1. Academic Pediatric Association QUALITY IMPROVEMENT TRAINING: Module #1 Overview: The Model for Improvement and Deming’s System of Profound Knowledge This work is supported by a grant from The Centers for Disease Control & Prevention.

2. National Partnership for Adolescent Immunization PI: Peter Szilagyi Coordinators: Christina Albertin, Nui Dhepyasuwan Ed Marcuse (communication expert) Cindy Rand Jan Schriefer (QI expert) Stanley Schaffer Janet Serwint William Stratbucker Donna D'Alessandro William Atkinson Paul Darden Sharon Humiston (moderator) Keith Mann (QI expert) FACULTY & CONSULTANTS

3. This is part of the APA series on Quality Improvement. The examples focus on adolescent immunization, but the principles are widely applicable. The series includes: 1. Overview: The Model for Improvement and Deming’s System of Profound Knowledge 2. Improvement cycles and the psychology of change 3. Initiating a QI project 4. More tools to better understand the system 5. How will we know that a change is an improvement? An introduction to QI measurement 6. Changes we can make that will result in improvement

4. Module 1 Objectives 1. Describe briefly 3 steps you need to take before starting the actual remedial QI process. These correspond to the modeling processes of Juran’s Diagnostic Journey. 2. Describe briefly the 4 inter-related components of a problem that Dr. Deming argued needed to be understood as part of the conceptual modeling of a problem. 3. Describe briefly 2 aspects of the actual remedial QI process. These correspond to Juran’s Remedial Journey, or the Model for Improvement. 4. Outline how research is different than QI

5. Importance of a Thoughtful QI Approach If you want to improve your clinical setting, what are your options? 1. Keep doing what you are doing & hope for different results (the definition of insanity) 2. Just do something new & hope for the best Unexpected consequences? Sustainability? Isn’t this approach the root of a lot of our cynicism? 3. A thoughtful QI approach

6. 1. Three steps you need to take before starting the actual remedial QI process

7. Don’t “Just Do It” Before you start making changes, key steps include: 1. Development of a (general) mission statement 2. Conceptual modeling of the problem 3. Prioritization of possible changes

8. 1) Development of a general mission statement What are you trying to accomplish – in a general way (e.g., “We want to increase our adolescent immunization rates.”) At this phase, you probably do not know the specifics (e.g., For which vaccines are your rates low? Are they only low for a subset of patients?) Development of a more specific Aim Statement is covered in Module 3

9. 2) Conceptual modeling of the problem A. Formal methods – conceptual flow diagrams, decision flow charts B. Informal methods – cause & effect diagrams, 5 whys These tools will be introduced in Module 4.

10. 3) Prioritization of possible changes (Tools to help you with this are in Module 6.)

11. QUESTION #1 Which of the following is NOT a step you need to take before starting the actual remedial QI process? 1. Model the problem 2. Spread the change to affiliated clinical sites 3. Write a general mission statement 4. Choose a change to test

12. QUESTION #1 Which of the following is NOT a step you need to take before starting the actual remedial QI process? 1. Model the problem 2. Spread the intervention to affiliated clinical sites (This step may come after an intervention has been shown to be successful.) 3. Write a mission statement 4. Choose a change to test

13. 2. Four inter-related components of a problem Dr. Deming argued these needed to be understood as part of the conceptual modeling of a problem.

14. For complex problems… Quick fixes  True long-term solutions

15. “Boost teen immunization rates!”

17. NameMeaningExample SystemWhat are the parts of the process and how do they relate to one another? “Frankly, the doctors don’t know what the nurses have already told the parents about adolescent vaccines, nor do the nurses know what the doctors plan to say.”

18. NameMeaningExample SystemWhat are the parts of the process and how do they relate to one another? “Frankly, the doctors don’t know what the nurses have already told the parents about adolescent vaccines, nor do the nurses know what the doctors plan to say.” VariationHow do the outcomes change from time to time? Which of these changes is an inherent part of the process (common cause) and which is not typically part of the process (special cause)? “During some times of the day our computers are so slow that it would take 5 full minutes to pull up an adolescent’s past immunization record.” (Common cause) “3 nurses were out sick today so many things did not get done.” (Special cause)

19. NameMeaningExample SystemWhat are the parts of the process and how do they relate to one another? “Frankly, the doctors don’t know what the nurses have already told the parents about adolescent vaccines, nor do the nurses know what the doctors plan to say.” VariationHow do the outcomes change from time to time? Which of these changes is an inherent part of the process (common cause) and which is not typically part of the process (special cause)? “During some times of the day our computers are so slow that it would take 5 full minutes to pull up an adolescent’s past immunization record.” (Common cause) “3 nurses were out sick today so many things did not get done.” (Special cause) Theory of knowledge What do people in the organization view as meaningful information? (This affects their learning and decision-making.) “I don’t believe the CDC estimates on how many adolescents have sex. At least I don’t think it’s true for our patients.”

20. NameMeaningExample SystemWhat are the parts of the process and how do they relate to one another? “Frankly, the doctors don’t know what the nurses have already told the parents about adolescent vaccines, nor do the nurses know what the doctors plan to say.” VariationHow do the outcomes change from time to time? Which of these changes is an inherent part of the process (common cause) and which is not typically part of the process (special cause)? “During some times of the day our computers are so slow that it would take 5 full minutes to pull up an adolescent’s past immunization record.” (Common cause) “3 nurses were out sick today so many things did not get done.” (Special cause) Theory of knowledge What do people in the organization view as meaningful information? (This affects their learning and decision-making.) “I don’t believe the CDC estimates on how many adolescents have sex. At least I don’t think it’s true for our patients.” PsychologyWhat is the understanding of the people in the organization on how interpersonal and social structures affect performance of the system or process? “Boys will be boys, so they are going to be exposed to the HPV virus and my brother’s son had genital warts so I heard about how horrible they can be.”

21. If you do not know how to ask the right question, you discover nothing. W.E. Deming

22. What are the potential beliefs about HPV vaccine clinic held by those within the system? How could those beliefs impact the success of the QI project What are barriers to change within the clinic (people / processes)? That is, what are the attitudes to change itself that make change harder. Questions that help clarify the theory of knowledge & psychological aspects of the problem:

23. How could the barriers be overcome? What could we do to motivate the healthcare workers? It is key to recognize that different things motivate different people. What additional information does this group need and how would you gather that information? Questions that help clarify the theory of knowledge & psychological aspects of the problem (continued):

24. Variation: How do the outcomes change from time to time? Common cause variation Due to factors inherent in the system (the noise in the system) Accounts for most of the variation Example: Some days more patients show up so everyone is pressured and shots during acute visits do not happen

25. Special cause variation Due to unexpected factors Accounts for little of the variation Example: On March 3 rd, someone accidentally locked the room that had the vaccine refrigerator so on that day no one got vaccinated Variation (continued)

26. Why do we care about differentiating these causes of variation? Design: Usually, we want our QI change to address problems inherent to the system, not just blips Analysis of outcomes: After we put our change in place, when we are analyzing the outcome we want to be sure that improvement is part of the (new) system, not just a blip

27. QUESTION #2 At the QI team’s first meeting, team members report hearing the opinions (shown on the next page) about the office’s low adolescent immunization rates. Which of the 4 aspects of Dr. Deming’s System of Profound Knowledge corresponds to the team members’ concern? (Use each of the 4 only once.)

28. Your choices are Appreciation for the system, understanding variation, theory of knowledge, & psychology

29. Your choices are Appreciation for the system, understanding variation, theory of knowledge, & psychology

30. 3. Two aspects of the actual remedial QI process

31. Model for Improvement (aka Remedial Journey) 1. Answering Nolan’s 3 fundamental questions for improvement 2. Running rapid cycle improvement trials

32. Nolan’s 3 Fundamental Questions for Improvement 1. What are we trying to accomplish?  Focused aim statement 2. How will we know that a change is an improvement?  Measurement system – balanced measures, run charts 3. What changes could we make that might result in improvement?  List of change hypotheses

33. Rapid Cycle Improvement Trials (aka PDSA Cycles) Plan a change Do it in a small test Study the results Quantitative data (run charts) Qualitative data (front-line worker experience) Act Modify or replace the change hypothesis OR Accept and deploy results

34. 4. What is the difference between QI and research?

35. Research or QI? QI and research?

36. Institutional Review Each organization has different policies on having their Institutional Review Board (IRB) decide what is research and what is a QI project. Be sure to work with your IRB before beginning your project.

37. Summary 1. Before starting the actual remedial QI process develop a mission statement, model the problem, and prioritize possible changes. 2. 4 inter-related components of a problem you need to understood include the system, variation, knowledge and psychology. 3. The Model for Improvement includes answering 3 essential questions and then doing PDSA cycles iteratively. 4. Research is different than QI; make sure you comply with the policies of your IRB.

38. The End of Module #1