Lesson 1: What is the Science of Improvement?

Lesson 1: What is the Science of Improvement?

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  • Lesson 1 - What is the Science of Improvement? > Lesson 1 Lectures > Why Improve Health and Healthcare?
  • Lesson 1 - What is the Science of Improvement? > Lesson 1 Lectures > Introduction to PDSA Cycles
  • Lesson 1 - What is the Science of Improvement? > Lesson 1 Lectures > Improving Rounds for Don Goldmann's Residents
  • Lesson 1 - What is the Science of Improvement? > Lesson 1 Lectures > Faculty Footnotes
  • Lesson 1 - What is the Science of Improvement? > Lesson 1 Lectures > Your Turn

Lesson 1 – What is the Science of Improvement? > Lesson 1 Lectures > Why Improve Health and Healthcare?

  • This was an iconic shot across the bow of US health care.
  • The report describes six dimensions of high quality health care.
  • In every case, it was obvious that the system was underperforming and people were not getting the health care they deserve.
  • Even when there was good evidence for best care practices- for example, methods to screen for and control high blood pressure- approximately 50% of patients weren’t receiving the recommended care.
  • There have been some efforts to revise this framework in recent years, especially to emphasize value, which is a ratio of quality and cost of care, and equity.
  • There’s been an appropriate emphasis on prevention, not just acute care.
  • What is relatively unique in the US is the magnitude of disparities in health and health care, particularly in the deep South, where costs are the highest and health and health care outcomes the poorest.
  • Now in the US, it’s quite fashionable these days to blame these gaps and disparities on a broken health care system, and incompletely insured population, lack of alignment between payment and care delivery, and a host of other factors.
  • Now, I can’t emphasize strongly enough that policy and payment reform alone cannot achieve the very high level of health care quality we need.
  • We always need to be mindful that dramatic changes in the health care system almost always have unanticipated consequences and can leave caregivers and patients struggling to deal with new, often confusing regulations, payment structures, and reporting requirements.
  • Now, I also want to make it clear that while good quality improvement is really important, improvers and change agents always should celebrate and attempt to leverage advances in technology and therapeutics.
  • Now, I can promise you that this dramatic improvement would not have been possible without advances in IV fluid delivery systems and catheter materials and designs.
  • We also can do a much better job partnering with patients and families, so that they participate in their care and can voice their own preferences and concerns.
  • We can make our care systems more efficient, so that we reduce waste, reduce burnout, and increase joy in work.
  • We can make health care much safer and reduce the chances that patients will experience harm anywhere across the continuum of care.
  • In other words, we’ll increase the value of health care.
  • Now, I should add that the Institute of Medicine’s report focused on health care.
  • The same principles of quality improvement can and should be applied to improving the health of the population and addressing the social determinants and so-called upstream factors that lead to poor health.

Lesson 1 – What is the Science of Improvement? > Lesson 1 Lectures > Introduction to PDSA Cycles

  • DON GOLDMANN: Now that we’ve introduced the basic components of the model for improvement, let’s discuss those PDSA cycles, or small tests of change, because they’re so fundamental to getting started on your improvement journey.
  • Remember, we’re talking mainly about the how of implementation, and we’re emphasizing small iterative tests of change that can be performed quickly to catalyze rapid learning.
  • Based on what we find on the data we get from the PDS, we then revise our plan if necessary, and act to change our plan and develop another hypothesis and then run another experiment.
  • The question is, how do you actually get that done in practice? How do you execute on that evidence-based plan to get the checklist performed? Well, we know that among the things you’re supposed to do when you put in a central venous catheter are to prep the skin with a certain kind of antiseptic called chlorhexidine, and then use a large surgical drape.
  • The question is, how do you get them to be at the bedside reliably so that the care team can use the chlorhexidine and the large drape when they’re ready to put the catheter in.
  • So you now do an experiment, and lo and behold- and not surprisingly probably- the drape is there, the antiseptic is there, the physician uses them when he or she puts in the catheter.
  • So I’m going to talk about, of all things, cucumbers.
  • So This year I decided I was going to plant cucumbers.
  • I ran around my bed and looked at my cucumbers with tremendous admiration.
  • So then I come back from work one day and come home, and I see that my cucumber vines had been chopped off by a weed whacker.
  • He has a weed whacker, and he chopped off my cucumber.
  • I’ve got this theory that if I prop this cucumber vine up on the raised bed more carefully, the weed whacker won’t get to it.
  • This wasn’t a very deep study, but it was clear that this was a disaster for my poor cucumber.
  • My next experiment was to put a large flower pot in front of the cucumber vine hoping that the guy with the weed whacker would understand.
  • I come home from work, and another PDSA cycle has failed.
  • I want to find the guy, the weed whacker guy, and basically grab him by the shoulders and shake him and say, you’re killing my cucumber.
  • We want to do things better, make things better for the weed whacker guy as well as for myself and my cucumber.
  • So my next PDSA cycle was to put the cucumber up on a trellis.
  • I prop the cucumber up on that trellis, and then the weed whacker really won’t be able to reach it.
  • My prediction was, get the cucumber vine out of the way so the weed whacker absolutely can’t get to it.
  • My cucumbers are thriving, and I’m telling you I had the best marinated cucumbers.
  • We said it before, but I’ve seen countless teams that are so eager to start testing that they don’t really stop to consider how confident they are that their change ideas are going to lead to improved outcomes.
  • Even when there is good evidence that a specific change works, the question is, how well do I predict this change will work in my context or my situation? The impact I’m telling you will seldom be as great as it may appear from a study in the literature.
  • So you include getting rid of the razor in the package of changes you want to make to drive down surgical site infection rates.
  • Its impact can be lost among the effects of all the other changes in that package of interventions.
  • You may not be able to improve the surgical site infection rate unless you better understand those currently unmeasured factors and the context in which you’re implementing your changes.
  • This kind of rigorous and sometimes painful thinking will force you to set some priorities about which changes you want to start trying to implement first.

Lesson 1 – What is the Science of Improvement? > Lesson 1 Lectures > Improving Rounds for Don Goldmann’s Residents

  • Many of you are familiar with these teaching rounds, during which trainees present the history, the physical exam, tests, treatments, and the plan for the patients on our service.
  • Then we go to see the patients so I can verify what the trainees have told me, assess the patient myself, and talk to the care team and family.
  • Truth be told, I think I conduct these rounds skillfully, and I think I’m a pretty good teacher.
  • Don tends to be late for rounds and when he arrives, he sometimes seems distracted and checks for messages on his mobile phone a lot.
  • You may not know this, Don, but we often don’t get home until 9:00 or 10:00 at night, because we have so much work to do after we’re done with the rounds.
  • My aim was simple- be on time for rounds every day, by the end of my 2 and 1/2 week rotation on the consulting service.
  • If I got to rounds on time but trainees still could not get home at a reasonable hour, I doubt that they would be satisfied and give me a good evaluation.
  • The y-axis showed minutes late for rounds, the x-axis showed the day of the week.
  • Seven minutes isn’t so bad. And while there is some variation from day to day, 10 minutes, one minute, nine minutes and so forth, I clearly was doing rather well.
  • At this point, I have to tell you I was just trying harder, but it made no fundamental changes in my daily work other than checking my watch frequently- am I running late- and then running rather than walking to rounds.
  • We did a quick decision bedside rounds in the morning for about 30 minutes, so we could focus on new issues when we met at 3:00.
  • This simple change streamlined afternoon rounds, eliminated frantic pages and calls from the care team, and gave us a sense that we were in better control of our own workflow.
  • By being mindful of my other aim, to end rounds earlier, I started noticing when I was getting off message and digressing into stories and anecdotes that didn’t relate to the patients under my care.
  • I won’t show you that graph, but rounds almost always ended before 6:00, and the trainees noted on the next evaluation, ta-da, that they appreciated getting out of rounds earlier.

Lesson 1 – What is the Science of Improvement? > Lesson 1 Lectures > Faculty Footnotes

  • DAVID WILLIAMS: One of the things that we like to do at the end of each lesson is spend a little time with the faculty and go through a couple of highlighting questions that sort of dive deeper into some of the concepts that we’ve talked about.
  • I want to ask you, one of the things that was brought up in the first lesson was talking about the IOM report and how it really described the inequities that were happening in health care.
  • I like to back up a minute and think about where you have to act in order to make real change.
  • The way I think of it is, well, they’re the people, right? Individuals who are receivers of health care, and trying to be healthy.
  • I think at each of those level, if we use basic quality improvement methods and tools, we’re going to accelerate change.
  • DAVID WILLIAMS: So even in your answer, I’m hearing you describe quality improvement in terms of the four lenses of the system of profound knowledge and thinking about systems, and thinking about data, and thinking about how we build knowledge.
  • So one of the questions that comes up a lot in terms of thinking about the IOM report, and really sort of realizing about these inequities that were happening in health care, is that it had to really kind of transform the way people think about how care’s delivered and appreciating the variation that existed in care.
  • I’m curious, what was that transition like? Or what were some of the challenges for providers and administrators as they had to recognize that there was that inequity, and we had to fix it? DON GOLDMANN: Yeah, well, there’s the absolute pivotal work of Jack Wennberg and the “Dartmouth Atlas,” which was the first time that the magnitude of variation in basic care in this country, the US, was really demonstrated.
  • So we can either sit there and put our head in the sand and say, well, our patients are different.
  • DAVID WILLIAMS: Well, and that raises a good final question for me, which is, as you’re thinking about this complex issue and you’re looking at all this variation, I can imagine that a tendency for many folks was to say, well, let’s study it.
  • Let’s look and try to analyze and find the perfect solutions.
  • What I hear you describing in the lesson is actually encouraging people to start small and use the model for improvement and use the Plan-Do-Study-Act cycle as a way to test changes and learn.
  • Talk a little bit about why that is such a strong process and method for learning.
  • So I thank Don for this quick question and answers.

Lesson 1 – What is the Science of Improvement? > Lesson 1 Lectures > Your Turn

  • We’ll introduce the key elements and building blocks of a personal improvement project after each lesson and we will want to learn together as you make progress.
  • Eating fewer calories won’t improve my fitness much, I’ll wager, but exercise will both increase my fitness and increase my calorie expenditure.
  • As you’ll learn later, calories out is one of the two drivers for losing weight and there are a variety of changes in my life I can try to get rid of calories and become more fit.
  • Don’t work on what to do when you see a bear unless you plan to encounter bears very frequently and want to work on a life and death problem.
  • What’s the problem I’m addressing and what’s the gap between where I am now and where I want to be? In this case, my endurance is pathetic and I want to be able to climb a steep hill or walk briskly to town without huffing and puffing.
  • I’d like to do something that will both increase my endurance and help me expend calories at a greater rate than I’m doing now.
  • I’d like to lose pounds and increase my fitness.

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