Pediatric Specialties Care Division Director Center for Advancing Pediatric Excellence Levine Childrens Hospital at Carolinas Medical Center February 4 2017 AAP National Center for Medical Home Implementation ID: 907807
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Slide1
Sustain and Spread
Laura Noonan, MD
Pediatric Specialties Care Division
Director, Center for Advancing Pediatric Excellence
Levine Children’s Hospital at Carolinas Medical Center
February 4, 2017
AAP National Center for Medical Home Implementation
Family Engagement Quality Improvement Project
Learning Session 2
Slide2Sustainability Planner
Seven key factors
Clarify what you are sustaining
Engage leadersInvolve and support front-line staffCommunicate the benefits of the improved processEnsure the change is ready to be implemented and sustainedEmbed the improved processBuild in ongoing measurement
NHSScotland Quality Improvement Hubhttp://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-topics/spread-and-sustainability.aspx
Slide courtesy Dr. Alan S. Weller & Dr. Ruth S.
Gubernick
,
June 2016 Learning Session for Family Engagement Quality Improvement Project
Slide3Holding Your Gains:Sustaining Your QI Project
Courtesy Greg Randolph, MD, MPH
Slide4Objective
4
Slide5Sustainability
“There will come a time when you think you are finished. That will be the beginning.”
-Louis
L’Amour
Slide6It Ain’t
Over ‘til
It’s Over…
Yogi Berra
Slide7How Do They Do It?
Slide8Sustainability: Key Strategies
Assign
Ownership
of SystemHardwire Sustainability into the System Measurement
Senior Leadership
Slide9Sustainability: Key Strategies
Assign
ownership
of sustaining to an individualClarify what you are sustainingHardwire sustainability into your systemInvolve and support front line staff
Benefits of new processContinue measuring to monitor sustainability Continue involving senior leadership
9
Slide10Ownership
Assign “Process Owner” for sustainability
Gives leaders updates, calls team meetings as needed
Monitors data
Designs ongoing improvements (PDSAs) as neededAdapt, create tools that will make it easy to continue doing the right thing
10
Slide11Ownership
Assign “Process Owner” for sustainability
Periodic Communications
Awareness and technicalCelebrate milestones!
11
Slide12Process Owner Checklist
Take a few minutes to review the checklist
Then we will address any questions and highlight some key points…
12
Slide13“Hardwire” Sustainability
Involves numerous staff
Job descriptions / recruitment include expectations
Staff evaluations include expectations & metrics
13
Slide14“Hardwire” Sustainability
Plan for turnover/absences
Staff orientation includes relevant training
Cross training for critical rolesDocument roles/responsibilities!Contingency plans for special situations
Educate/involve patients
14
Slide15Ongoing Measurement (Quality Control)
Simplify Measures
Decrease number – to one measure if possible
Decrease frequency of measurement
Use your DataHave a plan to take action if data shows slippage Meetings, planning, recruiting
15
Slide16Need to Monitor?
Slide17Lucy’s Chocolate Factory
Starts with stable process then goes “out of whack”
“The willing workers” (Ethel & Lucy)
No process + No planning = ^ defects/errors
Management - Are the workers involved in setting the goals of the work? They are the process
Slide18Senior Leaders
Engagement
Process Owner gives regular status updates
Work with leadership to add to “dashboard”Look for opportunities to give visibility to your good workCelebrate milestones
18
Slide19References
Bandura A.
Social Foundations of Thought and Action
. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986. Brown J., Duguid
P. The Social Life of Information. Boston: Harvard Business School Press, 2000.Collins J. Good to Great.
Harper Business Publishing, 2001.
Dixon, N.
Common Knowledge
. Boston: Harvard Business School Press, 2000.
Langley J, Nolan K, Nolan T, Norman, C, Provost L.
The Improvement Guide
. San Francisco:
Jossey
-Bass 1996.
Prochaska
J., Norcross J.,
Diclemente
C.
Changing for Good
. Avon Books, 1995.
Trustees of Dartmouth College.
Clinical Microsystems.
http://www.clinicalmicrosystem.org
Slide20What is Spread?
Testing
vs.
Implementingvs.
Spreading
Slide21Improvement
Hold Gains
Spread
Creating a New System
Improvement
Hold Gains
Spread
more accurate
Slide22Diffusion (Spread)
“
Diffusion is the Process by Which (1) an
Innovation (2) Is Communicated Through Certain Channels
(3) Over Time (4) Among the Members of a Social System”Diffusion of Innovations
Everett M. Rogers
Simon & Schuster, Inc. 1995
Slide23Reflection
Think of a time in your experience when you attempted to spread an improvement, or when an improvement was spread to you
What worked?
What didn’t work? Volunteer to share your story….
Slide24Ready to Spread?
Initial project team successful in making changes that improve process or outcomes
Is process of improving care understood?
E.g., Model for Improvement
Is there solid leadership for spread?
Need both “front line” and “senior” leadership
Slide25What Affects Spread?
Perceived
attributes of the “change”
Nature of the people/social environment
Leadership
Slide26“Perceived” Attributes of Changes that Spread
Relative advantage
over current process or system
Compatibility
with current process or system
Simplicity
of change
Trialability
– test change with little investment (risk/cost/time)
Observability
of change
-- Everett Rogers
…think of the cell phone
Slide27Better Ideas
Relative advantage
Compatibility
ComplexityTrialability
Observability
Better Ideas
Slide28Better Ideas
Poor
Fair
Good
Very Good
Excellent
Relative advantage
Compatibility
Complexity
Trialability
Observability
Slide292. Nature of the People
(Everett Rogers’ work)
Late Majority
35%
Early Majority
35%
Early Adopters
13%
Traditionalists
15%
2%
Innovators
Slide30Leadership for Spread (Change)
Inspire and communicate shared vision
Model the way
Challenge the process Enable others
Encourage the heart From: Kouzes and Posner
Create urgency
Form a powerful coalition
Create vision for change
Communicate the vision
Remove obstacles
Create short-term wins
Build on change
Anchor the changes in corporate culture
From:
Kotter
Slide31Communicate Shared Vision
Understand the changes and how they lead to improvement
Target influential people (early adopters)
Use various communications and everyday opportunitiesExplain why change is needed…status quo is no longer good enough!!!
Appeal to values, hopes, interests of targetsUse the attributes of successful changes to guide your communicationsUse an “elevator speech”
Slide32Leadership Choices
Comp
l
eteness
C o v e r a g e
Optional
Collective
Authoritarian
Slide33Diffusion Curve in Practice
https://youtu.be/fW8amMCVAJQ
Slide34Other Factors that Affect Spread
Buy-in
Institution
(department) specific evidenceDataIncentivesMeasurement
FeedbackTools for spreadSpread champion
Slide35The Concept of “buy-in”
To achieve a meaningful culture change in a system you should try to obtain as much buy-in as possible
It is helpful to find evidence that a change is needed: institution specific data
Share stories that illustrate the need “Drama”
Share other centers’ successes
Slide36Measure!
Data collection – what are you already measuring?
Don’t reinvent the wheel
Sources for measurement
North Carolina State Health statistics (NC CATCH)IHI downloadable forms
Slide37Feedback Feedback
Feedback
Newsletter reports of dataStaff meetings
Visits to areasCelebrationsOTHER IDEAS
Slide38Feedback
Feedback
Feedback
Slide39Tools for Spread
Project management
PDSA cycles
Spread championSpread checklist
Slide40What is a Spread (Improvement) Champion?
Improvement representative that is
Invested in the intervention
Knows the dataAssists with administration and staff buy-in
Can also be the spread champion
Slide41Set-up
A Framework for Spread
Social System
Knowledge Management
Measurement and Feedback
Leadership
Better
Idea(s)
Adapted from IHI Model that was adapted from work of Everett Rogers
Slide42Spread Checklist
A.
Organization Leadership is engaged
Better ideas. Case for changes established Set-up. Key groups/target pop identified
B.
Communication
Communication
. Plan for raising awareness is established; mode for transference of knowledge is selected
Slide43Spread Checklist (continued)
C.
Strengthen the Social System Key Messengers. Responsible parties, communities of practice, support strategies
Communities & Technical Support. Help strategies for new teams, change documents, strategies to overcome barriers
Transition Issues
. Strategies for ongoing leadership support, connection to front-line teams identified
Slide44Spread Checklist (continued)
D. Measurement & Feedback
Measurement & Feedback. Plan for measurement: staffing plan to support measurement, communication plan identified
E. Knowledge Management Knowledge Management. Plan for capturing, documenting, organizing new learning, spread process, overcoming barriers in place