Multi-Specialty MOC Portfolio Approval Program Progress Report Version 1.0, as of July 1, 2012

Key Driver Diagram What is a key driver diagram? A key driver diagram is a tool intended to help organize your ideas and discover various causes that contribute to the issue you are trying to improve. The key driver breaks down the aim of your project into primary and secondary drivers, and helps you determine what changes to make. Primary drivers are factors that are part of your system that directly impact the outcome, or aim, of your QI effort. Secondary drivers are the opportunities for change (interventions) in your QI effort. They directly impact the primary driver of your aim. Does my diagram have to look exactly like the one provided? No. It is just a tool and may be modified based on the nature of your QI effort and discussions in your QI team. How does this relate to measures? Primary drivers are usually outcome measures and secondary drivers are usually process measures, though this is not always the case. What is the benefit of a key driver diagram? It quickly identifies the important aspects of your QI effort by explicitly defining the logic behind your improvement effort. In identifying the aim you must identify what you want to change or improve (primary drivers) and how you will improve (secondary drivers or interventions). The diagram, when read right to left indicates that if you perform the secondary drivers (interventions) then the primary drivers will improve, and the improvement of the primary drivers will satisfy the aim. Get Help IHI: OPQC: Stanley Healthcare: NICHQ: Resource Page Applicable Program Standards QI Efforts Corresponding Narrative Questions 1 (Aim) 3 (Interventions)

Specific Aim Primary Drivers (outcomes) Attributes of a good aim statement: (Specific, Measurable, Actionable, Realistic Timely) Revision Date: Global Aim Key Driver Diagram Secondary Drivers (interventions) What we’re working on now Key

PDSA/PDCA Evidence Why this format? We believe that improvement occurs through multiple tests of change (improvement cycles). How is this applied? Usually improvement begins with a very small test of change, a follow-up change, and subsequent tests of change that build toward wide scale implementation of successful interventions. How do I use this form? In each test of change (improvement cycle) briefly indicate: What: what is the objective of this test change. What is the IOM Quality Dimension addressed by this cycle? This relates to the Plan stage. Who: define the patient population for this test of change. This relates to the Plan and Do stages. Where: identify the location of the test of change. This relates to the Plan and Do stages. When: indicate the timeframe of the test of change. This relates to the Plan and Do stages. Who executes: identify the individuals or groups that implemented the intervention(s). This relates to the Do stage. Results: indicate the results of the test of change. This relates to the Study stage. This represents evidence of multiple tests of change (improvement cycles) via presentation of data. How many tests of change (improvement cycles) do I have to have? The current program standards require a minimum of one full cycle of assessment. Future evolutions of the standards will require more than one full cycle of assessment. Multiple cycles emphasize and encourage the iterative learning process and potentially have the greatest impact on improving patient care. Note: The DMAIC format used in developing and testing change in the Six Sigma approach to quality improvement was derived from the PDSA/PDCA format and doing multiple DMAIC efforts is equivalent to doing multiple PDSA /PDCA cycles. Get Help IHI: OPQC: NICHQ: Langley, GJ, Moen, RD, Nolan, KM, et al. The Improvement Guide (2nd edition). San Francisco, Calif: Jossey-Bass; Resource Page Applicable Program Standards QI Efforts Corresponding Narrative Questions 2 (patient population) 3 (interventions) 6 (IOM Quality Dimension)

PDSA/PDCA Evidence TEST 1 What: Evidence knowledge and application Who: Where: When: Who executes: Results: TEST 2 What: Evidence knowledge and application Who (population): Where: When: Who executes: Results: TEST 3 What: Evidence knowledge and application Who (population): Where: When: Who executes: Results: TEST 4 What: Evidence knowledge and application Who (population): Where: When: Who executes: Results: Do StudyAct PlanDo StudyAct PlanDo StudyAct PlanDo StudyAct Plan

Results Why a chart? Plotting data over time is quick way to identify whether the interventions in your QI effort are leading to improvement. What is the benefit of a run chart? There are several benefits of using run charts. They help determine when interventions truly led to improvement by displaying a pattern of data. There are established rules for determining when statistically significant change has occurred in data displayed in a run chart that you can investigate. They indicate the value of an intervention by temporally displaying whether change occurred at the time of the intervention They identify how well or how poorly the interventions are doing toward achieving your aim How do I make a run chart? Plot time along the X axis and what you’re measuring along the Y axis. Make sure to provide a legend for the chart, label the axes, and provide a relevant title for the chart so that it can be easily interpreted. You can add pertinent information such as the goal as identified in the aim, the median, and notes (called annotations) about when events occurred. A run chart can be created from most spreadsheet tools. How many run charts do I have to have? Ideally you would have one chart per measure. Note: To address HIPAA issues, the run chart should represent aggregated data and not identify individual patients or physicians. Get Help IHI: HCI: Langley, GJ, Moen, RD, Nolan, KM, et al. The Improvement Guide (2nd edition). San Francisco, Calif: Jossey-Bass; Resource Page Applicable Program Standards QI Efforts Corresponding Narrative Questions 3 (interventions) 4 (measures)

Results

Lessons Learned For the purposes of this report, a lesson learned is knowledge or understanding gained by experience. The experience may be positive or negative. It should be significant in that it has a real or assumed impact on the activity, valid (factually and technically correct), and applicable in that it identifies a specific design process or decision that reduces or eliminates the potential for future failures and mishaps or reinforces a positive result. Lessons learned highlight strengths or weaknesses in preparation, design, and implementation that affect good performance, outcome, and impact. What is the distinction of a lesson learned? A lesson is learned rather than just identified, when it has gone through the following steps: 1.Reflection on the experience. 2.Learning points are identified—what was the difference between what was planned and what actually happened 3.Analysis has been performed—why was there a difference 4.The experience is generalized—what should be done in the future to avoid the pitfall or repeat the success 5.Action is taken—a document, procedure, policy, structure, budget, etc. needs to be changed. If nothing changes, nothing has been learned. Why must I take action? Talking about how things get done or working on how things get done does not, in and of itself, accomplish anything. It is through action that real change occurs. When are lessons learned captured? Lessons learned can be captured at any point throughout the life of the activity. The best time to capture lessons are when they occur. How many lessons learned need to be documented? As many as you feel are relevant or necessary to be shared. Resource Page Applicable Program Standards Sponsors 1.2 Participation 3.3 Corresponding Narrative Questions 7 (Lessons Learned)

Lessons Learned Lesson 1 Lesson 2 Lesson 3

Sustainability and Spread Developing and implementing successful quality improvement efforts is important, but not enough to make a measureable improvement on the quality of patient care. Too often improvements remain unknown and unused by others within the organization. In this section, identify how the improvement effort will be sustained and spread within the organization. How is sustainability defined? For the purposes of this program, sustainability is the maintenance of an improvement effort’s results for a minimum of 6 months to a year following initial implementation of the improvement. Is there a prescribed way to spread improvement efforts that must be used? No. Every organization is different. While tools exist to help you in this process, you are not required to use a specific tool or methodology. Resource Page Get Help Framework for Spread: Tool for Spread Planning: Factors for Spread (RWJ): Research on Sustainability: Applicable Program Standards Sponsors 1.2 QI Efforts 2.7 Participation 3.1 Corresponding Narrative Questions 8 (Sustainability and Spread)

Sustainability and Spread Plan 1 – Status Plan 2 – Status

Physician Participation Identify the participation requirements that must be met in order for physicians to obtain MOC Part IV credit from the approved QI Effort. What is meaningful participation? For the purposes of this program, meaningful participation is demonstrated by having an active role in the QI effort over a period of time in which the physician implements the interventions related to the effort, collects data (if not automated or performed by another), and reviews the measure data relative to the effort. How is participation captured? Physician participation in a QI effort should be captured in an attestation completed and signed (electronically or via hard copy) by the physician and the leader of the effort. Resource Page Applicable Program Standards QI Efforts Participation Get Help Foster, Ogrinc, Hamby, Weeks (2002): “Improving the effectiveness of physician participation in local quality improvement efforts.” Quality Management in Health Care. Spring, pages Center for Studying Health System Change:

Physician Participation Requirements for participation in order to earn MOC Part IV credit – Include length of time, involvement, etc.