1. FMEC Meeting, September 28, 2012 Sara G. Shields, MD, MS, FAAFP Marie Caggiano, MD, MPH Konstantinos Deligiannidis, MD Stacy Potts, MD

2. Learning Objectives 1) Summarize the basic principles of quality improvement using the Institute for Healthcare Improvement’s Model for Improvement. 2) Construct a fishbone diagram, a process map, an enhanced PDSA worksheet, and a simple graph of data results for their chosen QI project. 3) Compare and contrast strategies for teaching these concepts in residency education.

3. What is quality improvement? 3 Overlapping Functions Root Cause Analysis Peer Review Staff Training Provider Credentialing Feedback to Staff & Providers Board Reports Patient Safety Initiatives Patient Complaints Risk Assessment Trend Analysis Overlapping Functions Root Cause Analysis Peer Review Staff Training Provider Credentialing Feedback to Staff & Providers Board Reports Patient Safety Initiatives Patient Complaints Risk Assessment Trend Analysis Adapted from ECRI Institute

4. How does it differ from Research? ComponentQuality ImprovementResearch Purpose Examines internal processes and guides action toward improvement. Generates new knowledge, tests hypotheses Scope Examines internal institution/process- specific issues May be able to generalize to other patients, situations and settings Informed Consent Generally not required unless results are being shared externally Must be obtained if human subjects are involved. DesignFocuses on process Scientific framework Well-controlled Subject Selection Available patients or subpopulations of patients Based on research purpose, study design, power analysis, and statistical models ResultsUsed by the specific institution/organization. Presented and available to others.

5. How does QA differ from QI?  Focused on finding poor providers.  Data is displayed statically.  They are looking at a slice in time.  Difficult to make changes.  No plan for change is presented. (Carey&Lloyd, 1995)  Focused on improving a process for better outcome.  The interest now includes data on programming, delivery of care, cost, charges, payments, patient satisfaction. Quality AssuranceQuality Improvement

6. Crossing the Quality Chasm Safe Timely Effective Efficient Equitable Patient-centered (C)ulturally competent

7. Model for Improvement Source: http://www.apiweb.org/services.htmhttp://www.apiweb.org/services.htm

8. Other QI Models Care Model Lean Model FADE Focus, Analyze, Develop, Execute/Evaluate Six Sigma

9. QI Tools Aim statement Process mapping Data presentation

10. Model for Improvement 1.The Aim 2. The Measures: How will we know a change is an improvement? Process AND outcomes 3. The Changes: What change can we make that will result in improvement? What changes to track with data?

11. Model for Improvement Source: http://www.apiweb.org/services.htmhttp://www.apiweb.org/services.htm

12. The Aim What are we trying to accomplish? How good do you want to be? By when? A good aim addresses an issue that is important to those involved; it is specific, measurable, and addresses these points: 1. How good? 2. By when? 3. For whom (or for what system)?

13. A Good Aim Statement… It is precise. It includes a numerical goal. It is feasible (achievable ) It is measurable. It includes a time frame. SMART Specific Measureable Achievable Realistic Time

14. Examples of Aim Statements By June 2010, 80% of our GDM patients will have appropriate postpartum testing documented by 3 months’ postpartum 75% of residents will integrate ICC into 75% of their well child visits by May 31 st, 2012. To increase the percentage of WCC appointments scheduled with PCP To increase teen vaccine levels at our health center to meet Healthy People 2020 goals by December 2013. To decrease total visit time to less than 60minutes by October 31, 2012.

15. Model for Improvement Source: http://www.apiweb.org/services.htmhttp://www.apiweb.org/services.htm

16. The Measures How will we know a change is an improvement? 1. Process AND outcomes 2. Try to have measures that are already being collected 3. Simplify the measures 4. Qualitative measures are also important 5. Remember “balancing” measures

18. Measurement for Research Measurement for Learning and Process Improvement PurposeTo discover new knowledge To bring new knowledge into daily practice TestsOne large blind testMany sequential, observable tests BiasesControl for as many biases as possible Stabilize the biases from test to test DataGather as much data as possible, just in case Gather just enough data to learn and complete another cycle DurationCan take long periods of time to obtain results Small tests of significant changes accelerate the rate of improvement

19. Examples of Measures # of diabetics seen in last 3 months with either monofilament testing or podiatry visit in last year # of well child visits for one provider where mother received interconception care screening tool # of gestational diabetics who had postpartum testing for diabetes within 12 weeks of delivery Time for medical assistant to check list of teens needing vaccine appointments # of newborn visits with early check-in

20. “Balancing Measures” Process/Outcome Measure “Balancing” Measure # of diabetics seen in last 3 months with either monofilament testing or podiatry visit in last year # of well child visits for one provider where mother received interconception care screening tool # of gestational diabetics who had postpartum testing for diabetes within 12 weeks of delivery Time for medical assistant to check list of teens needing vaccine appointments # of newborn visits with early check-in # of diabetics with eye exam Duration of well-child visit when ICC tool is used Unreimbursed DM testing postpartum Cycle time delays in triage during teen vaccine trial Patient satisfaction with NB visit duration

21. Measurement planning Develop a plan before data collection begins Include written data definitions of measures Goal is useful data, not perfection!

22. More on Measures Numeric goals, with expected completion date Baseline data (relevant to stated goals) “Random samples” (to make it do-able) Remeasure data (“apples” to “apples”) Identify additional actions, as needed Share the “lessons learned” throughout the organization Continue to remeasure until goal has been SUSTAINED for a reasonable period.

23. Types of Measures Quality indicators as measures of health care structure, process, or outcome. Structural measures describe the environment or the settings of care. Process measures describe the steps or actions taken to give care. Outcome measures describe the effects of care on the patient.

24. Defining Measures Be very detailed If percent or rate, specify numerator/denominator If average, identify calculation If score, describe how the score is derived When measuring such characteristics as “accurate“ “complete,” or “timely,” describe specific criteria

25. Data collection plan Who will collect the data? How often? What are the specific data sources? What to include/exclude? How will these data be collected (manual, automated)?

27. Model for Improvement Source: http://www.apiweb.org/services.htmhttp://www.apiweb.org/services.htm

28. Quality Cycle

29. The Changes What change can we make that will result in improvement? What changes to track with data? 1. Brainstorming 2. Team involvement 3. Frontline people have critical roles Registration staff Medical assistants

30. Six Ways to think about Change Critical thinking about current system Benchmarking Taking patient’s perspective Using technology Creative thinking Change concepts

31. Change Concepts Category Concept Eliminate waste Improve workflow Optimize inventory Change work environment Producer/customer interface Manage time Focus on variation Error proofing Focus on product/service Eliminate unused items Find & eliminate bottlenecks Inventory/demand Think basics Focus on outcome Do tasks in parallel Standardization (formalize) Use reminders Listen to customers

32. Examples of Changes Train medical assistant to do monofilament testing Questionnaire for mothers at well child visits Point-of-care reminder in postpartum chart for all gestational diabetics

33. P is for Plan, Plan, Plan 1. Identify an opportunity for Improvement 2. Organize a team 3. Develop a flow chart of current process 4. Target one step to improve 5. Develop an Operational Definition 6. Collect and plot data 7. Identify process variables

34. Strategy What is the general approach to achieving the outcome? What resources may be needed and who else will be involved? When and how will the improvement be evaluated for results?

35. What is the CURRENT process? Not what ideally should be happening What the exact process is, what happens right now Have to know process before changing it! Ask “is there a standardized process?” If yes, then flow chart that process If no, work to agree on one process

36. “If a process is ineffective, it will still be ineffective even if it is automated. Before pursuing technology options, organizations should redesign their processes to be effective and use technology to simplify and standardize those processes.” “While technology can solve a lot of problems, it is not a panacea. Human beings must still be very present when interacting with technology to ensure its proper and effective use.”

38. Process Mapping A picture of the way a process actually works Goal: understand existing process Then develop ideas about how to improve it. high-level flowchart -- panoramic view detailed flowchart -- close-up view

39. Put in photo here of our process map for vaccines

41. Process Mapping (2) Clarify complex processes Identify steps that do not add value E.g. delays; needless storage and transportation; unnecessary work, duplication, and added expense; breakdowns in communication. Gain shared understanding of process Use this knowledge to collect data, identify problems, focus discussions, and identify resources. (Eventually, the basis for designing new processes)

42. Constructing a Flowchart 1. Specify the beginning and the end. 2. Start with a simple high-level flowchart (5-20 steps). 3. Use standard symbols. 4. Use post-it notes to describe the major steps. Write one step per post- it, making it possible to move steps around as needed. It is often helpful to use "ing" words, e.g., "calling for advice", "initiating a project." Try to describe the process in less than 20 steps. 5. Once you have agreed on the steps and their order, identify which are decision points (diamonds). 6. From this picture, identify where improvements might be made. 7. Check the results with others who work in the process.

43. Creating an effective flowchart http://www.improvementskills.org/remotes/mod04_fl owchart.cfm http://www.improvementskills.org/remotes/mod04_fl owchart.cfm

45. Fishbone/Cause and Effect Diagram People Materials Equipment Process Environment Other

46. Fishbone Diagrams The 4 M’s: o Methods, Machines, Materials, Manpower The 4 P’s: o Place, Procedure, People, Policies The 4 S’s : o Surroundings, Suppliers, Systems, Skills

47. Fishbone Diagrams: the bones Identify factors within each category that may be affecting the problem/issue and/or effect being studied. e.g. ask... "What are the machine issues affecting/causing...“ Repeat this procedure with each factor under the category to produce sub-factors Keep asking, "Why is this happening?" Add additional segments under each factor and subsequently under each sub-factor. Continue until you no longer get useful information as you ask, "Why is that happening?"

49. Do Try out the test on a small scale. Document problems and unexpected observations. Begin analysis of the data.

50. Study Set aside time to analyze the data and study the results. Complete the analysis of the data. Compare the data to your predictions. Summarize and reflect on what was learned.

51. Presenting Data Spreadsheet Histogram/bar chart Run chart—outcome over time

52. IHI Improvement Tracker http://app.ihi.org/Workspace/tracker/

53. Run Charts Run charts are graphs of data over time Run charts have a variety of benefits: Formulate aims by depicting how well (or poorly) a process is performing. Determine when changes are truly improvements by displaying a pattern of observable data in real-time Give direction through improvement process Inform about the value of particular changes.

55. Run Chart Tool http://www.ihi.org/knowledge/Pages/Tools/RunChart.aspx http://www.ihi.org/knowledge/Pages/Tools/RunChart.aspx

57. Act modify or change idea in anticipation of next trial  series of PDSA cycles Goal: break a major change into smaller steps learning generated in the first leads to the next, which provides the foundation for the next, and so on Move from hunches and ideas to demonstrable improvement Remember: measure! to test changes to determine if successful or not

58. Act Refine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for the next PDSA.

59. QI sample 15-20 working days Initial tracking Sample in the same manner 4–6 weeks later. For one week/5 working days. Again 12-16 weeks later ACT – Policy/Procedure Train all staff Monitoring Plan = Quarterly, Bi –annually, or annually. ACT DO STUDY

60. Beyond Act—the next steps…

64. Tips for real life QI Stay a cycle ahead. Scale down the scope of tests. Pick willing volunteers. Work with those who want to work with you. Avoid the need for consensus, buy-in, or political solutions. Don’t reinvent the wheel. Pick easy changes to try. Avoid technical slowdowns. Reflect on the results of every change. Be prepared to end the test of a change.

65. Resources AAMC Med Ed Portal http://services.aamc.org/30/mededportal/servlet/segment/mededp ortal/information/ http://services.aamc.org/30/mededportal/servlet/segment/mededp ortal/information/ Search “Quality Improvement” Online programs IHI Open School MUSC online program - http://etl2.library.musc.edu/qi/signin.php?error=0 MUSC online program http://etl2.library.musc.edu/qi/signin.php?error=0 Vanderbilt http://www.mc.vanderbilt.edu/root/vumc.php?site=qicour se http://www.mc.vanderbilt.edu/root/vumc.php?site=qicour se

66. Your Turn! Break into three groups Design a quality improvement project to take back to your home office or institution Use the Model for Improvement Aim statement, process map, thinking about data Come back and present to larger group