The Science of Improvement
Dwight Evans
The speaker does not have any relevant financial relationships with any commercial interests
Consider “Marie”







Marie works at a food stall
Marie presented with burning pain in her chest and
headaches
Dx: GERD, HTN and Diabetes Mellitus Type 2
Root problem: BMI of 36
Diet: unhealthy
Environment: surrounded by temptations for fatty,
sugary foods (“Junk Food”)
Key: Where does “Marie” live?
 Gabon (West-Central Africa)
Health Affairs
32(2013):813-816
“Science of Improvement’s”
Mission:
To relieve suffering due to:
Poor health and
Poorly Designed and Delivered
healthcare
To continually improve the delivery of
Healthcare to the population you care
for, helping them achieve the fullest
potential health and wellbeing in a
sustainable fashion
Questions to ask in
Evaluating Healthcare (HC) Outcomes
– Evidence Based Medicine together with Evidence-Based Management
How many of your patients are
receiving care consistent with current
best practice?
1.
•
How does the healthcare you deliver
need to change to reflect best
practice
2.
•
3.
(Evidence-Based Medicine - EBM)
(Evidence-Based HC Management -EBM)?
Do your healthcare professionals /
managers have the skills and support
to make these necessary changes?
Classic Definition of Impaired Quality –
“Deficiencies in the Delivery of Care”

Overuse (of procedures that cannot
help) [Up to 15% of actions]

Underuse (of procedures that can
help) [Up to 50% of actions]

Misuse (errors of execution)
Underuse/Undertreatment



Definition: Patients not receiving
services from which they would benefit
Example: Heart Failure patients not
treated with ACE inhibitors
Why a Problem?: desired outcome is
reduced because they do not realize the
health benefits of these treatments
Overuse


Definition: Patients receiving services
from which they would not benefit
Example: MRI/CT in a patient with acute
(no neurological s/s) back pain

Why a Problem?: The provision of
services whose expected net benefit is less
than the expected net benefit of either
providing a different service or no
intervention at all
Misuse

Definition: Appropriate health services are

Example: patients with renal insufficiency

Why a Problem?: the probability of a good
provided ineptly [~3.5% of hospital patients
experience a serious adverse event]
who require aminoglycoside antibiotics but
receive doses that are not reduced to match
their renal function
outcome is diminished by the added risk of
avoidable complications
Which is the Most Dangerous?
How Hazardous is Health Care?
DANGEROUS
(>1/1000)
REGULATED
ULTRA-SAFE
(<1/100K)
100,000
Driving
Healthcare
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
10
Bungee
Jumping
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
Number of encounters for each fatality
1,000,000 10,000,000
Antimalarial Drug Quality

In six countries Antimalarial drugs
obtained from private pharmacies

Active content (chromatography)
measured:
35% failed – not the right agent
 Unfortunately ~ 33% were artemisin
monotherapies (75%) produced in
appropriately


Result: risk of patient safety: no active
drug given as well as increase in drug
resistance
Bate et al, “Antimalarial Drug Quality in most severely malarious parts of Africa – a six
country study, PLOS One 3:e2132-2135; 2008
HC-Associated Infection in Africa




Hospital-wide prevalence of HAI ranged from 2.5%
to 15%
Surgical ward prevalence of HAI ranged from 8% 46%
 Mainly surgical site infections (3% -31%)
 ~ 27 infections per 1,000 patients in Peds
Surgical patients
Main causative organisms: gram-negative rods
 Pseudomonas, E.coli, Klebsiella, Enterobacter, etc.
Real burden of HAI is greater in areas with weak
infrastructure and fewer resources (this data is
mainly from large teaching hospitals)
Nejad et al (WHO); “Healthcare-associated infection in Africa: a Systemic Review” Bull WHO 2011;89:757-765
Medication Errors in Ghana Hospital ED Patient Safety Issue



Study: Nursing medication administration
27% of ED Patients had Medication Errors
 Omission and Wrong Dose – most common
 27% of the errors were clinically severe
Causes: unavailability of drug, staff factors
(overcrowding, understaffing, multitasking,
too many verbal orders, frequent interruptions
and incomplete patient data), prescription and
communication problems
Acheampong et al Medication Administration Errors in an Acute Emergency Department of a Tertiary
Healthcare Facility in Ghana Journal of Patient Safety,2015
Patient Safety - Reliability



What if your hospital has a 80-90%
institutional success rate?
“great”?
but from an individual patients’ standpoint,
it is unacceptable
For the individual patient, reliability is an
“all-or-none” matter
Optimal Patient Safety requires a
framework for improving reliability standardized protocols for care that are
evidence-based and widely agreed upon is
essential
Behaviors to guide Pt Safety
work

I am humble and curious



I will respect, appreciate and help others
I am accountable for continuously
improving:




Curiosity is one disease that can never be
cured
Myself
My organization
My community
Avoid “I” statement –which implies power
over others
The 6 Fundamental
Domains of Quality
1.
2.
3.
4.
5.
6.
IOM
Safety: as safe in healthcare as in our home
Effectiveness: matching care to science;
avoiding overuse of ineffective care and
underuse of effective care
Patient Centeredness: honoring the
individual, and respecting choices
Timeliness: less waiting for both patients
and those who give care
Efficiency: reducing waste
Equity: closing gaps in health status
amongst groups
A Transformed [Highly Reliable]
Healthcare System [“A Place you
want to be…”]
A Framework
1.
No Needless Deaths
[Safety]
2.
No Needless Pain
3.
No Helplessness
4.
No Unwanted Waiting
5.
No Waste
6.
No Unfairness
[Effectiveness]
[Patient Centered]
[Timeliness]
[Efficiency]
[Equity]
How to Determine the Value You
Provide to Your Patients:
VALUE=
VALUE = “A” X
Outcome
Cost
Access + Technical + Functional + Satisfac.
COST
“Delight Index”
A= “Appropriate”
If “A” = 0, Do nothing
If “A” = 1, appropriate care
The Triple Aim
As hospitals work to achieve the Triple Aim on behalf of patients
and communities, they must actively engage trustees and
communities now in the changes that will inevitably come
1999 IOM Report “To Err Is Human”
A wake-up call to all Healthcare
systems:
Documented the ways in which Healthcare
was harming patients and identified things
that should never happen
The “Status Quo” is no longer
acceptable
IOM report [2001]:
“Crossing the Quality Chasm”
• Identified things that should always happen
• Identified that while our investment in biomedical

improvements is astounding
 Our lack of investment in the delivery
systems management is equally as
astounding
 Ask the questions
 What is the ideal delivery mechanism?
 Why do we do what we do?
Between the Health Care we have and the
Care we could have is not just a gap, but a
Chasm
Crossing the Quality Chasm

Three main strategies:

Use all the science we know (EBM,
EBM-management)

Cooperate as a system

Center Care on the patient
Crossing the Quality Chasm
Our Task: “Science of Improvement”
Where We
Think We
Are
“One doesn’t leap over a
chasm in two steps”
Chasm
Where We
Actually Are
Goal:
Evidence
Base
Medicine
Basis for “Science of Improvement”


The key element in the “Science of
Improvement” is the premise that
quality is a system property
Therefore, what primarily determines
the level of performance is the
design of the healthcare system
Systems Thinking



A system is a network of
interdependent components that work
together to try to accomplish a
specific aim (Deming)
A system has flow, constraints,
sequence and context
A system has an aim
o

HC systems aim: meet the needs of
patients, families and communities
HC is an Open System: capable of
continuous improvement
System Attributes



“ We must accept human error as
inevitable – and design around that
fact.” - Don Berwick, M.D.
“The Search for zero error rates is
doomed from the start”
If You Want a New
Level of Performance?
Design a New System!
Apply the
“Science of Improvement”
To HC Delivery Systems
“The Science of Healthcare
Delivery”
[Evidence-Based HC Management]
Why Do “Science of Improvement”
“It is not necessary to
change
Survival is not
mandatory”
W. Edward Deming, Ph.D.
The First Law of Improvement [Step #1]
 “Every
System is perfectly
designed to get the results it
gets.”
Paul Betalden, M.D.
o
This reframes Performance from a matter of
effort to a matter of system design….
If you want to improve results
you must change the system!
Systems Thinking

“Healthcare Organizations are
the most complex
organizations to manage”
“Running a Hospital isn’t Brain Surgery…
It’s Harder!”
System Behavior
80%
20%
Joseph Juran
Poor Performance
due to the
design of the
system
Poor Performance
due to the efforts
of the people in
the system
System Flow for just One Patient
Test
External
Demand
Test
PC
Test
MDT
SC
Surgery
Follow
up
Radiation
Discharge
Follow
up
Chemo
Bed
Oncology
Test
MDT
Why “Science of Improvement”
not QA Activities?


Quality
Assurance will
support best
outcome within
system design
“Science of
Improvement”
will transcend
design
specifications
QA
S of I
System Paradox: Work Harder?
Effort
Improving Time
Actual Performance
Working Time
Capability
Time
Repenning, NP and Sterman, JD: Nobody Ever
Gets Credit for Fixing Problems that Never Happened
www.webmit.edu
System Paradox: Work Smarter!
Effort
Actual Performance
Improving Time
Working Time
Capability
Time
Repenning, NP and Sterman, JD: Nobody Ever
Gets Credit for Fixing Problems that Never Happened
www.webmit.edu
Approach to Change
INSANITY:
Doing the same thing over and over
again
and expecting different results.
Albert Einstein
Change
“Change is Good,
You go first”
Change

To create great health (high value)
We must create great “systems”
of care for patients

Improvement begins with our will


But to achieve improvement we need a
method for system change

Thus, models of “Science of Improvement”
EB Medicine vs. EB Management
•
•
You can’t have healthy patients
without having a efficient healthcare
delivery system
In order to have evidence-based
“care” you have to have evidencebased “management” (Delivery of
Healthcare)
•
Difficult because of the urge to act can overwhelm
the need for evidence to inform that work
The “Science of Improvement”
Basic
Clinical
Science
Science
What is the
Pathophysiology?
What is the
Diagnosis and
Appropriate
Intervention?
Health
Care
Delivery
Science
How do we
Best deliver
the
Intervention To
Everyone?
Evaluation
Science
Does
The
Intervention
Work?
“The problems of Healthcare throughout the world are not primarily ones of medical knowledge or even political
will- they are problems of effective management and execution.” Jim Kim, MD, PhD, President, World Bank
“Community of Scientists”
The Basic Sciences of
Quality/Pt Safety
Use Evidence-Based Management
Principles (adapted for HC) to Improve
Healthcare Organizations as “Systems”
Change from the “Why” do this to
“How” to do it!
“Science of Improvement
Methodologies”
A central concept of the “Science of Improvement” is
that decision making should be based on data not
anecdotes. Good data is obtained by systematic
collection
Improvement, Change and Learning are
intertwined in changing systems
The Road to Improvement passes through Change
and the best way to change is to learn from
multiple Improvement cycles
Science of (Quality) Improvement Methods
[EBM for Organizations]
1.
IHI – Model of Improvement [Rapid
Cycle Improvement]


2.
3.
4.
5.
6.
7.
Advanced Clinic Access
Inpatient Flow [managing hospital
operations]
Lean Thinking
Theory of Constraint
Queuing Theory
Six Sigma
ISO 9001
Baldrige Criteria for Performance
Excellence
Model for Improvement - Institute for
Healthcare Improvement (IHI)
[Method A]


The Model for Improvement is a simple
yet powerful tool for accelerating
improvement
Not meant to replace change models that
organizations may already using but to
accelerate improvement
Model for Improvement - IHI
The model has two parts:

Three Fundamental Questions:
1.
2.
3.


Setting Aims: What are we trying to accomplish?
Establishing Measures: How will we know that a
change is an improvement? [Measurement]
Selecting Change: What changes can we make
that will result in improvement?
The Plan-Do-Study-Act (PDSA) cycle to test
and implement changes in real work settings
Rapid Cycle Improvement (RCI) = multiple
small tests of change
AIM

Skill #1
Use the Acronym of “SMART” (to help you
choose an appropriate “aim”)





Specific
Measurable
Actionable
Reliable
Timely

Aims should be ambitious – stretch goals

Make it obvious that the current system is inadequate
and that a new one is required
Examples:


By Jan. ‘16, the # pts transferred from ER to ward < 1
hour from decision to admit will decrease by 40%
• By March ‘16, the # pts transferred from ICU to ward <
4 hours from time ready to move will decrease by 50%
Measurement
Skill #2
Why Measure? How do you known if a
change leads to an improvement?
To know if a change is an improvement
you must Measure
We measure to define where we’ll be, not
to record where we were!
Don’t get caught in the search for the
perfect metric—”good enough”
Measure


Remember: Measurement is not the
Goal – Improvement is the goal
You need just enough data to know
whether or not the changes you put
in place are leading to improvement



Do not wait for a big “Master Plan”
Be agile: “What can I do by next
Tuesday?”
Track and trend your data over time
(Run Chart)
Change
Skill #3
Develop the Skill to find promising alternatives to
the usual processes:



Journals, professional meetings, Colleagues,
Real Curiosity / Search widely
Develop clear alternatives

Continuous patient flow (find Waste in system)





Waiting rooms
Forms in bins
Batching in the Lab
Phone calls on hold
Don’t settle for educating staff
or Giving incentives

- a slow method of change
These rely on stressing the existing
system instead of building a new one
Model for improvement
What are we trying to
accomplish?
goals and aims
How will we know that a
measures
change is an improvement?
What changes can we make
that will result in the
improvements that we seek ?
Act
Plan
Study
Do
change principles
testing ideas
before
implementing
changes
Traditional view of successive plan–do–study–act (PDSA) cycles over time depicted as a
linear process.
Ogrinc G , and Shojania K G BMJ Qual Saf 2014;23:265-267
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Model of Improvement
Basically = the “Scientific Method” “EvidenceBased Medicine”
 Plan: Hypothesis (aim)
 Baseline Measurement
 Identify the steps in the process (process
mapping)
 Do the Experiment (PDSA cycle - RCI)
 Study (observe the results -post-Experiment
Measurement)
 Analysis: evaluate the data and then accept
(incorporate into your processes) or reject the
change studied
 Next Hypothesis - Next RCI (PDSA)
Lean Thinking

Lean describes a philosophy and mindset
that centers on:




[Method B]
Eliminating waste
The consistent delivery of Value
The resolution of bottlenecks and constraints
that affect the consistent delivery of value by
maximizing flow
In Lean, Value is defined by the customer;
*Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient Care Delivery System: Charles Protzman, George Mayzell,
Joyce KerpcharAuerbach Publication: 2011
What is Lean?

In the context of organizations, Lean is
often referred to as a “journey” because it
requires time and commitment to undertake
the cultural transformation required to truly
operationalize lean thinking and practices
across an organization
Lean Concepts

Value


Waste



Value is determined by the “customer” (patients;
ordering provider)
Anything that does not add value from the
patient’s perspective
(or, is not necessary for compliance)
Value stream – Map the process

The actions (and waste) taken to create value
Lean = Waste

Waste is disrespectful of:

Humanity because it squanders
scarce resources

HC Staff because it asks them to
do work with no value

Patients by asking them to endure
processes with no value
Lean - Eight “Wastes”
1.
2.
3.
4.
5.
6.
7.
8.
Waiting
Transportation
Defects
Unused human talent
Extra processing
Motion
Inventory
Overproduction
The Five S’: Sort, Straighten,
Shine, Standardize and Sustain

5 S: an organized, never ending, effort to



Remove all physical waste out of the work place
that is not required for doing work in that area
Setting things in order
Identify, label, allocate a place to store it so that
it can be easily found, retrieved and put away
Lean Thinking
5S
Workplace Organization
Five “S”

Sort

Simplify (Set in
order)

Standardize

Sweep (Shine)

Sustain (Self
Control)
NOT

Scrounge

Steal

Stash

Scramble

Search
Average Time To Get 8 Drugs
= 3:07
Average Time To Get 8 Drugs
= 1:08
Stabilizing Equipment Availability
5-S Techniques:
Sort
Set in order
Standardize
Shine
BEFORE
Sustain
Benefits
Clean equipment =
pathogen vector
Saves frustration,
searching
Freed up $20K-worth of
unused equipment for
use elsewhere
AFTER
IV Pumps
(4)
Always Plugged In
Waste “Pre / Post- Lean
Unit 1. Basement -Plumbing
(Before) and (After)
LEAN A3
1. Reason for Action:
VISION / Analysis
Problem Statement
Team and AIM
4. Gap Analysis:
What Change
needed?
7. Completion Plan:
Sustain new process
Spread
2. Current State:
Map Process
Baseline
measurement
5. Solution Approach:
Change
8. Confirmed State:
Sustain & Spread
3. Target (or Future)
State:
Map Ideal/
Target State
Measure
6. Rapid Experiments
(RCI)
Change
9. Insights:
Ideas to help sustain
and spread
“Science of Improvement”
How the Process “Flows”
Content: What Skills Do Each Employee Need?
Few
People
Many
People
Everyone
(All
Staff)
Change
Agents
(Middle
Managers,
Project
leads)
Operational
Leaders
Experts
(Executives)
Unit
Based
Teams
Shared
Knowledge
Continuum of SI Knowledge and
Skills
A key operating
assumption of building
capacity is that
different groups of
people will have
different levels of need
for PI knowledge and
skill.
Important to make
sure that each group
receives the
knowledge and skill
sets they need when
they need them and in
the appropriate
amounts.
Deep
Knowledge
Second Law of “Improvement”

Be open and honest about “failed”
tests:



These are often the most valuable RCIs
It is natural for humans (HC workers)
to want to forget about experiments
that don’t work
But all scientists know that learning
from failure is just as important as
learning from success
“Science of Improvement”:
Attitude



[Step 3]
To learn something new is Humbling. It
requires that we put aside our “expert”
status and become learners: disciples,
open, teachable, obedient
We don’t like feeling stupid; we’d much
rather be the Teacher, the one with all
the answers, but first we must embrace
the humility discipleship requires
Willingness to Fail
Failure?

Senior Management should interview
front-line staff that are involved in
quality / patient safety issues:

Listen carefully to their emotions
Anguish
 Shame
 Embarrassment
 Fear
 Anger


These emotions can be insights to
motivate major change
TASEKI
“Your Burden”
JISEKI
“My Burden”
Reaction to Change: Facing Reality
in your attempt to Change a System
Staff response to identified System Defects:
……
Denial
.…..
Anger
3. “Yes, my data, but not a problem”
……
Bargaining
4. “Yes, poor me”
……
Depression
……
Acceptance
1. The Data are Wrong
“No, it can’t be true”
2.
Why Give Me this Data?
“Why Me?”
5. I accept/admit the burden of
Improvement
“It’s OK, what will I do”
Kubler-Ross: Stages of Grief
Quest for Quality
“Science of Improvement”
“Tools”
Data
Information
S of I Tools –
Value Stream Mapping is:


o
[Tool A]
A powerful improvement tool to define,
describe, and communicate clinical,
administrative and operational processes
Also known as process flow diagrams,
a pictorial
representations of how a process works
An easy to understand set of diagrams that show
how the steps in a process fit together by tracing
the steps the “object” of the process goes
through from start to finish. (a lab test, a clinic
visit, a specialty visit, an imaging study, etc. )
Flow Mapping Symbols

Elongated circles – signify the start
or end of a process:
Start

Rectangles – show
actions/instructions
Task
Flow Mapping Symbols

Diamonds, which highlight where
you must make a decision
Decision
Arrows (
) are
used to connect the
symbols – sequence
and interrelationships
Y
E
S
NO
Value Stream Mapping

A set of processes that delivers value

every step in a process is mapped:
Who does it?
 How long does it take?
 Are there any problems with a step?
(defects)


Identified “waste” (non-value steps) to
be eliminated
Why Use Flow Mapping as a Tool?


Allows a team to identify
the actual flow or
sequence of events in a
process that any
product or service
follows
Flowcharting is a picture
that helps people
develop an objective
understanding of the
process
Value Stream Map - Example
Current State to Future State
Patient
Arrives at
Registratio
n Desk
Clerk
requests ID +
medical card
Patient
Preregistered?
Not enough
Registrars
Clerk/Registrar
requests ID +
medical card
Not enough
Escorts
Radiology
No
Clerk
assigns
patient to
Registrar
Patient
Arrives at
Registration
Desk
Yes
Patient
escorted to
Outpatient
Registrar enters
patient
information into
system
Patient information
scanned into
System and Verified
Patient
Arrives at
Outpatient
Radiology
Potential Solutions:
 Cross train clerks/registrars
 Card Reader + IT Integration into registration system
 Move Radiology Clerk Station Closer to Radiology
 Better Signs and Directions from registration to
Radiology
Patient
Arrives at
Outpatient
Radiology
Now this is where it gets a little complicated
111
SI Tools – Fishbone Chart
[Tool B]
Cause & Effect Diagrams (Fishbone or
Ishikawa diagrams)
 A schematic means of relating the causes
of variation on a process
 A drawing to organize the contributing
causes to a problem in order to prioritize,
select, and improve the source of the
problem
 Useful for teams: focusing a discussion
and organizing large amounts of
information coming from a brainstorming
session.
Fishbone Diagram
Equipment
People
No on responsible
for pt. Flow
Not enough
computers
Providers are
late
Equipment
broken
Problem:
Inventory low
Charts missing
Materials
Lengthy
Appointments
No Std Registration
process
Poor staff
communication
Process
Checkout
process delays
The Pareto Chart




[Tool “C”]
It ranks the potential contributing causes
identified by the cause-and-effect analysis.
It focuses the improvement effort by
identifying the main contributors to the
problem.
It is based on data collected over time.
Invented by the nineteenth-century
economist Vilfredo Pareto.
The Pareto Principle, or the “80/20” rule, says that 80%
of a problem is caused by 20% of the possible causes.
Address the “vital few” causes and not the “trivial many”,
and you will achieve improvement
n=60
Pareto Chart for Late Lab Work
(Example)
60
100%
95%
55
50
Number of Delays
90%
87%
80%
45
70%
68%
40
Break Point
35
30
25
26
60%
50%
43%
40%
20
15
30%
15
11
20%
10
5
5
0
3
10%
0%
Causes of Delays
Run Chart


[Tool D]
A run chart is a graphical display of data
that shows trends over time
Benefits:


Easy to make and interpret
Provide a picture of the current process
Is the process performing at the targeted level?
 Is the change you initiate associated with results
in the right direction?
 Does your process have a lot of variation?

Results: 30% Improvement in ED
activity: door to bed time
Door to Bed
50
45
Influenza
40
Current LOS
35
30
25
Epic Go
-Live
Avg Door to Bed
Baseline Door to Bed
20
Goal Door to Bed
15
10
5
0
Linear (Avg Door to
Bed)
Next Component
Agility
How do I implement this the new
information in this Thursday’s
Lancet into next Tuesday’s new
practice?
“What can I do by Next Tuesday?”
Time Problem?
“I was just too busy trying to
cut wood with this dull saw
to stop and sharpen it.”
Exhausted Wood-Cutter
Measurement –
Science of Improvement Process
They Say One Person can only do so
much!
They’re right!
That’s why we do “Science of
Improvement” activity in teams!
Team Based Improvement

Staff need a culture that acknowledges that the best
care comes from people working as a team, not as
“lone rangers” with the sole responsibility for the
success or failure of their actions




T ogether
E veryone
A cheives
M ore
“Doctors still perceive that they are the
center of the healthcare universe. Healthcare
is a team sport, and we don’t optimally work
in teams”
"The people in the field are
the closest to the problem,
closest to the situation,
therefore, that is where
real wisdom is."
Colin Powell
How Leaders Help Spread S of I

Effective leaders challenge the
status quo:


By both insisting that the current
system cannot remain, and
By offering clear ideas about superior
alternatives
How Leaders Help Spread S of I

Give Positive Feedback:

Teams that have leadership support do
better than those who don’t

Public Support: your direct involvement /
support in implementing S of I will be
noticed
“What you reward will be valued by your
staff”
How Leaders Help Spread S of I

The Role of Leadership:
Not Passive permission to proceed
but Active Engagement in the Process

Leaders set the tone for a facility

Success at improvement at your
facility depends on the culture you
establish
How Leaders Help Spread S of I

Recruitment and Retention:


Ensure that your staff feel that their
tasks are perceived as being
“worthwhile”
S of I “Fair” where positive
examples [Posters] are on show for
your employees to consider
Spread S of I by Storytelling

Combining a Patient “story” with Data is very powerful

Show results in other clinics (local facility, your area or
anywhere)

Show service chiefs what’s in it for them: stories where
patient care improved, chaotic clinics now thriving

Talk about S of I in Staff meetings

Gather stories by walking around to clinics – let them tell
you why this is exciting for them

Story boards/Data Wall (a physical space where you posts
results for all to see)
Why doesn’t you Hospital Change
(i.e. Learn new ways)?

Not because problems are very complex
or difficult to solve
 Not because your employees
lack motivation
 But:
“Every System is perfectly designed
to get the results that it gets”
Your (“poorly designed”) system is
designed to give you this result!
Why doesn’t you Hospital Change
(i.e. Learn new ways)?


Your organization treats improvement as
“added on” work or after-hours work [instead
of your actual job]
Teams don’t have time, data and license to
make changes

Most systems leave too little time for reflection (RCI)
on work
• Opposite extreme: you don’t win the
Tour de France by planning for years for
the perfect first race but by constantly
making small improvements as you
progress through many tournaments
The Currency of Leadership is Attention

Positive signals
Prioritize your schedule – make time to
meet with project staff
 Conduct project reviews – ask about
aims, put their work into the broader
context of overall organizational mission,
focus on the results, help team overcome
barriers, provide encouragement
 Tell Stories: formal and informal
communication: if your stories reinforce
the cultural changes and practices needed
to achieve breakthrough results:
encourage more rapid adoption of needed
practices

Four Fundamental Principles
for Senior Managers in HC Transformation
1.
There is no substitute for direct
observation
“You can learn a lot by Watching”
Yogi Berra
Not indirect observation (reports, interviews,
survey, etc.) but direct observation. You must
learn to observe with precision
Four Fundamental Principles
for Senior Managers in HC Transformation
2.
Proposed changes should always be
structured as experiments
Follow the scientific method: experiments are used to test
hypotheses and results are used to refine or reject the
hypothesis [Method of Improvement: PDSA]
Problem solving should be structured so that you explicitly
test assumptions in your analysis of your work
Thus you need to explain gaps between predicted and actual results
Like “Theory of Constraint” – “Negative branch
reservations” You must fully understand both the problem
and the solution (and any potential problems that arise in
your HC system from that proposed solution).
Four Fundamental Principles
for Senior Managers in HC Transformation
3.
Workers and Managers should
experiment as frequently as possible
The focus is on many, quick, simple experiments (Rapid Cycle
Improvement)
For each RCI (PDSA Cycle):
a) Predict how much change is anticipated
b) What is your “theory” as to why this will work
Get Front-line Staff to practice the process of observing and
testing many time. [And thus: Quality/Process Improvement]
Again: decrease the “burden” on the staff not the system
Four Fundamental Principles
for Senior Managers in HC Transformation
4.
Manager should coach not fix
Front-line staff should be constantly solving problems.
The more senior the manager, the less likely he/she
will be solving problems himself
Senior managers become “enablers” (Teachers, Coaches not
Technological specialist)
Teach front-line staff how to observe and experiment (looking
for wasted effort)
Teach staff how to find opportunities for improvement
Make it “Safe” for staff to test as many ideas as
possible (Pilot changes)
HC Transformation
 Therefore, Senior Managers
should be spending close to 70%
of their time doing “Science of
Improvement” work to
“transform” your HC System!
What gets in the way of Success?


Teams don’t really utilize the PDSA
model – Failure is an important
result
Teams skip to solutions





Forgetting to have the “doers” do the
measuring
Not setting a “starting” or “finish” date
Belief that you can do it a lot faster than you
think
Settling for a mediocre goal
Failure to have the team measure do it’s own
measurement
Caution

The S of I Principles are Tools to mold
your local environment…. Not the actual
work to make needed change

Goal: improved Efficiency, Quality and
Patient Safety in your facility

Unless RCI (many PDSA test cycles)
occurs you won’t get any change /
improvement
Caution

S of I Principles can not be implemented
by Senior Management Mandate

Instead - implementation occurs by
Font-line clinical or administrative
teams

Using S of I tools (principles) may lead
to different processes in different sites –
freedom to innovate
Continuing Success

If you don’t invest time in ensuring that
any gains are maintained (“Hold the
Gain”) you will lose most of the value

Keep “Science of Improvement” Teams active

Encourage continual data collection / analysis

Continue to watch for new barriers that will
need to be addressed
SDSA Cycle



PDSA: focuses on experimentation
SDSA: focuses on standardization
Once you have run the PDSA (RCI) and
have achieve a desired level of
performance – you want to maintain this
gain


Adopt new a new standard method (till you
need to make new improvements)
SDSA cycle is how you hold the gain
“Ideal Employee”
1.
A Noisy Complainer:
•
2.
A Nosy Troublemaker:
•
3.
Speaks up to managers about the
situation – risk: being seen as someone
without competence
Actively pointing out colleagues’ mistakes
Does not convey an impression of
flawless performance:
•
But rather openly acknowledges his / her
own errors
“Ideal Employee”


When an employee sees a defect,
error or potentially dangerous
workaround, she calls a patient
safety alert
The Leader will respond and begin
the process of identifying the root
cause and what needs to be done to
mistake-proof the process


People see the same problem, every
day, for years ---- inefficiencies
and irritations– and occasionally
catastrophes
Do you ever do anything about it?
Too Much “Science of Improvement”?
“When I was a resident I was
learning so much so fast that I
sometimes felt my brain was
on fire”
"Don't be afraid of learning
too much;
it will never happen!"
Dr Stephen Miles
Learning Points



Not all change is improvement, but all
improvement is change
Real improvement comes from changing
systems, not changing within systems
To make improvements we must be
clear about what we are trying to
accomplish (Aim), how we will know
that a change has led to improvement
(measurement) and what change we
can make that will result in an
improvement
Managing Complex Change
Vision
Skills
Incentives
Resources
Action Plan
CHANGE
Skills
Incentives
Resources
Action Plan
CONFUSION
Incentives
Resources
Action Plan
ANXIETY
Resources
Action Plan
GRADUAL
CHANGE
Action Plan
FRUSTRATION
Vision
Vision
Skills
Vision
Skills
Incentives
Vision
Skills
Incentives
Resources
FALSE
STARTS
Paradoxes in Science of Improvement

S of I only happens at the front line

A Front line team is the only place where the knowledge for
improvement exists

Improvement cannot be mandated (show/tell)

Failure is valued because we learn

The Road to Improvement passes through Change and the
best way to change is to learn from the PDSA actions

Starting is harder than continuing

Degree of improvement culture is almost entirely
dependent on interest of top leaders

Spread is a decision for wide-spread adoption of new
change
In the system of the future…







All work is done in teams
Flatter organization with less hierarchy
Servant leadership
“Improving our work IS our work”
All teams will have and regularly use
improvement skills to achieve mission
Standardization is not a bad word or
concept
Measurement is imbedded in daily work
“Science of Improvement”
Communication Guidelines
1.
2.
3.
Speak the truth; but do it in love Eph. 4:15
Speak to those directly involved in the
issues
Col. 4:5
Speak respectfully

4.
Ok to be passionate, but with respect
Eph. 4:29
Remember you are addressing a
problem, not the person you are talking
to
Eph. 4:2,25

Not testing motives, evaluating behavior, but
addressing a problem