MODEL FOR IMPROVEMENT QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM

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MODEL FOR IMPROVEMENT QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM – 2017 -18

MODEL FOR IMPROVEMENT QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM – 2017 -18

After this session you will be able to… • • Prepare your improvement charter

After this session you will be able to… • • Prepare your improvement charter Develop your problem statement Establish an AIM statement Define measures relating to your AIM Construct a driver diagram for your project Develop change ideas Use the PDSA cycle to test change ideas 2

THE MODEL FOR IMPROVEMENT Specify and set the aim Establish measures Change concepts &

THE MODEL FOR IMPROVEMENT Specify and set the aim Establish measures Change concepts & change ideas PDSA Cycle Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 3

IMPROVEMENT OPPORTUNITY (BASED ON YOUR SITE QI MEETING OUTPUT) 4

IMPROVEMENT OPPORTUNITY (BASED ON YOUR SITE QI MEETING OUTPUT) 4

DEFINITION - “CHARTER” • • A written constitution or description of an organization’s functions

DEFINITION - “CHARTER” • • A written constitution or description of an organization’s functions Your QI Team’s commitment to a “blueprint” as to how to structure its improvement efforts http: //www. oxforddictionaries. com/definition/english/charter 5

YOUR OPPORTUNITY FOR IMPROVEMENT Keep in mind the opportunity for improvement that you have

YOUR OPPORTUNITY FOR IMPROVEMENT Keep in mind the opportunity for improvement that you have selected 6

CHARTER – RECALL YOUR PROPOSED TEAM MEMBERS AND ROLES Proposed QI Team • Team

CHARTER – RECALL YOUR PROPOSED TEAM MEMBERS AND ROLES Proposed QI Team • Team Lead(s) • Member A • Member B • Member C • Supervisor Roles - 7

CHARTER – PROBLEM STATEMENT • • • What is the problem you wish to

CHARTER – PROBLEM STATEMENT • • • What is the problem you wish to address? Why is it a problem? Where do we observe the problem? Who is impacted? When is it ongoing or recurrent? Which of the Quality Dimensions are involved? “A problem well defined is half-solved” 8

PROBLEM STATEMENT – EXAMPLE WHAT • “No Shows” – Patients with appointments who fail

PROBLEM STATEMENT – EXAMPLE WHAT • “No Shows” – Patients with appointments who fail to attend without cancelling 9

PROBLEM STATEMENT – EXAMPLE WHY • Disrupts stable patient flow during clinic • Limits

PROBLEM STATEMENT – EXAMPLE WHY • Disrupts stable patient flow during clinic • Limits appointment availability for others in need • Uncertainty introduced into patient’s health care need – how do we follow up to ensure patient does not still need a visit? • Lack of knowledge as to root cause 10

PROBLEM STATEMENT – EXAMPLE WHERE • Greater problem in residents’ clinics as population seen

PROBLEM STATEMENT – EXAMPLE WHERE • Greater problem in residents’ clinics as population seen often less attached 11

PROBLEM STATEMENT – EXAMPLE WHO • Patients – those who fail to attend and

PROBLEM STATEMENT – EXAMPLE WHO • Patients – those who fail to attend and possibly lack follow-up, and those who lack access to an appointment not kept • Staff – hard to allocate staff resources; reception – additional phone calls to f/u • Physicians – hard to decide what to do – wait, work on other task etc. 12

PROBLEM STATEMENT – EXAMPLE WHEN • Occurs regularly in residents’ clinics, much less commonly

PROBLEM STATEMENT – EXAMPLE WHEN • Occurs regularly in residents’ clinics, much less commonly with staff MDs, nurses and allied professionals 13

PROBLEM STATEMENT – EXAMPLE WHICH • Access - ++ • Efficiency - +++ •

PROBLEM STATEMENT – EXAMPLE WHICH • Access - ++ • Efficiency - +++ • Patient centered - + • Effectiveness - + • Equity - ? 14

PROBLEM STATEMENT – EXAMPLE Our problem is the number of appointments not kept, particularly

PROBLEM STATEMENT – EXAMPLE Our problem is the number of appointments not kept, particularly for residents’ schedules. This disrupts the normal flow of patients, creates uncertainty in the need for follow-up, makes it difficult to assign time and resources, and limits appointments for others in need. We are uncertain where to assign cause – with patients or with our systems for appointment booking and follow up. 15

EXERCISE Problem Statement (15 min) • • • Create a Problem Statement Discuss with

EXERCISE Problem Statement (15 min) • • • Create a Problem Statement Discuss with a partner Share at your table 16

THE MODEL FOR IMPROVEMENT Specify and set the aim Langley, Nolan, Norman, Provost; The

THE MODEL FOR IMPROVEMENT Specify and set the aim Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 17

THE MODEL FOR IMPROVEMENT Specify and set the aim “Begin with the end in

THE MODEL FOR IMPROVEMENT Specify and set the aim “Begin with the end in mind. ” This is your Aim Statement Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 18

SPECIFY AND SET THE AIM 1. Describe what you are trying to accomplish. Benchmark

SPECIFY AND SET THE AIM 1. Describe what you are trying to accomplish. Benchmark against: • evidence-based best practice • knowledge experts – including local colleagues • medical literature 2. Set the aim, which defines the goal 19

SPECIFY AND SET THE AIM What are we trying to accomplish? • • •

SPECIFY AND SET THE AIM What are we trying to accomplish? • • • What system is to be improved? Who is the population of focus? What is expected to happen? What is the timeframe? What is the goal? 20

SAMPLE AIM STATEMENT • Aim statements should be “SMART” • • • Specific Measurable

SAMPLE AIM STATEMENT • Aim statements should be “SMART” • • • Specific Measurable Attainable Relevant Time-bound 21

SAMPLE AIM STATEMENT “ 60% of adult patients diagnosed with diabetes will achieve targeted

SAMPLE AIM STATEMENT “ 60% of adult patients diagnosed with diabetes will achieve targeted blood pressure of < 130/80 mm Hg, within 12 months. ” • • • Specific Measurable Attainable Relevant Time-bound 22

SAMPLE AIM STATEMENT “ 75% of patients will be seen by a health care

SAMPLE AIM STATEMENT “ 75% of patients will be seen by a health care provider within 5 minutes of the scheduled appointment, within 3 months. ” • • • Specific Measurable Attainable ? ? ? Relevant Time-bound 23

INCORPORATING PRESENT AND FUTURE STATES INTO AIM STATEMENTS We will reduce the number of

INCORPORATING PRESENT AND FUTURE STATES INTO AIM STATEMENTS We will reduce the number of patients failing to attend for their appointments with residents, from 15% of residents’ booked appointments to 10%, within the next six months. 24

EXERCISE Aim Statement (15 min) • For your opportunity for improvement: Draft an Aim

EXERCISE Aim Statement (15 min) • For your opportunity for improvement: Draft an Aim Statement. Is it SMART? 25

DEBRIEF What Aim Statements did you craft? 26

DEBRIEF What Aim Statements did you craft? 26

THE MODEL FOR IMPROVEMENT Establish measures Measures must relate to the AIM statement Langley,

THE MODEL FOR IMPROVEMENT Establish measures Measures must relate to the AIM statement Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 27

MEASUREMENT Measurement for Learning and Process Improvement Measurement for Research Measurement for Accountability or

MEASUREMENT Measurement for Learning and Process Improvement Measurement for Research Measurement for Accountability or Comparison Purpose To bring new knowledge into daily practice To discover new knowledge Comparison, choice, reassurance, spur for change Tests Many sequential, observable tests One large "blinded" test No tests Biases Stabilize the biases from test to test (accept consistent bias) Control for as many biases as possible Measure and adjust to reduce bias Data Gather "just enough" data to learn and complete another cycle (small sequential samples) Gather as much data as possible, "just in case" Obtain 100% of available, relevant data Run charts or control charts Hypothesis tests (Ttests, F-tests, Chisquare), p-value No change focus Determining if change is an improvement Source: Provost, , L. & Murray, S. . (2007). “The Data Guide: Learning from Data to Improve Health Care. ” Associates in Process Improvement and Corporate Transformation Concepts. 28

MEASURING THE SYSTEM • A system is an interdependent group of items, people, or

MEASURING THE SYSTEM • A system is an interdependent group of items, people, or processes working together toward a common purpose • Healthcare systems – complex, adaptive • Requires a “family of measures” which includes outcome, process, and balancing measures • Follow measures frequently and continually while you improve through many tests of change 29

OUTCOME MEASURES Captures what is important to the patient and reflects how the overall

OUTCOME MEASURES Captures what is important to the patient and reflects how the overall system is working Answer the question: • Are we fulfilling our aim? • This is the “so what” piece, and reflects what is most important to the patient Examples: 1. Safety - Adverse events post hospitalization 2. Access - Seeing their preferred primary provider when sick 3. Patient-centered - Perceived ability of primary provider to hear and understand patients’ problems 30

PROCESS MEASURES Sometimes referred to as the “voice of the process” and reflects how

PROCESS MEASURES Sometimes referred to as the “voice of the process” and reflects how steps in the system are performing Answer the question: • Are we doing the things we thought would result in an improvement? • May not be as important from the patient’s point of view (compared to the desired outcome) Examples: 1. Safety - Time to first follow up appointment post discharge 2. Access - Number of same day appointments available at start of day 3. Patient-centered - “Red Zone” time – percentage of visit cycle time that patient spends with provider 31

BALANCE MEASURES Looking at a system from different directions/dimensions. What happened to the system

BALANCE MEASURES Looking at a system from different directions/dimensions. What happened to the system as we improved process and outcome measures? Answer the questions: • Are we inadvertently having a negative impact on other parts of the system through our actions? • What could go wrong if we do this? Examples: 1. Safety - Unnecessary appointments 2. Access - Increase in variation of volume of appointments per day 3. Patient-centered - Leaving later in the day 32

DO YOUR MEASURES ALIGN? Safety • Adverse events post hospitalization (O) • Time to

DO YOUR MEASURES ALIGN? Safety • Adverse events post hospitalization (O) • Time to first follow up appointment post discharge (P) • Unnecessary appointments (B) Access • Seeing their preferred primary provider when sick (O) • Number of same day appointments available at start of day (P) • Increase in variation of volume of appointments per day (B) Patient-centered • Perceived ability of primary provider to hear and understand patients’ problems (O) • “Red Zone” time – percentage of visit cycle time that patient spends with provider (P) • Leaving later in the day (B) 33

SOME COMMON SYSTEMS (& MEASURES) IN PRIMARY CARE Clinical Administrative • • • Screening

SOME COMMON SYSTEMS (& MEASURES) IN PRIMARY CARE Clinical Administrative • • • Screening (cancer screening) Health Promotion (vaccination rates) Acute Care (antibiotic use) Chronic Disease (Hb. A 1 C) End of life care (pain scores) • • • Scheduling (same or next day access when sick) Patient flow (cycle & wait times) Billing – (Access bonus) System Integration (% seen within 7 days post-discharge) 34

EXERCISE Measures (15 min) Looking at your Aim Statement, what are appropriate measures for

EXERCISE Measures (15 min) Looking at your Aim Statement, what are appropriate measures for your QI initiative? • Outcome • Process • Balance 35

DEBRIEF Will a few of you share your Aim Statement, and a § Process

DEBRIEF Will a few of you share your Aim Statement, and a § Process measure? § Outcome measure? § Balance measure? 36

DRIVER DIAGRAM • How do we demonstrate the relationships among system aims, system outcome

DRIVER DIAGRAM • How do we demonstrate the relationships among system aims, system outcome measures, primary & secondary drivers? • How do we visually describe causality in our complex environments? • Where does my QI project fit? • How is it anchored to broader QI work? 37

DRIVER DIAGRAM • Creates a logic model to develop and communicate an approach to

DRIVER DIAGRAM • Creates a logic model to develop and communicate an approach to achieving an aim • Identifies hypothesized relationships among primary and secondary drivers of change • Provides a structure for identifying and cascading measures 38

DRIVER DIAGRAM EXAMPLE https: //www. youtube. com/watch? v=yfc. E_Q-IRFg 39

DRIVER DIAGRAM EXAMPLE https: //www. youtube. com/watch? v=yfc. E_Q-IRFg 39

IHI 100, 000 LIVES CAMPAIGN A SYSTEM AIM IHI will partner with participating hospitals

IHI 100, 000 LIVES CAMPAIGN A SYSTEM AIM IHI will partner with participating hospitals to avoid 100, 000 hospital deaths “over the next 18 months (by June 2006), and every year thereafter” beginning in December 2004. Practices: • • • Rapid Response Teams Medication Reconciliation Prevent central line infections Prevent surgical site infections Preventilator-associated pneumonia Evidence-based care for MI Wachter, R. , Provonost, P. The 100, 000 Lives Campaign: A Scientific and Policy Review. Journal on Quality and Patient Safety. November 2006, vol. 32, No. 11. 40

DRIVER DIAGRAM EXAMPLE 41

DRIVER DIAGRAM EXAMPLE 41

DRIVER DIAGRAM EXAMPLE Julie E Reed et al. BMJ Qual Saf doi: 10. 1136/bmjqs-2014

DRIVER DIAGRAM EXAMPLE Julie E Reed et al. BMJ Qual Saf doi: 10. 1136/bmjqs-2014 -003103 42

EXERCISE Driver Diagram (15 min) Using flip chart paper and post it notes, develop

EXERCISE Driver Diagram (15 min) Using flip chart paper and post it notes, develop a portion of a driver diagram including: • Aim Statement • Primary Drivers • Secondary Drivers – Your QI Project 43

THE MODEL FOR IMPROVEMENT Develop change ideas Reflect on your practice, brainstorm, use system

THE MODEL FOR IMPROVEMENT Develop change ideas Reflect on your practice, brainstorm, use system diagnostic tools and use change concepts to develop change ideas. Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 44

REACTIVE CHANGE • • • Keeps the system running Responds to an immediate problem

REACTIVE CHANGE • • • Keeps the system running Responds to an immediate problem Short term impact NOT QI Hire someone to phone patients to come in for their screening tests 45

FUNDAMENTAL CHANGE • • • Essentially alters an activity Necessary to prevent problems Lasting

FUNDAMENTAL CHANGE • • • Essentially alters an activity Necessary to prevent problems Lasting impact = QI e. g. Use electronic reminder systems to improve screening rates 46

CHANGE IDEAS • Specific ideas that you can test and implement to effect change

CHANGE IDEAS • Specific ideas that you can test and implement to effect change • Sources: – System diagnostic tools – Your team – Brainstorming – Change concepts 47

SOURCES OF CHANGE IDEAS • • • System cause analysis informs change ideas –

SOURCES OF CHANGE IDEAS • • • System cause analysis informs change ideas – system diagnostic tools Learn from knowledge experts. What has worked at other practices? Think logically about current procedures. Involve those closest to the situation Think creatively. Use technology Copy, replicate, duplicate. No need to reinvent the wheel! Begin. Don’t anticipate how impactful a change idea may be – be open to ‘testing’! 48

CHANGE CONCEPTS General approaches to change that have been shown to generate additional change

CHANGE CONCEPTS General approaches to change that have been shown to generate additional change ideas. 49

CHANGE CONCEPTS • • • Eliminate waste Find & remove bottlenecks Improve work flow

CHANGE CONCEPTS • • • Eliminate waste Find & remove bottlenecks Improve work flow – Minimize hand-offs – Do tasks in parallel Use technology Standardize Force Function • • Any duplication of effort? • Is the right person doing the right thing at the right time? • • • Are there technological efficiencies? Is there unnecessary variation? Make the right thing, easiest Is there a step that slows the entire process? 50

EXERCISE Generate change ideas (10 min) • Select 1. 2. 3. 4. one person’s

EXERCISE Generate change ideas (10 min) • Select 1. 2. 3. 4. one person’s QI opportunity at your table Review the opportunity Review system diagnostic tools to find change ideas Brainstorm change ideas Choose a change concept to help generate more ideas 51

DEBRIEF Generate change ideas • How many change ideas did you generate? 52

DEBRIEF Generate change ideas • How many change ideas did you generate? 52

THE MODEL FOR IMPROVEMENT Testing change ideas Langley, Nolan, Norman, Provost; The Improvement Guide,

THE MODEL FOR IMPROVEMENT Testing change ideas Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 53

FROM OPPORTUNITY TO TESTING CHANGES Improvement Opportunity Problem Statement CHANGE IDEA Langley, Nolan, Norman,

FROM OPPORTUNITY TO TESTING CHANGES Improvement Opportunity Problem Statement CHANGE IDEA Langley, Nolan, Norman, Provost; The Improvement Guide, 1996. 54

EXERCISE Testing change ideas (10 min) October Sky movie clip http: //www. youtube. com/watch?

EXERCISE Testing change ideas (10 min) October Sky movie clip http: //www. youtube. com/watch? v=c. P_OM 5 VVc. So While viewing, pay attention to… • • • # of tests of change (PDSAs) Team roles Use of prediction 55

DEBRIEF Testing change ideas What did you observe? • # of tests of change

DEBRIEF Testing change ideas What did you observe? • # of tests of change (PDSAs) • team roles • Use of prediction 56

PDSA: PLAN-DO-STUDY-ACT Please refer to the PDSA Worksheet 57

PDSA: PLAN-DO-STUDY-ACT Please refer to the PDSA Worksheet 57

PSDA WORKSHEET Plan: Describe the following: objective of the cycle and details • Data

PSDA WORKSHEET Plan: Describe the following: objective of the cycle and details • Data to be collected – who, what, when, where • Predictions & questions Do: Carry out the change or test; document problems and unexpected observations Study: Complete the analysis of data. Compare the data to your predictions and summarize the learning Act: What changes need to be made? Plan for the next cycle 58

TESTING A CHANGE IDEA PLAN • • • State the purpose Predict what you

TESTING A CHANGE IDEA PLAN • • • State the purpose Predict what you think will happen What feedback will you be looking for from the test – quantitative or qualitative measure? 59

TESTING A CHANGE IDEA DO • Prepare: detail the test actions & tasks •

TESTING A CHANGE IDEA DO • Prepare: detail the test actions & tasks • Conduct the plan • Collect data related to your measure 60

TESTING A CHANGE IDEA STUDY • Compare your results to your prediction 61

TESTING A CHANGE IDEA STUDY • Compare your results to your prediction 61

TESTING A CHANGE IDEA ACT • Decide what to do next • Implement your

TESTING A CHANGE IDEA ACT • Decide what to do next • Implement your decision 62

PDSA: ACT • MODIFY - Good results; negative outcomes can be managed • TEST

PDSA: ACT • MODIFY - Good results; negative outcomes can be managed • TEST UNDER OTHER CONDITIONS - Negative outcomes may be related to certain manageable conditions • IMPLEMENT - Consistent results after several tests; minimal negative impact • SPREAD - Results merit test on larger scale • DROP - Results do not justify effort; substantial unexpected negative outcomes 63

EXERCISE PDSA – Test of Change (10 min) • Select one person’s change idea

EXERCISE PDSA – Test of Change (10 min) • Select one person’s change idea at your table 1. 2. 3. 4. Review the change idea Plan a test of change for the idea Discuss your prediction Determine the feedback you will be looking for during the test (measure) 64

DEBRIEF PDSA – Test of Change • Did your colleagues at the table predict

DEBRIEF PDSA – Test of Change • Did your colleagues at the table predict differently for each test of change? • Did any table discuss a potential next test of change for the same idea? 65

PDSA actions must integrate with regular work activities • Designate time • Designate place

PDSA actions must integrate with regular work activities • Designate time • Designate place • Designate people 66

TESTING A CHANGE IDEA • QI initiatives need to be feasible • Each incremental

TESTING A CHANGE IDEA • QI initiatives need to be feasible • Each incremental PDSA is small and quick 67

ALTERNATIVE PROCESS • • • Anticipate iterative cycles Plan future modifications to test Document

ALTERNATIVE PROCESS • • • Anticipate iterative cycles Plan future modifications to test Document your test Innovate Keep it small to keep it feasible Keep it focused “No one PDSA cycle will change the world. ” 68

PDSA’S - SMALL, REPEATED TESTS OF CHANGE 69

PDSA’S - SMALL, REPEATED TESTS OF CHANGE 69

PDSA CYCLES IN A SEA OF COMPLEXITY 70

PDSA CYCLES IN A SEA OF COMPLEXITY 70

FROM OPPORTUNITY TO TESTING Improvement CHANGES Opportunity CHANGE IDEA 71

FROM OPPORTUNITY TO TESTING Improvement CHANGES Opportunity CHANGE IDEA 71

Now you are able to … • • Prepare your improvement charter Develop your

Now you are able to … • • Prepare your improvement charter Develop your problem statement Establish an AIM statement Define measures relating to your AIM Construct a driver diagram for your project Develop change ideas Use the PDSA cycle to test change ideas 72

QUESTIONS 73

QUESTIONS 73