Slide 1 Hello and welcome to Lake Superior ... - Lake Superior QIN

Hello and welcome to Lake Superior Quality Innovation Network Learning Session 2.This is the third webinar of the series which will guide your quality improvement team on how to test changes using a methodology called Plan, Do, Study Act, or PDSA. I am Kristi Wergin, a program manager for Lake Superior Quality Innovation Network. I am pleased to introduce Kim Nott, Director of Nursing Services at Golden LivingCenter-Wabasso, who will share an example of how their team completed PDSA cycles as they worked on improving their systems and processes related to preventing unintended weight loss.

Slide 1 Plan-Do-Study-Act (PDSA) NNHQCC Learning Session #2 Webinar 3 Kristi Wergin Program Manager LSQIN Kim Nott Nursing Director Golden LivingCenter-Wabasso August, 2015

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Objectives •

Describe the relationship between Plan-Do-StudyAct (PDSA) and the Model for Improvement

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Identify key concepts about testing changes on a small scale using PDSA cycles

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Execute a small test of change within your nursing home

The objectives for this webinar and activity are to: • Describe how PDSA fits into the Model for Improvement • Identify key concepts for testing changes on a small scale using PDSA cycles and • Execute a small test of change within your nursing home

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Be a Continuous Learning Organization Plan and implement tests of change

Change Package https://www.lsqin.org/wp-content/uploads/2015/03/NHChangePackage-032615-Final-508.pdf

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In Learning Session #1, we talked about the importance of developing the culture in your nursing home to better support quality improvement. The NNHQCC Change Package offers strategies that your team can implement to develop and enhance your quality culture. One of the strategies of high performing nursing homes found in the Change Package is to be a continuous learning organization. A culture that supports quality plans and implements test of change uses the methodology of Plan, Do, Study, Act. Please refer to the link on this slide to find other proven strategies to improve the quality culture within your nursing home.

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The Model for Improvement What are we trying to accomplish? How will we know that change is an improvement? What changes can we make that will result in an improvement?

Act

Plan

Study

Do

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In the first webinar of this series, Liz spent some time reviewing the Model for Improvement from the Institute for Healthcare Improvement. This model consists of three questions that should be your guide as you work on performance improvement projects. PDSA is initiated when your team is asking the third question on this slide, “What changes can we make that will result in an improvement?” You have worked together has a team to set a goal (what are we trying to accomplish) and to develop measures (How we will know that change is an improvement?). Now is the time to figure out what to do to make improvements. Perhaps you have used brainstorming, flow charting, process mapping, or a review of evidence based practice to come up with ideas for improvement. Or perhaps, your team has done root cause analysis to define what the real problem is. Hopefully, one or more of these quality improvement techniques have helped you recognize what system changes have to happen that will result in improvement. Your next step is to use PDSA, to test the change and figure out if your hunch or theory will indeed result in an improvement.

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Act

Plan

Study

Do

Hunches, theories, and ideas 4

Study

Act

Do

Plan

Do

Study

Plan

Act

Plan

Do

Act

Study

Changes that result in improvement

When doing a PDSA cycle, your team is testing the hunches, theories, and ideas identified during brainstorming, flow charting, process mapping, reviewing of evidence based practices, and/or completing a root cause analysis. This image represents how, after testing a change and learning from each test, you may need to refine your changes through several cycles to get the improvement results your team is looking for.

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Two Parts to the Model for Improvement The Thinking Part

The Doing Part

What are we trying to accomplish?

Plan

How will we know that change is an improvement?

Do

What change can we make that will result in an improvement?

Study and Act

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If your teams have completed the webinars and activities in learning session #1 as well as the first two webinars and activities in this learning session, you have done a lot of “thinking.” You have identified at least one area in your nursing home that needs improvement and you have set a goal and developed measures. You have also worked together as a team to determine what changes need to be made in your processes and systems that may result in improvement. Now it is time for the fun part-the doing part. Now you get to try out your “hunches”, what you think will make a difference. You may want to do this on a small scale-perhaps on just one neighborhood, or maybe even with just one resident, to determine if the change in your system is feasible, and it results in improvement, before trying it out facility wide. PDSA does not have to be a complicated process. Let’s look at a few examples of PDSA cycles We will start with an example from Golden LivingCenter-Wabasso that Kim Nott will share with us.

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Golden LivingCenter - Wabasso Kim Nott, DON

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Golden LivingCenter Wabasso

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GLC Wabasso keeps abreast of our area of concern by reviewing our many areas of data. For this weight loss PIP we reviewed data from point right and Minnesota quality indicators. During this review we noted high number of residents with significant weight loss some were losing 5-15 pounds per month

Scenario •

The IDT team reviewed Point Right data and Minnesota Quality Indicator data.

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They noted a high number of residents with unintended weight loss. Some residents were losing 5 to 15 pounds a month.

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Kristi thank you for inviting me. Golden LivingCenter-Wabasso is a 44bed skilled nursing facility located in Wabasso, Minnesota (MN). located in the "Heart of Redwood County". GLC's main healthcare service offerings consist of skilled long-term geriatric care and post acute rehabilitative care. In addition, we have a unique niche and are licensed in the State of Minnesota, to provide Outpatient Chemical Dependency Counseling (CD) services.

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Our QAPI team decided we would try to reduce the number of residents with unintended weight loss by 5.77% in 1 years time. Our actual goal would be to reduce our weight loss from 8.77% to 5.77% . The initial changes we would make would be to monitor meal intake and implement weekly weights.

The Thinking Part What are we trying to accomplish? Reduce the percentage of residents with unintended weight loss to 5.77% or less over a one year time frame. How will we know that change is an improvement? The percentage of residents with unintended weight loss will decrease from 8.77% to 5.77%. What change can we make that will result in an improvement? Provide education to staff on monitoring meal intake and implement weekly weights on all residents.

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Plan PLAN

• What is the objective of the test? • What do you predict will happen and why?

• What change will you make? • Who will it involve (e.g., one unit, one floor, one department)?

• How long will the change take to implement?

List your action steps along with person(s) responsible and timeline

1. Staff will be educated by Director of Dining Services and licensed staff on monitoring and documenting resident meal intake by 03/01/2015. 2. All residents will be weighed weekly by nursing assistants starting 03/01/2015. 3. Nursing assistants will notify the licensed staff of resident’s weight. Licensed staff will document weights in PCC beginning 03/01/2015.

To begin with we educated our staff on proper monitoring of weights. Thinking we would be ahead of the game. We then started weekly weight . We educated the staff that our C.N.A would do weekly weights and then give them to the licensed nurse. The licensed nurse would then put the weight in our Point Click Care system.

• What resources will they need?

• What data need to be collected? 10

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Plan PLAN

• What is the objective of the test? • What do you predict will happen and why? • What change will you make? • Who will it involve (e.g., one unit, one floor, one department)? • How long will the change take to implement? • What resources will they need? • What data need to be collected?

List your action steps along with person(s) responsible and time line

4. IDT will review potential risk for weight loss by reviewing things such as meal intakes, eating difficulties, meal attendance, weight loss, and behaviors starting 03/1/2015. 5. For weights that are out of line from last one, licensed staff will complete reweights, obtain therapy referrals as needed, and review medication and any changes in condition.

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Describe what actually happened when you ran the test

1. Began weekly weights on 03/01/2015. • Implement the change. Try out the test on a small scale. • Carry out the test. • Document problems and unexpected observations. • Begin analysis of the data.

For weights that were not stable the licensed staff were directed to ask for a reweigh. The IDT team would ask for therapy referrals as needed review meds and any change in condition

This slide shows steps to that process.

DO DO

Weekly Our IDT team reviewed weights with losses and gains. We were reviewing meal intakes, any eating concerns, meal attendance weight loss and even included resident behaviors.

2. Director of Dining Services gathered the results and reviewed weights entered into PCC on 03/04/2015. 3. IDT team began reviewing and analyzing the data through weekly grand rounds. 4. Director of Dining Services initiated monthly weight loss meeting which involves line staff. 12

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STUDY STUDY

• Set aside time to analyze the data and study the results and determine if the change resulted in the expected outcome. • Complete the analysis of the data. • Compare the data to your predictions. • Summarize and reflect on what was learned. Look for: unintended consequences, surprises, successes, failures.

Describe the measured results and how they compared to the predictions

We really thought our efforts would be successful., However during our QAPI analyzation we found had only minimal improvement.

1. During monthly QAPI, IDT analyzed the data on 04-01-2015. 2. Results - weight loss had only minor improvement. 3. Results were not what we expected IDT team thought we would head off the weight loss by closely monitoring weights and focusing more on meal intake.

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STUDY STUDY


Describe the measured results and how they compared to the predictions 4. IDT team reviewed analysis of data. Monthly maintenance checks on calibration of our equipment found that our scale was calibrating correctly. However, scale was electronic and after further brainstorming and inspection, we found the there was an issue with the battery pack on the scale which was causing the scale to not perform effectively.

Our QAPI team then went a little further and analyzed, our maintenance checks our scale calibration etc. and found that wasn’t it. After further brainstorming and monitoring of staff we found it was a scale issue, related to the battery pack on the scale . When there was movement it would change the weight recorded

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QAPI then decided we would purchase a new scale

ACT ACT

Describe what modifications to the plan will be made for the next cycle from what you learned

• If the results were not what you wanted Adapt you try something else Refine the • Purchased a new scale and repeated change, based on what was learned the PDSA cycle. from the test. • Adapt – modify the changes and repeat PDSA cycle. • Adopt – consider expanding the changes in your organization to additional residents, staff, units. • Abandon – change your approach and repeat PDSA cycle.

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We then started the process again thinking this would solve our issue

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New PDSA Cycle

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PLAN PLAN

• What is the objective of the test? • What do you predict will happen and why? • What change will you make? • Who will it involve (e.g., one unit, one floor, one department)? • How long will the change take to implement? • What resources will they need? • What data need to be collected?


We educated our staff on the new scale and continued the other processes we had already put in place

1. Maintenance and licensed staff will educate line staff on how to use the new scale by May 1, 2015.

2. Nursing assistants will begin weekly weights using new scale on May 4, 2105. 3. Licensed staff will document weekly weights in PCC. 4. IDT team will continue weekly weight review during Grand Rounds. 17

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Our dietary manager continued her process and we still had weight losses.

DO DO

• Implement the change. Try out the test on a small scale. • Carry out the test. • Document problems and unexpected observations. • Begin analysis of the data.


1. Began weekly weights with new scale on May 4, 2015. 2. Director of Dining services gathered results from PCC starting May 11, 2015.

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STUDY STUDY

Describe the measured results and how they compared to the predictions


1. IDT team analyzed the data during QAPI on June 16, 2015. 2. Results - minimal weight loss noted. 3. This was not what we expected thought the new scale would be more accurate and would show a decrease in the rate of weight loss.

We again analyzed our data and still found only minimal improvement. We then began audits of our processes and competencies of our staff . Found that since we had switched from a digital scale to a manual scale that not all of our staff knew how to operate our new scale.

4. Did some further analysis and observations were completed. 5. Competencies of staff performing weights showed that many staff 19 did not understand how to read the new scale.

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ACT ACT

Describe what modifications to the plan will be made for the next cycle from what you learned

• If the results were not what you wanted you try something else Refine the change, based on what was learned from the test. • Adapt – modify the changes and repeat PDSA cycle • Adopt – consider expanding the changes in your organization to additional residents, staff, units • Abandon – change your approach and repeat PDSA cycle

Adapt • Educated staff via all staff in-services, small group huddles, and individual training. • Developed an auditing process that includes competencies for scale use. • Started the PDSA cycle again.

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Act

Plan

Study

Do

Hunches, Theories And Ideas 21

Study

Act

Do

Plan

Do

Study

Plan

Act

Plan

Do

Act

Study

Changes that result in improvement

Thank you , Kim. Your home’s experience illustrates how it is often necessary to make tweaks to the plan and complete several PDSA cycles before you have developed a system that will result in the improvement you are looking for.

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Another scenario •

Magnolia Care Center just completed an employee satisfaction survey

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They note that only 40% of the nursing assistants (NAs) hired in the last year rated their orientation as positive (good or excellent)

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They also noted that only 50% of newly hired NAs last year are still employed

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The Thinking Part What are we trying to accomplish? Make the orientation process a positive experience and decrease the turnover of newly employed nursing assistants How will we know that change is an improvement? Increase the percentage of newly hired nursing assistants who rate orientation as positive and decrease the turnover of newly employed nursing assistants. What change can we make that will result in an improvement? Assign a mentor for all new nursing assistants.

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I will share another example of how to use PDSA to test change. Magnolia Care Center just completed an employee satisfaction survey and after reviewing their data, they note that only 40% of the nursing assistants hired in the last year rated their orientation as positive (good or excellent). They also find that only 50% of newly hired NAs within the last year are still employed. This is disturbing to the Quality Improvement Team as they have been spending a lot of money orienting new staff that end up leaving.

Together, using the IHI Model for Improvement as a guide, they determine that they would like to : Make the orientation process a positive experience and decrease the turnover of newly employed nursing assistants. Their hunch is that if they develop a mentorship program and assign a mentor for all new nursing assistants, they will have a more positive orientation program, better onboarding and will be more likely to stay. They will know if the mentor program results in improvement if the percentage of newly hired nursing assistants who rate orientation as positive increases and the turnover of new nursing assistants decreases.

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The Doing Part-PDSA

They are now ready test this change by completing a PDSA Act

Plan

Study

Do

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PLAN PLAN

• What is the objective of the test? • What do you predict will happen and why? • What change will you make? • Who will it involve (e.g. one unit, one floor, one department)? • How long will the change take to implement? • What resources will they need? • What data need to be collected?


1. HR will develop a nursing assistant mentorship program by 9/30/15. 2. Clinical managers will identify and recruit nursing assistant mentors by 11/30/15. 3. Staff development will train nursing assistant mentors by 2/29/16.

They start by planning. Three major steps must be in place for this program to be started: They must develop a nursing assistant mentorship program, identify and recruit nursing assistants to serve as mentors, and they must train the mentors. They identify who is responsible for each of these tasks as well as develop a timeline

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PLAN PLAN

• What is the objective of the test? • What do you predict will happen and why? • What change will you make? • Who will it involve (e.g. one unit, one floor, one department)? • How long will the change take to implement? • What resources will they need? • What data need to be collected?


1. Clinical managers will assign nursing assistant mentors to all new NAs by 3/1/16. 2. DON will schedule NA mentorship meetings monthly starting 3/1/16.

3. HR will collect data - the percent of new nursing assistants rating the orientation experience as good or excellent prior to the intervention and 6 months after the intervention. 26

Planning continues once the mentors are trained. They choose a date to start pairing mentors to newly-hired nursing assistants, and they also create a schedule for monthly mentor meetings. HR collects baseline nursing assistant satisfaction survey data to help them determine if their intervention results in improvement.

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DO DO


• Implement the change. Try out the test on a small scale. • Carry out the test. • Document problems and unexpected observations. • Begin analysis of the data.

1. Change was implemented throughout the nursing home since this home averages only 2-3 new NA staff each month. 2. Monthly mentor meetings are positive mentors are coming up with great suggestion on ways to improve orientation. 3. Gathered baseline data from prior to mentor implementation - 40% rated orientation as good or excellent.

Next comes the DO step. They decide to implement the program throughout the home as they only average 2-3 new Nursing Assistant hires each month. Data starts to be collected and the mentors start meeting monthly to discuss how things are going The monthly mentor meetings turn out to be quite a positive step as they result in some great suggestions for improvement.

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STUDY STUDY


Describe the measured results and how they compared to the predictions 1. Results met expectations - NAs rating orientation as positive increased from 40% to 83%, and new NA staff turnover rate decreased. 2. Monthly mentor meetings were positive - gave NAs an opportunity to share ideas. 3. The mentor program worked best when a mentor was only assigned to one new team member at a time - not always possible due to number of trained mentors. 28

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ACT ACT

• If the results were not what you wanted you try something else Refine the change, based on what was learned from the test. • Adapt – modify the changes and repeat PDSA cycle • Adopt – consider expanding the changes in your organization to additional residents, staff, units • Abandon – change your approach and repeat PDSA cycle

Describe what modifications to the plan will be made for the next cycle from what you learned Adapt: • Offer mentorship training annually and as needed so that each neighborhood has at least three trained mentors. Adopt: • Hold monthly NA meetings for all NAs not just the mentors. • Expand the mentorship program to licensed nurses. Abandon: • The process worked well - nothing will be abandoned. 29

The next step is studying the results of the test. The data they have collected turn out to be very positive. A satisfaction survey completed 6 months after the start of the mentorship program shows that the number of nursing assistants rating the orientation as positive increased from 40% to 80%. In addition, the monthly mentor meetings were quite a success. These meetings gave the mentoring nursing assistants an opportunity to share not only ideas about the mentorship program, but also other ideas to improve the quality of the home. They also found that they didn’t have enough trained mentors. The mentors shared that it was very difficult to be a mentor to more that one nursing assistant at time. Finally the team acted on the their findings of this test of change. They decided to adapt the mentorship program to include annual, and as needed, mentorship training so that each neighborhood had three trained mentors. In addition, they adopted monthly meetings for all nursing assistants since their input proved to be very valuable to their quality improvement efforts. They also decided to expand the mentorship program to include nurses.

Due to the success of this PDSA, the team determined that they did not need to abandon anything.

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Team Activity Meet with your team to: • Become familiar with the PDSA Cycle Worksheet. • Review these examples of PDSA cycles: six minute Domestic Lean Goddess Video, Sample completed worksheet (from RCA Toolkit for Long-Term Care)

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These two examples demonstrate that PDSA is not a complicated process. Completing PDSA cycles is the backbone of the quality improvement process. As a matter of fact, your teams are probably completing PDSA cycles regularly without putting that label on it. As you work to make improvements, you should be continually trying new things and making changes until you reach the improvement you are looking for. We want to make sure that your team is comfortable with completing PDSA cycles. We have included a PDSA cycle worksheet as part of the activity for this webinar. Please review it with your team. On the activity worksheet, you will find two resources to review with your team. One is a six-minute video and the other is an example of a completed PDSA worksheet that is taken from the RCA Toolkit for Long-Term Care.

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Team Activity Meet with your team to • Review Donna’s Diary entries and comments for the category most similar to your performance improvement project • Brainstorm 3-5 small test of change ideas

To help you think about PDSA and how it relates to the performance improvement project that you are currently working on, please review the entries and comments in Donna’s Diary for the category most similar to your performance improvement project. A link to Donna’s Diary is located on your activity sheet. Reviewing these entries and comments should help your team brainstorm ideas that may result in a PDSA cycle.

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Team Activity Meet with your team to • Write a short entry on Donna’s Diary in appropriate category that includes a PDSA you have done, are currently doing, or are thinking about doing

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Team Activity www.donnasnhdiary.org

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The National Nursing Home Quality Care Collaborative is indeed a national collaborative effort. As part of this collaborative, Lake Superior Quality Innovation Network includes over 600 nursing homes in three states that are trying all kinds of innovative things to improve the quality of care and the quality of life for residents and staff. One way to collaborate with each other is by sharing your stories on Donna’s Diary. Donna, a fictional DON, shares her experiences as she works to implement quality assurance performance improvement practices with her team to enhance the quality culture within her nursing home. Please create an entry on Donna’s Diary and share what your team has done, or are doing, or are even thinking about doing so we can learn from each other. To comment on Donna’s diary, go to www.donnasnhdiary.org and click on the category, found on the right side of the page, that is most similar to what you are working on for you performance improvement project. When you click on the category, you will find a place to comment at the bottom of the page. Please comment briefly about a PDSA you have done, are planning on doing, or are thinking about doing in the comment section.

Don’t forget to come back and read what others have shared-it might give your team some great ideas!

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Included with this webinar is a PDSA worksheet for your team to use the next time you are planning a test of change.

Team Activity • Use the PDSA worksheet when planning the next test of change for your current focus area.

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Thank you for participating in this webinar. In the next and final webinar for Learning Session #2, you will hear more detailed information that will help you team create an action plan.

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Thank You

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For further information about PDSA or about the Nursing Home Quality Care Collaborative, please contact your state Lake Superior Quality Innovation Network lead.

Contact the Lake Superior Quality Innovation Network Michigan: MPRO Kathleen Lavich 248-465-7399 [email protected]

Minnesota: Stratis Health Kristi Wergin 952-583-8561

[email protected]

Wisconsin: MetaStar Liz Dominguez 608-441-8266 [email protected]

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This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-15-144 072815