[Don Goldmann] One of the biggest problems I see in quality improvement in general is that folks run off to do their PDSA cycles uh and then we find out that the cycles and the tests have been done uh on things that don't matter that much for what they want to accomplish. So uh I'm assuming that you're coming to this session today with a specific aim in mind. there's some measurable outcome that you want to achieve and the question is where do you begin?
So the way I would like to help you begin is to think about the pathway between your ideas for change uh the evidence-based practices the innovations that you think are important. Uh what's the relationship between them and the outcome you want to achieve? I I call this the causal pathway. It's really cause and effect. You have some level of belief that if you do certain things, you will advance your measurable outcome. Things will improve.
So, a driver diagram is a simple visual somewhat intuitive display to help you understand where you're going with your work and also to help others understand what you need them to do to help you. Uh so, uh let's think about something simple. As you know, I like to talk about myself. Uh this seems to be a problem that I have. Uh maybe I should work on PDSA cycles on that. But today I'm going to talk about losing weight.
So I think if you're looking at me, you're probably saying, "Well, he's a pretty fit guy for someone his age." But actually, I'm a little disappointed in the way my body is shaping up, and I could easily stand uh to lose 5 to 10 pounds. And uh that's a measurable aim. Let's say 5 pounds. That's a modest and achievable aim should be.
What are the key drivers? What are those major highly leverages leveraged things that I need to do to lose that 5 pounds? So, uh let's talk first about the primary drivers, those things that are kind of at the very heart of the matter. As far as I know, there are only two major drivers for me losing weight. One is calories in, the other is calories out. So, those are my primary drivers. There are only two.
When you set up your project or have your own personal work you want to do, you may have three, four, even five drivers. But if you're getting to be six, seven, or eight or nine drivers, you're just not getting it down to the level you need to be to to be simple uh and actionable. So, uh, calories in, calories out.
Now, what things can I do to reduce my calories in? Well, that sounds relatively simple. I can uh for example uh cut down on sugary soda drinks and uh monitor measure how many Cokes or whatever it is I have during a week uh as a effort to improve my caloric intake.
So right away you see that in any driver diagram uh the uh uh changes have to be measurable. How am I going to know that I'm actually improving? So in the case of sugary drinks, it may be I go from five a week to two a week and I'm going to measure that. I'm going to do my tests of change around that.
Uh in terms of uh another change I might make, I I this is stressful work. I mean talking to you certain level of stress, although I love doing it. And uh at the end of the day, I do like to go home and with my dinner, I'll have a glass of wine. Well, I don't know if you know this, but a glass of wine is 150 to 200 calories. That's an extra 150 to 200 calories in measurable calories that that I'd like to cut down.
So maybe I'll say on the weekends it's not so stressful. I won't have my glass of wine and right away there's 300 calories fewer in. Now the other thing you want to think about is uh driver diagrams are pretty simple. They're linear and you can see that on the illustration that uh you're seeing now. But sometimes it's a little more complex.
So drinking that glass of wine has an effect on calories out. Well, how can that be? Well, uh, I should be going to the gym. That's part of my calories out part of the driver diagram. I should go several times a week. I I promise you, I've had a glass of wine, my 180 calories in. I'm not going to the gym. So, there's 400 calories that aren't coming out.
So, that's kind of how a a driver diagram works. And you can get very specific about the kinds of changes you want to make uh that you believe will result in the improved outcome and how you're going to measure it. So, I hope that's clear because now I'd like to move us on to a healthcare example.
So, I'm an infectious disease guy. I don't know if I've told you that in previous lessons, but that's what I do. So, uh uh I worry about things like MRSA or methasylan resistant staff orius. And we're going to go through a driver diagram for how we can measurably reduce colonization and infection with MRSA.
So, similar to what I just told you about uh losing weight, uh there are only two major drivers for reducing MRSA. One is a driver to reduce spread and colonization. The other is the driver to reduce actual infection if you should become colonized. Those are the two major drivers that you see here.
and array behind them are what we call secondary drivers or you can think of these as major highly leveraged changes that are going to help you accomplish these aims. So obviously things like uh screening patients for methasone resistant staff orius might be important to help you control the spread or certainly careful hand hygiene wearing gowns and gloves keeping your precautions routines highly reliable.
That's all going to help you uh reduce spread of the organism uh and uh therefore reduce the chance of infection. But let's say uh you now have a patient who's colonized, you still want to reduce the risk of infection.
That's where for example uh the bundles for clapses that we discussed last time comes in. If you are fidious about your care of those central venus catheters, then the chance that patient will get an infection with MRSA even if they're colonized are drastically reduced. the same for ventilator associate pneumonia bundle. So those are your drivers uh to reduce infections.
And behind those to the right on this particular uh uh demonstration, there are even more specific changes, ideas that you think are evidence-based uh that will help you achieve your goal. That's really all there is to it. I'll just say that be sure that whatever you want to change, whatever idea you have uh is measurable, that you can actually do PDSAs and measure your improvement.