Lesson 4 – Practical Tools that Support Improvement

Lesson 4 – Practical Tools that Support Improvement

“Lesson 4 Lectures”
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  • Lesson 4 - Practical Tools that Support Improvement > Lesson 4 Lectures > Moving from Theory to Action
  • Lesson 4 - Practical Tools that Support Improvement > Lesson 4 Lectures > Driver Diagrams: Visualizing Your Change Theory
  • Lesson 4 - Practical Tools that Support Improvement > Lesson 4 Lectures > A Few Cautions for Improvers
  • Lesson 4 - Practical Tools that Support Improvement > Lesson 4 Lectures > Creating Conceptual Models
  • Lesson 4 - Practical Tools that Support Improvement > Lesson 4 Lectures > Your Turn
  • Lesson 4 - Practical Tools that Support Improvement > Lesson 4 Lectures > Faculty Footnotes

Lesson 4 – Practical Tools that Support Improvement > Lesson 4 Lectures > Moving from Theory to Action

  • In Lesson 2, Don Berwick- one of the leaders who brought improvement into healthcare- shared the nuts and bolts of applying the Model for Improvement to your life and your work.
  • Then in Lesson 3, I explained the basics of measurement and the importance of collecting and displaying data when working on improvement.
  • Choose name, choose some measures, choose some changes, and get to work.
  • What can you do by next Tuesday, and how often is it that easy to get started? But don’t be fooled into thinking improvement is easy.
  • I don’t tell you that to dissuade you, but rather to reinforce the point that creating and sustaining meaningful change is hard work.
  • We’ll introduce some more practical tools, of course, but we’re only going to dig deeper into the testing and learning you need to do when working in improvement.
  • ” People long for the quick and memorable formula that makes rolling up your sleeves and having to think hard unnecessary and removes uncertainty.
  • Building a theory requires doing your due diligence to check the research and understand the current process data.
  • Finally, these subject matter experts can take what they know and start to answer the three questions from the Model for Improvement.
  • What are we trying to accomplish? How will we know it changes an improvement, and what changes do we think will result in improvement? Each of these questions supports you and your team in developing a theory and structure for converting ideas to outcomes.
  • In sessions to follow, we will talk about methods that help you and your team to identify change ideas and organize your theory to support your improvement efforts.

Lesson 4 – Practical Tools that Support Improvement > Lesson 4 Lectures > Driver Diagrams: Visualizing Your Change Theory

  • Well, a driver diagram- or as some people call it a key driver diagram- is a simple, rather intuitive visual display to help you understand precisely where you’re going with your work and also help others understand what you’re trying to do.
  • A good driver diagram clearly shows the relationship between your change of ideas and the outcome you want to achieve.
  • We’re going to go through a driver diagram for how we can measurably reduce colonization and infection with MRSA.
  • It turns out there are only two major drivers for reducing MRSA colonization and infection.
  • One is a driver to reduce the spread or transmission of the MRSA organism.
  • The second is the driver to reduce actual infection if a patient becomes colonized with MRSA.
  • Now, arrayed behind them are what we call secondary drivers or sometimes you can think of these as major highly leveraged changes that are going to help you accomplish your aims.
  • Let’s look first at the driver preventing colonization by reducing transmission of MRSA.
  • Now, let’s look at the other primary driver reducing infection.
  • Even if a patient becomes colonized with MRSA because there have been some problems in that primary driver of reducing transmission, the chances that he or she will actually get infected can be reduced dramatically by taking fastidious care of invasive devices.
  • When this driver diagram was first developed, the evidence for decolonizing patients with chlorhexidine washes and an intranasal antibiotic called Mupirocin was just emerging.
  • We were not yet confident that decolonization would actually reduce transmission and infection risk.
  • The point I’m trying to make is that a driver diagram and the theory and causal pathway behind it should be dynamic, changing as evidence for specific interventions accumulates.
  • I’ll just remind you to be sure that whatever you want to change, whatever idea you have is measurable and that your PDSAs reflect the main cause and effect relationships reflected in the driver diagram.

Lesson 4 – Practical Tools that Support Improvement > Lesson 4 Lectures > A Few Cautions for Improvers

  • A potential barrier to implementing decolonization of patients with MRSA might be the expense of chlorhexidine and the time it takes personnel to wash the patient with the antiseptic.
  • We sometimes get so caught up in the logic of our driver diagram and our project plan that we don’t think enough about possible unintended consequences.
  • Let’s say we are really good at screening those MRSA patients and putting them on isolation precautions.
  • Well, now, staff will have to gown and glove just to go in the patient’s room.
  • There are several studies that show exactly this- that staff are less likely to enter the room of a patient on isolation to do those tasks.
  • Predicting the side effect of your MRSA reduction program would allow you to take steps to ensure that patients in isolation get exactly the same quality of care as any other patient.
  • As a result, we have to anticipate that the effect of our interventions may turn out to be less than we had hoped.
  • We call this the “attributable effect” of an intervention, and we tend to overestimate this attributable effect.
  • I often ask my colleagues to be specific in a mathematical sense about the expected or attributable effect.
  • Now, that may be important, but I’m willing to wager that the overall attributable effect of cleaning your nails on MRSA transmission will be small- perhaps as small as 1%. This would be dwarfed by the attributable effect of gowns, gloves, and hand hygiene.
  • You may not see a change in the outcome you’re seeking because the attributable effect of that one practice, its signal, is just too small.

Lesson 4 – Practical Tools that Support Improvement > Lesson 4 Lectures > Creating Conceptual Models

  • In our field, we’re all asking what creates health, and then, of course, how can we influence those factors? Conceptual models diagram the causal links between variables at multiple levels that impact the outcome of interest.
  • To understand what impacts and creates your health issue, review articles and case studies that have sought to achieve your same aim.
  • To think about how health care impacts health status and equity, you might start by drawing, very simply, use of services with an arrow to health status.
  • Then you ask yourself, what impacts the use of services? What is upstream of that? And is it simply that use of services impacts health status or what else could be going on there? These questions, along with a review of the literature and your own knowledge, could lead you to something like the adapted Institute of Medicine model of access to care, which outlines variables impacting health care equity.
  • It diagrams the connection between these variables, like personal, structural, and financial factors to elements of service use, health care quality, health status, equity, and patient views of care.
  • How does appropriateness of care and bias or stereotyping impact patient views of care? How does transportation affect the use of services and who we would partner with? These are questions that could be generated from conceptual models and the theories they depict.
  • Conceptual models give us a solid grounding of what is known about the factors that influence health, giving us direction for our improvement work, research questions, and partnerships to improve health.

Lesson 4 – Practical Tools that Support Improvement > Lesson 4 Lectures > Your Turn

  • DON GOLDMANN: By now you’ve heard at least a number of times that I think it’s extremely important to understand the causal pathway between the changes you want to make and the outcome you want to achieve.
  • That cause and effect relationship is shown very clearly on a driver diagram, and we’ve been going over how you build a driver diagram.
  • So as an example, let me haul out the driver diagram we used in one of the lectures in this lesson that shows me losing weight and becoming more fit.
  • So I picked a more realistic aim, and you’ll remember that’s getting to the gym twice a week and to get my calories out, I’m going to be on an elliptical at least twice a week for 30 minutes at level 12.
  • So that’s what I’m focusing on in this revised driver diagram, and you can see I revised it here.
  • By exercising I’m going to get more calories out and I’m going to get more fit.
  • We’re still talking about the causal pathway, and you’re still going to make a visual display.
  • We’ve been over that before, and that’s over here on the left side of the diagram.
  • Maybe your project isn’t as simple as calories in and calories out.

Lesson 4 – Practical Tools that Support Improvement > Lesson 4 Lectures > Faculty Footnotes

  • Dave and I are going to discuss some issues, and I have a few questions based on your really excellent lectures that I hope you’ll help me with and help the students.
  • Can you just give a few tips about how to assemble a team, and even more importantly, how do you get all of their ideas on the table? Are there any tools or tricks? DAVE WILLIAMS: Yeah, I think assembling a team is really important.
  • Having more people that are involved in the process, and especially that represent different parts of the process, increases the amount of knowledge that you’re bringing to your improvement team.
  • So I like to pick teams, that as I mentioned, represent different parts of the process, different stakeholders, maybe even your patient or the customer in the process, and include them in the team so that they can share their individual perspectives and experience.
  • So it’s really important too, to make sure that you’re working through hearing the ideas of everybody, making sure that you capture all ideas.
  • Then that enables you to go back and really see different change concepts and potential opportunities that emerge from the various perspectives.
  • So the big question is to go from just the challenging idea that somebody’s either presenting for or against a concept, to saying, how can we convert that into a test to learn more? Because we may, even if it’s the wrong idea, learn something about the process that’s helpful.
  • What I find is that if you empower both the idea for and the idea against using a small test of change, it enables you to encompass all the ideas, kind of work with both people and learn together.
  • If they have a secretary or an assistant, I try and find out what they like in the morning, and I bring them their cappuccino and a hot bagel, and sometimes that helps.
  • DAVE WILLIAMS: Well, and I’ll throw out one thing I recognized from doing improvement in a lot of other countries, is that we tend to jump right into doing work and we fail to get to know people.
  • A really helpful way to convert somebody over into the process that you’re working on is to spend a little time trying to understand them and understand what motivates them, and then build your case in that motivation.
  • In some tribal communities In the United States, people sit down and they smoke a pipe and they talk about just stuff for a long time and then they get to the point or they’ll ask about the crops or the sheep before they get to the point.
  • He said well, you know the front line comes to me and they have a pain point, and we have a hack-a-thon.
  • So I think it’s really, really important to look at the bigger system, appreciate where all the connections are in relation to the process that you’re working on, and then trying to figure out what makes that process reliable.

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