The Olympic Team Trials: An Orientation to the Institute for Healthcare Improvement Breakthrough Series* Joe Kyle, MPH Kim McCoy, MPH, MS *some adaptations for MLC collaboratives

Objectives By the end of this session, you should be able to—  Describe the elements of a successful Breakthrough Series collaborative  Recognize and define the phases of the Breakthrough Series model  Understand how this applies to the MLC-3 collaboratives

Who is IHI? The Institute for Healthcare Improvement (IHI) is an independent, not-for-profit organization whose work is to help lead the improvement of health care around the world.

What is the IHI Breakthrough Series? IHI’s Breakthrough Series (BTS) is an improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim.

IHI Breakthrough Series (6 to 18 months time frame) Select Topic (develop mission) Planning Group Develop Framework & Changes Participants ( teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports (listserv) Phone Conferences Visits Assessments Monthly Team Reports Dissemination Publications, Congress. etc. AD P S Expert Meeting AP1AP2 AP3* LS – Learning Session AP – Action Period *AP3 – continue reporting data as needed to document success Holding the Gains

Goals for a BTS Collaborative  Achieve results  Accelerate improvement– get results faster!  Define, document, and disseminate good ideas  Develop leaders of change

Example of BTS Model* Applied to Public Health *some adaptations for MLC collaboratives ISSUE 1: Implementing Clinical Practice Guidelines for Smoking Cessation in all Public Health Clinical Settings ISSUE 2: Improving capacity for Health Improvement Planning at local health departments

BTS Phase 1 Topic Selection

IHI Breakthrough Series (6 to 18 months time frame) Select Topic (develop mission) Planning Group Develop Framework & Changes Participants ( teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports (listserv) Phone Conferences Visits Assessments Monthly Team Reports Dissemination Publications, Congress. etc. AD P S Expert Meeting AP1AP2 AP3* LS – Learning Session AP – Action Period *AP3 – continue reporting data as needed to document success Holding the Gains

Topic Selection 1. There is a gap between science (evidence) and practice 2. Examples of better performance exist 3. A good “Business Case” exists for the topic

Topic Selection for BTS Public Health Example Smoking Cessation HIP – Community Engagement Gap btw science and practice Clinical practice guidelines are proven to be effective AND guidelines implemented unevenly across programs Community engagement guidelines exist AND practice varies by local health department Examples of better practice Fully implemented in one large FP program in X state; One large WIC site in our state MAPP, ACHI, state and local work (e.g. Assess Now – Washington) Business Case Proven impact on reducing smoking, a critical health status issue for public health Legally mandated to do it, lack of resources to do everything, evidence of significant disparities

BTS Phase 2 Developing the Technical Content

IHI Breakthrough Series (6 to 18 months time frame) Select Topic (develop mission) Planning Group Develop Framework & Changes Participants ( teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports (listserv) Phone Conferences Visits Assessments Monthly Team Reports Dissemination Publications, Congress. etc. AD P S Expert Meeting AP1AP2 AP3* LS – Learning Session AP – Action Period *AP3 – continue reporting data as needed to document success Holding the Gains

Content Development 1. Collaborative Charter 2. Change Package 3. Measurement Strategy

Collaborative Charter  Establishes a common vision for the work Problem statement Problem statement Gap between science and practice Gap between science and practice Mission statement Mission statement Business case for improvement Business case for improvement Specific goals Specific goals Expectations Expectations

Change Package  The essential changes needed to accomplish the mission Evidence-based strategies Evidence-based strategies Model practices Model practices Credible expert opinion Credible expert opinion

Measurement Strategy  Key measures that will be used to track improvement  Definitions of data elements  Data collection methods

How is technical content developed?  Staff do initial research with one or two experts  Panel of experts broadens and deepens the content  Staff work with other experts to enhance and “package” the content for the Collaborative  During the Collaborative the content is tested and developed further; package is revised.

Expert Meeting- A Key Step  Invite experts in topic area Multidisciplinary Multidisciplinary Mix of research and applications expertise Mix of research and applications expertise Practitioners necessary Practitioners necessary Best thinkers and doers on the topic Best thinkers and doers on the topic  Develop the technical content  Identify faculty for Learning Sessions

Development of Technical Content Public Health Examples Smoking Cessation HIP – Community Engagement Problem Statement Clinical practice guidelines not implemented in all public health clinics Community involvement in local public health planning is insufficient Mission Statement Clinical practice guidelines implemented consistently in all public health clinics All community groups actively engaged in local public health planning Goal WIC, FP, and STD clinics implementing the guidelines Participation by historically disenfranchised groups

BTS Phase 3 Prework

IHI Breakthrough Series (6 to 18 months time frame) Select Topic (develop mission) Planning Group Develop Framework & Changes Participants ( teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports (listserv) Phone Conferences Visits Assessments Monthly Team Reports Dissemination Publications, Congress. etc. AD P S Expert Meeting AP1AP2 AP3* LS – Learning Session AP – Action Period *AP3 – continue reporting data as needed to document success Holding the Gains

Why Prework?  Establish an action-oriented culture  The teams come ready to work  Engage others– lay foundation for the improvement back home

Prework for the Planning Group Planning Group- Collaborative staff, small group of experts  Completing first iteration of the Change Package  Selecting and enrolling teams  Creating and testing Prework materials  Preparing teams  Assessing resources

Prework for Collaborative Teams Collaborative Teams- Local staff, community partners, other stakeholders  Discuss aims and focus work  Engage the senior leader  Initiate measurement and other information gathering  Identify resources and develop a budget  Storyboard This is a different type of learning experience

BTS Phase 4 Learning Sessions and Action Periods

IHI Breakthrough Series (6 to 18 months time frame) Select Topic (develop mission) Planning Group Develop Framework & Changes Participants ( teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports (listserv) Phone Conferences Visits Assessments Monthly Team Reports Dissemination Publications, Congress. etc. AD P S Expert Meeting AP1AP2 AP3* LS – Learning Session AP – Action Period *AP3 – continue reporting data as needed to document success Holding the Gains

Learning Session Objectives Learning Session 1 Get Ideas Get Methods Get Started Learning Session 2 Get More Ideas Get Better at Methods Get a “Stride” Learning Session 3 Celebrate Successes Get ready to Sustain and Spread Action Period 1Action Period 2 Test all changes on small scale Test & implement all changes

Learning Session Deliverables  A viable plan for the first test of change  A written and feasible project plan that includes testing multiple changes  The motivation and confidence to get started immediately

Action Periods– Where the Rubber Meets the Road Opportunity for the teams to  Test changes  Measure results  Get help from colleagues

Action Periods Opportunity for staff to  Support teams in their improvement work  Build collaboration and shared learning  Assess collaboration and progress This is the time of maximal learning

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? Act Plan DoStudy From: Associates in Process Improvement

Plan, Do, Study, Act  Plan – who, what, when, where  Do – implement change, collect data  Study – analyze results – if test was successful, then Act, if not, then Plan again  Act – Implement on a broad scale and move to next cycle

PDSA Cycle Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Small Scale Test Follow-up Tests Wide-Scale Tests Implementation of Change

PDSA Cycle Public Health Examples Smoking Cessation HIP – Community Engagement 1 Test clinical practice guidelines with 1 provider in 1 clinic for 1 week Test engagement strategy with 1 population group in 1 neighborhood 2 Test clinical practice guidelines with 1 provider in 1 clinic for 2 weeks Test engagement strategy with 1 population group in multiple neighborhoods 3 Test clinic practice guidelines with all providers in 1 clinic for 1 month Test engagement strategy with multiple population groups in 1 neighborhood

BTS Phase 5 Holding the Gains and Spread

Holding the Gains  Continued tracking of improvements  Part of the BTS Design! Spread Definition-- Adapting change to areas or populations other than your pilot populations

Why Think About Spread Early in Your Collaborative Planning?  For those planning a collaborative: Helps identify which organizations or persons to invite to collaborative Helps identify which organizations or persons to invite to collaborative  For the collaborative’s teams: Aids in team’s selection of their pilot population Aids in team’s selection of their pilot population Can think about who to involve and cultivate relationships for spread Can think about who to involve and cultivate relationships for spread

Examples of Spread  One county clinic site to all county clinic sites  One population group to multiple population groups  One preventable chronic disease program to multiple chronic disease programs  One neighborhood to an entire city

Holding the Gains and Spread Public Health Examples Smoking Cessation HIP – Community Engagement 1 Implementation of clinical guidelines in all public health clinics Implementation of engagement strategies by all local health departments 2 Incorporate measure of clinical guidelines in performance measurement system Annual reporting on community engagement – by population group - in performance measurement system 3 Monitor smoking rates among clinic clients Monitor community satisfaction

Does Spread without Sustainability Make any Sense? The Total Health Care System AP SD AP SD Small-scale tests of change System or Population of Focus for the BTS (defined by team’s Aim) AP SD S P R E A D Success

Lessons Learned/Tips  Flexibility  Focus  Short-term process improvement vs. long- term outcome improvement  Incentives  Failure as valuable as success (sometimes more so)