Overview of Quality Improvement Terminology and Principles 86,408 PLWA – reported in the 8 states At least 43,000 PLHIV – estimated TOTAL POTENTIAL IMPACT: IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States

IOM - Definition of Quality “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990)

‘QI is not QA’ Motivation Measuring compliance with standards Means Quality Assurance Quality Improvement Motivation Measuring compliance with standards Continuously improving processes to meet standards Means Inspection Prevention Attitude Required, defensive Chosen, proactive Focus Outliers: “bad apples” Individuals Processes Systems Scope Medical provider Patient care Responsibility Few All

QI vs. Accreditation and Clinical Research Aspect Improvement Accountability (Accreditation) Clinical Research Aim Improvement of care Comparison, reassurance, spur for change New knowledge Test observability Test observable No test, evaluate current performance Test blinded Sample size “Just enough” data, small sequential samples Obtain 100% of available, relevant, data “Just in case” data Testing strategy Sequential tests No tests One large test Solberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3.

Balance between Data Collection and Quality Improvement Activities Infrastructure

Principles on the Quality Improvement Journey…

Success is achieved through meeting the needs of those we serve.

Most problems are found in processes, not in people.

Do not reinvent the wheel – Learn from best practices.

Achieve continual improvement through small, incremental changes.

Actions are based upon accurate and measured data.

Infrastructure enhances systematic implementation of improvement activities.

Set Priorities and Communicate clearly

Introduction of Quality Improvement Model: PDSA Cycle 86,408 PLWA – reported in the 8 states At least 43,000 PLHIV – estimated TOTAL POTENTIAL IMPACT: IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States

Model for Improvement 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

In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment? 1602 1689 1757 1796 1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment? 1602 1689 1757 1796 (195 years later) 1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

Treatment of Scurvy Stephen J. Bown - Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail; St. Martin's Press, 2004 In 1601 lemon juice, as a protective against scurvy, is recorded by James Lancaster. In 1612, Woodall recommended citrus fruit for protection against scurvy on sea voyages. In 1753 James Lind published A Treatise on the Scurvy which portrays his experiment on-board the ship Salisbury in 1747. From 1772 to 1775 sailors on historic voyages with Captain James Cook remained free from scurvy. In 1796 lemon juice was officially introduced in the British Navy as a prophylactic against scurvy. In 1865 British Board of Trade adopted the policy for the merchant marine.

How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article? 2 years 5 years 10 years 20 years 1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article? 2 years 5 years 10 years 20 years 1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

Treatment of Ulcer – Dr Marshall Timetable: 1979: Dr. Robin Warren, pathologist at Royal Perth Hospital, Australia found bacteria in stomach of patients 1981: Dr. Barry Marshall starts residency 1982: Marshall cultivates bacteria: Helicobacter pylori, 100% in Duodenal Ulcer and 77% in Gastric Ulcer 1984: first publication in Lancet; presents treatment of ulcer with common antibioticum 1994: National Institute of Health recommends treatment of ulcer as suggested by Dr. Marshall Conclusio: Too long to adapt proven concept - how can we adapt existing knowledge faster in daily actvities New ideas come from outsiders ‘Early Adopter’ Diffusion of Innovation Everett Rogers B) Neugeborenenstation in Honulu, Hawaii hat jährlich $120,000 Dollar für Schutzmasken, Plastik Handschuhe usw. ausgegeben. Nach 13 Studien wurde dort eine 14. Studie durchgeführt mit dem selben Ergebnis: es gibt keinen messbaren Unterschied der Ansteckungsrate zwischen der Vergabe von Schutzkleidern an Besuchern und der Nichtvergabe. C) CQI Team: billinf Team, six months still trying to find causes, did not start to change things around. HAND OUTS

In a recent article in the Journal of Quality Improvement 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot? 23 days 60 days 397 days 504 days 1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

In a recent article in the Journal of Quality Improvement 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot? 23 days 60 days 397 days 504 days 1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

Survey of 92 Quality Improvement Projects in Journal of Quality Improvement Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11): 619-632 504 days from problem identification to completion of first pilot 397 days from first team meeting to the end of first cycle 75 days to describe current situation in flowchart 62 days for data collection if change was improvement

How can we accelerate change and improvements in HIV programs?

Model for Improvement Act Plan Study Do Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Act Plan Study Do MFI model for Improvement How many have heard? Elegantly simple model that is useful … 3 questions plus the PDSA cycle Go over 3 questions and plan do study act ; pdsa

What are we trying to accomplish? Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Why this question is important … highly corelated with success of a team ..

that a change is an improvement? Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? What is the second question … how will we know? Why is this important ….

What change can we make that will result in improvement? Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? So what is the third question? The changes that you make should align with your aim and measures… Where do they come from ? IHI change packages… chanes with a pedigree… have a high degree of belief they willwork .. Have worked .. Ideas in the op doc.. Op Doc.. Each other..

The PDSA cycle for learning and improvement Act Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) What changes are to be made? Next cycle? Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data

Why Test? Increase your confidence that the change will result in improvement in your organization Learn how to adapt the change to conditions in the local environment Minimize resistance when you move to implementation Basically, a PDSA cycle is a test. In a way, it’s like a high school biology experiment. You develop a theory (if we use an adherence screening tool with each client or patient, we’ll be able to help more patients adhere to treatment), and then run a small test to see if your theory is true. Testing out improvement ideas is a tremendous help to implementation. From tests, you can Know that your idea will work in your organization Fine-tune an idea to meet the specific situation in your program or clinic Show people that the idea can work, so they’ll be more likely to give it a try themselves.

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 result in improvement. The answer lies in the repetitive nature of the tests. You run one PDSA cycle, and then another that is a little more complex (based on what you learned from the first), and then another that is still more complex.

The cycles build on each other… Hunches Theories Ideas Changes That Result in Improvement A P S D DATA Very small scale test Follow-up tests Wide-scale tests of change Implementation of change This diagram shows how the cycles build on each other. Eventually, you get to a wide-scale test of a change – trying a new screening tool in the entire clinic, for example. By the time you get to this point, when you’re involving all the staff – even those who are cranky and cynical – you’ve got a pretty good sense that the new tool will work. So, in a sense, you’ve taken the risk out of trying something new.

PDSA Cycle to incorporate the use of a new CM form Improve Access to HIV Primary Care D S P A DATA A P S D Cycle 1E: Implement and monitor the standards D S P A Cycle 1D: Revise and test tool with all clients for one week A P S D Cycle 1C: Present refined tool to all 3 case managers and document feedback A P S D Introduce new CM Intake/ Assessment Form Cycle 1B: Revise tool and test with Karl’s clients next Monday Cycle 1A: Adapt new CM form and test with one of Joanne’s patients

Tips for PDSA Cycles “What change could you implement by next Tuesday?” Use the “Rule of 1”: 1 facility 1 office 1 provider 1 patient We’ve learned: Keep the first test small. Remember Dr. Smith and her 35-minute screening tool. Give yourself a chance to even to fail in this first test. Sometimes you learn the most from trying something that really doesn’t work. A common question to those starting their first PDSA cycle is: what change can you implement by next Tuesday? This question forces you to think small by reducing the sample size (‘just a few records’) and decreasing the implementation timetable (‘within a few days’) to a minimum. One way to help you and your colleagues “keep it small” is to remember the Rule of 1. Design the first test for one facility, one office, one provider or one patient. See what happens, act on that knowledge, and then scale-up the test.

Useful, not perfect, data Use “huddles” to report Tips for PDSA Cycles Volunteers at first Useful, not perfect, data Use “huddles” to report Learn from others (‘Steal shamelessly, Share senselessly’) Just get started! Here are three more important pointers for success: Start out with your friends. Don’t try to convince the skeptics until you have proof. To get the proof, use volunteers – people who are interested in doing things differently. This isn’t a randomized clinical trial. It’s a test. You don’t need double-blind data, you need information about how to make things work. Whether Dr. Smith’s test took 34.3 minutes or 36.72 minutes doesn’t matter. The point is that it took about 35 minutes, and that was way too long. Scheduling a formal meeting will take at least a week – pretty silly to do that to discuss the results of a one-day test. Grab people when you can, share information as it comes up. Dr. Smith could find Sally after the patient visit on Thursday morning and say, “Sally, that tool took 35 minutes, this will never work.” Sally might say, “Wow, you’re right. Joan and I found other tools, let me get her and we’ll come up with some others that might be better to try next.” The important thing is to keep moving forward, because…

References Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62 Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81 Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; “The Improvement Guide” San Francisco, CA; Jossey-Bass, 1996 Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55

PDSA Large Group Case Study What PDSA do you suggest for the following scenario? An agency wants to initiate a QI project to remind clients of their upcoming appointment.

PDSA Case Study Does your PDSA have the following three qualities? Can you do the PDSA “by next Tuesday”? Can you collect just enough data to know that this change will result in improvement? Do you have a hypothesis?

National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street—13th Floor New York, NY 10007-2919 888-NQC-QI-TA Info@NationalQualityCenter.org NationalQualityCenter.org