGN
…..and in the real world.
8
TEST &
MODIFY
TEST &
MODIFY
APPROVEIF NECESSARY
TEST &
MODIFY
The Quality Improvement Approach
START TO
IMPLEMENT
DESIGN
In the conference room
…..and in the real world.
9
Use scarce resources wisely
Learn more from doing than planning
Learn about the change: Cost, How much improvement,
Side effects
Reduce resistance to change
Increase peoples’ degree of belief in the change
PDSA Cycles: Why Test?
Improvement Guide, 2009, Chapter 7, p. 142
10
At the heart of all improvement
We use SCIENCE to test CHANGES we
THEORIZE will lead to improvement.
Three questions that guide and
support pragmatic rational action
But HOW & WHY does it work so well?
Quality Improvement Fundamentals LLC
11
Remember this?
• The Lens of Profound Knowledge: Theory of Knowledge
and the use of data for improvement … how it works …
Question: “can I get a drink without missing something key?”
Prediction: “yes!, I can make it really fast, < 1 min.!”
The project problem: “I’m thirsty!”
Theory: fountain is close, so, I should have time, 1 min.?
Knowledge: fountain right outside door, w/cool water
Observation/life/experience/doing/living/seeing
New Data: fountain was removedQuality Improvement Fundamentals LLC
12
“No Pass Zone” in effect
(Outcome)
Process Measures focus improvement on processes that directly impact results (outcome indicator)
Lift devices all operational and have
standardized belts
Fall Assessment at admission
Non-cluttered patient room with equipment in
correct position
Focusing on just the results is the
old American “Management by
Objective”
Reminders to nurses about need to prevent falls. Negative consequences
for a nurse whose patient falls
Falls(process)
(process)
(process)
(process)
(process)
Number of
Falls(Outcome measure)
Number of Catches(process measure)
(trash it in favor of a “Just Culture”)
Percent FA at Admin(process measure)
Number of Device Errors(process measure)
“Percent SupraNeat”or maybe “Count of Clutter”
Every outcome is the result of
perfectly designed processes!
Quality Improvement Fundamentals LLC
13
We need data over time to show improvement
Quality Improvement Fundamentals LLC
1Improvement is the result
of a change in the process
and gains are held …3
result is positive, relevant, meaningful …
2
on a measure that matters to the organization
4
REAL
SUSTAINABLE
IMPROVEMENT
14
All improvement requires change but
not all change results in improvement
A simple truth…
The People v. Process (4% v. 96%)
Quality Improvement Fundamentals LLC
15
A lot of people know what CPR stands for
All forms of intelligent life practice science:– Humans: we can do science consciously
– Non-humans: still practice science, don’t know it, but still do …
Building knowledge:– The organization: live and die by the amount of knowledge
– Stuff you “didn’t know you didn’t know”
– About a pretty good idea NOW instead of waiting for “silver bullet”
Test a change BEFORE implementing it!– Huge cost of failure associated with a change IMPLEMENTED before
tested. Failure cannot be measured in $ alone!
– Staff have power to change their work. Testing changes w/PDSA empowers staff, leverages deep SMK and reduces staff resistance.
More detail…
Quality Improvement Fundamentals LLC
16
Activity ≠ Change
Is a change:
Use a new form
Run a review meeting
Use the form on the next 10 cases
New outreach process
Is NOT a change:
(but may be a necessary
preliminary task however)
Planning
Having a meeting
Educating staff
Creating a protocol
Assigning responsibility
A change forces new behavior patterns in
people, or changes the steps/function
within a piece of technology
17
Where “PDSA” fits in …
The “Aim”:“Unit Two will reduce the number of falls with injury
to ZERO by the end of 2014 with the guidance of
Sue Grace CNO”
The measures:Number of Falls
Number of Falls with Injury
Percent Restraints (balancing measure)
Change:1st order change (more resources, more of the
same ideas) VS. 2nd Order Change
(Fundamental change)
PDSA:Multiple cycles run, multiple ideas tested, WHAT
DOES and DOES NOT produce improvement?
BUILD KNOWLEDGE ABOUT THE SYSTEM!
Are negative results as useful as positive
results when caring for a patient? Quality Improvement Fundamentals LLC
18
“I did not fail one thousand times; I have found one thousand ways that won’t work.”
Thomas Edison
19
Failed Test…Now What?
Be sure to distinguish the reason:
– Change was not executed
– Change was executed, but not effective
If the prediction was wrong – not a failure!
– Change was executed but did not result in improvement
– Local improvement did not impact the secondary driver or
outcome
– In either case, we’ve improved our understanding of the system!
Quality Improvement Fundamentals LLC
20
Cycles of Tests Build Knowledge and
Confidence
Proposals, theories, hunches, intuition
Changes that will result in improvement
21
Sustaining improvements
and Spreading changes to
other locations
Developing
a change
Implementing a
change
Testing a
change
Act Plan
Study Do
A pretty
good idea, a
hunch
Test under a
variety of
conditions
Make part of
routine
operations
Act Plan
Study Do
Act Plan
Study Do
Over time, more cycles mean …
… m
ore
KN
OW
LE
DG
E!
Avoid the cost of failure!
“Just do it” vs. (carpet)
Quality Improvement Fundamentals LLC
22
Clinicians already use science
Nurse: “my patient is a newly diagnosed diabetic that is showing signs of confusion, is
sweating a lot and complains of dizziness”
Nurse: “I need to get this blood sugar back in
the normal range between 70 – 110, ASAP!”
Nurse: “Blood sugar was showing noise
until the most recent measure, it was 40!”
Nurse: “patient needs sugar”
“I will order a juice from NuServ and have pt drink immediately. I
predict this will raise blood sugar”.
“I’m giving patient juice and watching them drink it all.
Patient was delighted to do so”.
“Latest blood sugar is 78”
Reduce dose of insulin before meals
P
DS
A
Quality Improvement Fundamentals LLC
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If reality were just that easy…
Some ideas for change are a lot more
complicated than “Just do its”
How would we test the idea for
change …
“Med Pass Sterile Cockpit”
… I guess we could just implement it?
Jump to implementation or test?
Quality Improvement Fundamentals LLC
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Work With and/or Steal Shamelessly
From Others (and give Them Credit)
• Likely someone from your sector has solved the problem or
a piece of it
• If not, likely someone from your sector is currently trying to
solve the problem
• If not, likely someone from your sector has tried to solve
the problem and has failed (and you can learn from them)
• If not, someone from an adjacent sector has worked to
solve a similar problem
• If not, someone from a completely different sector has
worked to solve a problem that could be helpful with the
problem you are facing
25
The nurse who thought of the idea “Med Pass Sterile Cockpit” learned of it from a past employer
– Great! “Borrowing” a change idea is a quick way to improve!
– A lot of nurses were concerned about interruptions that happened during a med pass
– What is a “sterile cockpit”, where did this come from?
– The nurses idea was to have the nurse doing med pass wear a hat that marked her as “do not disturb”.
– Nurse wanted the change idea done now! “We should do this now!”
Beg, borrow & steal …
Quality Improvement Fundamentals LLC
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Benefits of “try B4 buy”…
Jumping to implementation could potentially:– Have a cost of failure is everything doesn’t go smoothly
– Doesn’t take into consideration expert opinion/ideas of staff
– Might not please medical or non-clinical staff
– “Unintentional Chaos” because people are well intentioned …
Testing the idea would potentially:– Lower resistance of nursing staff
– Lower resistance of medical staff
– Attract all involved to improvement, to empowerment!
– Lead to the best possible “Sterile Cockpit Med Pass” process
Quality Improvement Fundamentals LLC
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Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
PLAN: the hardest part of
running a cycle
… and then list ALL the gory details! ALL!When: btw Monday 9/1 and Wednesday 9/3, 9:30 pass
only.
Where: Unit One only, Who: Michelle Roberts all 3 days
Data: vocal feedback from Michelle, RNs on duty, MDs
rounding and any staff who visit unit one, # of
interruptions
How: nurse will place hat on when entering med room. The
only interruptions allowed are emergencies. Unit clerk will
educate staff not involved with test about rules of hat.
Let’s run a cycle …
If we create a “sterile cockpit” during med pass, will nurses find value in not being interrupted? How can we reliably identify a nurse doing a med pass?
The Plan always, ALWAYS, contains a question
and a prediction to the question!
Q
(Prediction never Y/N, no learning in that! WHY? WHY and HOW will it work? WHAT IS YOUR THEORY!)
Interruptions can lead to errors. We had an error here from being interrupted that almost cost the life of a patient! Less interruptions will reduce the room for errors. The nurse doing the med pass will find this idea very attractive.I think we can identify the nurse doing med pass by using a brightly colored hat.
P
After the 1st cycle you can
make life a lot easier by
copy/paste for 2nd cycle …Quality Improvement Fundamentals LLC
28
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
DO: tweak the PLAN &
make sure PLAN is followed
Let’s run a cycle …
The DO is the part when we execute on our PLAN
• Note any tweaks made to PLAN in order to not
cancel test. Reality usually breaks a PLAN
• Are we testing the idea as laid out in the PLAN?
DO9/1/2014: we had to ask Marcy and Daryl to take the
duties of the unit clerk since she was out sick
9/1/2014: initial response from Michelle is very positive.
“I don’t get anxious when someone walks by. Normally I
would think “someone is looking for me””
9/2/2014: Unit clerk still out sick. Marcy going to
continue education people who walk onto unit about the
meaning of the hat
9/2/2014: another RN noted that she gets interrupted by
PTs too. She made her own script that reduces this
9/3/2014: Unit clerk back but Marcy and Daryl going to
finish out last day of test
9/3/2014: test followed planQuality Improvement Fundamentals LLC
29
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
STUDY: compare data to
predictions
Let’s run a cycle …
The STUDY is where we compare our data to our
predictions. Does the data support our
predictions?• Data can be soft (qualitative), can be the opinions and
observations of SMEs
• Data can be hard (quantitative), can be hard numbers
like the # of interruptions
Best practices is to use both hard & soft data in cycles!
STUDYMichelle absolutely loved the huge reduction in interruptions. She counted 6 interruptions over the 3 days, a number she insisted was way lower than without the hat on. All the interruptions were from staff not aware of the details of the test going on. She recommends the hat be switched to a sash bc the hat isn’t that comfortable and will probably fall off depending on hairstyle. Michelle forgot how often PTs interrupt med pass with simple concerns (5 times). RN Lilly noted she asks her patients a set of questions aimed at reducing simple requests while she does med pass. All 3 doctors and staff visiting unit thought the idea was great.
If the data does not support the
prediction in the PLAN we first
check the DO to make sure we
tested the idea as PLANEDQuality Improvement Fundamentals LLC
30
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
ACT: Implement?, Tweak?
or Abandon?
Let’s run a cycle …
ACT is where decide our next steps based on the
data being compared to the prediction• Tweak is trying again a different way the next cycle
• Implement is making the change permanent
• Abandon is not pursuing the idea any more
ACTBased on the number of interruptions, and vocal feedback from all, this idea is worth pursuing. One more cycle is needed to gather enough data to make the case for change compelling for the other three nursing units. For the next cycle, the hat is out and Michelle is going to create 3 sashes each with “Please do not disturb in med pass” stenciled on the front in large letters. All three nurses on Unit One will use the sashes during med pass for the next three weeks. RN Lilly is going to run a cycle with two other nurses to try her script she uses on PTs before the med pass. If we can verify with data the script works at reducing interruptions on the PT side then we will have hard data to support adopting it house wide. We don’t know how many interruptions happen during a typical med pass so a cycle will be run to collect this data to use to sell the idea house wide (and maybe spread to our sister hospitals)
What do we do BEFORE abandoning an idea for change?
Did you know … research uses PDSP[ublish]!
Quality Improvement Fundamentals LLC
31
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
ACT: Implement?, Tweak?
or Abandon?
Let’s run a cycle …
ACT is where decide our next steps based on the
data being compared to the prediction• Tweak is trying again a different way the next cycle
• Implement is making the change permanent
• Abandon is not pursuing the idea any more
What do we do BEFORE abandoning an idea for change?
Did you know … research uses PDSP[ublish]
So after one cycle we:- Know hat won’t work and we will use a labeled sash- The idea brings value as shown in hard/soft data- Uncovered the idea of patient med pass interruptions- Found out RN Lilly has her own script that reduces PT
interruptions so we will test (cycle) a few nurses using it to see if it works and to find the “best fit script” that reduces minor PT requests during med pass
- Learned we don’t know how many interruptions happen so a cycle of learning will be used to find out (use this data to sell)
- Got a lot of people involved in thinking, in improvement, we made improvement an attractive thing
- We reduced resistance to a new change because a lot of staff were involved. Staff will hone final change. EMPOWERMENT!
Quality Improvement Fundamentals LLC
32
On PDSA cycles in general
What is the unit of measure in In tennis? Weight lifting?The unit of measure in improvement is the cycle (PDSA).The best predictor of an improvement teams success at reaching goals is # of … ???
How small should my test be? Think small tests, small enough to accurately answer the questions with enough data to sell idea to others. 1 nurse, 1 Patient, 1 doctor, 1 day…Before implementing a TESTED change, triangulate three things:
When starting improvement, look for the “firestarters” in your organization. Don’t try to convert anyone. Go to the willing, the rest will follow later.
Degree of Belief
ResistanceCost of Failure
Quality Improvement Fundamentals LLC
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KNOWLEDGE is what we want/need!
* More knowledge means better change ideas
* An org lives and dies by what it knows
KNOWLEDGE, with it, no cycle is a failure
“This idea we tested did not result in improvement!”
In healthcare, are negative results as useful as positive?
Theory is so important. The org, WE, need to share our
theory because it drives progress, provides a SHARED
UNDERSTANDING.
Document cycles to avoid well-intentioned chaos, others
can help refine the cycle and the organization can use this
knowledge later because it stored is on the network.
Thinking in cycles is easier with each successive cycle.
A wonderful way to reduce anxiety.
On PDSA cycles in general
Quality Improvement Fundamentals LLC
34
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
PLAN: the hardest part of
running a cycle
Let’s run another cycle …
Will switching to specialized floor mats at side of residents beds result in lower falls and increased resident and env ser satisfaction?
The Plan always, ALWAYS, contains a question
and a prediction to the question!
Q
(Prediction never Y/N, no learning in that! WHY? WHY and HOW will it work? WHAT IS YOUR THEORY!)
Mary will observe no falls during the 3 days.
Environmental services will prefer the placement of the newer mats right after cleaning as they will no longer have wait 15 minutes to come back later to place the older mats.
Residents will appreciate the floor mat always being there instead of having to check to see if there is a mat on the bedside before standing up.
I further predict mold will not be a problem because these same mats are used by public pools
After this cycle, we will have feedback that will confirm we should order mats for the entire facility.
P
After the 1st cycle you can
make life a lot easier by
copy/paste for 2nd cycle …
A large nursing home that wants to purchase
$12,000 of floor mats to reduce falls. The idea
was brought up by an employee who asked some
questions while at a local pool.
This environmental services employee was aware
that a couple of bad falls had occurred because of
missing floor mats. They were missing because
after cleaning the floors they had to dry for 15
minutes before the mats are placed back down on
floor.
Environmental Services employees sometimes
wait > 15 minutes because of competing
priorities/requests.
Quality Improvement Fundamentals LLC
35
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
Plan continued, the gory details:
WHAT: Four of Meyers part # 23746,
“SwabDeck Perforated No-Slip Mat” will be
placed at the side of residents beds
WHERE: in rooms 202, 204, 206 and 208.
WHO: Environmental services staff Andre
Torksen will place mats immediately after the
end of floor cleaning.
DATA: All four residents ambulate and are
currently assigned to Mary Swanson till the end
of the month. She will obtain feedback from the
assigned CNA (Todd Carson) and residents on
their perception of the value of the new mats.
WHEN: New mats come in Monday June 23rd.
This test will start on June 25th with the first floor
cleaning around 4:00 P.M. and run through the
last floor cleaning Friday at 4:00 P.M. (for a total
of three cleaning cycles).
Let’s run another cycle …
Quality Improvement Fundamentals LLC
36
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
DoPlan was carried out as detailed with the exception
that CNA was assigned to another unit on second day
of test. Mary Swanson educated different CNA Liz
Petrowski on the test and will ask her for feedback on
the mats as well as Tod Carson
Environmental Services has said it is way easier on
them to clean and place floor mats. It is one less
round they have to make. Also don’t have chance to
be pulled in another direction before placing mats
back down
Environmental Services also brought up that many
times they have to move personal belongings out of
the way when cleaning floors. Falls have happened
because of personal items.
Let’s run another cycle …
Quality Improvement Fundamentals LLC
37
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
StudyMary observed no falls during the 3 days and
environmental Services said it is way easier on
them to clean and place floor mats. It is one less
round they have to make. Also don’t have chance
to be pulled in another direction before placing
mats back down. This test made them aware
they often move personal belonging in order to
clean floor. Moved items during all cleanings.
Residents commented on 3 occasions that having
the mat down at all times was nice.
CNAs said it was nice to know they wouldn’t slip on
wet floor. One CNA said they had almost fell
before bc of a wet floor around resident’s bed.
Mold cannot form under mat due to material used.
More falls have occurred here due to personal
items versus the missing floor mats.
Let’s run another cycle …
STUDY: compare data to
predictions
Quality Improvement Fundamentals LLC
38
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
ACT: Implement?, Tweak?
or Abandon?
Let’s run another cycle …
ACT is where decide our next steps based on the
data being compared to the prediction• Tweak is trying again a different way the next cycle
• Implement is making the change permanent
• Abandon is not pursuing the idea any more
What do we do BEFORE abandoning an idea for change?
Did you know … research uses PDSP[ublish]
So after one cycle we:- Found another larger area for opportunity to reduce falls- Discovered this test of a change idea led to another idea
because environmental services was asked for feedback
ActAlthough no falls occurred during the 3 floor cleanings,
the “discovery” that residents' personal items are often
moved by environmental services leads us to put a hold
on this idea and pursue testing ideas for change related
to stowing and organizing these items.
Mary, Todd, the residents and environmental services
have been asked to brainstorm ideas for change related
to personal belongings.
Floor mat idea shelved until this area of opp is worked.
Quality Improvement Fundamentals LLC
39
We can provide you with a best practices PDSA short form to
start testing right away
Just make sure you share before Plan, before you start to test
Is there a PDSA tool to use?40
Best indicator of a projects success is the # of cycles run
PLAN is the longest part to generate
PLAN must have a change, question & a prediction in detail
PLAN must have some sort of data to learn from
PLAN also must have all the gory details, who, what, when …
DO is used to record last minute changes, are we testing what…
STUDY is used to compare our data to our predictions from PLAN
ACT is used to abandon, adapt, adopt change
ACT typically leads to another test
THE MAIN GOAL IS TO BUILD KNOWLEDGE …
… which eventually leads to improvement!
In summary …
Quality Improvement Fundamentals LLC
41
Break
How will we test our change ideas: A PDSA exerciseImprovement Coach Professional Development Program
Workshop 1, Day 3
February 1, 2017
Karen BaldozaChristina Gunther-Murphy
Session objectives
• Apply rapid-cycle PDSA testing
• Understand how theory and prediction help your
learning
• Demonstrate how to collect real-time
measurement
• Appreciate the opportunity for learning together
44
Session agenda
Topic Time
Set-up 10 minutes
Play 15 minutes
Debrief 15 minutes
45
A model for learning and change
The Model for Improvement was developed by Associates in Process Improvement. [Source: Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.]
46
Preparation
• Get into groups of 3-5 people (so 2 teams per
table)
• Designate a spinner, timekeeper, and recorder
47
Objective: Test to spin a US coin for the longest amount of time in 15 minutes
Materials:• US coins - quarter, dime, nickel, penny• PDSA tracker form• Run chart template • Smartphone timer
Let’s
Play!
# Plan Do Study Act# What questions?
Theories?Prediction
What do you see? How Long?
How did what you see match prediction?
What now? Adopt, adapt, abandon?
1
2345678910
25
20
15
10
5
1 2 3 4 5 6 7 8 9 10PDSA Test Cycle
Seco
nd
s
Data Collection on a Run Chart
PDSA Tracker
# Plan Do Study Act
#What questions? Theories? Prediction What do you see? How Long? How did what you see match prediction?
What now? Adopt, adapt, abandon?
1 Large coins last longer Nickle = 10 seconds Started to wobble. Time = 7 No, Three seconds short. Large Size/weight Adapt - Test Quarter
2 Bigger quarter will spin longer Quarter = 10 seconds Started to lose spin fast. Time = 8 Two seconds short. Size may be more important Adapt?
3
4
5
6
7
8
9
10
10
7
5
3
1
1 2 3 4 5 6 7 8 9 10
PDSA Test Cycle
Seco
nd
sData Collection on a Run Chart
PDSA Tracker
Get Me To My
Meeting On Time
A Personal Improvement Project
By Phyllis M. Virgil,
IHI Improvement Advisor
51
Session Objectives
• See the life cycle of a personal
improvement project from start to finish
• Recognize the value of using a personal
improvement project to learn and model
the way
52
Personal Improvement Project
• Required part of my QI education.
• Provided personal experience and
testimony.
• Results gave an ideal tool to introduce
and teach a complex topic.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
53
54
Customers’ Voice
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
55
Customer Voice
• Timeliness expected by customers.
• “Fashionably late was no longer in style.”
• Provided real opportunity for personal
improvement.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
56
Organize an Effort
Team Leader - Me
Team Facilitator - Me
Others consulted: Department/Position
Boss Ad Hoc Facilitator
Customers Persons who suggested PIP
Co-worker 1 Willing listener
Co-worker 2 Another willing listener
Co-worker 3 And yet another listener
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
57
Improvement Roadmap
Week
1-2
Week
3-4
Week
5-6
Week
7-8
Week
9-12
Q1 Aim
Q2 Measure
Q3 Ideas
Q4 Test
Q4 Sustain
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
58
Ground Rules
I would use the Model for Improvement as
my thought process.
I would collect data and plot it overtime on
run/control charts.
I would PDSA (test) my improvements.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
59
Block Diagram
Schedule Meeting
Prepare for Meeting
Get to Meeting
End Meeting
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
60
Boundaries
Schedule Meeting
Prepare for Meeting
Get to Meeting
End Meeting
Look at Watch for Time At Meeting Ready to Work
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
61
Aim Statement
Within 12 weeks I will delight my
associates & customers, by
being on time every time.
At Meeting Ready to Work
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
62
63
Measure
Understand Quality Requirements
Measure Performance Overtime
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
What is MOST
Critical to Quality?
Meeting Arrival Timeliness
Selected it because customers were commenting
on this important aspect of my process.
Dimensions of Service Quality
1. Time & Timeliness
2. Completeness
3. Courtesy
4. Consistency
5. Accessibility/Convenience
6. Accuracy
7. Responsiveness
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
65
Operational Definition
Actual Timeliness of Arrival (ATA) as
measured by the minute variation from the
scheduled start time
(plus = late, minus = early)
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
66
Timelines Data Collection Plan/FormCombined with Time Plot Chart
Combined with
run/control
chart form.
ATA Data:
Minutes Early or Late
Date
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
67
Control Chart Actual Time of Arrival
One Special Cause Found
Median = 1 min. LATE
Upper Limit = 10 min. EARLY
Lower Limit = 8 min.LATE
Positive
Special
Cause
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
68
Actual Arrival Time
Data Analysis
ATA control chart showed that on average I was
arriving one minute late, and my performance varied
between 10 minutes late and 8 minutes early.
I found one positive special cause beyond 8 minutes
early which I believed was a result of my own
exaggerated awareness of my behavior given my
study (similar to the “Hawthorn” effect).
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
69
Actual Time of Arrival
Special Cause Strategy
I decided to collect more data rather than
act on this one point special cause. I
theorized that my process performance
would settle down as it became normal for
me to chart my arrival times.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
70
Control Chart Actual Time of Arrival
Performance Stable and Predictable
Median = On TIME
Upper Limit =
16 minutes EARLY
Lower Limit =
16 minutes LATE
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
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Customer Requirements
On Time
Ready to Work
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
72
Purpose of Tracking Data and
Understanding Variation
C T
Q
1
I will know change is an improvement when my
actual arrival time is always be below zero.
Mean of Zero
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
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Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
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Identify Change Ideas
Understand what causes
variation in performance.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
Current Process Flowchart
Get meeting
materials
together.
Look at
watch.
Continue
other work.
Should I go
now? Do a little
something.
Gather
supplies
needed.
Refresh
self.
Get coffee.
A
Decide it is
too early to
get ready.
NO
YES
Arrive at
meeting.
Coffee
available?
Search,
make, or
give up.
Materials
found?
Search
until found,
or give up
NO
YES
A
NO
B
B
YES
Walk to
Meeting
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
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Cause Effect Diagram(AKA: Fishbone Diagram)
Arrival at
Meeting
Gathering
Timing Refreshing
Materials
Supplies
Timex Coffee
CosmeticsJudgement
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
77
Get meeting
materials
together.
Look at
watch.
Continue
other work.
Should I go
now? Do a little
something.
Gather
supplies
needed.
Refresh
self.
Get coffee.
A
Decide it is
too early to
get ready.
NO
YES
Arrive at
meeting.
Coffee
available?
Search,
make, or
give up.
Materials
found?
Search
until found,
or give up
NO
YES
A
NO
B
B
YES
Walk to
Meeting
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
Drivers of Improvement
Remove Unnecessary Steps
78
Key Drivers Impacting
Actual Arrival Time (Outcome)
Judgment on Timing
Getting materials together
Searching for coffee
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Change Ideas
Look and Act
Flash Prep Process
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81
PDSA1 Look and Act
Get meeting
materials
together.
Look at
watch.
Gather
supplies
needed.
Refresh
self.
Get coffee.
A
Arrive at
meeting.
Coffee
available?
Search,
make, or
give up.
Materials
found?
Search
until found,
or give up
NO
YES
A
NO
B
B
YES
Walk to
MeetingDecided to eliminate
continued work of any sort. When
I looked at my watch I will
immediately proceed to getting
ready to go.
Made a Simple
Improvement(Remove, Reorder, Combine)
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
82
Flash Prep
Getting Materials Together
I figured if I was really organized I could cut out a
good chunk of my prep time, and consequently
leave earlier to get to an event.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
83
Process Measure
Operational Definition
Material Gathering Time
Measured in minutes lapsed starting at the
time I begin my effort to collect materials and
ending with the time all materials are all in my
arms, and I am ready to go.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
84
Control Chart Material Gathering Time
Two Special Causes Found
Median = 4 min.
Upper Limit = 11 min.
Lower Limit = 0 min.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
85
Analysis of Variation
Material Gathering Time
On average it took me 4 minutes to find my materials.
When I added control limits I found two special causesabove the upper control limit.
The first was when my process was interrupted by a telephone call.
The second was when someone
stopped for a surprise meeting.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
86
PDSA 2 Special Cause
Improvement Action
Institute a permanent self control policy whereas
I will not answer the phone while getting ready,
and I will politely and firmly turn surprise visitors
away to meet at a later time.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
87
PDSA 3 Materials in a Flash
Instituting a “ready at grab”
desktop system.
Organize for a “constant state of
readiness”.
By using clearly labeled “multicolored
pocket folders” for all active projects
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
88
PDSA 3 Change Prediction
• I predicted that I would be on time almost
every time.
• I thought my customers would be happy.
• My pre-meeting stress level would decline.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
89
PDSA 3 Study
Gathering time dramatically reduced.
Materials found in lightening speed.
On time most all of the time.
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
90
Control Chart Material Gathering TimePerformance Stable, Predictable, Dramatically Improved
From Minutes to Seconds!
Median = 30 SECONDS
Upper Limit = 97 SECONDS
Lower Limit = 2 SECONDS
Note: The improvement was so significant I had to change my scaling from minutes to seconds!
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Material Gathering Time
Comparison of Limits Old/New
Before
NEW (O to 1.5 min.)
OLD (2 to 11 min.)
Result = 90%
IMPROVEMENT
After
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Control Chart Actual Time of ArrivalStable, Predictable, and Dramatically Improved!
Result = 200% IMPROVEMENT
IMPROVED PERFORMANCEBASELINE PERFORMANCE
On Time, most every time!
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93
To Sustain Gains
I will always organize my major
project materials in multi-colored
pocket folders, and keep them on
the top of my desk ready to go!
Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
94
© Phyllis M. Virgil Get me to my Meeting on Time, a Personal Improvement Project by Phyllis M. Virgil.
95
How will we test our change ideas? Planning a PDSA cycle
Day 3
William Peters
February 1st, 2017
Lunch
Facilitation SkillsPart A
February 1, 2017
Day 3
Phyllis Virgil
Session Handouts
Team Tools
Facilitator Interventions
99
Session Objectives
• List key team facilitator skills
• Describe four questions to decide when to
intervene
• Identify tools and tips for interventions
• Discuss strategies to handle difficult behaviors
100
Session Agenda
Topic Time
Definitions and descriptions 20 minutes
When to intervene & what to say 20 minutes
Tools and Tips for Interventions 15 minutes
Handling Difficult Behaviors 20 minutes
101
Facilitation Definition
• Fa·cil·i·ta·tion (noun) - ‘To make easy or
easier’ (Oxford Dictionary, Thesaurus, 1996)
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources
and Services Administration HIV/AIDS Bureau.
102
Facilitation Aim
Aim of group facilitation:
To help establish and maintain an
environment within learning is created
and common goals are achieved.
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources
and Services Administration HIV/AIDS Bureau.
103
The End of Good Meeting Facilitation
• Transfer of knowledge and skill
• Team self facilitation
Source: Phyllis M. Virgil, Team TrainingPhoto Credit: England Highways Agency England via Flickr
104
Let’s start thinking...
What are the behaviors (or skills) of
successful facilitators that you have
experienced?
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources
and Services Administration HIV/AIDS Bureau.
Photo Credit: CDC/ Dawn Arlotta acquired from Public Health Image Library
105
Table Exercise Facilitator Skills (15”)
Identify the behaviors (or skills) of successful facilitators that you have
experienced (10”)
• Assign group facilitator
• Use structured brainstorming to list behaviors or skills of successful
facilitators that you have experienced
• Record about 20 ideas on one flipchart page, label A-Z...
• Using multi-voting dot method to identify what skills your group
thinks are especially important: everyone dot their top 5 choices (no
double dotting)
• Circle the items that got the most votes
Be prepared to report out top five to the large group (5”)
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources and Services Administration HIV/AIDS Bureau.
106
Key Facilitator Skills
• Planning Skills - plan ahead and anticipate challenges
• Diagnostic Skills – ‘read’ verbal/non-verbal clues of the
group, understand team dynamics and recognize barriers to
team effectiveness
• Intervention Skills – understand when (or when not) to ask
questions, offer feedback, provide problem solving methods,
push for outcomes, ensure involvement or wrap up
• Goal-getting Skills – keep the outcome of the group in mind
• Evaluative Skills – formally assess group outcomes
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources and Services Administration HIV/AIDS Bureau.
107
Should I Intervene?
Source: Phyllis M. Virgil, Team Training
108
The Role of “Traffic Cop”
Specific words and phrases useful in directing traffic:
Observing
Clarifying
Focusing
Stimulating
Balancing
Summarizing
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources and Services Administration HIV/AIDS Bureau.
109
Table Exercise
• Identify group facilitator and recorder
• Identify specific words and phrases which would be useful in directing traffic
for your assigned role (10 min)
Observing = Table 1
Clarifying = Table 2
Focusing = Table 3
Stimulating = Table 4
Balancing = Table 5
Summarizing = Table 6 & 7
• Record on your flip chart and be prepared to report out to large group
Developed by the New York State Department of Health AIDS Institute National Quality Center. Funded through a cooperative agreement with the Health Resources and Services Administration HIV/AIDS Bureau.
110
111
Interventions Not Detentions
A Facilitators Tool Box
Source: Phyllis M. Virgil, Facilitators Tool Box
112
Interventions Not Detentions
A Facilitators Tool Box
Ground Rules
1) No interruptions.
2) Speak one at a time.
3) Cell phones on off.
4) Listen.
5). ……………….
6). …………….
Source: Phyllis M. Virgil, Facilitators Tool Box
113
Providing Feedback Without Fallout
• Describe, specific, behaviors...
• In a timely, respectful manner, in a manageable amount
4 STEP INTERVENTION
D-E-S-Cribe
1) Describe behavior(s)
2) ID Possible Effect
P-A-U-S-E
&
L-I-S-T-E-N
3) Solicit input
4) Choose what to do
Source: Phyllis M. Virgil, Facilitators Tool Box
114
Getting to Yes by Fisher and Ury
Source: Phyllis M. Virgil, Facilitators Tool Box
115
Diffusing Conflict and Confusion
Structured Discussion
1. What is your position?
2. Why? (data, experience, rationale)
Source: Phyllis M. Virgil, Team Training
116
Toss it back to the team...
• Remember meetings are team sport.
• Resist being the savior.
• Summarize positions, and throw
decisions back to the team.
• Ask what does the team want to do?
• Follow structured discussion with open
discussion.
• Go two rounds if necessary.
Source: Phyllis M. Virgil, Team Training
117
Dysfunctional Behaviors
/
Photo credit: Pixabay
118
Facilitator Interventions
Dysfunctional Behavior Possible Intervention
Overly Talkative, Dominates Table 1
Rambles, Inarticulate Table 1
Blaming Table 2
Intimidation, pulls rank Table 2
Leaps to Decisions Table 3
Withdrawn or Shy Table 3
Source (c) M. K. Key, The Art of Facilitating Teams: A Two-Day Course.
119
Facilitator Interventions (continued)
Sniping Table 4
Side Conversations Table 4
Plop or Discounting Table 5
Leading and Loaded ?s Table 5
Opinion as Fact Table 6
Hidden Agenda Table 6
Interrupting Table 7
Broken Record Table 7
Source (c) M. K. Key, The Art of Facilitating Teams: A Two-Day Course.
120
Table Exercise (15 minutes)
Identify Facilitator Intervention Strategies (10”)
• Assign group facilitator
• Develop one or two possible interventions for
your assigned behaviors
• Record these on your flipchart
Be prepared to report to larger group (5”)
121
Session Review
• Listed key facilitator skills
• Identified four questions to decide when to
intervene
• Reviewed 12 tools for team intervention
• Discussed strategies to handle difficult behaviors
122
Remember...when facilitating a team
You are also working to build capacity. Teach your teams how to plan
and manage effective meetings by modeling, then relax!
Time
Co
ach
Invo
lvem
en
t
Low
High
New
Team
Mature
Team
Source: Phyllis M. Virgil,
Graphic Source: Executive Learning Inc. Team Training Materials.
Photo Credit: Andrés Nieto Porras
123
Break
124
Teamwork and Communication: Understanding Working StylesImprovement Coach Professional Development Program
Workshop 1, Day 3
February 1, 2017
Karen Baldoza
Session objectives
• Summarize key concepts from the human side
of change
• Describe four working styles and how to apply
this knowledge to yourself and your
improvement teams
• Identify small changes you can make to your
own style to be more effective
126
Session agenda
Topic Time
Overview: The human side of
change and working styles
10 minutes
Exercise 35 minutes
Debrief 7 minutes
Wrap-up and flexing your style 8 minutes
127
Appreciation
of a system
Understanding
Variation
Theory
of
Knowledge
Human Side of Change
The Lens of Profound Knowledge
QI
The system of profound
knowledge provides a
lens. It provides a new
map of theory by which
to understand and
optimize our
organizations. It
provides an opportunity
for dialogue!
128
Key concepts from the Human Side of Change
Improvement Guide, page 84
Differences in people
• People have their own preferences, aspirations, motivations, and learning
styles
• People may have differing beliefs and values
• Changes aimed at improvement have to recognize the differences in people
and account for them
Behavior is driven by motivation
• Observing the behavior of others does not often give us a clear window into
what is motivating someone’s behavior
• We tend to perceive the behavior of others through our own filters
• Understanding what is motivating someone rather than relying on our
interpretation of the behavior can help us take appropriate actions to build
commitment to change
129
…what you are trying to do.
Your self-perception is
based on…
…what they are seeing you do.
Their perception of you is
based on…
MOTIVATIONMOTIVATION
internal
130
Different personalities in a team
• A team can perform better if the team recognizes
and deals with different personality types
• The team can use their different strengths as an
asset
• How can you learn how different team members
operate and benefit from these different
perspectives?
131
Understanding yourself and
others
Flexing the gap across
the chasm of behavioral differences
'Strengths' for each style become
'Weaknesses' when
overused
Back-up Styles' that emerge in
response to excessive
stress
Working styles: An approach to
understanding self and others
132
133
Source: People Styles at Work and Beyond – Making Bad
Relationships Good and Good Relationships Better/ Robert Bolton and Dorothy Grover
Bolton, 2nd ed. 2009.
A - Analytical
•Cautious actions and decisions
•Likes organization and structure•Dislikes involvement with others•Asks many questions about specific details
•Prefers objective, task-oriented work environment
•Wants to be accurate and therefore relies too much on data collection
•Seeks security and self actualization
B - Driver
•Takes action and acts decisively
•Likes control•Dislikes inaction•Prefers maximum freedom to manage self and others
•Cool and independent, competitive with others
•Low tolerance for feelings, attitudes and advice of others
•Works quickly and efficiently by themselves
C - Amiable
•Slow at taking action and making decisions
•Likes close, personal relationships•Dislikes interpersonal conflict
•Supports and "actively" l istens to others
•Weak at goal setting and self-direction
•Demonstrates excellent ability to gain support from others
•Works slowly and cohesively with others
•Seeks security and inclusion
D - Expressive
•Spontaneous actions and decisions, risk taker
•Not limited by tradition•Likes involvement
•Generates new and innovative ideas•Tends to dream and get others caught
up in the dream
•Jumps from one activity to another
•Works quickly and excitingly with others
•Not good with follow-through
Working Styles Characteristics
Overview
of the
Styles
Less
Less
More
More
Assertiveness
Re
spo
nsiv
ene
ss
134
Working Styles profile
• Working styles are predictable patterns of
behavior that others can observe.
• Knowledge of these styles can be a huge
benefit when working in teams.
• Every style has its strengths and
weaknesses.
135
The goal: Know thy self!
• Be aware of your habitual patterns of behavior
• Recognize how others perceive you and how you come across
• Learn to make small adjustments that will increase the quality and productivity of your interactions (Don’t let your style get in the way of productive interactions)
136
But, realize that 75% of the people with
whom you work…..
• Work differently from you when in groups
• Plan differently when with others
• Are motivated by different things
• Differ in willingness to take risks
• Make use of time differently
• Make decisions differently
• Manage tasks differently
137
Know others
• Observe others more correctly and truthfully– Recognize
others’ behavior
• Learn to be accepting of others’ behavior without too
high a degree of tension
• Understand others’ behavioral preferences so that you
understand what you can do to make the team more
productive
• Attempt to meet the needs and preferences of the
project and people involved
• Interact with others as they prefer to be interacted with
138
138
Keep in mind…
No style is “best” – each has strengths
and limitations
We do not fall neatly in any one box,
but are often a mixture of “styles”
139
Analytical
• Cautious actions and decisions
• Likes organization and structure
• Dislikes involvement with others
• Asks many questions about specific details
• Prefers objective, task-oriented work
environment
• Wants to be accurate
• Seeks security and self actualization
140
Amiable
• Supports and "actively" listens to others
• Demonstrates excellent ability to gain support from others
• Works cohesively with others
• Likes close, personal relationships
• Slow at taking action and making decisions
• Dislikes interpersonal conflict
• Weak at goal setting and self-direction
• Seeks security and inclusion
141141
Driver
• Takes action and acts decisively
• Likes control
• Dislikes inaction
• Prefers maximum freedom to manage self and others
• Cool and independent, competitive with others
• Low tolerance for feelings, attitudes, and advice of others
• Works quickly and efficiently by themselves
142142
Expressive
• Spontaneous actions and decisions
• Risk taker
• Not limited by tradition
• Likes involvement
• Generates new and innovative ideas
• Tends to dream and get others caught up in the dream
• Jumps from one activity to another
• Works quickly and excitingly with others
143
So you need to know thy self
and others!
• Observe others more correctly and truthfully -Recognize others’ behavior
• Learn to be accepting of others’ behavior without too high a degree of tension
• Understand others’ behavioral preferences so that you understand what you can do to make the team more productive
• Attempt to meet the needs and preferences of the project and people involved
• Interact with others, as they prefer to be interacted with
144
Exercise: The Four Basic Working Styles Groups
Am E
DAn• Identify which of the four basic Working Styles groups you
fall into
• In the case of a tied score, you should pick the working
style you feel is most like you
• Go to the designated flipchart for your Working Style
group.
145
Working Style Group __________________
Appreciate Don’t Appreciate
How to Influence this
Style
Expressive
Exercise: The Four Basic Working Styles Groups
Am E
DAn
Once each group lists the key aspects of its Working Style we
will rotate around the room and let each group comment on the
other groups’ notes.
146
What did you learn?
• Did this exercise cause you to think
differently about people who have different
working styles than you do?
• What insights did you gain from this
exercise about yourself?
• How will you use this experience to work
differently with your improvement team?
147
A few more useful concepts in understanding
behavior
• Strengths, when overdone or misapplied,
can be perceived as weaknesses
• Personal filters influence perceptions of
self and others
From Elias Porter, PhD, Relationship Awareness Theory
148
Potential strengths of each People Style
Analytical
• Logical• Systematic
• Thorough• Prudent
• Serious
Driver
• Efficient• Decisive
• Pragmatic• Independent
• Candid
Amiable
• Cooperative• Supportive
• Diplomatic• Patient
• Loyal
Expressive
• Persuasive• Enthusiastic
• Outgoing• Spontaneous
• Fun-loving
People Styles at Work and Beyond, Bolton and Bolton, 2nd ed. 2009, page 64
149
Strengths, when overdone or misapplied,
can be perceived as weaknesses
Analytical
• Task-oriented Impersonal
• Systematic Bureaucratic
• Thorough Nitpicky
• Prudent Indecisive
Driver
• Results-Oriented Impersonal
• Pragmatic Shortsighted
• Independent Poor collaborator
• CandidAbrasive
Amiable
• Supportive Permissive
• Diplomatic Conflict avoider
• Cautious Risk averse
• People-oriented Inattentive to
task
Expressive
• Persuasive Poor listener
• Fast-paced Impatient
• Visionary Impractical
• Fun-loving Distractive
Some examples…
150
Flexing your style
• Not all the time – when it is important
• Change your own behavior
• Adjust 1-3 key behaviors
• Four Steps:
1. Identify (3 questions)
2. Plan (P)
3. Implement (D)
4. Evaluation (S, A)
151
151
B - Driver Strategies as a team leader or member Strategies when under stress
Takes action and acts decisively LISTEN TO OTHERS! Under stress – Often takes over, dictates
Likes control Acknowledge different points of view Offer options for moving forward
Dislikes inaction Be Patient Recommit to results and time frame
Prefers maximum freedom to manage self and others
“Calm Down” internally Calm down
Cool and independent, competitive with others
Pay attention to others’ feelings Seek input from others
Low tolerance for feelings, attitudes and advice of others
Use time efficiently Delay decision-making
Works quickly and efficiently by themselves
Provide Options Restate others’ concerns
A - Analytical Strategies as a team leader or member Strategies when under stress
Cautious actions and decisions MAKE A DECISION Under Stress – Often avoids and withdraws
Likes organization and structure Be more flexible, more open-minded Logically discuss the issue
Dislikes Involvement with others Openly show more concern for other people Acknowledge a need for time
Asks many questions about specific details Be decisive with data Set a deadline
Prefers objective, task –oriented work environment
Listen for people’s feelings Ask questions
Wants to be accurate and therefore relies too much on data collection
Use time accurately Seek opinions from others
Seeks security and self-actualization Provide evidence and service to influence decision-making
Working Styles Tips Sheet152
Working Styles Tips Sheet
C - Amiable Strategies as a team leader/member Strategies under stress
Slow at taking action and making decisions Assert your opinions Under stress- concedes to others, acquiesces
Likes close, personal relationships Be Less sensitive Allow them to express disagreement
Dislikes interpersonal conflict Be willing to take risks Speak Up
Supports and “actively” listens to others Say “no” more often State your thoughts in a logical concise manner
Weak at goal setting and self-direction Let people know what you think Ask open questions about concerns
Demonstrates excellent ability to gain support from others
Support relationships to establish rapport
Seeks security and inclusion Incorporate facts into your opinion
D - Expressive Strategies as a team leader/member Strategies when under stressSpontaneous actions and decisions, risk taker RESTRAIN and check Under stress- Often attacks and confronts
Not limited by tradition Talk less Separate emotions from factsLikes involvement Spend more time looking at the facts Acknowledge feelings and points of viewGenerates new and innovative ideas Control time and emotion Refrain from pouncing on the quiet onesTends to dream and get others caught up in the dream
Think before you speak Seek to gather information from all team members
Jumps from one activity to another Incorporate facts into your decisionsNot good with follow-through Encourage decision making with incentives and
stories
153
A final thought…
Managers (team members) who consistently
accomplish a lot are notably inconsistent in
their manner of attacking problems and
approaching situations.
They continually change their focus, priorities,
behavior patterns, and their own leadership
styles based on with whom they interact.
Harvard Business Review
Skinner and Sasser, Versatile and Inconsistent, HBR, November 1977
154
Case Study: Antibiotics within 4 hours of arrival
February 1st, 2017
William Peters
Day 3
Increased focus on
Pneumonia from Board
and Medical Staff, want to
do better…
Certain Leaders believed
we need a more structured,
proven way to engage in
improvements…
Decrease the time to
Antibiotics for pneumonia
patients (<4 hours)
Institute for Healthcare
Improvement “Improvement
Advisor” program
Improving Pneumonia Care: Antibiotics
within 4 hours of Arrival
Background:156
Used the Model for Improvement
Used The Model to
get project rolling
by asking the first
three questions
and putting them
in to a “Charter”
157
We will dramatically
reduce the time to first
dose antibiotics for ER
and direct admit
pneumonia patients.
Whenever medically
efficacious, we will
ensure these patients
receive their first dose
of antibiotics within 4
hours of arrival.
4
from Door to first dose within
Aim Statement:
Quality Improvement Fundamentals LLC
158
What are we trying to accomplish? Dramatically reduce the time to first dose antibiotics for Emergency
Room and Direct admit pneumonia patients
100% of our community acquired pneumonia patients will receive antibiotics within the first 4 hours
…and Why?
Pneumonia is the 6th leading cause of death in the U.S.
3rd at DCH during Fiscal Year 2005
Variation in length of stay – longer stays mean higher cost, less reimbursement
Pneumonia patients who receive timely antibiotics (less than 4 hours of hospital) arrival have been shown in studies to have statistically significant reduced mortality rates both in the hospital and for 30 days after admission
These same patient have shorter lengths-of-stay compared to pneumonia patients who had received antibiotics later than 4 hours
Lower length of stay will reduce variable cost for treatment for pneumonia patients
Charter
Quality Improvement Fundamentals LLC
159
Success was obtained by
answering the 3 questions in the
“Model for Improvement” followed
by “rapid cycle testing”
We will dramatically reduce the time to first dose antibiotics for ER and direct admit pneumonia patients.
Percent Pneumonia Patients receiving Antibiotics
within 4 hours of Arrival.
&Time from Arrival to First Dose Antibiotics for
Pneumonia Patients
A Flow Chart was created for both sides of
the process; ER and Direct Admit.
Reduce effects of failed large test by
doing small scale tests. This increases
buy-in and reduces resistance
Subject Matter Experts generate ideas for
change by using logic, “Change Concepts”
and Creativity
Quality Improvement Fundamentals LLC
160
Flow Chart for ER Admits
Walk-In
Arrival
Ambulance
Arrival
Short-Reg,
Triage and RN
Assessment
Initiate Rad
Standing
Order?
Short-Reg
(Arrival T ime)Triage
X
yes
no
RN
Assessment
Initiate Rad
Standing
Order?
yes
no
MD
AssessmentA
APneumonia
Patient?
Patient
Out
yes
no
MD Orders
Labs
Rad Standing
Order Already
Followed? no
yes
MD Orders
Chest X-rayED Clerk
Enters Orders
Radiology
Assesses OrderB
BPatient ready
for Chest X-
ray?
no
yes Radiology
Ready for
Patient?
no ?
delaydelay
Chest X-ray
Performed
Chest X-ray film
made available to
ED
Chest X-ray
interpreted by ED
MD
Diagnosis of
Pneumonia
made?
Patient
Out
no
yes
Confirm with
Radiologist
C
IV Accessed?
yes
no
IV retry
successful?
no
yes
Call IV
TherapyIV Therapy
ArrivesIV Accessed
X
E
Quality Improvement Fundamentals LLC
161
Flow Chart for ER Admits
yes
ED MD Orders
AntibioticBlood Cultures
Drawn?no noC
Pneumonia
Patient
Admitted?
Patient
Out
no
no
PMD
Contacted?
PMD
agrees to
admit?
yes
Patient
Out
yes
ED RN Aware
of Order
ED Clerk enters
orders for Blood
Cultures
D
D 1st Blood
Cultures Drawn
2nd Blood
Cultures Drawn
30
Min.
no
Antibiotic
in Pyxis?
ED RN Calls
Pharmacy
yes
yes
Nurse prepares
Antibiotic
Documented first
dose antibiotics given
by ED RN
Nurse orders
X-rayRadiology
Assesses Order
Patient ready
for Chest X-
ray?
no
yes Radiology
Ready for
Patient?
no
delaydelay
Chest X-ray
Performed
Chest X-ray film
made available to
ED
Pharmacy mixes
X E
Antibiotic
delivered
to RN with
scripting
Removing this single step
reduced average wait time by
18 minutes
Quality Improvement Fundamentals LLC
162
Some ideas/areas we tested …
Triage in ED
Chest X-Ray Process
ED – MD change
ED Education Blitz
Rx Delivery Processes
IP Admission
ADC – Admit process
Protocol Changes
Med First
?
Quality Improvement Fundamentals LLC
163
Did we improve?
Changes produced a new level of performance …
New lower average time to first dose antibiotics. Average now around 116 minutes.
Quality Improvement Fundamentals LLC
164
Did we improve?
Changes produced a new level of performance …
Past 5 months at 100%. Process of caring for patients has change significantly.
165
Comparing 2 groups towards the end of Improvement Effort revealed:
Antibiotics received: > 4 Hours (n=121) < 4 Hours (n=497)
Percent 30 day readmit 14% 10%
Average LOS 7.2 5.2
Average variable cost per case $6,048 $5,721
Press-Ganey Inpatient Survey:“Wait for tests and treatments” 81.5 (79th percentile) 86.1 (99th percentile)
…additional benefits…
• Successful test of the Model for Improvement.
• Jump start on upcoming P4P at individual physician level.
• A publicly reported Quality indicator we will now be doing very well at.
• Another step towards guaranteeing APU from Medicare.
Results
Quality Improvement Fundamentals LLC
166
Tying it all together
February 1st, 2017
William Peters
Day 3
Day 3 Debrief and Next Steps
Program design and key dates
Jan 12
12-1:30 PM ET
Prep
Webinar
Jan 30-Feb 1
San
Francisco
Workshop
1
Apr 6
12-1:30 PM ET
Final
WebinarWorkshop
2
Mar 13-15
San
Francisco
Feb 16
12-3 PM ET
Feb 22
12-3 PM ET
Mar 2
12-3 PM ET
Virtual
Workshop
1
Virtual
Workshop
2
Virtual
Workshop
3
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