Download ppt - GHA Hospital Engagement Network HAC Learning Collaborative

GHA Hospital Engagement Network

HAC Learning Collaborative

Webinar ~ September 19, 2012Webinar ~ September 19, 2012

Kelley Dotson, GHAKelley Dotson, GHAFreya Gilbert, Hughston HospitalFreya Gilbert, Hughston Hospital

Meryl Montgomery, MCCGMeryl Montgomery, MCCG

Learn. Act. Improve. Learn. Act. Improve. Spread.Spread.

Keep the Drum Beat Keep the Drum Beat Going.Going.

Follow-Up from 8/28 Evaluations

• Technical Issues with Webinar– Screen and volume– Transcript with handouts– View the presenters

• Webinar Material Availability– Agenda emailed with links– Materials posted to GHA website

• Participation in Sharing and Learning– Allow participant to submit questions/requests prior to webinar– Open forum during webinar to allow sharing– Small group meetings with similar hospitals– Subscribe to the list serve at HealthcareCommunities.org (exchange info-

EBP, Examples)

• Application of Reliability Concepts– Hospitals examples through presentations– Open forum for exchange of information



• Review concepts of the Reliability Theory used at specific hospitals

• Discuss improvement work for reliable design concepts

• Share struggles and ideas related to using concepts of the Reliability Theory

Learning Objectives

Reliability Theory Concepts in Practice

Med Rec - Hughston Hospital

Freya Gilbert, RNAdministrative Director of

Quality & Clinical PracticeHughston Hospital



Analyzing Testing & ImplementingQuestion the Connection

Key Question Your Evaluation

Is the connection between goals and processes clear? (Failure to connect process measures to outcome goals makes no sense!)

Medication Reconciliation-We learned to have an overall measurable goal and then to develop short term goals and objectives. Finding some objectives that we could reach quickly. Accomplishing quick wins starts the momentum and facilitates engagement from the front line staff.

Is the design strategy primarily vigilance and hard work?

Has some degree of segmentation been used to test?

Is standard work with testing been part of the design?

Is a design methodology being used?

Are small tests of change being used in a rapid cycle?

Is data collection rapid enough?



Analyzing Testing & ImplementingQuestion the Design

StrategyKey Question Your EvaluationIs the connection between goals and process clear?

Is the design strategy primarily vigilance and hard work? (Am I guilty of using hard work and vigilance as my only strategy)

Hard work is involved with any project but a focused on drilling down to processes to simplify. Process flow chart completed on steps for admitting patient at each point. Looked at differences and planned on ways to standardize process. Stratagy was to motivate front line staff by involving them in each step of the improvement process. Ask about their needs and thoughts for improvement.








How to Measure Human Factor

How to Measure the Human Factor Human

Factor Tests of Study the Design Process

Identify Human Factor Tests of Change &

Resulting Defects

Develop Process to Resolve Defects

Performance Rate = LESS than 95%

Performance Rate = 95% or GREATER

Processes are varied, optional, & dependent upon human factor•Common equipment•Standard order sheets •Personal check lists•Written policies/procedures •Multiple choice protocols

Processes are standard, routine, & instigate human factor•Decision aids•Prompters•Standard defaults •Hard stops•Redundant processes

Compliance feedback shared without solutions = “Work harder” next time

Good Intent to Comply + Vigilance & Hard Work Process Failure Invited Performance NOT Sustained

Habits, patterns, & schedules used in the process design to enhance compliance

Human Factors (at least 25%) + Reliability Science

Process Failure Prevented, Identified, Mitigated Performance Sustained

Education and training to provide information to increase awareness with NO standard process specified

Education and training provides information to increase knowledge with processes specified, articulated, & tested



Analyzing Testing & ImplementingQuestion SEGMENTATION

Key Question Your EvaluationIs the connection between goals and process clear?



Yes. We looked at each step of our medication reconciliation process by admission type & location. Focus was placed on obtaining the initial medication history.







Segmentation-Enables control of some variables -Defines boundaries success of

sequential expectations-Tests validity rather than addressing the barriers -Forces understanding of the

differences among segment -Fosters deeper understanding of design complexity -Allows the formation of predictable timelines

• Finding the FIRST Segment– MUST represent a reasonable volume– Should have clearly defined boundaries– Involve willing participants to avoid barrier of agreeing– Allows neutralization of key variables or barriers– Establishes a design theme

• Identifying OTHER Segments– Total segment topics not to exceed 4-5– Segment follows design theme (type of admission, physician,

etc.)

– Segments differ by a distinct design feature– Adjustment of the initial segment division as the design

develops– Segments cover the population involved in the topic



Testing & ImplementingQuestion STANDARDIZATION vs STANDARD

WORK





Yes. We analyzed a specific step in a process to determine working, identified possible failures and an improvement goal, and then standardized process for all admitting units, and continue to test.






Standardization - Standard Work

*KEY LEARNING POINT*

A standardized process design using knowledge of human factors & acceptable science is superior to varied processes

•Allows training of new employees & enables testing of current employees•Provide the appropriate infrastructure (the how, what, where, who & when)

– The “what” we are standardizing is based on scientific evidence• Initial standardized protocol requires little time when testing a very small scale• Changes to the protocol in the initial stages should be required and encouraged

– The “how” is based on systems knowledge and does not require scientific evidence• Defects are studied and used to redesign the process

Successful description of a process by 5 front line process users likely to achieve 95% performance

& to sustain the performance over time







Is a design methodology being used? Lean Six Sigma, Plan Do Check Act Tools used were audit form, walk through of process on each unit, flow chart each unit, FMEA, analysis of results, run charts



Analyzing Testing & Implementing

Question the DESIGN METHODOLOGY



Three Step Design for Reliability

Steps Techniques1. Prevent initial failure by standardizing

the process to achieve 80%a. Identify the process to standardize

b. Segment the population to test the design for anomalies

2. Identify failures in step 1 and apply an

action to achieve 80% for these failures

a. Utilize a robust concept to make visible failures from step 1 after step 1 has achieved 80% reliability

b. Once the failure is identified, apply an action to mitigate the failure

3. In either step 1 and/or step 2 detect the

failures and use the knowledge from

analysis of the failures to redesign

a. Identify common failures

b. Develop a method to measure & study failures

c. Utilize knowledge of common failures to redesign either step 1 or step 2

Points to Remember- Perfection is the enemy of DESIGN - Constant testing of observed defects- The design is designed by the people who use the design - Segmentation tests the design



Analyzing Testing & ImplementingQuestion the SMALL, RAPID CYCLE

TESTSKey Question Your EvaluationIs the connection between goals and process clear?






Yes. Data analysis was shifted from the quality department to all members of the team to determine compliance or non-compliance with indicators. This shift enabled the care providers to identify issues from a perspective broader than the focus. When identified, issues would be solved by implementing and testing change or added to the “parking lot” for review at a later time. Collaboration between departments to discuss tests was very beneficial (PACU and Rehabilitation staff).




How to Evaluate

• Are testing cycles being used on an acceptable basis?

• Are huddles occurring after the tests for quick redesign?

• Are records being kept of the tests?• Do all team members have test

responsibilities?



Analyzing Testing & ImplementingQuestion COLLECTION &

MEASUREMENT


Is the connection between goals and process clear?






Is data collection rapid enough? Yes. Initially, every 2 weeks, and then monthly . Each unit involved obtained & reviewed 10 med rec forms. If a problem was identified went to specific unit and asked staff the questions to identify barriers.



Design Measurement = Process Measures

Using Failure Modes in Process ReDesign •Assess defects in the current design (Process Failure)•Prioritize failure modes in terms of overall affect on the reliability of the process•Establish process measures based on the prioritized failure modes

– Incorporate established measurement into the INITIAL design– Evaluate process improvement using small samples over time

Using Measurement to Evaluate Design / ReDesign (Process Measures)•Data collected by the team using established process measures•Data collection strictly follows a define tempo / schedule•Data can initially be collected for segments

PROCESS Measurement vs OUTCOME Measurement•Process measures are collected by the primary team

– Process Measure Goals set at 95% (10-2)•Outcome measures are NOT collected by the primary team

– Outcome measures goals set at 0 / 100%

Reliability Theory Concepts in Practice:

HITTING THE WALL - MCCG

Meryl Montgomery, RN, MSNNursing QI Coordinator, Magnet Program

Director

Medical Center of Central Georgia



**Key Question** What do we do when the team just seems stuck?

•Use the 7 Question Analysis •Check the rules of engagement•Use the spread analysis

Testing Implementation and Spread

Hitting the Wall



Outcome

Goals

Key

Drivers

2009

Processes

Decrease pressure ulcers

Provide high quality care using processes based on EBP.

- Best practices bundle- Standardization of supplies / devices-Staged surface replacement-Shift assessments-EMR prompted interventions, embedded EBP

HITTING THE WALLPROCESSES TO IMPROVE OUTCOMES



Outcome

Goals

Key

Drivers

2010

Processes



- Critical care specific bundle- NSIC (Nurse Sensitive

Indicator Champion) model- Patient partnership and

education- PAR stock- Mandatory education and

shadowing WOCN- Competency evaluation in sim

lab- Proactive turn clock- Engage procedural units- Monitor leading and lagging

indicators

HITTING THE WALLMore Processes to Improve Outcomes



PROCESSES - EBP Bundle

Offload pressure with surfaces

Avoid shearing: slides and lifts

Focus on vulnerable times Heel protectors

Body aligner/ wedge Ear, ETT protectors

Other device-specific strategies Chair cushions

Single cloth pad for incontinence No-diapers or plastic

Clean and dry Barrier cream and cleanser

Nutrition POA assessment

Turn q 2 hours Risk assessment each shift

Prevention on admission Sacral pads

Patient/family education HOB<30 degrees

Focus on mobility Out of bed when possible



LOTS of processes, hard work and diligence

Outcome

Goals

Key

Drivers

2011

Processes



Integrate with falls and Safe Patient Handling: focus on immobility and offloading- SIMPLIFYUpdate bundle for best practicesResearch100% inpatient surfacesDevice-specific bundlesMonthly prevalence for units >5%



Results: Leading Indicator: use of prevention strategies



HAPU vs. POA- going in the right direction



HAPU prevalence rates 3Q10-2Q12



Stepping Back to Move Beyond the Wall

Review the 7 Questions to Analyze Testing & Implementing


Is the connection between goals & process clear?

√ Connecting goals and EBP processes?


OOPS- hard work- re-educate (“nag”). Vigilance- audit (“snitch”)


SOME- pilot sacral pads in critical care


SOME- however, lack of clarity among care providers

Is a design methodology being used? √ design methodology used?


SOME- inconsistent.

Is data collection rapid enough? SOME- prevalence quarterly- not enough to test for changes



Hitting THE WALL in 2012

• Sustain HAPU rate just under <5%• Prevention strategy utilization >70%• Underperform compared to >500 beds and Magnet

hospitals• Focus on education, expectation, engagement,

encouragement, RCA, report out• Join GHA HEN HAC- RCA, process flow, small tests

of changeStepping back- where we are with reliable process design strategies?



Stepping Back to Move Beyond the Wall

Review the Rules of Engagement

Engage (adaptive)

How does this make the world a better

place?

Educate (technical)

What do we need to know?

Execute (adaptive)

What do we need to do? What can we do

with our resources and culture?

Evaluate (technical)

How do we know we improved safety?

Senior leaders

Staff

Team leaders

Engage Team Members Using the 4 E’s2

www.ahrq.gov/cusptoolkit/2assembleteam/assembleteam.pptx



Stepping Back to Move Beyond the WallReview the Stages of Engagement

Engagement: “To involve oneself or become occupied; to participate fully and deeply”

Active support of the project

Engaged

Apathy

Aversion

Uninvolved

www.ahrq.gov/cusptoolkit/2assembleteam/assembleteam.pptx



Stepping Back to Move Beyond the WallKey Questions To Analyze Spread



Stepping Back to Move Beyond the WallUtilize the Spread Analysis

IHI Science of Improvement Tools•A Framework for Spread: From Local Improvements to System-Wide Change

• A key factor in closing the gap between best practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas.

•Spread Planner • The Spread Planner is a set of questions designed to assist

organizations in identifying the key actions they can take to turn a local success into a system-wide improvement.

http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSpreadingChanges.aspx



Outcome Goals Key Drivers Current Processes

Decrease

pressure ulcers

A3 Learning from defects/ PDCA Weekly executive rounding

Redundancy - Admission checklist to begin- Immobility/ offload process- Standard work for both RN and CT, but

need clear WWWWHWW- 4 eyes on all admissions

IV5 Interview 5 RN and 5 CT in critical care and med surg to assess reliability of prevention bundle

1x4 NSIC complete tool to monitor prevention aspects for 1 unit, 1 pt, 1 shift•Findings track to barrier busting, addressing human factors•Ex. Hunting and gathering supplies- increased PAR stock

Standard work Turn Team

Moving past the “nag and snitch”*climbing over & going around THE

WALL



BEFORE attempting the MOVE…What have others done when you hit the wall?

• Present– Stepping back to move forward– EXCHANGE ideas

• Future– Ideas implemented– Beyond the WALL



Exchange Ideas to Prevent HACsFalls – Med Rec – Pressure Ulcers - VTEs

Possible Topics for Discussion among Participants•Tips for doing Small Tests using “1”•Results from Data Collection/Analysis•Successful interventions for each HAC•Beneficial Tools and/or Frameworks •Evidence Based Practice (EBP) guides/tools•Supportive research findings•Policy / Procedure development

**Remember to email questions/requests to [email protected] if

preference is to anonymously initiate a discussion**



To-Do List

• Submit process data• Collect data using the worksheet

• Email data to [email protected]• Current collection should be the 3rd month of process data collection

and submission

• Complete the electronic evaluation

• Remember…complete & send the sign-in sheet if listening to the recording

• Join the Georgia HEN Community of Practice on the HealthcareCommunities.org website• List Serve is excellent way for hospitals to share information

• List serve is excellent way for HEN to provide information



Educational TELNET/Webinars

Next Telnet/Webinar

•3rd Wednesday every month•October 17, 2012•11:00 am – 12:00 pm