QI approach to EDL
completion
May 2012
Emma Vaux
Objectives
• To identify key elements which drive EDL
completion and content
• To identify changes likely to impact on
EDL completion and content
The Improvement Guide, API
What are we
trying to
accomplish?
1. Reduce the incidence of HAP
by 50% over a six month period
in 8 adult wards
2. Engage junior doctors, nurses
and AHPs in quality improvement
methodology
How do we
know a
change is an
improvement?
1. Incidence of HAP has been
reduced on these wards
2. Embed new skills in QI
methodology and demonstrate
learning and development
What change
can we make
that will result
in an
improvement?
1. Implement interventions from
Saving Lives 2006 ventilator
associated care bundle relevant
to HAP
2. Use QI methodology at the
frontline to make a visible change
Driver Diagrams, a useful tool to
help us understand the system and
the messiness of life.
PURPOSE OF DRIVER DIAGRAMS
• Helps you to set priorities
• Identifying the drivers that will have the biggest
impact
• Help organize your theories about what it
takes to achieve improvement
• Leads you to the third question in the model for
improvement – What changes can you make
that will result in improvement?
• Helps you then understand your current level
of performance on these drivers
• Essentially is a set of concepts – to make these
concepts operational you will need to identify
measures that indicate progress towards aim(s)
PRIMARY DRIVERS
• 2 or 3 key elements that will deliver
the goal or aim
SECONDARY DRIVERS
• Processes, cultural norms or structures
that contribute to the primary drivers
• Changing these may lead to improvement
• Differ in relative impact on outcome
• Should be necessary and sufficient to
achieve goal – or why bother?
Step 1 AIM
• Set AIM
• SMART
• Example
“across the Trust, to increase the proportion of
completed EDLs within 24 hours prior to
discharge by 75% by October 2011 so that we
can increase the number of patients discharged
by 10am on their discharge date, and increase
our reimbursement for their admission”
Step 2
• Primary drivers
• Directly contribute towards our aim
• Key things need to deliver to achieve aim
• They are high level
• Ask yourself:
– If I made an improvement in this driver what would it achieve?
(Would it move you closer to your aim?)
– If I did all these things (all primary drivers) could anything else
stop me achieving my aim? If so, you may have missed another
primary driver.
– You are likely to have two or four primary drivers
Primary drivers
AIM:
Increase
number of
EDLs
completed
within 24
hours of
discharge to
enable
effective
discharge
planning
Discharge decision
EDL Completion
Pharmacy
Content
Step 3
• Secondary drivers are the factors contribute to
the key elements
• These are the areas where you can start to
identify actions, interventions or change ideas
that will begin to affect your primary drivers and
move you towards your aim
• If find it hard to understand the drivers or to think
what other drivers there may be, try looking at it
the other way around:
– If we don’t have certain things in place, what goes
wrong?
Primary Drivers
Discharge
decision
AIM: Increase
number of EDLs
completed within
24 hours of
discharge to
enable effective
discharge
planning
EDL
completion
Pharmacy
Content
Secondary Drivers
•Ward round times
•Ward round structure
•Consultant-led decision making
•Elective admission- predictable
•Emergency admission
•Junior doctor availability
•Opportunities for completion
•Time needed for completion
•TTO completion
•Opening times
•Ward pharmacist
•portering
•Information to GP
•Mandatory
•format
•coding
Step 4
• Relationship arrows
• These indicate how the drivers affect one
another
• A secondary driver may impact on more
than one primary driver
• This starts to highlight the cause and
effect relationships and where there may
be greatest gain from improvement efforts
Primary Drivers
Discharge
decision
AIM:
Increase
number of
EDLs
completed
within 24
hours of
discharge to
enable
effective
discharge
planning
EDL
completion
Pharmacy
Content
Secondary Drivers
•Ward round times
•Ward round structure
•Consultant-led decision making
•Elective admission- predictable
•Emergency admission
•Junior doctor availability
•Opportunities for completion
•Time needed for completion
•TTO completion
•Opening times
•Ward pharmacist
•portering
•Information to GP
•Mandatory
•format
•coding
Step 5
• Priorities for action
– Once you have identified your drivers you can
start to identify priorities for action,
interventions and change ideas
– Where can you most influence your aim?
Step 6
• Agree measures
– You can then start to identify relevant,
appropriate measures that fit each driver to
show progress towards your overall aim
– It may be difficult or take time to show
progress in your overall aim. These measures
will help demonstrate what progress is being
made and can help others stay interested and
motivated in your project.
Primary Drivers
Discharge
decision
AIM:
Increase
number of
EDLs
completed
within 24
hours of
discharge to
enable
effective
discharge
planning
EDL
completion
Pharmacy
Content
Secondary Drivers
Step down ward
•Ward round times
Sick,
•Ward round structure
discharges,
rest•Consultant-led decision making
•Elective admission- predictable
Nurse-led
discharge
•Emergency
admission
•Junior doctor time
•Opportunities for completion
Anticipated discharge
•TTO completion
times
7•Opening
day week working
•Ward pharmacist
•portering
•Information to GP
•Mandatory
•format
Pocket
card guidance
•coding
Driver Diagrams: Summary
– Help identify the essential factors
– Help you prioritise your improvement efforts
– Help you define meaningful measures
– Help break down a big task into manageable
steps
– Help communicate your aim and why you are
doing certain things
– Work well when you involve others in
developing and sharing them
Decision time!
• Overall aims
• QI projects to achieve this
Process mapping template
Improvement Idea / PDSA
/ Action
Person
Target
Responsible Date
OVERCOMING BARRIERS - FORCE
FIELD ANALYSIS
What is it?
Force Field Analysis is a QI tool designed to identify driving (positive) and restraining
(negative) forces that support or work against the solution of an issue or problem.
When the driving and restraining forces are identified, steps can be taken to reinforce the
driving forces and reduce the restraining forces
What does the Force Field do?
Allows comparisons of the “positives” and “negatives” of a situation
Enables easy comparisons
Forces people to think together about all the aspects of making the desired change a
permanent one
Encourages people to agree about the relative priority of factors on each side of an issue
Supports the honest and open reflection on the underlying root causes of a problem and
ways to break down barriers
FORCE FIELD ANALYSIS
WORKSHEET
Driving Forces (+)
Restraining Forces (-)
ISSUE OR PROJECT:
______________________________________
Actions to reduce the Restraining Forces:
•
•
•