Six Decision Making Options

Six Decision Making Options

Association for Hospital
Medical Education (AHME)

April 13, 2011

Christiana Care Health System

Newark Delaware

Resources Developed by

Christiana Care Health System

Lee Ann Riesenberg, PhD, RN

Loretta Consiglio-Ward, RN, MSN

Carol K. Moore, MS, RN, NP

Thea Eckman, RN, BSN, CCRN

Teri Foy, MEd, RT

Theresa Fields

Donna Mahoney, BS, CPHQ

Omar Khan, MD, MHS

Contact Information

Lee Ann Riesenberg, PhD, RN

Director Medical Education Research & Outcomes, Christiana Care Health System, Newark DE

Research Assistant Professor, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia PA

Brian W. Little, MD, PhD

Chief Academic Officer, Christiana Care Health System, Newark DE

Table of Contents

Improvement Project Work Book

Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems, and Safety Course

Course Syllabus

Course Meeting Details

Course Overall Goals

Course Overall Objectives

Course Summary at a Glance

ACT Background Information

Course Facilitator Training Program

Facilitator Textbooks

Decision Tools for Performance Improvement

Six Decision Making Options

Risk Reduction Strategies: recommended hierarchy of actions

Effort/Benefit Matrix

Diagnostic Tools

What Is A Fishbone Diagram?

Sample Fishbone Diagram

Flow Chart Instructions

Sample Flow Charts

Estimate the Cost of Implementing your Plan

Measurement Resources

Data Presentation

Control Charts

Performance Improvement Checklist / Action Steps

Check Sheet

Pareto Chart

Scientific Writing and Publication Resources

Squire Guidelines

Quality Scoring System

Acronyms and Other Relevant Resources

Quality Improvement & Patient Safety Acronyms, Definitions, and Web Sites

Quality Journals

Improvement Project Work Book

PLAN
  • Clearly define the process opportunity (opportunity statement).
What are you trying to accomplish?
Specific population that will be affected?
Is it measurable?
Opportunity statement is a single sentence that is specific, measurable, and addresses these points:
How good?
By when?
For whom (or for what system)? / PLAN THE IMPROVEMENT
Define the opportunity statement.
Example statement: Reduce the incidence of pressure ulcers in the critical care unit by 50 percent by June of 2012.
______
______
______
Examples of Measurable Words to Use for Opportunity Statement
Reduce / Improve
Decrease / Increase
Transfer every patient / Achieve >95% compliance
Eliminate / Grow
PLAN
[Insert your institutions’ logo or quality symbol here.] / Insert your institution’s Mission/Quality Focus below and describe how your project links to that focus.
[Insert institution Focus] (describe your project linkage):
______
[Insert institution Focus] (describe your project linkage):
______
[Insert institution Focus] (describe your project linkage):
______
[Insert institution Focus] (describe your project linkage):
______
PLAN
  • Identify key stakeholders and bring them into the process (i.e., interdisciplinary, key stakeholders and content experts).
/ Identify potential resource individuals (anyone who might be able to help you obtain needed information).
Resource Individual / Team Member Who Will Contact
Identify individuals involved in the current process (individuals or groups currently affected by the process).
Individuals or Groups
Currently Affected / Team Member Who Will Contact to Gather More Insight
Identify all departments/units that your project might affect. This goes beyond those currently affected, as your project may bring other departments/units into the process.
Departments/Units
that Might be Affected / How Might They be Affected?
Is there a team or individual at your institution who is already working on this issue? If yes, how will you work with them?
______
______
PLAN / Schedule meetings with key stakeholders
Stakeholder: ______
Team member(s) assigned:______
Meeting date: ______
Members attending: ______
Stakeholder: ______
Team member(s) assigned:______
Meeting date: ______
Members attending: ______
Stakeholder: ______
Team member(s) assigned:______
Meeting date: ______
Members attending: ______
Stakeholder: ______
Team member(s) assigned:______
Meeting date: ______
Members attending: ______
PLAN
  • Gather background data about the current process
  • Conduct a literature review
How did you identify the opportunity?
  • A strategic goal for the year?
  • Practice change recommendation?
  • System/ departmental data?
  • Satisfaction results?
  • An event that happened?
  • Personal experience?
/ Clarify current knowledge of the process or practice.
  • Review best practices/ conduct a literature review (Potential databases: Medline/PubMed, ERIC, CINAHL, PsychInfo).
  • Provide data/information from your own institution
______
______
______
______
______
______
______
______
PLAN
  • Identify potential causes of the problem or identify gaps in the process.
/ What information is already known about the current practice or process?
  • Fishbone diagram (cause and effect diagram)
    (pages 25-28)
  • Flow chart current state of the process and/or practice if appropriate (pages 29-33).
Use appropriate Performance Improvement tool(s) to identify gaps or potential causes of the problem; i.e., brainstorming, Fishbone diagram, flow chart, etc. [list or attach PI tool(s)].
PLAN
  • Analyze baseline data related to the process, if available.
/ Collect baseline data about causes of the problem or gaps in the process. Select potential baseline measures to use and describe how you will obtain the data.
Measures / How will you obtain the data?
DO
  • Generate potential action plans /strategies.
/ DO THE IMPROVEMENT
Develop a list of potential solutions/action plans for your project.
For every solution listed, identify the data needed to determine if the change led to an improvement.
Potential Solutions “What” / Measure/Data Source
DO
  • Plan the action plans/strategies.
/ Consider the feasibility of the potential solutions above. Things to consider include cost, time to implement, steps to achieve, and barriers. List potential barriers and feasibility considerations below.
Feasibility Notes: ______
______
______
______
______
______
______
______
DO
  • Identify potential costs.
/ Use the “Estimate the Cost of Implementing your Plan” (page 34) to guide your discussion of the following:
1.Identify start-up costs: ______
______
______
2.Identify operating costs: ______
______
______
3.List possible savings: ______
______
______
4.Would your plan create any billable services? ______
______
______
5.Would your plan create non-financial benefits? ______
______
______
6.Categorize your Plan
 An ongoing financial expense (but worth it in terms of gaining desired outcomes)?
 Cost neutral?
A moneymaker for the hospital or group (increased performance may streamline processes, make them more efficient and effective, and still deliver improved care for your selected patient)?
What does your team need to do to get better answers to the cost questions above? Assign team members to find the answers.
Team Member NameAssignment From Above
______
______
______
______
______
DO
  • Plan the action plans/strategies.
  • Implement the selected action plans/strategies, asking who, what, when, where, & how.
  • Develop Education plan, if appropriate.
  • Do Rapid Cycle Improvements (small test of change) – one resident, one nurse, one unit, one patient.
/ Develop and implement recommended action plans/strategies (i.e., rapid cycle PDSA).
Action Plans/Strategies
(What) / Responsible Person(s) (Who) / Location (Where) / Target Date
(When)
1.
2.
3.
4.
Meet with key stakeholders prior to testing.
Date(s) scheduled:______
______
______
GO LIVE!
Rapid Cycle Test Implementation Date(s): ______
______
______

1

CHECK
  • Gather data to evaluate process and effectiveness of action plans /strategies.
  • Analyze the data to determine if the process has improved. If no improvement, identify the opportunity or process to be improved.
  • Identify and evaluate results of measures to determine if the process improved (include cost savings / avoidance).
  • Identify if there are other unmet customer needs that need to be revisited.
/ CHECK THE RESULTS
Display outcome measures/data demonstrating baseline and post measurement, if appropriate. Provide new flow chart of processes, if appropriate. Put notes on results in this section.
Action Plan/ Strategy Number / Measure / Data Source / Responsible person(s)
NOTES (about your results):
ACT
  • Adopt the action plans/ strategies.
  • Identify areas where processes can be standardized or reduce variation.
  • Identify any lessons learned.
  • Identify systemic implications, barriers or changes that may be beyond the scope of the team.
  • Identify ongoing measures/data of the process to sustain improvement.
/ ACT
Describe the path forward to implement plan, for next rapid cycle PDCA, or to sustain improvement:
______
______
______
______
______
List lessons learned
______
______
______
______
______
______
______
______

Communicate Results and CELEBRATE SUCCESS / STORYTELLING!

Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems, and Safety Course

Course Syllabus

Course Director Lee Ann Riesenberg, PhD, RN

Director Medical Education Research and Outcomes

(302) 623-4488

Team FacilitatorsLoretta Consiglio-Ward, RN, MSN

Carol Kerrigan Moore, MS, RN, NP

Christine Chastain-Warheit, MLS, AHIP
Thea Eckman, MSN, RN-BC, CCRN

Teri Foy, MEd, RT

Carmen Pal, RN, BSN, PCCN

Leslie Konizer, MS, CPHQ

Dean A. Bennett, RPh

Susan Coffey Zern, MD

LaRay Fox, CNMT, MEd

Course Faculty

Brian Aboff, MD, FACP
Sharon Anderson, RN, BSN, MS, FACHE
Michele Campbell, RN, MSM, CPHQ
Jerry Castellano, PharmD, CIP
Loretta Consiglio-Ward, RN, MSN
William Conway
Neil Jasani, MD
Omar Khan, MD, MHS
Robert Laskowski, MD, MBA / Linda Laskowski-Jones, RN, MS, ACNS-BC, CCRN, CEN
Brian W. Little, MD, PhD
Donna Mahoney, BS, CPHQ
Carol Kerrigan Moore, RN,MS APN
Terri Lynn Palmer, MPA
Patty Resnik, RRT, MBA, CPUR
Lee Ann Riesenberg, PhD, RN
Glen Stryjewski, MD, MPH
Maureen Seckel, RN, MSN, APRN-BC

Course Administrative Support

Theresa Fields

1

Course Meeting Details

Course Attendance:

Learners must arrive promptly at 4 PM and attend at least 10 of the 12 sessions to receive credit (no exceptions). Successful completion of the ACT program and ability to engage in the required teamwork requires consistent attendance. Recognizing that there are occasions that might require your presence elsewhere, we have elected to accept a maximum of two class session absences. Anticipated absences need to be communicated to course facilitators and team members prior to the class session. In the event of up to two absences, it is expected that you will collaborate with members of your team to ensure that you have received all materials distributed in class, and that your contribution to the teamwork component is disseminated to your team. Any additional absences compromise both learner objectives and teamwork in designing a performance improvement project plan. Therefore, a third absence will require immediate withdrawal from the course. Absences and withdrawals from the ACT course class sessions will be communicated to program directors for residents; to immediate supervisors, managers, or directors for nurses and allied health participants; to the chief academic officer for medical students. This is to ensure a shared knowledge and understanding of any barriers to full participation in the course. Admission into the course will not be granted if it is determined that you are not able to attend the first and last session of the course.

Course Overall Goals

  • Increase learner’s competence in systems and practice improvement while stimulating inter-professional learning and collaboration.
  • Increase learner’s awareness of how national and local systems, rules, and regulations contribute to systems-based issues in the practice environment.
  • Promote learner’s role as advocates for quality and safety in patient care.

Course Overall Objectives

By the completion of this course, learners will be able to:

  • Identify system problems that compromise the quality and safety of care.
  • Analyze system problems and the effect they have on patient care.
  • Synthesize findings from the research literature as it applies to the problem being investigated.
  • Utilize systematic methodology for practice-based improvement activities.
  • Develop an evidence-based, performance improvement project plan with preceptor support as part of an inter-professional team.

1

Course Summary at a Glance

Week / Date/Location / Topic(s) / Pre-session Assignments: Readings, IHI Modules, & Other Assignments (to be completed prior to session)
1 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Quality, Safety, and Performance Improvement Overview / Readings
Berwick DM. Escape fire: Lessons for the future of health care. The Commonwealth Fund. 2002.
Annual Operating Plan
IHI Lessons (Instructions to access the IHI Lessons are on pages 9-11)
  • Patient Safety 101: Lesson 1—To Err is Human
  • Quality Improvement 101: Lesson 3—The Institute of Medicine’s Aims for Improvement

Between Session Work / Using what was learned during this session, identify 1-2 possible improvement ideas and write the ideas on the “ACT Course Work Sheet # 1”
2 / (Insert Date)
CCHS Main Hospital Conference Room 1100 / PDCA, RCA, High Reliability / Readings
McKeon LM, Oswaks JD, Cunningham PD. Safeguarding patients: Complexity science, reliability organizations, and implications for team training in healthcare. Clinical Nurse Specialist 2006;20(6):298-304.
Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA 2008;299(4):445-447.
IHI Lessons
  • Quality Improvement 101: Lesson 1— Errors can happen anywhere and to anyone
  • Quality Improvement 102: Lesson 1— An overview of the model for improvement
  • Quality Improvement 102: Lesson 2—Setting an aim

Between Session Work / Complete “ACT Course PDCA Worksheet # 2” for each of the team’s top 2-4 project ideas.
3 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Teams and Opportunity Statement / IHI Lessons
  • Patient Safety 103: Lesson 1—Why are teamwork and communication important
  • Leadership 101: Lesson 1—Taking the leadership stance
  • Leadership 101: Lesson 2—The leadership stance is not a pose

Between Session Work / Complete “ACT Course PDCA Worksheet # 3” to middle of page 3
4 / (Insert Date)
CCHS Main Hospital Conference Room 1100 / Measurement and Outcomes
Health Care Economics: Part 1 / IHI Lessons
  • Quality Improvement 101: Lesson 4—How to get from here to there: Changing Systems
  • Quality Improvement 102: Lesson 3—Measuring
  • Quality Improvement 103: Lesson 1—Measurement fundamentals

Between Session Work / Finalize fishbone, start flowchart (if appropriate), continue with background research
5 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Previous ACT Team Presentation
AND
IRB / Readings
Gawande A. The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker December 10, 2007. Available at: Accessed June 4, 2008.
Newhouse RP, Pettit JC, Poe S, Rocco L. The slippery slope: Differentiating between quality improvement and research. JONA 2006;36(4):211-219
IHI Lessons
  • Patient Safety 103: Lesson 4—Developing and executing effective plans

Between Session Work / Complete “ACT Course PDCA Worksheet # 3” pages 4 & 5
6 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Change Theory / Readings
VanHoy SN, Laskowski-Jones L. Early intervention for the pneumonia patient: An emergency department triage protocol. Journal of Emergency Medicine 2006;32(2): 154-158. Additional readings may be assigned.
Weed J. Factory efficiency comes to the hospital. The New York Times July 11, 2010.
IHI Lessons
  • Quality Improvement 102: Lesson 4—Developing change
  • Quality Improvement 102: Lesson 5—Testing change
  • Leadership 101: Lesson 3—Influence, persuasion, and leadership

Between Session Work / Plan meeting with key stakeholders
7 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Workforce Issues
AND
Variations in Care / Workforce Readings
The Adequacy of Pharmacist Supply: 2004 to 2030, Executive Summary
Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med 2007;82:827-828.
Kirch DG. Vernon DJ. Confronting the complexity of the physician workforce equation. JAMA 2008;299(22):2680-2682.
Variations in Care
Gawande A. The cost conundrum. The New Yorker June 1, 2009.
Davis K, Schoen C, Stremikis K. Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally. Commonwealth Fund; June 2010.
IHI Open School Module:
  • Quality Improvement 101: Lesson 2—Health care today

Between Session Work / Complete “ACT Course PDCA Worksheet # 3” pages 6 & 7
8 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / The Evolution of the US Health Care System (History)
Between Session Work / Continue work on Performance Improvement Project
Complete self and team member evaluations
9 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Health Care Economics: Part 2 / Readings
Review the previously assigned article: Gawande A. The cost conundrum. The New Yorker June 1, 2009.
IHI Open School Module:
  • Quality Improvement 105: Lesson 1—Overcoming resistance to change
Assignment: Each participant needs to bring their print-out from IHI Web Site of the Completed IHI modules.
Between Session Work / Complete “ACT Course PDCA Worksheet # 3” pages 8 & 9
10 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Teamwork Time
Between Session Work / Focus on finalizing implementation and post-data collection; Finish first draft of presentation for practice.
11 / (Insert Date)
Ammon Med. Educ. Building, Back of Auditorium / Practice Presentations
Complete confidence survey during this session
12 / No class, unless needed for weather make-up
Deadline for submitting final PowerPoint to your Facilitator
13 / (Insert Date)
Ammon Med. Educ. Building, Auditorium / Formal Performance Improvement Project Plan Presentations and Reception

Note: All course requirements must be met prior to receiving Certificates of Completion.

1

ACT Background Information

ACT is a graduate level interdisciplinary curriculum for systems-based practice and practice-based learning and improvement. The original ACT curriculum was developed by Harvard’s Partnerships for Quality Education (PQE) ( a national initiative of the Robert Wood Johnson Foundation. It has been piloted over the past five years. Christiana Care Health System is one of “six of the top performing ACT sites” and as a result we received an extension grant from Robert Wood Johnson Foundation, which will be used to continue our work on: curriculum development, evaluation and improvement, and outcomes research. This two-year extension grant started in January 2007 and concluded December 2008.

The course brings learners together with faculty and health system leaders to learn about systems and practice improvement. Learners work together in teams to identify a health care system-based performance improvement opportunity, review best practices and relevant literature, and design and present an evidence-based performance improvement project plan.

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