Lesson 5: Using Systems Principles to Spread an Improvement Project

Lesson 5: Using Systems Principles to Spread an Improvement Project

“Lesson 5 Lectures”
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Summaries

  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Spreading a Checklist
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Using Flow Diagrams in Improvement Work
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Finding the Right Flow Diagram for You
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Improvement in Action: Cambridge Health Alliance
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Improvement in Action: A Closer Look
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Your Turn
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Bonus Lecture: Diagramming a System
  • Lesson 5 - Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Faculty Footnotes

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Spreading a Checklist

  • You’ve probably heard about the surgical checklist.
  • He tested the checklist in his own operating suite, probably first with his own patients, as he’s a surgeon.
  • When had a prototype that he felt worked well in his own academic surgical practice, he tested it more widely and quite rigorously in eight hospitals, including hospitals in Canada, India, Jordan, New Zealand, the Philippines, Tanzania, England, and the United States.
  • It’s important to note that the technical specifications for the checklist included considerable direct training of surgical teams.
  • To facilitate adoption, Dr. Gawande always recognized that it’s the elements of the checklist, not a specific form or document, that are important.
  • If a surgical team has a form that works better for them, that’s fine, as long as the key checklist items in the technical specifications are implemented reliably.
  • So based on this experience Ontario, Canada decided to mandate the use of the checklist in surgery.
  • Team training was not required and the need for local adaptation and learning was not emphasized.
  • Most observers, having looked at that study, concluded that the implementation approach was deeply flawed, and questioned self-reported claims by the hospitals that their rate of adoption of the checklists were extremely high.
  • So does the surgical checklist work? And can it be deployed at scale? If you examine the checklist and what it’s meant to do, you’ll see that it’s much more complicated than implementing a simple bundle of practices to prevent central venous catheter bloodstream infections.
  • So let’s hone in on one aspect of the checklist, the section entitled anticipated critical events.
  • Further studies may help determine whether the checklist really is ready for deployment at scale.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Using Flow Diagrams in Improvement Work

  • Now you may be saying to yourselves, didn’t we already have a short lecture on flow diagrams in Lesson 4? And yes, that’s true.
  • You can use flow diagrams to learn and generate ideas for change, especially when there’s variation in how people carry out a step or series of steps.
  • In two short segments, I’m going to share four tips on how to use flow diagrams, and then three different types of advance diagrams that will be helpful to you on your improvement journey.
  • Often, a secondary and equally important benefit of developing a flow diagram is the team building that happens during the process.
  • Remember, the best way to develop a flow diagram is to get those who touch the process and do the work, including ideally the customer, together to outline the process.
  • They start to see the roles and relationships between the steps and people involved, and it creates a learning experience for the whole team.
  • It can be your personal improvement project, or for those of you who have gone ahead and tried to develop a flow diagram at work, a project related to your work.
  • Have you looked at the diagram since you’ve created it? Remember to display and use it at all of your meetings.
  • Continue to learn from the places where there is variation in how people carry out a step or series of steps in the process, where the steps are unclear, and where steps fail.
  • Once you’ve mapped the current process, pretend you have all the resources you need, time and money are no barriers here, and you can start all over and design the process from scratch.
  • You might not be able to test and implement the ideal process, but it might provoke some new thinking and help you design an improved process that’s better than the current state and closer to the ideal.
  • As a provocation to help generate change ideas and spark some new thinking, team members asked themselves, if we started over from scratch, what would this process look like ideally? And then mapped an ideal process that only had five steps.
  • This exercise helped them to see all the places they could standardize information, consolidate steps, and eliminate many that had been put in the process to compensate for errors in other parts of the process.
  • Simply noting on your flow diagram the number of times something happens, or doesn’t, or the amount of time it takes, for example, helps with your data collection and planning subsequent PDSA cycles.
  • Depending on what you’re measuring, you’ll be able to see things like frequency, variation, and reliability of steps in your process.
  • If Jill can do that step in 30 minutes and it takes me two hours, what might I learn from Jill about how she does that step so I can be more efficient? Tip four: use flow diagrams to standardize and communicate.
  • The flow diagram is an important tool to help you standardize and communicate about the new process.
  • Once you have an improved process, a flow diagram is an easy way to document the new process and share it with others.
  • You can use it to train new and existing staff on the improved process.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Finding the Right Flow Diagram for You

  • It’s helpful in understanding the flow of the process between the various groups, and the responsibilities, handoffs, and interdependencies between them.
  • A swim lane diagram helps the team break traditional barriers, create a spirit of cooperation, and articulate each group’s responsibilities and contributions to the process.
  • A value stream map is a fundamental and critical tool in Lean that can be very useful in all quality improvement efforts, especially when you’re looking to cut out non-value added steps and improve efficiency with a particular focus on the customer’s perspective.
  • When a team creates a value stream map, they write down each step and analyze whether each step or action is valuable, meaning creates value from the customer’s perspective, capable, or achieves a good quality result every time, available, meaning is able to operate when needed, adequate, has the capacity to respond to the customers orders as needed, and flexible, meaning the degree to which the step can switch over quickly and at low cost from one product to another.
  • Then the team looks for three critical attributes of each value stream: flow versus stagnation, push versus pull, and level versus erratic.
  • Once a team has detailed the current state, it will move to designing a better future state that will help both the customer and the organization.
  • At the end of these value stream mapping exercises, you will often see two maps: a current state map that follows a product from order to delivery to view the current conditions, and a future state map that shows the team the opportunities for improvement identified in the current state to achieve better performance.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Improvement in Action: Cambridge Health Alliance

  • The title of our quality improvement project is Improving Depression Screening Rates among diabetic patients.
  • The specific aim of our project is to improve the annual depression screening rates among our diabetic patients from a baseline of 51% to 70% within six months.
  • Using the tools that we learned from the IHI Open School curriculum, we identified the different problems that could be contributing to the suboptimal depression screening rates among our diabetic patients.
  • Using the fishbone diagram, also called the cause and effect diagram, our residents identified five different areas in which improvements can be implemented.
  • Specifically, the five areas are staff workflow, technology, organization culture, patient adherence, and physical environments.
  • Our first PDSA cycle is actually a learning cycle, in which we gather all the medical staffs, including secretaries, medical assistants, nursing, as well as physicians, to draw a process map and to clarify the roles in the depression screening process.
  • CHIN FUNG: Who will be entering the score into the computer, and finally, who will be modifying the health maintenance field into the electronic medical record system.
  • CHIN FUNG: Another problem that we identified was that sometimes the depression screening forms were not appropriately entered into electronic medical records.
  • CHIN FUNG: One change that we implemented was a pre-clinical huddle session, in which the medical assistant and the physicians sit down to review the task that needs to be completed for the clinical sessions.
  • Overall, these changes were very successful in our clinic, and we were able to improve the depression screening rates for our diabetic patients from a baseline of 51% to 74% over the course of three months.
  • Two, we were able to learn the different tools and quality improvements which is essential for our primary care practice.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Improvement in Action: A Closer Look

  • CHA has a great track record in integrating quality improvement into its daily work, especially in integrating it with a training program for residents and junior doctors.
  • We’ve just heard a great example of this from Chin, and now I’m privileged to be talking to Rachel Hathaway, who just graduated from residency training program here at Somerville Hospital Primary Care, and she’ll be able to tell us a little bit about what it’s like to try and do quality improvement as a trainee.
  • So what do you think is done here that’s so special and unique in getting residents so fired up about quality? RACHEL HATHAWAY: You know, Don, it’s really challenging for residents to participate in quality improvement with all of the other educational priorities that they have.
  • In some ways, it also feels natural for residents to be engaged in quality improvement work.
  • While there’s a lot of competing priorities for resident time, it also feels important for residents to participate in quality improvement initiatives.
  • It gives residents a sense of ownership over the systems in which they’re working, and it also gives them a sense of improving the care for the patients that they see every day.
  • A lot of the quality improvement work that’s happening in residency programs are very short, one-month bursts of time.
  • Like you say, it’s really challenging to do quality improvement work unless it’s longitudinal.
  • We felt that by picking a project that the institution was working on already- that had dedicated resources and other leaders- that we’d be better able to accomplish meaningful work that then would have a structure to continue forward once we finished our part of the project.
  • We hear that when medical students, or nursing students, other health professional students have been through the open school and then they get into their actual training- the clinical setting- all that learning gets extinguished because the organization hasn’t figured out that these folks are allies in their quest to constantly improve the quality of care.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Your Turn

  • What was the measurable aim that you hoped to achieve? And describe the improvement methods you used to try and achieve that aim.
  • What did you learn that helped you achieve your aim or at least make progress toward your aim? On the other hand, be really explicit about the barriers you encounter, because if you’re going to continue to improve or sustain the gains you made, you’re going to have to deal with those barriers in a very concrete way and probably do some tests to mitigate or to counter the barriers that you’ve already learned are a problem for you.
  • I really hope to sustain the progress I’ve made over the year and maybe even to get to a higher level of fitness.
  • You need to think about what you’re going to do to either get all the way to your aim if you haven’t achieved it yet or sustain the gains you’ve made.
  • Very often we get all excited about our improvement projects, we meet an aim, everything looks great, and then we lose interest or we get distracted or it’s too hard, and our performance begins to fall off.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Bonus Lecture: Diagramming a System

  • What was the measurable aim that you hoped to achieve? And describe the improvement methods you used to try and achieve that aim.
  • What did you learn that helped you achieve your aim or at least make progress toward your aim? On the other hand, be really explicit about the barriers you encounter, because if you’re going to continue to improve or sustain the gains you made, you’re going to have to deal with those barriers in a very concrete way and probably do some tests to mitigate or to counter the barriers that you’ve already learned are a problem for you.
  • I really hope to sustain the progress I’ve made over the year and maybe even to get to a higher level of fitness.
  • You need to think about what you’re going to do to either get all the way to your aim if you haven’t achieved it yet or sustain the gains you’ve made.
  • Very often we get all excited about our improvement projects, we meet an aim, everything looks great, and then we lose interest or we get distracted or it’s too hard, and our performance begins to fall off.

Lesson 5 – Using Systems Principles to Spread an Improvement Project > Lesson 5 Lectures > Faculty Footnotes

  • I’m very lucky to be here with Karen Baldoza who talked to you about flow diagrams and value streams.
  • So let’s say we’ve done our flow diagram, and we’re really happy with it.
  • Now we have to figure out, where do we do our monitoring of that diagram to make sure we’re doing what we said we’d do reliably? And where do we want to do our testing to continuously improve? So do you have any tips that would help people make that kind of a prioritization of where to start? KAREN BALDOZA: Absolutely.
  • Some magic happens here, and we’ll go back and figure out what that is.
  • On one axis, you have impact, high or low, and on the other axis effort, high and low.
  • Then you can sort of think about your change ideas and plot them on that grid.
  • They’re so happy with it they put it on the wall, and they may even laminate it.
  • DON GOLDMANN: And then I want to know, well, do you ever go back to this as you learn? As you do your work? How do you get folks to revisit their flow diagram and revise it as a way of continuously learning? KAREN BALDOZA: Yes.
  • You’re so proud to get to the end of it you want to capture it and put it in PowerPoint and laminate it.
  • Once you put it in PowerPoint, it feels permanent and hard to change.
  • As you were talking, I think you must have said three or four times, from the customer’s point of view.
  • If you’re doing a value stream in a car manufacturing plant, let’s say, I’m very sure that Ford Motor Company or Toyota is thinking about the customer.
  • A lot of the times when I’ve seen waste being taken out of the system, it’s the production system, from the health care system’s point of view, not so much from the real customer, the patient.
  • Even if it’s a very internally feeling process, they always try to extend that out to the perspective of the customer or the person paying for the service.
  • We always talk about put the customer right in the room.
  • Put the patient right in the room and ask them, use them, when you’re doing your flow diagram.
  • Ask them, what would they be willing to pay for? Quite frequently, when they tell us what they would like, it’s usually less expensive, much easier to do, and pretty quick, simple fixes, often, when you actually get the customer’s perspective.
  • If you can’t have the customer in the room, go out there and do interviews, do surveys, gather all of that information so you have at least a proxy for the customer’s voice if you can’t have them in the room.
  • So rather than sitting there trying to figure that out, they went out to the provinces and found out that they were breaking in farm families.
  • The reason you can put your sneaker now in the washing machine is because the Japanese manufacturer asked the customer what they were using the machine for.
  • Actually going out to the customer and observing and talking to them in their environment even better- DON GOLDMANN: Oh, yeah.
  • DON GOLDMANN: Why rely on the spoken word when you can go and see it visually? KAREN BALDOZA: Yeah, absolutely.

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