Performance Improvement --An Overview Auxford Burks, MD Albert Einstein College of Medicine Department of Pediatrics/ Jacobi Medical Center

Thanks to: Daniel Hyman, MD, MMM Chief Medical Officer, Ambulatory Care Network New York Presbyterian Hospital Who provided all of this material

Fundamental Questions for Improvement 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 an improvement?

Model for Improvement Aim: What are we trying to accomplish? Measures: How will we know that the change is an improvement? Ideas: What changes can we make that will result in an improvement?

Model for Improvement Aim: What are we trying to accomplish?

What are we trying to accomplish? Aim: A written statement of the accomplishments expected from each pilot team’s improvement effort Different forms are useful: A general description of aim Specific patient population Some guidance for carrying out the work

The Team’s Aim Should Be: Strategic Relevant Exciting Important A stretch, not business as usual Achievable, not impossible Understandable

Sample Goals/Measures 95% of patients with asthma will have symptom frequency documented in their record (day and night) – process measure 95% of patients will have asthma severity specifically identified at all visits where asthma is addressed – process measure 90% of patients with persistent asthma will be treated with an appropriate antiinflammatory medication, at an appropriate dose – process measure 95% of patients with asthma will have a documented assessment of tobacco use or exposure and counseling to reduce risk if applicable – process measure There will be an X% reduction in ED/hospitalization rate over Y period of time – outcome measure Visit volume in clinic will be unchanged – balancing measure

AIM: Why the Change is Desired A known performance deficiency in an important process A gap between current performance and desired performance

Why an Aim Statement? Answers and clarifies “What are we trying to accomplish? Creates a shared language and shared methods Facilitates organizational conversations and understanding Supports accountability for team leaders

Developing the Aim Statement Write a clear and concise statement stating the “who, what, when, and where “ Who will undertake the work, and who will be affected by it What does the team intend to do When will the aim be accomplished Where - define pilot site and spread site(s)

SMAART Aims Specific: Understandable, unambiguous Measurable: Numeric goals Actionable: Who, what, where, when Achievable (but a stretch) Relevant to stakeholders and organization Strategic, Compelling, Important Timely: with a specific timeframe

Sample Aims We will improve the care of patients with asthma by adhering to evidenced based guidelines for diagnosis, assessment and treatment, thereby reducing morbidity/mortality By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 days or more in the 2-week period preceding a planned care visit.

Example of Elaborated Aim Statement Aim: By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 or more in the 2-week period preceding a visit. To effect change, we will be guided by using the six components of the Care Model for Child Health. Intermediate aims are that: 95% of children with persistent asthma will have severity classified at every visit. 95% of children with persistent asthma will be treated with appropriate maintenance anti-inflammatory medication. 90% of children will receive a written asthma management plan on which we will document family/self- management goals.

Ideas Aim Measures Model for Improvement Act Plan Study Do Act Plan What are we trying to Aim accomplish? How will we know that a Measures change is an improvement? What change can we make that Ideas will result in improvement? Act Plan Study Do Act Plan Study Do From: Associates in Process Improvement

A PDSA Cycle PDSA Objective: Test the use of encounter form to facilitate visit Will encounter forms facilitate severity classification? Dr. X will try form with severity class Qs with 3 patients on Thurs Revise form. Try new form with 3 patients tomorrow; MA will put form on chart. Dr. X found the form helpful for prompting; thought items on form should be in a different order. Need better process for getting form to provider. Dr. X tried with two patients. Couldn’t find a form for third patient.

Why Test? Increase your belief that the change will result in improvement Opportunity for learning from “failures” without impacting performance Document how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation

Ideas: What Changes Can We Make That Will Lead to Improvement? Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

Ideas: What Changes Can We Make That Will Lead to Improvement? Change Concept: A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Promote clinical care that is consistent with scientific evidence and family preferences Use tool to classify severity at every visit

Change Concepts vs. High Leverage Changes Vague, strategic, creative Specific, actionable, results Improve care of asthma patients Share info w/ patients & families and encourage self-management Document asthma management plan and goals for self-management Begin discussion of self-management goals w/ 3 patients on Monday

Repeated Use of the PDSA Cycle 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 Improve asthma outcomes Changes That Result in Improvement Reduction in ED visits Change Pkg. A P S D DATA D S P A Implementation of Change A P S D Wide-Scale Tests of Change A P S D Follow-up Tests Hunches Theories Ideas Very Small Scale Test

PDSA example I A pediatrician goes to a conference one October and learns all about Improvement, PDSA cycles, and how to improve care for patients with asthma. He returns to his practice completely enthused and ready to do something new that will improve care. We’ll call our protagonist in this story, Bill Caspe

PDSA example I Bill decides to look at his 5 person practice’s assessment of children whose parents call for refills of asthma medications to see whether the children: Need flu vaccines Are having symptoms too frequently (i.e. are not being well controlled on their current medication regimen) He develops a form and gives it to his nurse to use for one week when asthma meds are refilled

PDSA example I Is this a good PDSA cycle? What do you think happened? Why? Why Not? What do you think happened?

PDSA example II The pediatric residents in a community based clinic are taught about improvement, PDSA cycles, and how to improve care for patients with asthma. They are provided with baseline data that shows that only 20% of children have a severity classification of their asthma in the practice’s medical records

PDSA example II The residents develop a sticker that prompts the questions needing to be asked to determine symptom frequency One resident on ambulatory block tries the sticker for 5 consecutive patients with asthma.

PDSA example II Is this a good PDSA cycle? What do you think happened? Why? Why Not? What do you think happened?

PDSA Cycles “Negative results on the fish…Let’s try rubbing two sticks together.”

PDSA Key Points: Make the Cycle SMALLER!!! Break changes down into manageable parts This also allows people to: try things and give input more easily adapt feel included in decisions and development

Routine use of patient survey Repeated Use of the PDSA Cycle for Implementation Routine use of patient survey D S P A Cycles 5/6: Create orientation manual section on patient survey A P S D DATA D S P A Cycle 4: Use of survey for all patients A P S D Cycle 3: Try survey on other days with other providers and patients A P S D Cycle 2: Test - Use of new survey on two clinic days Test of patient survey Cycle 1: Introduce new survey form to one provider and staff

Multiple Cycles to Test and Implement Components of the Care Model Use of Flow sheet V.4 by all physicians and nurses Component: Decision Support D S P A From Chinatown, Asthma BTS, 2001 A P S D Learning Cycle 5: Implement use of V.4, do peer review of documentation and use D S P A Cycle 4: Trial of V.4 by all providers A P S D Cycle 3: Two week trail of V.3, review meetings A P S D Cycle 2: Try V.2 by two providers for a few days Will a flow sheet be useful for patients? Cycle 1: Gather sample flow sheets, try V.1with two patients

Things should be as simple as possible but not simpler. Albert Einstein