Planning Ahead. It is often been said that if you really want to succeed, you should start with the end in mind. Now, admittedly, this is not always possible. No one has a crystal ball and for our own personal journeys of development you don't always know what the end is, where it is or precisely what your role might be. But, for a project,+ it should be possible to envision this in a more concrete way and plan accordingly. It's helpful to think about Donabedian's very well-known framework for assessing the quality of care and indeed what we are thinking about and discussing today is improving the quality of the care that we deliver. He divided those elements of care into structures, processes and outcomes. Structures being those enduring features in this case, the healthcare enterprise on that persist. They might include physical structures, they might include equipment, they might include people who have a certain amount of training that's necessary. Processes are the things that we do, the tasks, and the workflow that we perform on and around patients, and the outcomes are the end results. In Planning Ahead, we would like to think in reverse. First, what are the desired outcomes? What are our goals? The second, what are optimal processes that we understand or believe will lead us to those outcomes. And as a subset of that, what measures or metrics will we design to measure both those outcomes and the processes. Proceeding even further back, what are necessary structures that will allow us to achieve our goals and also to sustain the performance and the achievement of those goals. Finally, at all stages, you would like to think about likely barriers. What is going to make it difficult to achieve outcomes, to perform processes reliably and well, and even to assemble and sustain the structures needed to support all of this work? There are some advantages to measuring outcomes. First, they are really what we care about. They are of primary importance. We would like to reduce mortality. We would like to improve patients functioning and well-being. We would like to reduce adverse events and other harms. There are some disadvantages to outcomes, however that are practical. First of all, if you only measure outcomes, this does not really improve your understanding of what is going on. Outcomes are caused by many factors and it may be difficult to attribute causality to the steps that you are taking in your project, or the performance of those steps by healthcare workers. It's also difficult to identify the level of where failures might occur. There are many factors at multiple levels of the healthcare system that affect outcomes. There are additional factors that occur outside of healthcare that may affect outcomes. There are non-health related factors that can contribute to mortality for example. There are some advantages and disadvantages of measuring processes. Processes are actionable in fact processes are actions and we can change them. Active errors are most often seen in the failure or the incorrect execution of those processes by providers and we can train people, and give individual people feedback, or groups of people feedback about those errors and potential improvements. Disadvantages are again that factors at many other levels of the system may influence outcomes and in fact, may at times influence those processes too. But, the bottom line here is that you may improve the processes without improving outcomes. So, going through those 4 E's of Translating Evidence into Practice. What needs to be done at each of them to ensure a sustainment? The first is perhaps less relevant to sustainment than some of the others, but for the first E to engage the hearts and minds of healthcare workers, and other healthcare staff using local examples. The impact of adverse outcomes on individual patients, particularly patients that are relatable to the healthcare workers that you are talking to. Also, data that comes from specific units or even specific providers. Here is the performance or the lack of good performance in your unit or even your failure to perform up to what might be an appropriate standard in some cases. These are very engaging and tend to both engage healthcare workers intellectually but also emotionally. We want them to care about the problem and we want them to be dedicated to trying to fix it. Educating includes providing facts and to some extent, providing skills. Some of the facts include the definition of the problem, who are we interested in, what are the inclusion criteria for who these definitions might be applied to, and who might these guidelines or recommendations apply to, what are current rates at which these problems or failures are occurring, and what has been the impact of these locally. This relates, of course, a little bit back to engaging healthcare workers. In terms of skills, we would also like to make sure that healthcare workers are able to apply these facts, these guidelines and perform in a reliable way. In executing the plan, we need to understand the workflow. We should already have studied this, but now we need to introduce elements into the workflow. Perhaps equipment, tools, tool kits, standard operating procedures, physical structures even that allow and make it easier for healthcare workers to do the right thing, and harder for them to do the wrong thing. Finally, we need to evaluate how we're doing. Early and frequent feedback is important, and then feedback about progress and sustainment.
