Rapid Cycle – PDSA- SDSA Worksheet – DNP
1a. Title of Project: Reducing Admission for Skilled Nursing Facility to Acute Care by utilizing the INTERACT tools
1b. Site, Facility Type, Microsystem Name, Vulnerable Population for this Project.
1c. Team Members: (Include titles and departments, not specific names of those leading this project as a team. Must be interprofessional. Include front line staff, patients, and family caregivers or consumer advocates.)
Leader: Director of Nursing and Administrator 5. LVN- DAY
Facilitator: Nezy Pullukalayil 6. LVN- NIGHT
Registered Nurse- Day 7. CNA- DAY
Registerted Nurse- Night 8. CNA – NIGHT
Coach: Meeting Days/Time: Tuesday July 20th 7.30am
Data Support: Data Analyst who is in charge of transition care with Performance Improvement Department
1d. Background What problem are we addressing and how do we know there is an opportunity for improvement? Provide background on the local problem as well as the larger issue…statewide, national, global. Make a case for why this needs to be addressed now. Create a sense of urgency (Kotter). Include evidence-based resources, citations, and references. Include a brief description of the facility and the results of the 5P assessment.
1e. Aim/Goal: What are we trying to accomplish? See IHI guidelines for AIM statement: http://www.healthychild.ucla.edu/First5CAReadiness/materials/siteInfra/IHIQualityImprovementResources.pdf) What do you envision will happen (your desired outcome) and by when. You can include your key core processes as the “how” you plan to accomplish it if you have an idea about the processes at this time. But focus on the AIM, not the processes.
1f. Measures and Indicators of Improvement: How will we know that a change is an improvement? Include both qualitative and quantitative quality indicators. What and how much will tell us we have succeeded? By when? Review levels of evidence from the Kirkpatrick model: Quantitative indicators: Numbers (/measureable)…percentages, incidences, rates. Qualitative indicators: Words, comments stories, exemplars. Textual data and media
1g. Change Theories: What one or two change theories or processes (other than Lewin’s) will be useful in leveraging/helping the team to success? Summary key concepts. Some options: Transformational Leadership (Bass/Riggio) or Transformational Learning Theories (Mezirow); Theory U (Scharmer); Kotter’s Stages of Change; Rogers’s Diffusion of Innovation; Greenhalgh & Colleagues’ Diffusion of Innovations in Health Systens Organizations; Bridges Transition Theory; Senge’s Five Disciplines; Quantum Leadership (Porter O’Grady & Malloch); Complexity Theory, Chaos Theory. Describe key concepts with the change theory and how it can help you design and/or lead your project for improvement.
Section 2 – Diagnostics/Evidence/Perspectives
2a. Current Process What is/are the current processes that exist that can be tapped into and/or needs to be improved. What are the current issues and outcomes?
2b. Costs of the Problem If nothing would be done to correct this problem, what are estimated costs of this problem in terms of dollars spent, lost revenue, and resources required?
2c. What Have we Learned From the Evidence so Far? What evidence (research, theories, best practices, standards, past experience) informs us about solving this problem?
2d. Key Stakeholder Analysis Who are the key stakeholders that can influence (enhance or prevent) our success and what would be a positive outcome for them?
Key Stakeholder How can they influence success?
(How can they enhance or impede progress?)
How will they benefit from this improvement? (Results/Outcomes)
(Use their own words if possible.)
2e. Diagnostics What needs assessment data do we have or do we need and what diagnostic tools and processes have helpedwill help us find the root cause and determine the best actions to leverage success? Include such processes as Microsystems/Organizational Assessment (5 Ps), The 5 Whys, Ishikawa Diagram, SWOT analysis, PEST analysis, key stakeholder focus groups, FMEA, Process Control Charts, Process Flow Diagrams, GAP Analysis, Organizational Culture, Safety Culture, and/or Organizational Capacity Assessment, SMART Chart, etc. Include the results of your systems diagnostic assessment so far.