Perinatal Improvement Community: Getting Started Kit
Getting Started Kit:
Perinatal Improvement Community
Institute for Healthcare Improvement
Learning Communities are comprised of improvement-minded organizations working together with the Institute for Healthcare Improvement (IHI) to implement best practices and explore innovative solutions to improve care in high-leverage areas. This document is in the public domain and may be used and reprinted without permission provided appropriate reference is made to the Institute for Healthcare Improvement.
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Perinatal Improvement Community: Getting Started Kit
Table of Contents
Step 1: An Overview of the Learning Community Experience 2
Step 2: An Overview of the Learning Community Charter and Models 5
Step 3: Confirm Sponsor and Create Your Team 11
Step4: Connect to the Extranet and Join the Listserv 16
Step 5: Perform the Perinatal Deep Dive 18
Step 6: Draft Your Aim 18
Step 7: Participate in Your Learning Community Onboarding Call 21
Step 8: Gain Understanding of the Model for Improvement 21
Step 9: Prepare for Your First Learning Session 22
Step 1: An Overview of the Learning Community Experience
The collective knowledge of Learning Community participants, coupled with the Institute for Healthcare Improvement (IHI) improvement expertise and guidance, gives organizations a strong framework for taking action and achieving, sustaining, and spreading breakthrough improvements. Participating health care organizations and faculty/staff will work together to improve care and develop the personal leadership skills of our participants. We will strive to have teams meet the goals within 12 months by sharing ideas and knowledge, learning our methodology for change, implementing proven change concepts, and measuring progress. The objective of the Community is action leading to improvement. This is a results-oriented Learning Community.
Methods
The Community involves multiple national and international organizations working together intensely to achieve significant improvements. Over 12 months, teams participate in two face-to-face Learning Sessions, monthly virtual meetings, and maintain continual contact with each other and faculty members through conference calls, listserv discussions, email, individual coaching calls and monthly progress reports.
All information about Learning Sessions, calls, and WebEx presentations will be posted to the Extranet to ensure that the most up-to-date information is available. The link below (Figure 1) outlines the basic structure for the year in your Learning Community. Figure 2 provides a basic outline of how to prepare your team for the year ahead. Please note: This calendar is a working draft and will change in response to participants needs
Figure 1
Expectations
The Institute for Healthcare Improvement and the Community faculty will:
§ Provide a designated IHI Director and Project Manager, in addition to faculty who have expertise in the subject matter and improvement methods
§ Provide information on subject matter, application of that subject matter, and methods for process improvement, both during and between Learning Sessions
§ Support knowledge management of promising changes and action toward results through Community Models i.e. Driver Diagram Change Package, Measurement Strategy, Perinatal Building Blocks
§ Provide communication strategies to keep teams connected to the Community faculty and colleagues i.e. Monthly Coaching Calls, All Team Content WebEx Sessions, Work Groups, List Serve Discussions, Extranet resources, Learning Sessions
§ Provide access to IHI Extranet for reporting, resources and communication
§ Review team reports and analyze data providing guidance and feedback to individual team improvement efforts and overall Community learning and development.
§ Foster growth and development of improvement capacity.
Participating organizations are expected to:
§ Connect the goals of the Learning Community to a strategic initiative in their organization
§ Designate a senior leader to serve as sponsor for the team
§ Provide the resources to support their team, including time to devote to this effort (the equivalent of approximately 1 FTE for project management for the duration of the Learning Community, weekly team meetings, time for team to run PDSA cycles, for example), and active senior leadership involvement
§ Share information with the Learning Community through the extranet i.e. posting resources or tools to share with Community and frequent contributions to listserv discussions and questions.
§ Post monthly qualitative and quantitative reports showing progress and learning toward their aim.
§ Review and analyze organizational data posted by the team for shift, trends and patterns. The extranet will create graphs and fosters team’s ability to analyze with automated run chart rules.
§ In alignment with team aim, design and execute tests of change first for learning, then improving and moving to implementation,
§ Participate in Community Learning Sessions, WebEx presentations and conference calls.
Getting Started Checklist
Figure 2
Step 2: An Overview of Learning Community Charter and Models
Rationale
Adverse events during labor and delivery can impose a heavy physical, psychological, and financial toll on the baby, family, care providers, and the community. Sound science that would allow us to deliver the best perinatal care is often known. Evidence-based guidelines for safe practices exist. And yet, application is unreliable.
Momentum however, is building across the country in the perinatal field-- there is no tolerance for elective delivery prior to 39 weeks gestation (misuse), non-medically indicated induction (overuse), and support for spontaneous labor (underuse). A renewed focus on the cost of interventions to the mother and newborn and the outcomes these interventions contribute create is underway
The challenge is to ensure that these guidelines of evidence-based care are applied reliable - to every patient, every time - by an effective, high functioning team in an environment of person centered care.
This Community seeks to meet that challenge.
Mission & Goals
Reducing Harm, Improving Care. Supporting Health. The IHI Perinatal Improvement Community provides results-focused improvement opportunities to teams with a wide range of content and improvement experience. Participants start with in-depth diagnostic and goal-setting processes and identify initial areas of focus based on their expertise in the topic and in improvement. Teams engage in rapid testing of changes and process redesign that have been shown to improve care, adapting them to their own settings, and linking measurement to the outcomes.
The core focus of the Perinatal Improvement Community has shifted to include the entire episode of pregnancy- from confirmation until six weeks after delivery. Today, global attention focused on achieving the IHI Triple Aim—better health for individuals, better outcomes for more of the population, at a lower cost has expanded our view.
For Labor and Delivery Units, this expanded focus translates into increased attention on the reliable determination of gestational age, the impact of non-medically indicated inductions, new mandatory reporting on the Perinatal Core Measure Set, and reversing the trend of rising Cesarean rates. In 2013-2014, the IHI Perinatal Improvement Community efforts will center on implementing structures and processes that will lead to improved outcomes in these four areas.
Overarching Goals adopted by the Community:
· Reduce harm to 5 or less per 100 live births
· Zero incidence of non-medically indicated deliveries prior to confirmation of fetal maturity (39 weeks)
· Advanced Bundle(s) Composite or Compliance greater than 90%
· Improve Nulliparous Cesarean Rate to alignment with Healthy People 2020 Goal
· 100% of the participating teams will have documentation of Person Centered Care.
Supporting Models
The Perinatal Community provides several knowledge management and improvement tools or methods that support the work of the community. Specifically these tools and methods are the Driver Diagram, Building Blocks, Change Package, The Model for Improvement, and Measurement Strategy. They are listed below with a brief description.
Driver Diagram: This driver diagram is a variation of the tree diagram quality tool. Utilized as a Driver diagram, the tool conceptualize an issue and its system components that helps to demonstrate a pathway to achieve the desired outcome. In essence, it clarifys the working theory of improvement.
The Perinatal Driver Diagram presents four primary drivers for reducing perinatal harm (adverse events), improving care, and supporting health: Perinatal Leadership; Reliable Design; Effective Peer Teamwork; and Person Centered Care. (see figure 4)
Figure 4
Building Blocks: The improvement work for the Perinatal Learning Community is strongly focused on changes in structure and process which realistically has taken organizations at least 18-24 months to begin to show results. This premise is built upon the following building block depiction of the work and the time it takes to successfully change the system and engage the team:
Figure 5
Change Package: The Perinatal Improvement Community is designed to close the gap between what is known and what is practiced. We know this will require change. We also know that not all change leads to improvement. A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combining these change concepts with knowledge about specific subjects such as Perinatal Care can help generate ideas for tests of change. A change package is a knowledge management tool that captures these creative and successful ideas for change in an organized and accessible manner around the Perinatal Drivers. (Follow Link to Change Package on extranet)
Listed below are a few of the promising change ideas from thePperinatal Driver Diagram Change Package:
§ Implementing the IHI Perinatal Bundles (Advanced Bundles, Vacuum Delivery Bundle, Neonatal Advantage Bundle)
§ Applying safe and reliable practice to management of the first and second stage of labor
§ Applying IHI’s Reliable Design Model to organizational specific vital processes
§ Adopting a common language for electronic fetal monitoring and training all members of the care team together in its use, and linking this standardization to credentialing.
§ Applying communication techniques such as appropriate assertion, conflict resolution, SBAR (Situation-Assessment-Background-Recommendation), and Crew Resource Management techniques
§ Adopting processes to understand and honor the woman’s preferences
§ Collaborating with women to better manage and reduce risk
Model for Improvement: IHI uses the Model for Improvement as the framework to guide improvement work. The Model for Improvement,* developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement. This model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.
Model for Improvement
Setting AimsImprovement requires setting aims.The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected.
Establishing Measures
Teams use quantitative measures to determine if a specific change actually leads to an improvement.
Selecting Changes
All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement.
Testing Changes
The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning.
Measurement Strategy: Measurement is a critical part of testing and implementing changes and a key element in the Model for Improvement. Measures tell a team whether the changes they are making actually lead to improvement. There are several types of measures that are used in improvement such as, outcome, process measures, and balancing measures. The Perinatal Community uses these types of measures as well as structure measures. The Perinatal Measurement Strategy document greatly assists teams by identifying and operational defining measures aligned with the community aim and purpose, as well as national efforts. (Link to Measurement Strategy on extranet)
Step 3: Confirm Sponsor and Create Your Team
Confirm Sponsor
Your sponsor may already have been identified on your enrollment form. If so, review the description here to ensure that the sponsor is the right one to support your improvement effort. Active partnership between leadership and the improvement team is needed to achieve results. Our experience shows that a team’s chance of success is greatly increased when a leader in the organization serves as a sponsor for the work by showing interest in the team’s work and providing targeted support for the team’s activities. Leadership involvement is key to improving results for your patients and your organization.
The sponsor is the person who is responsible and accountable to their organization for the performance and results of the improvement team. This person is generally not a member of the improvement team, but is a support for the team to accomplish their aim.
The team’s sponsor is responsible for:
§ Encouraging the improvement team to set its goals at an appropriate level to meet organizational goals and reaching agreement on the team charter;
§ Providing the team with the resources needed, including staff time and operating funds, and also a financial team member to help document the business case and help the improvement team with other cost issues;
§ Making it clear to the team that they have the time, resources, and authority needed to change organizational systems to accomplish their goal. Our experience is that the total resources required to do this work will be at least one full-time equivalent (FTE) for the project management of the project, weekly meetings for the improvement team, time for the core team to attend all Learning Sessions and monthly calls;
§ Ensuring that improvement capability and other technical resources are available to the team;
§ Regularly reviewing the work of the team; and
§ Developing a plan to spread the successful changes from the improvement team to the rest of the organization, including:
o Communicating what is learned from the improvement work in ways that motivate and mobilize the entire organization.
o Designating someone who will be responsible for leading the activities needed to support spread.
Resources for the team Sponsor include the IHI Leadership White Papers located on IHI.org.
Create Your Team
Including the right people on an improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs. Below is some specific advice gleaned from successful improvement teams.
Organizational Team: Your organizational improvement team should consist of a core improvement team that leads and manages the core work of the improvement team and other team members who are integrally involved in the current processes within the organization and desire to participate in the improvement effort. Every effort should be made to include those with direct care responsibilities.