[MUSIC] Welcome to Module nine, Implementing and Spreading Change: The Power of the Model for Improvement. Does anybody remember what the 4th component of quality improvement is? Remember the first component is knowledge of that system, and then the second component is knowledge of the variation or the data that's involved. And then the 3rd component is knowledge of the change. That means the human behavior component of it, and just the barriers that are evident in making a change. The 4th component though is the theory of knowledge. Remember it's the PDSA, or the model for improvement that helps to guide us in the understanding of the theory of the knowledge. So if we look back at the chapter we read last week, chapter 8, it's where we understood how to make the changes in the system. In that chapter, we looked at system change, but they're very complex, and not very linear. We also, in the chapter, looked at the elements of the complex adaptive system to help guide us on our change efforts. And we also looked at the Rogers's adoption of innovation, one of the psychology of change models that we can use in order to help facilitate change. And we also looked at the barriers and how to address these barriers. The one component of the chapter we didn't address last week was the role and utility of the PDSA cycles for testing these small changes and for building our knowledge about the system. This is the component that we're going to touch today in order to understand then how we make initial changes in a system. So, again, the PDSA cycle is used to test small changes in a system. Each of these tests of change is an experiment, where we make a prediction. For example, in our prior case study, where we were looking at reduction of deep vein thrombosis on a unit in a hospital, where we identified that if the patients would use their sequential compression devices more often than the reduction in DVT or deep vein thrombosis would occur. So, our prediction is, is that if we get the family or the patient involved in wearing the sequential compression devices more often, it will result in a reduction in our deep vein thrombosis. What we would do then is we would test an intervention. So maybe what we would do is put a little card on the trays of the patients so that the patients and families could see that when they're in bed or when they're in the chair that they should be wearing their compression devices. It's a prediction, so we experiment. We implement the small change and then we test to see if it does make a difference. What we're doing in this cycle of PDSA is building information step-by-step. Just a note is that the PDSA cycle or the model for improvement really was not designed for large scale evaluations. An example of a large scale evaluation would be implementation of the electronic medical record in a system or a hospital. These large scale implementations require different types of systems in order to get them to stick and spread. Now, let's look at the phases of a PDSA cycle. And the first is the Plan phase. In the Plan phase, you really want to look at the details of your test of change. And the first is looking at the scope and scale of your test of change. And then the second piece of planning your PDSA or your innovation or your change, is really to very carefully select you data collection methods. First let's look at the test of change, the scope plan. Now when were talking about scope, were talking about who you're going to trial this innovation with. Who's the population that you're trying to impact? When you're testing the plan phase, you want to address the scope and vary the characteristics of the people who you're implementing the innovation with. For example, you may want to try different types of patients for who you're testing the innovation on. So for example, you may want to test English patients differently than those who maybe speak Spanish. If you're trying it on staff, you may want to trial the intervention on physicians, and then also do a trial on nurses, because each one of the health profession's staff may actually take the intervention a little differently, and may require unique implementation strategies. When you're also considering the scope, you may want to alter the time of day that you're collecting the data, or that you're testing the intervention. For example you may want to test it during the night shift and then also during the day shift. So when you're planning, testing of your intervention you really want to consider the scope and trial it with different populations or different times of day. The second piece in the planning phase of the PDSA is to address the scale. You want to think about how you will address the size of your test. And what we recommend is really trialing it with one person first. Once you experiment and trial your intervention with one person, then we recommend multiplying your trial by 5, then try it with 5 different patients. And then again you can try it again with 25 patients. And every time you test this intervention, you're going to be learning because you're going to be predicting how you think it's going to be implemented and how it's going to take. And with each learning cycle then, you can alter your intervention, make changes, so the next time you do it, it's going to be improved. Similarly, with the data collection plan, you need to determine who is going to do the collection of the data, what actually they're going to collect, where they'll be when they collect the data, when they're going to do it and then how they're going to collect the data. So you have to think and plan about these specific components. What we have listed here is a very short data collection tool that you can use, in order to test the plan that you are going to implement. Here's an example, for hand washing. Now we're going to go through all the steps of the quality improvement modules that you've been attending. What might be the global aim for hand washing? Well, you might state that your global aim is really to reduce infections on your unit. And then what might be the specific aim for hand washing? A specific aim might address reducing all hospital acquired infection by 5% in your CCU unit, or your coronary care unit by this date. Then, you would do a huge system assessment of your unit to determine what are the factors that are resulting in the poor hand washing or your infection rates. In this system assessment, you might use a fishbone diagram, and in the fishbone, you might find that the time is a major factor for most of the staff on the unit. They just don't have the time to wash their hands in between patients. Another big factor that maybe would come out in a system's analysis, might be the availability of hand washing materials. So then you would want to brainstorm about what might be some changes that could be made in order to improve hand washing in order to lead to reduction in infections. And so one of the change ideas that came up with your team would be installing these dispensers outside all the rooms, and this idea then was needing to be tested. The team decides to create a data collection plan, and so they determine who is going to be the data collection. And they determine that some of the staff members on their team will be the participants for collecting the data when they implement these dispensers. In the plan they need to determine what, so they install five dispensers and assess the number of patient encounters, and then use of the dispensers. They also need to plan where they're going to do this data collection, and they identify that they'll do it outside the patient rooms. And then they need to determine when they'll do it. They decide they'll do these audits two hours per day in a random fashion. And then they determine and plan how they're going to collect this data and they create a hand washing tool. These audit tools can be very simple, its just a mechanism for collection of data to really understand if your predictions are working. So the team then decides to use this audit tool in order to assess if the hand washing has been completed. The next phase of the PDSA cycle is doing it. Here's where you carry out the plan that you just created to test the change. During this due phase, the team goes out, they use their audit tool, and they assess how often that these dispensers are being used. During the Do phase, it's important to not only collect quantitative data, or that audit data, but also to do a lot of interviewing and talking with people. Collecting this qualitative data so that you can really understand if the staff are feeling that this is a good intervention or not. On your audit tools, always leave a space for comments and other qualitative data that the data collectors can insert. The third piece, or phase of the PDSA is the study phase. Here is where you analyze the data that you collected from your audits, the data you collected from this test of the change. The pieces to consider for the study phase is, was the plan even carried out? Were the staff using the dispensers? The second component to consider for studying, was: was there a problem with data collection? Was there a problem with the data collection tool, or was there a problem with the auditors even showing up to collect the data? And then the third piece for the study phase of the PDSA is to really understand, did the results match your prediction? Was the installation of the dispensers increase the chances that the staff would wash their hands? The fourth phase of the PDSA is the act phase. And here's where you really consider, did the test work or not? And are there any improvements that could be made in order to improve the next phase of testing? When you consider the act stage of the PDSA, you're really asking the question of, what are the objectives for this next test of change, and then you repeat it again. The example for act would be, that there would be 100% compliance with dispensers during the day shift. During our next trial, we tested on the night shift. We use a run chart to display our data over time, and then we narrate our run chart to help us to really understand what's happening. What if we determine that the dispensers were used on the day shift but not on the night shift, then our next test of change would include a different intervention for the night shift. So in summary, the PDSA is really a cycle where you're planning, what your test of change is, and you're making predictions. And then you're doing the change and then studying it, and then making changes for the next test of change, remembering at all times you need to consider the scope of your intervention who you're trying to implement this with, and then also the scale. Remember, start small, do a lot of pilot work with one participant, and then increase by multiples of five. The reason this is so important is that many implementation plans or tests of change really don't improve our practice. The recent statistic from the Rand Corporation was that only about 40% of the improvement projects that we implement really create lasting change. And so by doing this small pilots and really changing and altering our test, will really help with the change efforts and success of our change efforts. With the PDSA’s then, another little model then to help you to understand is that with each one of these PDSAs, our intervention gets refined and our chances of success become better. This refinement of our intervention can be seen as sort of pilot testing. Then that moves us to the next phase which is the implementation. So, the PDSAs are the first step to implementation. With implementing the change, we are ensuring that this new process that we just tested and find out that it works. These new processes are embedded in our daily work of the clinician and staff in the unit that we're interested in. This intervention gets hardwired into the system. And because we do regular reviews of the outcomes and process measures, this helps the new process to be embedded into our practices. Now once we attain this implementation, then the next step is we're ready to spread. For many of you, spreading improvements may not be your main objective. Your main objective may be just improving the care on your unit. However, it is important to understand that the interventions for spread are somewhat similar to those interventions that you're using for that local change, that change on your specific unit. So in Chapter 9 the objectives were to really look at what effective strategies are there for sustaining and spreading change. And the second objective of Chapter 9 was really to follow its step-by-step approach to plan and spread your efforts. It also lists a lot of really common mistakes that you may benefit from learning about. And then in Chapter nine it helps you to plan for your success so that the little pilot test that you have implemented then gets sustained. Spreading the innovation. It's the process by which new ideas are communicated over time through usually a social system, with the intended outcome being the adoption of this new idea. The social system is usually communication and networks that really enhance the success for your idea to spread. The context for the spread is a part of an overall process of improvement. Usually spread start small where we're testing and refining our interventions and this then assures a solid implementation in one setting or local unit. And then the intervention or innovation can spread to other units and to the organization, or even to other organizations. It is really important to note that the benefits of innovation may seem clear, but change is a difficult process. In some instances we may need to accelerate the pace of our change deliberately. Well a guiding principle then, to note, is where patient safety is concerned, and there's a benefit from the change the approach needs to be very strategic very efficient and then sustainable. The first step is setting a foundation for the spread. It's very important to plan beyond that initial pilot site and then start early. When we start early, we can anticipate what might be needed for that spread beyond our local unit. We can ask, what are we spreading, and plan and prepare, and assemble a spread leadership team. And it's essential that you get the right people on you team. And then lastly, align the spread effort with the strategic goals of the organization. Who's responsible for spread, planning, and organization? Well the organizational leadership should provide the support structure that's established, supported, and maintained. When you're spreading an intervention that you’ve tested in a local unit, you really need to partner with the organizational leadership. Aligning the spread effort with the strategic goals requires the leadership to send a message out, that the status quo is no longer acceptable, that the improvement is crucial to the organization's future. And, it's important to use calls for improvement from accrediting agencies, evidence based practice, gold standards to really support the change that is actually needed. So establishing a spread aim, really the definition is to create a clear, concise statement of what an organization intends to accomplish. Having this clear message is essential and many times spread fails because the message is not clear. This means that you have to be clear on what's being spread, so the What question. It's also important to target your audience and your population. Who are you trying to spread this to? And then the time frame. When is the spread need to be completed by? And then the expected level of improvement. How much improvement is needed for us to realize or us to accept that success has been achieved? The second step then, for spread, is developing an initial plan for the spread or the how. In step 2, you really want to look at what the spread plan elements are. It's important to clearly articulate what the system for communication is, and here's where most organizations fall down. That there isn't a clear communication plan or how the spread, or how the intervention, is going to be communicated. Next, it's important to have a connection, to maximize the learning and support. Therefore, education plans need to be in place, so that staff have the building blocks that they need, and the resources they need to support the change. A third component for the initial plan for spread, is to really have a measurement system to track the progress and results. This is an audit system that is essential in any change that leadership is tracking the progress, and the results of the spread. And then lastly there needs to be a process for making adjustments as needed. If there are units where the spread is not taking hold, there needs to be a plan to how to adjust it, in order to ensure success. The measurement of the spread is essential, just like it is in our improvement efforts at the local level. In the spread example, though the system needs to include a main outcome measure of the process or the system of interest. Also essential is the rate of the spread of the specific improvements. In addition, you need to have some kind of feedback mechanism on data for the progress. These essential components of measurement will assure them that someone's monitoring the process and that the spread is being achieved. The third step for spread is carrying out and then refining the plan. The spread team must monitor the spread process and then make adjustments. There's continual improvements and continual monitoring. So in summary for chapter nine then, what we learned is that we begin with tests of change. We use the model for improvement in the PDSA in order to refine our intervention. Once our intervention is refined and we realize that we have a good intervention, we move to implementation or getting it to stick on our unit. And then after implementation, then our organization needs to then spread the intervention throughout the organization. That concludes module nine. And remember that luck favors the prepared mind or the prepared and deliberate organization. So every effort that you do, make sure that you plan, monitor, implement. And use feedback loops, in order to continually adjust your change efforts. [MUSIC]
