The Institute for Healthcare Improvement (IHI) Model for Improvement is a quality improvement approach, developed by Associates in Process Improvement, that focuses on establishing an aim, deciding on what changes will assist in achieving the aim, and choosing metrics that will demonstrate the effectiveness of changes made. This model incorporates testing changes to determine improvement through a Plan-Do-Study-Act (PDSA) cycle (IHI, n.d.).
How Does the Model for Improvement Work?
This model includes the following components:
- Aim: What do we want to achieve?
- Important to ensure the aim is measurable and defined, and answers the questions: How good? Who is this applicable to? What is the time period to achieve the aim by?
- The Institute of Medicine’s 6 domains of quality can be used as a guide in developing an aim statement: timely, effective, patient-centered, efficient, safe, and equitable.
- Measures- what metrics can be used to reflect that the changes made are resulting in improvement? There are 3 types of measures that can be evaluated: outcome, process and balancing measures.
- Changes- what interventions can be made to help achieve our aim?
- Consider the following to assist with deciding on what changes will work: best practice/research, national patient safety bundles, frontline staff suggestions, streamlining processes, reducing variation, and integrating human factors engineering including modifying the work environment and optimizing electronic medical record systems.
- PDSA Cycles
- Plan- develop a detailed plan for the changes, including data collection
- Do- implement the changes on a small scale
- Study- evaluate how well the changes are working
- Act – make changes based on evaluations. Often this means making minor adjustments to processes or interventions to get it right, or best adapt it to the environment (IHI, n.d.)
Case Example
The following case example applies the IHI Model for Improvement to reducing the number of obstetric patients who require massive transfusions. Experts recommend a multifaceted approach, however, for the purposes of this example, we will focus on one intervention, the development of an obstetric hemorrhage rapid response team. Setting up a process in which the right people respond at the right time, with defined roles, helps to ensure timely treatment of hemorrhage and mitigation of further complications including progression to massive hemorrhage.
AIM
Within 6 months, the number of women who receive massive transfusions, defined as receiving 4 units or greater of packed red blood cells during their birth admission, will be reduced by 30%.
| Metric | Definition | Examples |
| Outcome measures | What happened to the patient | Massive Transfusion Rate: Denominator: total number of women giving birth > 20 weeks gestation per month Numerator: total number of women per month who receive 4 units or greater of packed red blood cells during the birth admission |
| Process measures | Reflect steps in the process to achieve the desired outcome | – Chart review on the frequency of hemorrhage response team activation with a hemorrhage that meets criteria for activation -Percentage of nurses and providers who’ve completed hemorrhage simulation drills |
| Structure measures | Evaluate available resources, systems, and processes that impact how care is delivered- environment, equipment, staff, and guidelines | – Guidelines for obstetric hemorrhage, including response team
|
| Balancing measures | Used to evaluate if changes made cause unintended consequences in other areas | – Audit feedback from the team to evaluate if the use of resources in these events is leading to lack of needed personnel in other areas |
(Lyndon et.al., 2015)
Changes
A multidisciplinary team was pulled together to discuss who needed to be on the team, when to activate and how best to reach the team members. Literature was reviewed and the team chose to integrate applicable lessons learned from other organizations.
PDSA
The plan included staff education on the new process, debriefings after the events to evaluate team performance including how the rapid response team was working, and completion of audits by charge nurses. Once the plan was implemented, audits were used to study the effects. Audit results showed a recurrent theme: care providers were pushing back regarding activating the hemorrhage response team. This led to additional interventions to help remove this barrier: education for all staff that focused on empowering anyone to activate the response team; the mindset that if not needed, the team walks away and no harm is done but everyone is there if needed; and lastly one on one conversations between leadership and repeat offenders of pushback. The importance of PDSA cannot be underestimated, as it demonstrates that this is not a “one and done” change. As mentioned, often these interventions are based on research or national safety bundles which serve as the overall structure, but the details and adaptation to the clinical environment and staff involve continuous evaluation in order to ensure the best fit.
References
Institute for Healthcare Improvement (n.d.). Science of Improvement: How to Improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx
Lyndon A, Lagrew D, Shields L, Main E, Cape V. (2015). Improving Health Care Response to Obstetric
Hemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care)
Developed under contract #11-10006 with the California Department of Public Health; Maternal,
Child and Adolescent Health Division; Published by the California Maternal Quality Care
Collaborative.
Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS