All Wales Stroke Services Improvement
Collaborative
All Nations Centre, Cardiff
4th November 2008
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
The Model for Improvement
Part One
Dr Alan Willson
Director of Research and Development NLIAH
Director 1000 Lives Campaign
Director AWSSIC
Slide 2
All Wales Stroke Services Improvement Collaborative
Learning Objectives
– the theory
• The 3 questions of the Model for Improvement (MFI)
• PDSA cycles
• Run charts
– the practice
• Team aim for Stroke Services
• The ‘How’ of measurement
• The PDSA Cycle related to a Stroke service change
Slide 3
All Wales Stroke Services Improvement Collaborative
I Chart of ALOS on a ventilator
20
UCL=18.47
15
ALOS
Nurse Led Weaning
10
UCL=9.24
_
X=7.78
_
X=4.37
5
0
LB=0
Jan-06
Slide 4
Mar-06
May-06
Jul-06
Sep-06
LB=0
Nov-06
Jan-07
Month
Mar-07
May-07
Jul-07
Sep-07
Nov-07
All Wales Stroke Services Improvement Collaborative
National CVC maintenance bundle compliance
greater than 90% since April 2007
CVC Maintenance Bundle Compliance 2006-2008
100%
80%
60%
40%
20%
0%
e ly st er er e r e r ry r y ch ril ay ne ly st er er e r e r ry r y ch
n
b
b
u
u
a
a
Ju J ugu emb cto b em emb nua br u Mar Ap M Ju J ugu emb cto b em emb nua br u Mar
A pt O o v e c Ja Fe
A pt O o v e c Ja Fe
N D
N D
Se
Se
Slide 5
All Wales Stroke Services Improvement Collaborative
National CVC insertion bundle compliance >95% since
June 2007
CVC Insertion Bundle Compliance 2007-2008
100%
80%
60%
40%
20%
0%
r er
l
t
r
r
e
y
y
i
l
ry ar y rc h
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r
s
e
e
n
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b
a
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b
b
u
J ug em
M
A
J
o vem em anu br u Ma
t
c
t
A ep
e
J
O No De c
F
S
Slide 6
All Wales Stroke Services Improvement Collaborative
You can’t fatten a cow by weighing it….
Slide 7
All Wales Stroke Services Improvement Collaborative
How do we accelerate change?
The Model for Improvement
Slide 8
All Wales Stroke Services Improvement Collaborative
The 3 Questions are scalable
What changes
What are we
can we make
trying to
that will result
accomplish?What changes
in an improvement?
can we make
that will result
in an improvement?
How will
we know
the changes are
an improvement?
Slide 9
What are we
trying to
accomplish?
How will
we know
the changes are
an improvement?
What changes
What are we
can we make
trying to
that will result
accomplish?
in an improvement?
How will
we know
the changes are
an improvement?
All Wales Stroke Services Improvement Collaborative
Model for Improvement
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?
Slide 10
AIM
All Wales Stroke Services Improvement Collaborative
Aims
• Overall collaborative aim
• Specific aim
• Your local aim?
Slide 11
To improve the
outcome following
stroke
To increase the
reliability of delivering
4 care bundles for
acute stroke
All Wales Stroke Services Improvement Collaborative
Model for Improvement
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?
Slide 12
AIM
Goals
&
Measurement
All Wales Stroke Services Improvement Collaborative
Measures
Slide 13
All Wales Stroke Services Improvement Collaborative
Measurement
Tracking a few key
measures over time is
the single most
powerful tool a team
can use.
Slide 14
All Wales Stroke Services Improvement Collaborative
Royal Gwent % INR greater than 5
Change: Checked heparin stocks
on wards to rationalise
unfractionated heparin stocks on
general wards
Slide 15
All Wales Stroke Services Improvement Collaborative
Royal Gwent % INR > 5
Change: Checked heparin stocks
on wards to rationalise
unfractionated heparin stocks on
general wards
Slide 16
All Wales Stroke Services Improvement Collaborative
What are we trying to
accomplish?
How will we know
that a change is an
improvement?
What change(s) can we
make that will result in
improvement?
Change(s)
Slide 17
AIM
Goals
&
Measurement
All Wales Stroke Services Improvement Collaborative
Driver Diagram
Slide 18
All Wales Stroke Services Improvement Collaborative
Model for Improvement
Slide 19
All Wales Stroke Services Improvement Collaborative
The PDSA Cycle:
Act Objective
Plan
Adapt?
Adopt ?
Abandon?
Next cycle?
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Study Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
Slide 20
Carry out the plan
(on a small scale)
Document problems
and unexpected
observations
Begin analysis
All Wales Stroke Services Improvement Collaborative
Test of change have been going on for years
“Negative results on the fish…
Let’s try rubbing two sticks together.”
Slide 21
All Wales Stroke Services Improvement Collaborative
This is different!
A P
S D
Changes That
Result in
Improvement
Implementation of
change
Wide-scale tests of
change
A P
S D
Hunches
Theories
Ideas
Slide 22
Very small scale
test
Follow-up tests
All Wales Stroke Services Improvement Collaborative
Why test?
• Learn
• Design
• Confidence
• Resistance
Slide 23
All Wales Stroke Services Improvement Collaborative
Model for Improvement
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?
Slide 24
AIM
All Wales Stroke Services Improvement Collaborative
Aims
• Overall collaborative aim
• Specific aim
• Your local aim?
Slide 25
To improve the
outcome following
stroke
To increase the
reliability of delivering
4 care bundles for
acute stroke
All Wales Stroke Services Improvement Collaborative
Aim Exercise
Slide 26
All Wales Stroke Services Improvement Collaborative
Model for Improvement
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?
Slide 27
AIM
Goals
&
Measurement
All Wales Stroke Services Improvement Collaborative
What are we trying to
accomplish?
How will we know
that a change is an
improvement?
What change(s) can we
make that will result in
improvement?
Change(s)
Slide 28
AIM
Goals
&
Measurement
All Wales Stroke Services Improvement Collaborative
Share your changes…
Slide 29
All Wales Stroke Services Improvement Collaborative
The PDSA Cycle:
Act Objective
Plan
Adapt?
Adopt ?
Abandon?
Next cycle?
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Study Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
Slide 30
Carry out the plan
(on a small scale)
Document problems
and unexpected
observations
Begin analysis
All Wales Stroke Services Improvement Collaborative
How small is small ?
Slide 31
All Wales Stroke Services Improvement Collaborative
Tips for PDSA Cycles
• “What change could you test
by next Tuesday?”
• Start Small
• “Rule of 1”:
•
•
•
•
Slide 32
1 facility
1 office
1 provider
1 patient
•
•
•
•
Volunteers at first
Useful (not perfect) data
Use “huddles” to report
Learning first …
All Wales Stroke Services Improvement Collaborative
MODEL FOR IMPROVEMENT
A
S
PLAN
Objective for this PDSA Cycle
P
D
:
:
QUESTIONS
:
PREDICTIONS
PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE
PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE
DO
: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.
STUDY
ACT:
Slide 33
:
COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.
ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
CYCLE
:____ DATE
:____
All Wales Stroke Services Improvement Collaborative
Learning Objectives
– the theory
• The 3 questions of the Model for Improvement
(MFI)
• PDSA cycles
• Run charts
– the practice
• Team aim for Stroke Services
• The ‘How’ of measurement
• The PDSA Cycle related to a Stroke service
change
Slide 34