You want us to do
WHAT?
Perinatal & Neonatal Learning Network
December 3, 2013
Jennifer Ustianov MS RN IBCLC
Perinatal Content Lead
NICHQ
Objectives
• Outline the case for widespread use of
maternal and neonatal risk assessment tools
• Describe how the use of Improvement Science
can assist implementation within an existing
system of care
• Plan the tasks and first test of change for
implementing the widespread use/adoption of
risk assessment tools
Why me?
Leadership Introspection
Why now?
Maternal and Neonatal risks
What was learned in 2012?
• Over 30% of maternal and infant discharges had identifiable
risk
• Member hospitals have very good processes for getting
patients out of the hospital
• Significant numbers of patients with risks were not identified
for the specific intervention of early post-discharge evaluation
Why not now?
Creating the Case
• Insert updated MD stats on neonatal and
maternal outcomes
Key Elements of
Breakthrough Improvement
 Will to do what it takes to change to a
new system
 Ideas on which to base the design of the
new system
 Execution of the ideas
Factors which effect the
Will to change
•
•
•
•
•
Need and urgency for change
Life experiences
Positive and negative experience
Personality
Resources and Support
Ideas: bases for design of new system
Ideas come from:
• Strong evidence
• Good knowledge (our own or others)
• Hunches
• Open, supportive and agile team-based
environments
Execution of the ideas
•
•
•
•
•
•
•
•
•
Tap on expertise
Multidisciplinary planning team
Use tools and methods tested by others.
Test, Study; Test, Study; Test, Study.
Leadership support.
Identify and remove barriers and old way.
Illicit involvement and feedback.
Embrace grumbling as an opportunity.
Remember: with true change comes
learning
Model for Improvement
Three Fundamental Questions for
Improvement
1. What are we trying to accomplish?
2. How will we know that a change is an
improvement?
3. What changes can we make that will result
in improvement?
PNN and the Model for Improvement (MFI)
What are we trying to accomplish?
Project Aim
How will you know change is an improvement?
Measurement Strategy
What change can we make that will result in improvement?
Workplan
Test and Implement
Perinatal & Neonatal Risk Assessment
Aim Statement
Our aim is to improve communication between hospitalbased and community –based providers and between
hospital staff and families through standardization of the
discharge process for mothers and babies, including the
late pre-term infant. Success will be measured through
both process and outcome measures
Aim
Model for Improvement
By June 2014 the Neonatal
Risk Assessment Tool will be
implemented
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
TESTING
Tasks:
•Data collection: How, who,
when to collect data
•Design flags in EHR
•Identify community referral
network
•Create audit tool
•Education of ALL staff
•Celebrate wins
MEASURES
Outcome: 95% of neonates with
identified risks will have documented
appropriate referrals
Process: 80% of new admission
will have a completed neonatal risk
assessment within 24 hours
Tests:
P: Patti RN will use the Risk Assessment Tool
for the first admission
D: Patti was too busy to implement –critical ca
S: No assessment done in first 24 hours
Edit/Act: Next test will include communication
to next shift re whether assessment
was completely
Making it Happen for Improved
Outcomes
Team Planning
• Draft Aim statement
• Draft one Outcome Measure
• Draft one Process Measures
P-D-S-A Cycles
• A way to turn Ideas into Action
(P
D)
• A way to connect Action to Learning
(S
A)
Using PDSA cycles to
learn our way through
improvement
A P
S D
A P
S D
A P
S D
4. Implementation
testing
A few providers, varied
shift/time of day
3. More wide-spread tests
A few providers, one
shift/time of day
2. Then do f/u test over a variety of conditions
to understand scalability and identify
weaknesses
One provider, different
shift/time of day
1. Early tests are simple and
designed to learn then
One provider, one
succeed
shift/time of day
AIM
Concept D
Concept A
Concept C
Concept B
Change Concepts, Theories, Ideas
PDSAs
Why Testing
• Increase belief that the change will result in improvement
– dealing with uncertainty
– dealing with skeptics/ minimize resistance upon implementation
• Opportunity for “failures” without impacting performance
• Get idea of how much improvement can be expected from
the change
• Learn how to adapt the change to conditions in the local
environment
• Evaluate costs and side-effects of the change
Risk Assessment Tool
• Started at admission to capture pre-existing
risk factors
• Continued through admission to capture new
onset risks
• Framework for education, counseling,
consultations, and discharge referrals
• 1 tool to capture risk and coordinate care
Eight Step
To Change
Overview of Kotter’s Points, 1995
1. Establish a sense of urgency
RISK:
Based on market, competitive, social, performance (etc.) realities,
the change must be seen as critical to organizational survival/success
Not
Sufficiently
Compelling
!!!
2. Form a powerful guiding coalition
Not A
Credible/
Cohesive
Team
!!!
Assemble a leadership group with enough commitment, credibility,
influence, and authority to lead, model, and sustain the change effort
3. Create a Vision
A clearly stated “higher” vision that speaks powerfully to participants
and personally spurs them to “go the extra mile”
RISK:
RISK:
Vague,
Insufficient
Motivation
!!!
RISK:
4. Communicating the Vision
Use multiple vehicles and venues to communicate the new
vision/strategies Teach new behaviors by the example.
Less than
Over-Comm
by Factor of
10
!!!
Overview of Kotter’s Points, 1995
5. Empower others to act on the vision
Get rid of obstacles; Change systems /structures that seriously undermine
the vision; Encourage risk taking
6. Plan for and create short-term wins
Plan for and create visible performance improvements ; Recognize and
reward employees involved in the improvements
7. Consolidate improvements and produce still more change
Use increased credibility to amplify change in systems, structures, and
policies; Hire, promote, and develop employees who can implement the
vision; Reinvigorate process with new projects, themes, and change agents
RISK:
Not
Neutralizing
Resistance
!!!
RISK:
Leaving
Successes
to Chance
!!!
RISK:
Declaring
Victory Too
Soon
!!!
RISK:
8. Institutionalize new approaches
Articulate and reward the connections between the new behaviors and
corporate success; plan leadership succession consistent with the vision
Declaring
Victory Too
Soon
!!!
Implementing Change Strategies to Consider
1. The path of least resistance
2.
3.
4.
5.
- best use of the people willing to change
Impact
- biggest improvements early in implementation
Learning
- the most learning happens as the change is implemented
Resources
- best scheduling and use of available resources
Interdependence
- will the change work without all its components?
Implementing Change –
Foolproof the New Process/Procedure
Reduce likelihood of mistake/error
– Decrease the likelihood that a needed item is left off
the surgery cart by prepackaging kits of instruments
and other surgical items
– Make it impossible to attach the vacuum line to an
oxygen outlet by installing different sizes or shapes
for vacuum and oxygen connectors
– Get rid of old versions of forms!
Change the Culture –
Holding the Gains
• Make reversal as difficult as possible
• Establish a standard process
• Use measurement and audits
• Pay attention to maintenance processes,
especially orientation and training
Partnering with Patients
• When does this begin
• How do we individualize our education
• Who make it happen?
Engaging Partners and Community
Stakeholders
• Who are our partners in mitigating risk
– How do we engage them
– How can we partner in this work
• Who are your community resources
– Do you KNOW what they offer
– Do you TRUST what they provide
– Do you BELIEVE they can make a difference
Kotter’s 8 Reasons
Why Attempts at Change Fail
1.
2.
3.
4.
5.
6.
7.
8.
Not establishing a great enough sense of urgency.
Not creating a powerful enough guiding coalition.
Lacking a clear vision.
Under-communicating the vision by a factor of ten.
Not removing obstacles to the new vision.
Not systematically planning for and creating short-term
wins.
Declaring victory too soon.
Not anchoring changes in the corporate culture.
Team Planning
• Reflect on you Aim and Measures
• Use the worksheet provided to plan:
– Your tasks
– Your first PDSA (who, what, where, when)
– Report on aspect of this work to another team