VHA Systems Redesign; Transformational change in health care ...

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• Data display: Compelling display of data can serve to quickly communicate multiple complex measures AND engender action. The best tool to accomplish this is generally a run chart showing the measure of interest on the Y axis and time on the X axis. Adding a reference line representing the goal is helpful. Advanced measurement tools can put data into Statistical Process Control charts and do deeper analysis; however for most improvement work, simple run charts suffice. • Sampling vs. continuous measurement: A decision must be made about how much data is needed. If a team over-measures, then all the energy is focused on the measurement and not the results. If a team undermeasures, then they may not understand the process dynamics nor know if there is progress toward an aim. Don’t be afraid to sample. A good rule of thumb is this: If the data you are collecting requires a lot of effort, or is causing frustration among your team members, this is a good sign that you should re-think what data you need and/or how it is collected. • Level of detail. A good guideline is to measure everything at the frontline or team level where the process can be impacted. This allows each employee/team to know the impact of their process execution. Individual or team data can then be rolled up into sections, departments, services, or facilities as desired. 5. Change. What changes are you making to improve? Hard won experience has taught us that the practice of simply telling people what to do doesn’t work. This results in resistance. Underlying this resistance is often the belief that “we’re different” or “that won’t work here” or “it’s not ours.” For this reason there are two critical issues to understand in this area of change: first, focus on considering change principles, not necessarily “best practices” or strategies and secondly, use “small tests of change” as embodied in PDSA or an equivalent approach, before attempting large, system-wide change. Principles: Principles are “universal truths” in system design. They are like chapters in books that are common to all understanding while the details can be different. These underlying details or strategies are change ideas consistent with a principle that can be adopted or adapted by the team. Teams find some change principles work better/worse for a given situation and they should feel free to adopt, modify or create change strategies that work best for them, consistent with the principles. These principles are well worked out and exist for many common timeliness topics such as “Advanced Clinic Access” (ACA) and In-patient flow. They include Balancing Demand and Supply, Decreasing Backlog, Decreasing Queues, etc. Reliability principles include (5 “S,” visual controls, fail-safe design, etc). While further discussion of these principles is beyond the scope of this paper, remember that these may be topics for just-in-time training, research, or idea-mining. Testing: This testing and adoption process is best done through PDSA. PDSA is Plan-Do-Study-Act (also known as Plan-Do-Check-Act) and is intended to
communicate the imperative to do very small tests of change. It is a method that has stood the test of time and is incorporated into practically every improvement approach. The power of PDSA is the cumulative effect of small changes and the ability to try ideas on a small scale, fine tune them, build consensus and then generalize the change on a larger scale. The image of PDSA may be better stated to simply “follow your hunches”. PDSA could be thought of as trying out a new idea. Remember that small tests of change are paradoxically powerful and therefore the desired state for all improvement activities. 6. Sustain. If everyone on your team retires, how do you know these change strategies will continue to be used? It seems many teams do not celebrate enough. Before sustaining anything, don’t miss the opportunity to meaningfully celebrate successes both along the way and at the end. Then, the “sustain” strategies require us to think about what changes were successful first. Then think about the process and task changes that resulted in the success. Now we must “memorialize” those changes. This typically involves assignment of responsibility, changing of job descriptions, evaluations, reward systems, revising policies and new employee orientation/training. In addition, ongoing measurement of the key process is crucial to sustain. Past improvement efforts have often failed because the appropriate system changes and safeguards were not been put in place to assure the new processes are supported. Summary Historically, many improvement efforts have failed because of one or more of the basic elements noted above are absent. Experience has shown that choosing and using a consistent improvement framework to organize the improvement effort serves to clarify and facilitate the ongoing work. While no framework is perfect, the suggested TAMMCS approach is generally understandable and does work. Please address questions or comments to the VHA Office of Systems Redesign or Mike Davies by e-mail to Michael.Davies@VA.gov or 605 347 7416.
Page 1 and 2: VHA Systems Redesign A Plan for Org
Page 3 and 4: Quality Improvement “Unceasing ef
Page 5 and 6: Systems Redesign Journey “Having
Page 7 and 8: Systems Redesign (SR) Strategic Obj
Page 9 and 10: • Outpatient: Accomplishments Out
Page 11 and 12: Some Outpatient Questions • Ideal
Page 13 and 14: • Inpatient Flow: - National impr
Page 15 and 16: • Discharge Timeliness Accomplish
Page 17 and 18: SR Administrative Sub-committee •
Page 19 and 20: SR Systems Improvement Sub-committe
Page 21 and 22: Other SR Initiatives • Cancer Car
Page 23 and 24: Model Culture • Impetus to Improv
Page 25 and 26: Model Culture • Integration - Acr
Page 27 and 28: What’s Next FY 2010 • FY 2010 P
Page 29 and 30: 310 Health Care Management REVIEW O
Page 41 and 42: the course of a normal job. The tim
Page 43: Flow mapping can occur at a very hi

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