Change Concepts and Ideas

• Change Concepts and Ideas
• Change Concepts: Improving Effectiveness of Chronic Disease Prevention and Management
• Change Concepts: Improving Flow
• Change Concepts: Mistake Proofing (Poka Yoke)
• PDSA Cycles
• PDSA Ramps
• Run Charts

A change concept is a general notion or approach to improving patient care.  A change idea is an actionable and specific example of how this concept is applied in real life.  Change concepts can help QI teams brainstorm about specific ideas that might work in their local setting. 

Change Concepts:  Improving Effectiveness of Chronic Disease Prevention and Management

Ontario has a chronic disease prevention and management (CDPM) framework which identifies several change concepts for improving health outcomes (see figure).

1. Personal skills & self management support
   
   This change concept states that patients with chronic conditions should be setting personal action plans, making decisions about their care and developing problem-solving skills that help them reach their targets for good disease control.  This is done in collaboration with the patient’s team of health care providers. 
   
   Examples of related change ideas include:
   
   • use Canadian Diabetes Association peer support groups
   • set goals, targets with patients (e.g. weight reduction 20 lbs, BP < 130/80)
   • give patients copies of their flow sheets, run charts at each visit
   • use written action plans
   • dietician-led grocery tours to support healthy eating choices
     
   
   
2. Decision support
   
   Health providers use tools which help them decide on best treatment options for patients, or which remind them of what to do in which instances. 
   
   Change ideas include:
   
   
   • reminder system for physician to flag patients not in control of disease or not on right medications
   • electronic medical record to generate medication alerts
     
   
   
3. Clinical information systems
   
   Clinical information systems tell health care providers who their chronic disease patients are and their quality of care at any moment in time.  With this information, providers can get instant feedback on how well they are doing and areas for improvement. 
   
   Change ideas include:
   
   
   • implementation of a patient registry
   • extracting reports for key indicators
   • generation of run charts
     
   
   
4. Delivery system design
   
   Patient care is well designed in advance to ensure patient issues are reviewed systematically and regularly.  Visits are conducted in an organized rather than haphazard fashion. 
   
   Examples of change ideas include:
   
   
   • periodic, planned visits for complete reviews of all critical items for disease management
   • standing orders for lab tests 
   • protocols for insulin, coumadin, other medications requiring frequent dose adjustment
   • checklists of reviewsgroup visits with clinician and patients with similar health problems
   • identify leader within practice with special interest in a particular chronic condition
   • use home care to assist with home monitoring or patient self-management
   • improve coordination between hospital and community-based FP during discharge planning
     

Change Concepts:  Improving Flow

The following are examples of generic change concepts aimed at improving work flow or patient flow through the system:

1. Do things in parallel
   
   When steps in the delivery of care take place one after the other, think of doing them simultaneously, to reduce wait time. 
   
   Example:
   -    in a breast cancer screening program in one province, every time a screening mammogram was abnormal, the program would notify the patient’s family doctor.  The family doctor would then arrange for a follow-up appointment, and then book a diagnostic mammogram.
   
   Change idea:
   - if screening mammogram is normal, simultaneously book a follow up with the family doctor, and book the diagnostic mammogram. 
   
   
2. Match capacity with demand. 
   
   Example:
   -    We always get a surge in people calling for an appointment on Mondays, or after a long weekend. 
   
   Change Idea:
   - Maximize the number of appointment slots available on Mondays or after long weekends.  Avoid scheduling meetings at those times. 
   
   
3. Add or shift capacity to bottlenecks in the system.
   
   Example:
   -    a health care conference serves continental breakfast to participants.  Inevitably, there is always a line-up and congestion at the toaster.
   
   Change idea:
   -    add another toaster.
   
   
4. Automate. 
   
   If there is some task that requires manual labour and time, or is prone to human error, consider automating it. 
   
   Example: 
   Drug prescribing in hospitals requires a physician hand-written order, transcription by nurse, transmittal to pharmacy.  Errors may occur from illegible writing.  Patients on multiple drugs are at risk of adverse drug interactions.
   
   Change idea:
   - deploy computerized physician order entry (CPOE).  Remove transcription step.  Eliminate illegible handwriting errors.  Generate drug interaction alerts when drugs ordered. 
   
   Tip 1:  Before you automate, make sure you are not automating a bad process, or a process that should have been eliminated in the first place.
   
   Tip 2:  If your project’s main aim is to reduce wait times, then focus on automating steps at the bottleneck.  Otherwise, you might create longer waits at the bottleneck. 
   
   
5. Synchronize related services.
   
   Example:  patients have to visit different providers on multiple days, which wastes their time.
   
   Change idea:  on the day that a family practice has a diabetes clinic, arrange for diabetes educator to work out of the office that day and take immediate referrals. 
   
   
6. Eliminate non-value-added steps.
   
   Change idea:  Eliminate having to register twice at two clinics of the same hospital. 
   
   
7. Reduce travel distance between steps
   
   Example:  patients have to travel to many different places to get primary and community care services. 
   
   Change idea:  Co-locate family practices with pharmacist, social worker, nutritionist and mental health counselling. 
   
   Example:  Staff wash hands when they arrive on the surgical unit but not between patients.  It is inconvenient to travel to back and forth to the handwashing stations. 
   
   Change idea:  ensure hand cleanser is at every bedside so that providers to minimize travel and increase handwashing compliance. 
   

Recommended reading:

The following reference lists 70 generic change concepts:
GL Langley, KM Nolan, TW Nolan, CL Norman, LP Provost.  The improvement guide:  a practical approach to enhancing organizational performance.  Jossey-Bass, San Francisco, 1996.

Change Concepts:  Mistake Proofing (Poka Yoke)

Mistake proofing is the process of designing a system to prevent errors or minimize their effect.  Shigeo Shingo incorporated mistake proofing into the Toyota Production System, and the Japanese term for this process (poka yoke, pronounced “poka yokay”) is popular among QI practitioners of LEAN and six sigma methodologies. 

1. Forcing function
   
   Design the system so that it is impossible to make an error. 
   
   Non-health care examples:
   
   • Memory cards for cameras can only be inserted into their slots in the right direction, due to their shape, grooves and notches
   • the circular shape of a manhole cover makes it impossible for it to fall into the manhole
   • diesel gas nozzles won’t fit into regular gas tanks
     
   
   Change ideas in health care:
   
   • medical gas connectors won’t fit into receptacles for the wrong gas.
   
   
2. Constraining function
   
   Design the system so that it constrains some component from being able to lead an error. 
   
   Change ideas in health care:
   
   • remove concentrated KCl bottles from the nursing floor, to prevent unintended administration to patients.  
   
   
3. Reminders and alerts
   
   
   • generate a reminder of when a particular step needs to be done. 
   
   Change ideas in health care:
   
   • call patient 1-2 days before clinic appointment to remind him/her of visit.
   • Electronic medical record reminds physician when diabetes patients are due for 3 month check-up or blood work. 
   • Electronic medical record reminds physician of potential drug interaction.  
   
   
4. Avoid look-alikes.
   
   Avoid instances where two items, names, processes or patients look the same.  Rename or recode one or more items. 
   
   
5. Visual cues
   
   Label or visually code items so that it is easy to spot when it is in the wrong place. 
   
   Change idea:  surgeon signs the leg to be operated upon before surgery while patient is awake. 
   

Recommended reading:

J Grout.  Mistake-proofing the design of health care processes.  Agency for Health Research and Quality, Rockville MD,  May 2007.  AHRQ Publication NO. 07-0020.  Available at:  ahrq.gov/qual/mistakeproof/mistakeproofing.pdf