20 Day Challenge Day 6 – Planning for Improvement

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Recently I posted about a client of mine who applied for and was awarded an Innovation Grant from the Centers for Medicare and Medicad Services (CMS). You can read about their project here. The CMS Center for Medicare & Medicaid Services Innovations is one of the great legacy programs initiated by Donald Berwick, MD during his – far too short  – tenure as director of CMS. Modeled after the Instituite for Healthcare Improvement’s Triple Aim, the program funds local projects to pursue innovative ideas that can deliver better care, better health, and lower costs. As the largest purchaser of healthcare in the USA, CMS is, and should be, very influential in pushing for quality care.

In the weeks following this award, there was a lot of excitement and local and industry-wide attention praising the project proposal, the team who will lead it, and the organization that will execute it. Now, it’s time to work on that execution plan. In improvement, we frequently reference three success factors for our work: 1) having the will to improve, 2) having change ideas to test, and 3) execution. CMS knows that execution is an essential element to success and this Friday is the deadline for the award recipients to submit their operational plan for year 1. Their plan to execute.

Developing a project plan for execution can be daunting. Especially if the project is large in scale and has many parts. CMS recognizes this and provides award recipients with a pretty detailed template for designing the first 12 months of their project and for evaluating key milestones and potential bottlenecks to progress. The following are some of the many considerations for developing a solid plan for executing a large scale improvement project.

Charter – A project charter is a useful first step in planning for improvement. There are many templates for how to design a charter, but good ones aim to clarify the three questions we use as part of the Model for Improvement: 1) What are we trying to accomplish (AIM)?, 2) How will we know a change is an improvement (Measures), and 3) What changes can we make that will result in improvement (Change Ideas)? A charter also may provide context on defining why this work is important, tie it back to the organizational mission, establish a baseline, identify boundaries to the work, who will be involved and responsible, and detail specific context related to the execution. Some look at developing a charter as an exercise with limited value. I see it as essential to solid execution because it puts all of these critical elements on paper and it facilitates improvement teams to have difficult, but necessary, conversations to refine and define exactly what the plan is for the work. It also acts as a kind of contract for your improvement effort and something you can frequently return to if there are questions, you have scope creep, or your theory evolves. A charter is a great place to start your project.

Aim Statement – An aim statement helps us to answer the question: What are we trying to accomplish? It is time specific, measurable and defines the population to be effected. Example, reduce readmission rates of heart failure patients by 25% in 1 year. Aim statements are helpful in clarifying our work. They can be tough to draft and there’s value in improvement teams going through the process of drafting and refining an aim statement for their work until you achieve one that is a good fit. You can read more about aim statements here.

Measurement Strategy – The next question is: How will we know a change is an improvement? This requires measurement and likely more measurement than most organizations are used to in a traditional project. For improvement work, we need a family of measures that include outcome, process, and balancing measures.

  • Outcomes measures provide the voice of the customer and are the ultimate aim.
  • Process measures are the voice of the process and help us to test changes that result in improving the reliability of key processes. If we’ve selected the right processes to achieve our aim, as the process measures become reliable, we expect to see a change in our outcomes.
  • Balancing measures help us to see the impact of improvement on other areas. This helps us reduce the potential we will increase cost, reduce productivity, or negatively influence satisfaction.

A successful project requires a family of measures and each of those measures must have an operational definition and collection plan. Learn more about measures here. Finally, all measures need to be displayed graphically over time. To start, a line chart is appropriate, but as you gain more data and become more sophisticated, a run or Shewhart Statistical Process Control Chart will aid in your learning from measurement.

Driver Diagrams – A driver diagram is a visual representation of your change theory. It takes your aim and then breaks it down into its primary drivers. Each primary driver further splits into a series of secondary drivers. Driver diagrams are both a statement of your theory, but also act as your road map for improvement. Your improvement work will aim to test changes on the secondary drivers with the intent of improving the primary drivers and achieving your aim. Here is an example of driver diagrams for the IHI Impacting Cost and Quality Collaborative.

The Plan – Finally, we come down to the plan. There are many ways to approach a plan of execution for a project. You might develop a high level Gantt Chart that reflects the major elements of the project and shows both the time period it’ll take to complete each element and how those elements may be executed in parallel or sequentially. Or, for a complex project, you may prefer a Program Evaluation and Review Technique (PERT) that helps see the steps, the relationship of the steps, and the time to complete.

Another consideration in project planning is breaking the project down. It’s easy to get overwhelmed when you think about the whole project, but if you break it down in pieces or next steps, it can be easier to wrap your head around. I often ask teams to consider where they have will to start, what changes are in their control, where can you begin to do small, rapid, and frequent PDSA tests, are some elements easier than others. Directing people with questions like this help them focus on early learning and quick wins that build will, energy, and momentum that will help with the elements that are harder and take longer to execute. Finally, I use an energy grid process to help evaluate the tasks on our plate and the team members they are assigned to to make sure we are not over burdening any team members and being realistic about responsibility and capacity.

Rapid Cycle, Small Scale Testing – All of the work described enables you to move to testing. In most cases, we are aiming to start testing at the smallest scale possible to increase learning and reduce risk. Focus should be on rapid and frequent testing to help enhance learning for improvement. The more testing the better. I highly recommend using PDSA forms at the start to make sure that you are doing all four parts of the PDSA and to aid as a running record of your work and learning. A PDSA tracker form may also be helpful and it can allow you additional tracking that can roll up into aiding planning and provide data for later publication. PDSA testing is essential. A common mantra to build into your organization and keep progress moving is: What can you do by next Tuesday?

Other Considerations –  I’m just scratching the surface on the big buckets of planning. There are many more considerations including reporting, organizational and partner communication, team management, sponsor roles, implementation, and spread, and maintenance. Maybe these can be topics of future posts, if interested.

Planning for improvement may not be the most sexy of activities, but it is critical to the successful execution of improvement work. It helps teams align, projects to be clearly defined, and a strategy for execution and learning to be established. It’s tempting to jump in and start doing things, but it’s important to begin with a solid plan for execution. Best of luck.

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Time: 76 min

This post took a long time. I was interrupted to run a kiddo to camp, which may have broken my momentum. There also was a lot of content to share and link to. I did find it helpful to have a topic I was currently working on and that was of interest to me. Morning time writing and not traveling are definitely helping success on the 20 day challenge. I do need to consider strategies for reducing the time to post. I did create a list of blog ideas to support that. I may test shorter, more concise posts to see how they work and how I feel about the product. Please continue to provide me feedback from your experience as a reader.