Why is measurement critical to reliability? (Part 5 of 5) Frank Federico, RPh, IHI Executive Director So, welcome to part five of our five-part series on developing reliable design. Earlier I talked about the need for measurement, and measurement is so important because it’ll help you determine whether or not your processes are reliable. In this session, we are going to give you some hints about how to measure and how to display your data. One thing is, you don’t need to measure all your patients: Sample. Pick 5–10 events daily — just a small sample of the patients — and do it at the end of the day so that you can connect with the people who have done the work that day to determine if the process didn’t work, why didn’t it work, and what could we do to make it better? Plot your data over time and display those charts because when people see what’s going on, they will become more engaged, and they want to see the process get better. The small samples and the plotting over time with a simple graph is easy to do. Let the people who do the work collect the information because then they own it, and they’re part of it, and back-up plan becomes our measurement plan when it’s fully implemented. By that I mean that the back-up plan can tell you how many times that primary process, that first process, did not work. You don’t need special measurement for that, you just need to go ask the people who are involved in the back-up plan. So what are some of the measures that you can use? Well, how about just looking at 5–10 patients and at the end of the day determine: “Those patients who should have gotten the assessment today, who should have gotten the pressure ulcer treatment, should have gotten the head of the bed elevation today, did we do it — yes or no?” Now why is it only 5–10? Well, it’s not statistically relevant, but if it’s not working in that small sample, what good will it do to collect a much larger sample? You could put your energy into improving the process. Now in order for all of this to be successful, it’s really important that leadership has a role in this and the teams have a role. Leadership must insist that the teams focus on developing reliable and capable processes. It’s also important to ensure you have a reasonable timeline for the work that you’re doing. We sometimes start a project but don’t have an end date in mind, or we start a project and have too short of an end date in mind, which creates problems. Some interventions take time to develop and put in place. Others should be done rather quickly, but it’s important that as leaders [you] have an expectation and have a timeline, at which point you can check your milestones and see how you’re doing. Focus on the processes that will result in the desired outcomes. Developing reliable processes on anything else is a good idea, but unless they’re achieving the outcomes that you want, those aren’t the right things to work on. Most importantly, there are times when the teams who are doing this improvement work will need help. They should be able to ask for help and should be able to receive it. Sometimes it’s internal, sometimes it may have to be external. We started talking about segmenting your population. In order to prevent chaos again, we suggest that you limit your segments to 4–5 maximum. What will happen as you do your work, you’ll find that you’ll be able to combine some of the segments so that you’ll be able to limit them to four or five. We don’t want you to have 10 or 20, and then you have to customize based on the patient population for each of those segments. Here’s how you can help your team get started on reliable design. Help them start with segmentation. Understand that you can’t solve the problem for the entire population with just one process. Develop a high-level flow diagram and think of change concepts — like standardization is a key element. That first step of standardization should reach at least 80 percent reliability before you move on to a second step. If reliability is not improving, consider testing something else. Maybe you just have the wrong process, and continuing to work on that is not going to make it better. Maybe you have the wrong physician doing the work or the wrong idea about the concept, and it’s okay to do it differently. We are offering you the following grids that will help you in coaching your teams. Thank you for your attention, and I wish you good luck.