1. 1 Moving From Causal Analysis to Testing and Measuring Interventions Jane Caruso, NQC Consultant Kevin Garrett, Sr. Manager, NQC January 23, 2014

2. 2 Learning Outcomes Participants will be able to increase their knowledge in the following areas: Using data to determine your AIM Using causal analysis results to inform your intervention Planning PDSA Cycles Additional resources

3. 3 Agenda Overview QI Principles and Framework PDSA Cycles Grantee Examples Q&A

4. 4 Quality Improvement Fundamental Concept of Improvement: “Every system is perfectly designed to achieve exactly the results it achieves” Principles of Improvement: Understanding work in terms of processes and systems Developing solutions by teams of providers and patients Focusing on patient needs Testing and measuring effects of changes

5. 5 So The Question Of The Day Is: HOW DO WE CAUSE AN EFFECT? How do we know that if we do something, make a change….. it will cause the desired effect or have the desired outcome?

6. 6 Getting Started… Moving out of Wonderland!

7. 7 WHEN do you do your PDSA? QI Project Steps Step 1: Collect & clean data – ask it the right questions Step 2: Bring the right mix of people & skills to the table Step 3: Investigate the process/problem – look for a cause Step 4: Develop a Team work plan Step 5. Plan and Test Changes – PDSA Cycles Step 6: Evaluate Results with Key Stakeholders Step 7: Systematize Change

8. 8 Step 1: Data Run data often for cleanliness and comprehensiveness. Don’t base strategy development of poor data. Ask your data the right questions so that you get the right answers! Have you filtered your query properly? Did leave out the women with certain hysterectomies from your pap query? Did you omit the folks with positive history from your TB query? Present your data to your Team in a way that is useful and easy to understand. Use your data to help you both determine your aim, and design the strategies that will cause the effect you seek.

9. 9 Step 2: Team Composition Seek different skill sets: medical, clinical, data, quality, statistics, technical writers, social service and CM, administrators, consumers……and whomever might be relevant from the community for a QM Committee A QM Committee would be broad-based (above) and all inclusive….a QI Project Team might be a subset of the QM Team and include fewer members with a more targeted focus. Interaction between these two memberships is critical Listen to everyone and encourage a respectful interchange of experience and ideas. Encourage thoughts and ideas outside of the norm.

10. 10 What is the difference? Tests Putting a change into effect on a temporary basis and learning about its potential impact Tasks Steps that need to be accomplished prior to a test or implementation

11. 11 We look at “Cause” in 2 ways: What is “causing” the problem? What will “cause” a solution? Step 3: Investigate The Cause

12. 12 Step 3: Investigate The Cause Of The Problem What is Root Cause? “Root Cause is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of the problem.” Or, in other words It’s a brainstorming process with a systematic approach to get to the true root cause….through the relentless use of “WHY?” When Root Cause is addressed, and you fix it, the problem goes away and doesn’t come back.

13. 13 How do we find the cause? Fishbone (aka: Ishikawa) analysis The 5 Whys Focus Groups SWOT analysis Deep data dives Flow charts Pareto Charts Step 3: Investigate The Cause If we don’t know the cause of the problem, we cannot effectively design a strategy to produce the effect we are looking for.

14. 14 Step 4: Develop Your Team Work Plan Assign tasks Set goals Decide on a beginning and an end Timeline Measure Report back and share Allow for tweaks and set backs Format your work plan so it is written or in chart format, and it is easy to read and follow. It should identify what gets done, when, and by whom.

15. 15 Lancaster General Hospital. Comprehensive Care Center. PA

16. 16 Step 5: PDSA Time! Now that we have our data, our Team, our problem causes, our work plan, we can start to implement CHANGE that will CAUSE the desired EFFECT. Never stop your Team from trying something innovative, creative, or different! So now, we are ready to “cause” the fix!

17. 17 How can we accelerate change and improvements in HIV programs?

18. 18 Change Method The Model for Improvement (MFI) is a method to help accelerate change… and increase the odds that the changes we make are an improvement.

19. 19 Improvement is about learning trial and error (scientific method) improvements require change, however not all changes are an improvement Measure your progress only data can tell you whether improvements are made integrate measurement into the daily routine Improvements thru continuous cycles of changes Plan-Do-Study-Act approach changes are initiated on a small scale to test them before implementation Model for Improvement

20. 20 Model for Improvement

21. 21 Act Adapt? Adopt ? Abandon? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Next cycle? Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan (on a small scale) Document problems and unexpected observations Begin analysis The PDSA Cycle for Learning and Improvement

22. 22 PDSA (Test) Cycles Have Been Going on for Years “Negative results on the fish… Let’s try rubbing two sticks together.”

23. 23 Why Test ? Increase your confidence that the change will result in improvement in your organization Learn to adapt the change to conditions in the local environment Minimize resistance when you move to implementation

24. 24 The Cycles Build on Each Other… Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very small scale test Follow-up tests Wide-scale tests of change Implementation of change

25. 25 AIM/Goal: Increase patient access to care. AP SD AP SD AP SD AP SD AP SD AP SD Testing ……………….Implementation………….Spread PDSA Changes in Parallel CM adjust intake process Information Systems ADAP Eligibility Process AP SD AP SD AP SD AP SD AP SD AP SD AP SD AP SD AP SD AP SD AP SD AP SD

26. 26 How Do Tests Lead to Improvements? You learn something from each test That knowledge gets incorporated into the next test Over time, as you build knowledge and expertise, you design a change that will more likely result in improvement in your environment

27. 27 Grantee Examples

28. 28 From Lucy Graham – St. Mary's Family Medicine, Grand Junction, CO

29. 29 Why read an ice cream label? 3 minutes to administer Easy to document Validated tool in English and Spanish Assesses Prose literacy Numeracy (Quantitative) Document literacy From: National Quality Center Technical Assistance Call, October 18, 2012: Why read an ice cream label? Lucy Graham, RN, MPH, St. Mary’s Family Medicine, Grand Junction, Colorado.

30. 30 The Newest Vital Sign (Pfizer, Inc)

31. 31 Ice Cream Label Assessment Questions 1.If you eat the entire container, how many calories will you eat? Answer: 1,000 is the only correct answer 2.If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? Answer: Any of the following is correct: 1 cup (or any amount up to 1 cup), half the container. Note: If patient answers “two servings,” ask “How much ice cream would that be if you were to measure it into a bowl?” 3.Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? Answer: 33 is the only correct answer

32. 32 Ice Cream Label Assessment Questions 4.If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? Answer: 10% is the only correct answer READ TO SUBJECT: Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. 5.Is it safe for you to eat this ice cream? Answer: No 6.(Ask only if the patient responds “no” to question 5): Why not? Answer: Because it has peanut oil.

33. 33 Interpretation Number of correct answers: Tally up ‘Yes’ answers Score of 0-1 suggests high likelihood (50% or more) of limited literacy. Score of 2-3 indicates the possibility of limited literacy. Score of 4-6 almost always indicates adequate literacy.

34. 34 Where Did My Fish Go? Problem: Environmental studies in New York found that certain fish in certain areas of New York State should not be consumed in large quantities Fisherman are granted limited licenses to catch these fish Potential for commercial fisherman to over fish Where to get data to “measure” consumption

35. 35 Where Did My Fish Go? Potential Solutions?

36. 36 Where Did My Fish Go? Engage commercial fisherman to report data; use statistical analysis to judge consumption Potentially involve major retail outlets Public awareness campaign in regions most affected

37. 37 Where Did My Fish Go? Potential PDSA Cycles Try to limit the number of commercial fisherman that are licensed; adjust as the data starts showing a change Develop a public awareness campaign and then look to one area that the data revealed to be high consumers and conduct a survey; expand the survey as it shows results. What else?

38. 38 Patient Education Tool Kawanis Collins, Magnolia Medical Center Identified a new sub population at risk 43 clients on ADAP – September, 2012 ADAP State Guidelines for qualification changed from CD4<350 to CD4<500 – added 19 patients Adherence Teach Back Tool was used to educate 10 clients who were newly eligible to be on medication

39. 39 Take Your HIV Medicine On Time and Every Day Educator name:

40. 40 CD4-T The CD4 T cells in your body are your friends They are like a factory, making things that protect you from infection.

41. 41 HIV CD4-T But HIV is a clever virus. It hijacks your good CD4 T cells, and turns them into an HIV factory. Then you get a lot of HIV (a big Viral Load).

42. 42 Study: Progress Log Adherence Teach Back Tool WeekTotal ClientsStart MedsRefused Meds (9/10-9/14)211 (9/17-9/21)000 (9/24-9/28)000 (10/1-10/5)211 (10/8-10/12)110 (10/15-10/19)110 (10/22-10/26)110 (10/29-11/1)000 (11/5-11/9)110 (11/12-11/16)330 Total11 9 2

43. 43 Questions? Comments?

44. 44 Contact Information Jane Caruso, MS, NQC Consultant, NQC/HIVQUAL, janecaruso@comcast.net Kevin Garrett National Quality Center 212-417-4730 NationalQualityCenter.org Info@NationalQualityCenter.org Info@NationalQualityCenter.org