QI 102: How to Improve with the Model for Improvement
You notice that it's very easy to confuse medications at the community health center where you're working. They are lined up on the shelf and the labels are very similar. You decide that it's worth a try to highlight parts of drug names on certain labels to reduce confusion. Which change concept are you using? (A) Manage Time (B) Optimize Inventory (C) Design Systems to Prevent Errors (D) Improve Work Flow
Design Systems to Prevent Errors By making it easier to identify the medications, you are making it harder for the people in your organization to make mistakes. Choices A, B, and D are all valuable types of change concepts, but they do not apply in this example.
Starting with small tests of change: (A) Allows you to start testing on live patients right away (B) Improves the likelihood of buy-in from opinion leaders (C) Means you don't need to do any planning before each test (D) Should be done only with the consent of opinion leaders
Improves the likelihood of buy-in from opinion leaders Linking tests of change—with one test concluding and the next beginning at the same time, but this time on a larger scale or with a different scope—allows you to build support for your project. Each successive test is a way to demonstrate to key stakeholders that their input has value and that the project may actually lead to improvement. However, it's not necessary to seek consensus among stakeholders before testing changes.
Which of the following statements is true? (A) All changes lead to improvement; therefore, all improvement requires change. (B) While not all changes lead to improvement, all improvement requires change. (C) The changes that are known to lead to improvement should be implemented before testing.
While not all changes lead to improvement, all improvement requires change. All improvement requires change—but unfortunately, not all changes lead to improvement. It is precisely for this reason that after you test a change, you should study the results to determine whether you're closer to accomplishing your goal.
Having a clear aim statement is important in quality improvement work because:
Aim statements provide a clear and specific goal for the organization to reach. Whether you're trying to reduce your commute time or cut down on the incidence of surgical-site infections, having a clear and specific aim statement makes your project more likely to succeed. Good aim statements include a specific, measurable goal, a deadline for achieving the goal, and information about which population will be affected: how good, by when, for whom. They do not, however, remove all obstacles from the process. And while many funding requests and leaders require strong aims, it's not always a requirement.
You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success. After several tests, you decide to try implementing a modified version of the protocol at your institution. Which of the following might you do within the "S" portion of your next PDSA cycle? (A) Develop the final plan for the protocol implementation. (B) Document unexpected observations. (C) Analyze information collected. (D) Strategize how to move this to another hospital in the system.
Analyze information collected. "S" stands for Study. In this step you review the information collected during the "Do" step. Planning for implementation is part of the "Plan" step, and documentation of outcomes is part of the the "Do" step. Considering how to spread the change to another hospital is outside the scope of this PDSA cycle.
When trying to improve a process, one reason to use PDSA cycles rather than a more traditional version of the scientific method (such as a randomized, controlled trial) is that: (A) PDSA cycles are easier to run with a large team of people. (B) The results of PDSA cycles are more generalizable than other methods. (C) PDSA cycles are simpler to use than other methods. (D) PDSA cycles provide a mechanism to adjust improvement ideas as the project progresses. (E) Both C and D
Both C and D PDSA cycles allow for rapid and frequent review of data and then adjusting the test of change based upon those findings. For example, if a new guideline that's meant to improve pneumonia care isn't working, PDSA cycles allow you to change the guideline quickly and test its efficacy, rather than waiting until the end of a long study period.
Which of the following is one of the three key questions of the Model for Improvement?
How will we know a change is an improvement? The Model for Improvement, developed by a group called Associates in Process Improvement, begins with three fundamental questions: What are we trying to accomplish? How will we know a change is an improvement? What change can we make that will result in improvement?
Gathering and reviewing data during an improvement project—that is, measuring—helps you answer which of the three questions of the Model for Improvement? (A) How will we know that a change is an improvement? (B) What are we trying to accomplish? (C) What changes can we make that will result in improvement?
How will we know that a change is an improvement? Measures (both qualitative and quantitative) provide a way to gather information on the effects of the change you are testing. Without measures, you have no real way of knowing whether your change led to an improvement. Having good measures is critical if you wish to improve care and spread change throughout a system.
An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. Applying the Model for Improvement to the clinic's improvement goal, which of the following is the most reasonable aim statement? (A) Implement two PDSA cycles within six months of beginning the project. (B) Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months. (C) Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments. (D) Create an efficient process for scheduling return appointments at the time of checkout.
Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months. An aim statement must specify "how good, by when." Improving patient satisfaction with scheduling is a reasonable goal. Answer D is best described as an opportunity statement, as it contains no specifics about how much the clinic must improve, nor by when. Answer C is more of a "change" statement than an aim statement.
An aim statement should include the following:
Numeric goals, specific time frame, and the patient population or system affected Aim statements should specify measurable numeric goals, a time frame for attainment, and the group or system affected. Costs and team members, while important to the success of the quality improvement project, are not part of the aim statement itself.
As you recall, the IHI staff member's change idea involves leaving work by 5:30 PM each workday. Which of the following is an example of using technology to help her do so? (A) Comparing the time she leaves to that of the person who seems to go home earliest each day. (B) Cancelling two meetings every day. (C) Scheduling a reminder into her work calendar that pops up daily at 5:15 PM with the message, "Leave!" (D) Taking work home each night on a laptop computer.
Scheduling a reminder into her work calendar that pops up daily at 5:15 PM with the message, "Leave!" The programmed reminder is an example of using technology to make it harder for people to "drift" into less-than-optimal behavior. Answer A is an example of benchmarking. Answer B is an example of the change concept "eliminate waste" (assuming those meetings were not necessary in the first place). Answer D simply shifts the work to home, rather than creating a more efficient work pattern.
As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. Which of the following is an example of a process measure that you may collect as part of this improvement effort? (A) The rate of patients being readmitted within 30 days (B) The reasons for readmission to the hospital (C) The percentage of patients receiving a call within 48 hours of discharge (D) The cost of the labor associated with the calls
The percentage of patients receiving a call within 48 hours of discharge Gathering data about process changes is important—otherwise you won't know if you are consistently doing the things that you predict will lead to improvement. Further, if your outcome measures show improvement over the course of your project, having good process measures allows you to make a reasonable conclusion about the efficacy of your new processes and their relation to the outcome. Answer A is an outcome measure for this project, and answer D is a balancing measure.
The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should:
Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim. Including the right people on the change team is crucial to a project's success. The team should include representatives of all processes affected by the team's aim, which is why Brenda should review the aim statement. Further, it should include people with enough authority in the system to remove barriers and implement changes; people with clinical or technical expertise; and people who can drive the project on a day-to-day basis. A team representing just one profession is rarely as effective as an interprofessional team.
The Model for Improvement begins with three questions designed to clarify the following concepts: (A) Plan, do, act (B) Mission, goal, strategy (C) Aims, measures, changes (D) Will, ideas, and execution
Aims, measures, changes The Model for Improvement begins with three fundamental questions about any given improvement, designed to address the aim (what are we trying to accomplish?), the measures to be used (how will we know a change is an improvement?) and the changes to be used (what changes can we make that will result in an improvement?).
You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success. The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital? (A) Because the last success may have been a fluke. (B) So that you can publish your results. (C) Because this change may not be as effective in your hospital. (D) In order to demonstrate the ability of this protocol to improve care in other hospitals for those that created it.
Because this change may not be as effective in your hospital. Changes that work in one complex system may not be as effective, or effective at all, in another. The only way you will know for sure is to test the changes. Other reasons to test "proven" changes are to evaluate costs, minimize resistance and gain buy-in, and increase your own confidence that the change will lead to improvement in your setting
An aim statement should include the following: (A) Specific time frame, team membership, and numeric goals (B) Numeric goals, specific time frame, and the patient population or system affected (C) Patient population or system affected, estimated cost of improvement, and numeric goals (D) All of the above
Numeric goals, specific time frame, and the patient population or system affected Aim statements should specify measurable numeric goals, a time frame for attainment, and the group or system affected. Costs and team members, while important to the success of the quality improvement project, are not part of the aim statement itself.
During Brenda's first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brenda's approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to:
Remind the team of the Institute of Medicine's dimensions of health care quality. Writing an effective aim, especially when it comes to being specific about the improvement desired, can be surprisingly difficult. The Institute of Medicine's six dimensions of health care quality can often provide guidance and direction when a team is struggling to formulate an effective aim statement. (Reminder: A handy way to remember the six dimensions is the mnemonic "STEEEP": safety, timeliness, effectiveness, equity, efficiency, and patient-centeredness.)
An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic's improvement team hopes that this small change will improve scheduling. What is the team's next step? (A) Take a well-deserved break. (B) Develop their project-level measures. (C) Test their change plan using the PDSA cycle. (D) Report their results to clinic leadership and prepare a poster for a national meeting.
Test their change plan using the PDSA cycle. Once you have worked through the first three questions of the Model for Improvement — the questions about aims, measures, and changes — it's time to do a small test of change using the PDSA cycle. The clinic should have already developed their measures, and now is not the time for a break — because the hard work of improvement is just beginning!
Having a clear aim statement is important in quality improvement work because: (A) Aim statements provide a clear and specific goal for the organization to reach. (B) All grant agencies require clear aim statements when they are considering funding requests. (C) Aim statements remove all obstacles from quality improvement projects. (D) The leaders of all organizations expect to see these types of goals.
Aim statements provide a clear and specific goal for the organization to reach. Whether you're trying to reduce your commute time or cut down on the incidence of surgical-site infections, having a clear and specific aim statement makes your project more likely to succeed. Good aim statements include a specific, measurable goal, a deadline for achieving the goal, and information about which population will be affected: how good, by when, for whom. They do not, however, remove all obstacles from the process. And while many funding requests and leaders require strong aims, it's not always a requirement.
As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. What else should you add to the graph to best explain the improvement work your unit has done? (A) The cost of the improvement effort (B) Annotations to show when specific changes were tested (C) Explanation of what a PDSA cycle is (D) P-values showing statistical significance
Annotations to show when specific changes were tested When you go through multiple linked PDSA cycles in the course of a project, it's important to note which changes were tested and when, so you can make sense of the results. The cost may be important, but this data point won't show whether the team's changes led to improvement. P-values showing statistical significance are more commonly used in quality research than in quality improvement.
An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What's the next thing the clinic's improvement team should do? (A) Change their measures. (B) Measure to see if the change led to improvement. (C) Report their results to the clinic leadership and prepare a poster for a national meeting. (D) Implement the new scheduling process based upon their initial impressions of how everything is working.
Measure to see if the change led to improvement. The team has planned a test of change and now they've done the test. The team must now study how the test went (the "S" part of the PDSA cycle). They can look at a mix of process measures (such as how often appointments started on time) and outcome measures (such as how satisfied the patients were with the new process).
As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. What would you identify as the outcome measure for the project? (A) Average length of stay (B) The cost of labor associated with the calls (C) Rate of job satisfaction of those on the unit making the calls (D) Percentage of patients that are readmitted to the hospital
Percentage of patients that are readmitted to the hospital Answer D—hospital readmissions—is the ultimate measure we're trying to move with the project. In other words, that's the main thing we're trying to improve. Answer A is a process measure, which tells us if we are consistently doing the things that are leading to improvement. Answers B and C are both balancing measures, meaning that we're keeping track of them to make sure the changes we're making are not having a negative effect on other parts of the system.
Which of the following changes falls under the heading of "eliminating waste"? (A) Physicians type all consult responses directly into a computer rather than writing them in a patient's chart, thus saving paper. (B) Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols. (C) A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidence-based care (D) A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team
Physicians type all consult responses directly into a computer rather than writing them in a patient's chart, thus saving paper. Waste is an activity or resource that does not add value. When a physician writes an order and someone else enters that order into the computer (answer A), two steps are required. Changing the process so it only requires one step reduces waste as well as potential for error. None of the other answers explicitly focuses on reducing waste.
The Model for Improvement includes a process for learning from tests of change. What are the steps in this process?
Plan, do, study, act The testing component of the Model for Improvement is the Plan-Do-Study-Act (PDSA) cycle. Through PDSA cycles, teams quickly test changes on a small scale, observe what happens, tweak the changes as necessary, and then test again (perhaps with a larger or broader test group).
Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse). During Brenda's first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brenda's approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to: (A) Reconsider who should be on the improvement team. (B) Move the meeting to a later date, so that she can come better prepared. (C) Explain to the group that the aim is set, as both she and the charge nurse have already agreed on the wording. (D) Remind the team of the Institute of Medicine's dimensions of health care quality.
Remind the team of the Institute of Medicine's dimensions of health care quality. Writing an effective aim, especially when it comes to being specific about the improvement desired, can be surprisingly difficult. The Institute of Medicine's six dimensions of health care quality can often provide guidance and direction when a team is struggling to formulate an effective aim statement. (Reminder: A handy way to remember the six dimensions is the mnemonic "STEEEP": safety, timeliness, effectiveness, equity, efficiency, and patient-centeredness.)
Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse). The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should: (A) Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim. (B) Create a team of volunteers. (C) Create a team of managers and administrators. (D) Make sure only nurses are on the team, as they are the most likely to help her achieve her aim.
Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim. Including the right people on the change team is crucial to a project's success. The team should include representatives of all processes affected by the team's aim, which is why Brenda should review the aim statement. Further, it should include people with enough authority in the system to remove barriers and implement changes; people with clinical or technical expertise; and people who can drive the project on a day-to-day basis. A team representing just one profession is rarely as effective as an interprofessional team.
You're a medical assistant at a community health clinic. Sometimes, patients with unresolved problems need to come in for follow-up appointments. However, you notice that it's a real challenge to schedule these follow-ups within a week of the initial appointments. Which of the following techniques might be most useful as you search for a good idea for change? (A) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. (B) Quit and start working in a new clinic that functions more effectively. (C) Research possible upgrades to the appointment scheduling software. (D) Tell a member of the office staff that it would be great if follow-ups were scheduled more quickly.
Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. Coming up with a change that will address your problem is often one of the most difficult aspects of the change process. Brainstorming with colleagues may help, as can critical thinking and creative thinking about the problem at hand. In this case, simply moving to another clinic (answer B) might reduce your frustration but will not help the clinic. Improving the scheduling software (answer C) may be useful, but it's unclear at this point that technology is at the heart of the delays. Finally, the office staff very likely already know that patient follow-ups should be scheduled sooner, but some aspect of the process is making this difficult for them (answer D). Simply reminding them is unlikely to get results.
As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. Why might you consider collecting balancing measures? (A) To show that you met your aim (B) To make sure you are able to publish your study (C) To demonstrate to your hospital board that you were justified in using resources for this project (D) To make sure you did not unintentionally damage other aspects of the unit's work
To make sure you did not unintentionally damage other aspects of the unit's work Sometimes changes in one part of a complex health care system will lead to unintended additional changes in a different part, like ripples in a pond. Balancing measures can help ensure you're aware of these significant negative consequences, so that you can address them.
What's the main benefit of using change concepts to come up with improvement ideas? (A) Using change concepts makes PDSA cycles unnecessary. (B) Using change concepts makes it much more likely that the implementation will go smoothly. (C) Using change concepts will lead you to focus on quantifiable technological improvements. (D) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.
Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially. Change concepts can help you develop new, specific ideas for change that could lead to improvement. They don't necessarily improve the likelihood that implementation of these changes will go smoothly, however. Finally, testing the changes using PDSA cycles is still necessary!
Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse). Which of the following is the most effective aim statement for this project? (A) Within one month, 95 percent of physicians will tell nurses when a pain medication is ordered on emergency room patients. (B) Within three months, the emergency department will administer all pain medications within 45 minutes of order time. (C) Within two months, improve the timeliness of pain medication delivery by allowing nurses to stock the most commonly used medications in the emergency unit (D) Within three months, the emergency department will improve the timeliness of pain medication delivery to 100 percent of patients.
Within three months, the emergency department will administer all pain medications within 45 minutes of order time. Effective aim statements contain a time frame, a definition of the population to be affected, and specific, measurable goals. Answer B meets all three of these criteria. While answers A and C may be useful process changes to reduce the delay between the ordering and administration of medications, they are not aims in and of themselves. Option D is not specific enough, as it does not contain information about how much the department should improve.
You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success. After implementing the new protocol, you observe that patients are getting to the lab more quickly than before, but not as quickly as you had predicted. You examine the data and realize that there are really multiple issues delaying patients' arrival to the catheterization lab. Specifically, the emergency department needs to notify the lab staff in advance, but this communication rarely happens. Further, the schedule that the emergency department uses to contact the lab staff is riddled with errors. Based on the recommendations in this lesson, what should you do next? (A) Focus on fixing the schedule. (B) Discipline the emergency department staff who have failed to contact the catheterization lab in the past. (C) Focus on improving the communication between the emergency staff and the catheterization staff. (D) Work on improving both the schedule and communication at the same time.
Work on improving both the schedule and communication at the same time. You should start testing changes to both processes and run the tests concurrently. That way you can see how all the required changes work together. Remember, your goal is to bring knowledge into action—not to discover the single change that works best.
