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Quality Improvement and the Model for Improvement Hunter Gatewood, Improvement Advisor Learning Session 1 DSRIP RHP10 Learning Collaborative on Care Transitions.

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Presentation on theme: "Quality Improvement and the Model for Improvement Hunter Gatewood, Improvement Advisor Learning Session 1 DSRIP RHP10 Learning Collaborative on Care Transitions."— Presentation transcript:

1 Quality Improvement and the Model for Improvement Hunter Gatewood, Improvement Advisor Learning Session 1 DSRIP RHP10 Learning Collaborative on Care Transitions January 29, 2014

2 What is Quality Improvement? 2

3 Change at system level – Work at the frontline level – By multi-disciplinary staff teams Regular, ongoing assessment and measurement Reduction of variability Process focus, not individual as good/bad Examples – Establish reminder system to reduce no shows – Develop system to identify patients needing LDL test How do we do things better? 3

4 What is Quality Assurance? “The planned and systematic activities put in place to ensure that (quality) requirements for a product or service will be fulfilled.” Ensure that requirements, guidelines, regulations met Uses inspection (vs. regular measurement) Also known as quality control Examples: – Health code for restaurants – Licensing of providers – Audits of clinical facilities Are we (you) doing things right? 4

5 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement ActPlan StudyDo From Associates in Process Improvement. 5 AIM MEASURES CHANGES RAPID TEST OF CHANGES

6 Model for Improvement, Part 1 Aim Statements Monthly Measures and Run charts but first, 3 more distinctions 6

7 Diagram credit: hhs.gov, from original at Learning Collaboratives, DSRIP projects, and the Model for Improvement

8 Three DIFFERENT Uses of Numbers Research Judgment Improvement 8

9 Other Improvement Models Six Sigma LEAN (Toyota Production System) TQM CQI 9

10 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement ActPlan StudyDo From Associates in Process Improvement. 10 AIM

11 Characteristics of Good Aim Focused: Sets a clear goal to focus the team Measurable: can develop clear measures to track progress toward aim – Defines success numerically Time specific: establishes time frame (6-12 months) Clinically relevant, compelling Defines patient population 11 Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

12 Example Aims Within 12 months, decrease the percent of patients with >3 ER visits a year. Within six months, reduce waiting time for primary care appointments in SCC Clinic to Third-next Available Appointment Delay of 3 days or less. By December 2012, decrease the percentage of diabetic patients with HbA1c > 9 to ten percent. By {When}, increase/decrease {What} for {Whom} 12

13 Assess the Aim: Example 1 The QI team will meet five times in the next month – Focused: Sets a clear goal to focus the team? – Measurable and defines success numerically? – Time specific? – Clinically relevant? – Defines patient population? 13

14 Assess the Aim: Example 2 By December 2014, increase by 50% the percentage of patients with diabetes who got an HbA1c test in the past 12 months AND have HbA1c < 9%. – Focused: Sets a clear goal to focus the team? – Measurable and defines success numerically? – Time specific? – Clinically relevant? – Defines patient population? 14

15 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement ActPlan StudyDo MEASURES

16 Measurement for Improvement Purpose: To track progress (improvement!) over time and to promote buy-in. Audience: QI Team, Front-line staff and providers, Senior sponsors

17 RHP10 shared Care Transitions measures Pre-work, Appendix D 1.Discharge plan to patient % patients who received written plan at time of discharge 2.Discharge plan to provider % patients whose follow-up provider received discharge summary within 7 days of discharge 3.Community provider contact % patients with contact within 7 calendar days of discharge

18 Characteristics of a Good Measure Directly relates to aim Specifies patient population Data are available Able to collect data frequently Worth measuring for at least 12 months

19 Example Measures Number of days until third next available appointment. Aim: Within six months, reduce waiting time for primary care appointment to 3 days. Percentage of patients with HbA1c >9. Aim: By December 2012, decrease the percentage of diabetic patients with HbA1c > 9 to 10% or less.

20 Assess the Measure: Example 1 Number of times the QI team meets each month – Directly relates to aim? – Specifies patient population? – Data are available? – Able to collect data frequently? Aim: The QI Team will meet 5 times in the next month

21 Assess the Measure: Example 2 Number of improvements to the care of patients with diabetes – Directly relates to aim? – Specifies patient population? – Data are available? – Able to collect data frequently? Aim: Improve the care of diabetic patients over the next 12 months

22 Assess the Measure: Example 3 Percentage of patients with HbA1c testing during past 12 months – Directly relates to aim? – Specifies patient population? – Data are available? – Able to collect data frequently? Aim: By December 2012, 90% of DM pts. will have had an A1c in the past 12 months.

23 Sample Run Chart 23 Median

24 Run Charts Display ordered sequence of data and provide running record over time Can be used for any data that are sequenced over time (trending) Require no statistics Visually illustrate progress toward goal 24 Adapted from, NHS Scotland Tutorial Guide on Statistical Process Control.

25 Understanding Variation All sets of data demonstrate variation. Two types of variation – Random/common cause (NOT special; regular) – Special cause (something going on) 25 Adapted from, NHS Scotland Tutorial Guide on Statistical Process Control.

26 Common Cause Variation Inherent in the design of the process Normal fluctuations due to everyday reasons Process is “in control” – variation is predictable Nothing out of the ordinary Example: Arrival time to work 26

27 Special Cause Variation Due to unexpected events NOT inherent in design of the process Generally infrequent Suggests that process or system is “unstable” or “out of control” Also known as “assignable” variation Philosophy of statistical process control  identify and address special cause variation 27

28 Detecting Special-Cause Variation Four run chart rules Astronomical point Shift Trend Number of runs 28

29 29 Did the change result in improvement?

30 Change Made Change Made Change Made

31 Benefits of Run Charts Tells story visually Focuses on the process Prevents jumping to unfounded conclusions about what does/doesn’t work Motivates people to think like improvers 31

32 Team Meeting 1: Aim Statement and Measures

33 Model for Improvement, Part 2 Test changes small, using the Plan-Do-Study-Act Cycle

34 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement ActPlan StudyDo 34 From Associated in Process Improvement

35 Learning Objectives Learn the value of testing changes in care on a small scale before implementing widely Learn how to turn your ideas into tests (PDSAs) Plan a PDSA test to complete when you return to work

36 Why do Small Tests of Change? Understand the likelihood that change will result in improvement Understand the extent and limitations of the change Learn to adapt the change to local environment – Evaluate cost – Address unexpected consequences Gain buy-in and minimize resistance if change is implemented and spread 36 Adapted from the Institute for Healthcare Improvement Breakthrough Series College. 36

37 PDSA – Rapid Cycle Improvement 37 Act Questions & predictions (why?) Plan to carry out the cycle Plan Study Do Carry out plan Document Begin data analysis Complete analysis Compare data to predictions Summarize what was learned Adapted from the Institute for Healthcare Improvement Breakthrough Series College. Adapt Adopt Abandon

38 PDSA STEP by STEP 1.Identify a daily process need/problem 2.Brainstorm possible solutions 3.Choose one to test 4.Write a PLAN for your test 5.DO it! Conduct the test and document the data. 6.STUDY the data to determine whether or not this test solved the problem 7.Take ACTion-your most logical next step to solve the problem or retest for effectiveness

39 39 Example of PDSA Subject: Diabetes: Planned visits for blood sugar management. Plan: Ask one patient if he or she would like more information on how to manage his or her blood sugar. (Predict: Patient will say “yes”) Do: Dr. J. asked his first patient with diabetes on Tuesday. Study: Patient was interested; Dr. J. was pleased at the positive response. Act: Dr. J. will continue with the next five patients and set up a planned visit for those who say yes. Source: ihi.org

40 Exercise Stand in groups of 8 Get one tennis ball for your group Pick team’s timekeeper Name your team, quickly 40

41 “HEY, LET’S GO SEE HOMER BLOW HIMSELF UP.” 41 Video: “October Sky” Scene 6, “Rocket Roulette” (from 34:37 to 41:00)

42 Repeated Uses of PDSA Cycle 42 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 Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

43 Keys to Successful Small Tests of Change Scale down: do small tests Collect useful data during each test Test over a wide range of conditions 43 Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

44 Run PDSAs in Parallel 44 A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Specific Test Cycles Implement registry Group Visits Workflow redesign Team care approach

45 Using a PDSA Worksheet PLAN: activities and timelines, including person responsible DO: describe what actually happened during test STUDY: review data collected during plan phase and compare to predictions ACT: determine what to change and what to keep based on previous plan cycle (this is a new PLAN) 45


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