Change for the Better in Your Facility: some helpful frameworks

1. Change for the Better in Your Facility:some helpful frameworks Susanne Salem-Schatz MA Coalition for the Prevention of Medical Errors HealthCare Quality Initiatives Sharon Benjamin, Ph.D. Alchemy

2. Objectives The participant will be able to: • Identify at least 2 adaptive strategies for engaging front line staff in improvement initiatives • Understand and recognize technical vs. adaptive challenges and have some initial ideas on what strategies to use in each situation • Describe at least 2 features of the quality improvement framework

3. So Far You Have Heard • Why it is important not to use antibiotics unless absolutely necessary; • How the high prevalence of asymptomatic bacteriuria in the elderly can lead to unnecessary antibiotic use; • Expert recommendations for when to test and when to treat a suspected UTI;

4. I’m Convinced… • Much of what we heard today is not as widely understood as it should be. • Long-standing and habitual practices can actually harm the people we are trying to help. • Changing practices about urine testing and treatment of the elderly is very reasonable.

5. Time for Change • Seems like it should be easy • Now we know better • We intend to make a change • We are sure others will follow suit when we share what we have learned. • Not so fast! • Change can be hard and good intentions are not enough. • Not all change is the same • Different people need different reasons to change

6. Good News: We Can Help You Make Successful Change We offer tools and strategies to improve your chances of success, and Proven organizational approaches to practice improvement • Engagement strategies for finding better ideas • A quality improvement framework

7. Two Kinds of Problems Require Different Change Approaches Technical problems have right answers! These solutions usually get mandated by leadership. Problems that require people to change their behavior, or organizations to change their culture, require flexible solutions than emerge from engaging everyone.

8. Technical Change Technical challenges are problems that melt in the face of evidence about how to improve outcomes.

9. Toyota helped make the assembly of cars vastly more efficient and profitable. Giving possible heart attack victims aspirin improves mortality.

10. Technical Problems Are often permanently solved as research and evidence accumulate about the best ways to do things. New technology often opens the door to solving stubborn problems. Technical problems have right answers that can be universally applied and are usually mandated by leaders. Technical problems usually have COMPLICATED solutions such as new technology, processes and procedures.

11. But Not All Problems Are Technical There is a category of problem that resists permanent solution because they relate to people and their decisions and behavior. Such as what to do when you notice a change in a resident’s health or mental status. Knowing what to do requires critical thinking not a checklist. Treating this kind of problem as a technical problem leads to confusion, frustration, resignation and cynicism. One size doesn’t fit all!

12. We Often Get Confused And Try Technical Solutions for Nontechnical Problems ≠ What works in technical situations often doesn’t work with challenges that relate to human behavior. We need solutions that ADAPT to human needs.

13. Problems & OpportunitiesAwareness Iceberg 4% known to top leaders 9% known to middle managers 74% known to supervisors 100% known to the front line & customers Action unleashed @ the front line Yoshida, S., (1989) Quality improvement and TQC management at Calsonic in Japan and Overseas, Paper presented at the Second International Quality Symposium, Mexico.

14. Including Front Line Staff • Engages the very people “whose behavior needs to change to solve the problem” to identify existing solutions from within • Front line engagement & ownership can: elicit good ideas that account for day to day realities suppress the “immune rejection response”

15. Jasper Palmer discovered a better way to remove gowns and gloves Over and over we discovered staff who had better practices. And staff helped develop even better ideas….

16. Harrington staff step up the fight against hospital acquired infections

17. What You Can Do • Expand the circle of yourconversation • Don’t rely solely on education • ASK about their experience • What do they know about the problem? • What would they like to know? • What keeps them doing the right thing 100% of the time? • What ideas do they have that might help?

18. Organize Your Learning with Quality Improvement Tools and Strategies

19. The Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Act Plan Study Do Setting Aims Establishing Measures Selecting Changes W. EdwardsDeming *2001 Associates in Process Improvement

20. 100% of residents with treated UTI will meet criteria for urine testing • Proportion of reviewed UTI cases that meet program criteria • Rates of urine culture, UTI, CDI Act Plan Study Do Model for Improvement in Action Aim Measures Changes • Educate all staff and engage them in identifying and testing practice change solutions • Use decision support tools • Review cases daily; share results monthly *2001 Associates in Process Improvement

21. Act Plan Study Do PDSA: Small Tests of Change Plan: • 1 small change to test • Predict what will happen • Decide on what data to evaluate test Do: • Run the test • Document problems and observations • Organize your data Study • Analyze your data • Compare results to your predictions • Summarize what you have learned Act • Decide what to do next • More testing? • Try something else? • Finalize the change?

22. Some Tips For Testing • Small tests of change • Rule of 1 • 1 patient/resident – 1 staff person – 1 day • Test over a short period of time • If they say weeks, think days • If they say days, think hours • PDSA Worksheet to plan your test • Call for help!

23. Planning your Changes (in your handouts)

24. Using the model for improvement to prevent transmission of CDI: How Franciscan Hospital for Children makes it work.

25. Improve Communication of Current Precautions Status: Cycle 1 PLAN: • Standardize location of signage • Store precautions signage in convenient location near/with PPE DO: • Installed sign holder outside room • Stored one of each precaution signs in each sign holder ACT: • Reduce size of signs; magnetize signs to attach to door frame • Reconsider signage storage options CHECK: • Sign holders too big for available space to accommodate 4 signs per room • Sign fit well in holders; concern sign holders will break from continual expansion to remove/replace signs

26. Improve Communication of Current Precautions Status: Cycle 2 PLAN: • Reduce sign size; magnetize • Store extra signs in folder attached to precautions cart DO: • Created 4”X3” print area • Printed on magnetic sheets • Placed on metal door frame • Attached plastic folder to cart; filled with one of each precautions signs ACT: • Investigate smaller other sign holders • Create signs to fit CHECK: • Sign was easily knocked off frame. • Signs were too small.

27. Aim: Improve Communication of Current Precautions Status DATA D S P A A P S D D S P A A P S D A P S D Improved adherence to current precautions Cycle 1E: Implement sign holders for all rooms Cycle 1D: Educate clinical, ancillary, and support staff on new signage Cycle 1C:Increase size, post in plastic sign holder, test on one room get feedback Cycle 1B:Reduce size, magnetize for doorframe placement. Test on one room get feedback. Delays in precautions implementation Cycle 1A: Standardize precautions signage location, test on one room, and get feedback

29. Collaborative Results 2012-2013(N=17)

30. 2012-2013 (N=14)% of UTI meeting criteria for signs & symptoms