Quality Improvement Principles, Methods and Tools 4/21/2017 Quality Improvement Principles, Methods and Tools Marlene “Marni” Mason MCPP Healthcare Consulting MCPP Healthcare Consulting

4/21/2017 Marni Mason BSN, MBA Thirty+ years in healthcare as clinician, manager and consultant Primary & specialty care clinic nurse and nursing director – 15 years Consultant in healthcare performance measurement and improvement – 18 years Public health performance management – since 2000 Surveyor for NCQA (10 years) and Senior Examiner for state Baldrige Quality Award (late 1990s) Consultant for PHAB Standards Development (2008-2009) MCPP Healthcare Consulting

4/21/2017 Learning Objectives In today’s learning session, the participants will develop a better understanding of: Principles of Quality Improvement Selected Quality Improvement Methods Selected Quality Planning Tools Learn about Rapid Cycle Improvement (RCI) And Start development of QI team AIM statement Changed first bullet MCPP Healthcare Consulting

Collaborative with a Capital “C” 4/21/2017 Collaborative with a Capital “C” Systems are perfectly designed to produce the results they achieve MCPP Healthcare Consulting

IHI’s* Breakthrough Series 4/21/2017 IHI’s* Breakthrough Series Also known as the Collaborative Method It is an improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim Methodology to accomplish organizational system change *Institute for Healthcare Improvement www.ihi.org To make healthy living a reality for millions of Americans. Reducing falls—using citizens in their own neighborhoods to achieve measurable and sustainable change in specific health areas MCPP Healthcare Consulting 5

The Advantage of a Learning Collaborative for Improvement 4/21/2017 The Advantage of a Learning Collaborative for Improvement Learning collaborative: a group of multi-disciplinary teams from multiple organizations which come together over the course of a year in structured meetings and phone contacts to accomplish specific learning objectives. National experience demonstrates significant boost in pace and level of achievement of outcomes by sharing lessons learned. MCPP Healthcare Consulting

Identify Change Concepts 4/21/2017 Collaborative Process (IHI) Participants Select Topic Prework Identify Change Concepts P P P A D A D A D S S S Planning Group LS 1 LS 2 Outcomes Congress LS 3 Supports E-mail Visits Web-site Phone Assessments Senior Leader Reports MCPP Healthcare Consulting

Characteristics of a Collaborative 4/21/2017 Characteristics of a Collaborative Team approach Performance measures Teams from multiple organizations One for all, all for one Promotes a culture of change Standardizes practice Sustainable change Team approach—allows a process for all staff to become a part of the change; empowers staff and respects them for what they know Share openly, steal shaemlessly! Collaborating—realtionship in which each organization wants to help its partners become the best that they can be at what they do. Culture of change--Focuses on the details of change—what did you say to the person; what steps did you take to solve the problem; creates infrastructure and processes to allow for other changes sustainable change—really doing two things at once—achieving the specific goals you set for this project AND learning change methodology which can be used in other areas you want to change MCPP Healthcare Consulting

MLC-3 Collaborative Targets 4/21/2017 MLC-3 Collaborative Targets In Illinois, participation in the MLC-3 Learning Collaborative is focused on improvement in two target areas for MLC-3: Community Health Improvement Plans Chronic Disease Prevention-Obesity/Physical Activity (reduce preventable risk factors that predispose to chronic disease) MCPP Healthcare Consulting 9

MLC-3 Collaborative Approach 4/21/2017 MLC-3 Collaborative Approach All sites receive training in: Quality Improvement Methods & Tools Data Analysis Tools Rapid Cycle Improvement Method Site-based teams develop implementation plan for improvement Series of web-based phone sessions with coaching from consultant MCPP Healthcare Consulting 10

Principles of Quality Improvement 4/21/2017 Principles of Quality Improvement “Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” William Foster (many variations attributed to others) MCPP Healthcare Consulting

Performance Management There are countless real world examples of performance management applications from some very simple ones to some that are extremely complex. In examining how performance management can be useful in various public health practice applications, it often helps if we use a variety of examples – including some not necessarily drawn from public health. Here is a list of examples that we will use in our program today. Several will be the focus of more extensive examination and discussion as case study exercises. At first glance, it may not appear that these items have anything in common – but hopefully we can tie them all together using themes related to performance and performance management. Source of Slide: Turning Point Performance Management National Excellence Collaborative, 2004. Source: Turning Point Performance Management Collaborative, 2003. 12

The Quality Environment 4/21/2017 The Quality Environment Do you have an organization-wide commitment to assessing and continuously improving quality over time? Do you use data to decide on improvement initiatives and to know if the improvements are successful? Are your system decisions based on data? Do you know if your agency is achieving its goals? MCPP Healthcare Consulting

4/21/2017 Change vs. Improvement W. Edwards Deming stated “Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.” We must become masters of improvement We must learn how to improve rapidly We must learn to discern the difference between improvement and illusions of progress MCPP Healthcare Consulting

Principles of Quality Management 4/21/2017 Principles of Quality Management Know your stakeholders and what they need Focus on processes Use data for making decisions Understand variation in processes Use teamwork to improve work Make quality improvement continuous Demonstrate leadership commitment MCPP Healthcare Consulting

1. Know Your Stakeholders 4/21/2017 1. Know Your Stakeholders Identify stakeholders and their needs Set goals based on stakeholder needs Monitor performance and satisfaction to target performance improvement opportunities Improve or redesign how work is done MCPP Healthcare Consulting

Sector Maps for Planning – Example of Public Sector 4/21/2017 Sector Maps for Planning – Example of Public Sector Office of the Insurance Commissioner Governor / Legislature School Boards Public Schools (K-12) Private Schools (K-12) Health & Human Services Center for Disease Control & Prev. Center-Medicaid &Medicare Srvcs Fed. Drug Administration Employment Security Department Department of Health Community & Family Health Women, Infants & Children Licensing Boards Tribal Government Local Health Jurisdictions Health Care Authority Rural & Community Health Centers Dept. of Social & Human Services Local Government Public Library System Indian Health Service State Board of Health Bullets refer to examples of organizations and are not a comprehensive listing. 17

Example of Private Sector 4/21/2017 Example of Private Sector Consulting Foundations Professional Organizations Purchasers Hospitals Home Health Care Funding Foundations Rob’t Wood Johnson Health Plans Pharmaceutical Companies Primary/Specialty Medical Groups Providers Business and worksite programs SNF and Nursing Homes Ancillary Service Practitioners and Groups Insurance Brokers Media Bullets refer to examples of organizations and are not a comprehensive listing. 18

Example of Community-Based Sector 4/21/2017 Example of Community-Based Sector Service Organizations Thousands of community-based agencies: specific partners will be identified in each community United Way Community Centers Community Health Centers Federally Qualified Health Centers Migrant Health Centers Senior Centers Youth Associations YMCA / YWCA Boys & Girls Club Boy & Girl Scouts of America Campfire Girls and Boys Faith-based Community Organizations Communities of Color Organizations Community-based Daycare Sites All ages Birth to 3 childcare American Association of Retired Persons Youth Sports Associations Little League Pop Warner Soccer, etc Community Health Alliances Churches, Temples & Mosques Bullets refer to examples of organizations and is not a comprehensive listing. 19

Example of Academic/Research Sector 4/21/2017 Example of Academic/Research Sector Tribal Colleges Community Colleges State Universities Private Research Centers\ Private Universities Pharmacy Schools Nursing Schools Allied Health Professional Schools & Training Bullets refer to examples of organizations and is not a comprehensive listing. 20

Example of Target Populations

4/21/2017 2. Focus on Processes 85% of poor quality is a result of poor work processes, not of staff doing a bad job Processes often “go wrong” at the point of the “handoff” Attend to improving the overall process, not just one part—some of the most complex processes are the result of creating a “work around” MCPP Healthcare Consulting

4/21/2017 Focus on Processes Advice from NCQA, JCAHO and others—measure processes that are High-risk High-volume Problem-prone And Can be tracked and reported as summary or aggregate statistics MCPP Healthcare Consulting

Develop Process Flow Charts 4/21/2017 Develop Process Flow Charts High level flow charts [6-12 steps] initially Identify customer-supplier relationships More detailed flow charts as project unfolds [client flow, information flow, materials flow, decision making flow] Use for process redesign Use for adapting or adopting best practices MCPP Healthcare Consulting

The Logic of Public Health 4/21/2017 There are fewer incidents of foodborne illness Conditions in the restaurant don’t create unsafe food Public is sold food that is safe to eat We inspect restaurants # of inspections % of critical violations corrected within 24 hours rate of foodborne illness # of critical violations So that The Logic of Public Health MCPP Healthcare Consulting

Logic Models (Many Shapes/Sizes) 4/21/2017 Logic Models (Many Shapes/Sizes) Connect what we do every day to why we do it Show logical links between activities and goals Link our process objectives to our outcome objectives As long as the format is legible, logical, and it works for you, it’s probably fine Boxes and arrows are not required New computer software is not required MCPP Healthcare Consulting

Logic Model: Any Public Health Program 4/21/2017 Logic Model: Any Public Health Program Inputs Outputs Short Term Outcomes Intermediate Outcomes Long Term Outcomes Resources Activities Reduced Mortality Reduced Morbidity Improved Quality of Life Program Development Program Planning Materials Development, Distribution Informed, Targeted Program Appropriate, Targeted Materials Improved knowledge, beliefs, attitudes Staff Money Improved Behaviors MCPP Healthcare Consulting

4/21/2017 MCPP Healthcare Consulting

3. Use Data to Make Decisions 4/21/2017 3. Use Data to Make Decisions Use performance assessment data to target improvement Use data analysis tools to develop information Analyze data to identify root cause Use data to monitor performance outcomes MCPP Healthcare Consulting

Use Data to Make Decisions 4/21/2017 Use Data to Make Decisions Numerical Tools Conceptual Tools Affinity Diagram Brainstorming Process Flow Chart Interrelational Diagraph Matrix Diagram Tree Diagram Cause and Effect Diagram Check Sheet Bar Chart Histogram Pareto Chart Control Chart Run Chart [See Goal/QPC PH Memory Joggers] MCPP Healthcare Consulting

Use Data to Make Decisions 4/21/2017 Use Data to Make Decisions Brainstorming for root causes—theory generation relies on divergent thinking, no idea is a bad one… What can go wrong in the process we are studying? Problems in hand-offs between steps Problems in execution within steps Look at machines, materials, methods, measurements, and people MCPP Healthcare Consulting 31

Cause-effect or Fishbone Diagram 4/21/2017 Cause-effect or Fishbone Diagram Exercise: Constructing a Fishbone Diagram Organizes and displays theories Encourages divergent thinking Demonstrates the complexity of the problem Encourages scientific analysis (rule-out) Turn to page 23 in the PH Memory Jogger. MCPP Healthcare Consulting

4/21/2017 4. Understand Variation Sources of variation include: machines, materials, methods, measurements, people, environment Common cause variation occurs if the process is stable—variation in data points will be random and obey a mathematical law—it is said to be in statistical control, with a large number of small sources of variation Reacting to random variation in a process that is stable/in statistical control, it is called tampering and leads to further complexity, increasing variation and mistakes MCPP Healthcare Consulting

4/21/2017 Understand Variation Special cause variation arises because of specific circumstances which are not part of the process all the time and may or may not ever recur—if the recurrence is periodic, clues to the root cause may emerge Variation can be shown in control charts with mean and standard deviation Control charts are pictures of trend data with an extra feature—the range of variation built into the system MCPP Healthcare Consulting

4/21/2017 Understand Variation A sentinel event is a special cause variation requiring root cause analysis Examine specific incident(s) of special cause variation and make changes to a single element only after very careful analysis Need to investigate special cause variation before making any conclusions about performance level Failure to distinguish between common and special cause variation can be hazardous to organizational performance! MCPP Healthcare Consulting

Variation Exercise Joiner Associates – Hunter Conference exercise 4/21/2017 Variation Exercise Joiner Associates – Hunter Conference exercise Attributed to Brian Joiner’s 9 year-old son

5. Use Teamwork QI efforts need buy-in from all stakeholders 4/21/2017 5. Use Teamwork QI efforts need buy-in from all stakeholders Creative ideas are needed Division of labor is needed Process often crosses functions Solution generally affects many MCPP Healthcare Consulting

Use Teamwork Teams should develop a clear charge and support resources 4/21/2017 Use Teamwork Teams should develop a clear charge and support resources Teams should adopt working agreements (cell phone etiquette to decision procedures) Teams should assign roles of facilitators and recorders Team process has predictable stages that are useful to keep in mind: Forming, Storming, Norming, Performing MCPP Healthcare Consulting

Example of Alignment Wheel

4/21/2017 6. Make QI Continuous QI is a system-wide approach to assessing and continuously improving quality of the processes and services over time See inter-relationships, not parts Understand the flow of work, not the one-time snapshot Detail the work processes Determine cause and effect relationships Identify points of highest leverage Improve and innovate, not just change for change’s sake MCPP Healthcare Consulting

PDCA/PDSA Cycle definition 4/21/2017 PDCA/PDSA Cycle definition The Plan Do Check/Study Act Cycle is a trial-and-learning method to discover what is an effective and efficient way to design or change a process The “check” part of the cycle may require some clarification; after all, we are used to planning, doing/acting. It compels the team to learn from the data collected, its effects on other parts of the system, and under different conditions, such as different communities MCPP Healthcare Consulting

The PDSA Cycle for Learning and Improvement 4/21/2017 Plan Act Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection What changes are to be made? Next cycle? The PDSA Cycle for Learning and Improvement 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 MCPP Healthcare Consulting

Ongoing PDSA Cycles Self-Assessment or Accreditation 4/21/2017 Ongoing PDSA Cycles PLAN PLAN PLAN Target Improvements Accreditation Accreditation DO ACT DO ACT ACT DO Improvement work Areas for Improvement Evaluate Recommend Areas for Improvement Evaluate Improvement CHECK CHECK CHECK Report/Recommend Study Improvement Results One of the basic concepts of QI is called the Shewhart Cycle of Plan-Do-Check-Act. This cycle, when applied to the standards for PH, helps us complete each step before we move on to the next cycle. Completed 1 cycle with the final evaluation report. This led to Revised standards which are the first step in the current cycle. This training is part of the 2nd cycle– Step 2– “Do”the performance improvement work to address the standards. Report/Recommend Self-Assessment or Accreditation Self-Assessment or Accreditation Performance Improvement Cycle MCPP Healthcare Consulting

Make QI Continuous Use assessment to identify areas for improvement 4/21/2017 Make QI Continuous Use assessment to identify areas for improvement Charge QI team and provide support Provide QI training Use tools to understand root causes Use data for baseline and analysis Design process improvement to address root causes Train…train…train… staff on the newly designed process improvement MCPP Healthcare Consulting

Adopt or Adapt Model Practices 4/21/2017 Adopt or Adapt Model Practices Use data to identify need for improvement Identify exemplary practices in: other local departments, Michigan state programs and other states, CDC and other national organizations, www.naccho.org/topics/modelpractices other industries Describe your process (Logic Model) Study the exemplary practice process Adopt or adapt as appropriate MCPP Healthcare Consulting

7. Demonstrate Leadership Commitment 4/21/2017 7. Demonstrate Leadership Commitment Build a QI culture Connect the organization’s strategic plan to performance improvement Know and use quality principles Encourage all staff to use quality improvement in daily work Reward improvements Assure adequate QI infrastructure for quality assessment and improvement activities MCPP Healthcare Consulting

What questions do you have? 4/21/2017 What questions do you have? MCPP Healthcare Consulting

Rapid Cycle Improvement (RCI) and PDSA Cycles 4/21/2017 Rapid Cycle Improvement (RCI) and PDSA Cycles MCPP Healthcare Consulting

Why do we need a systematic model for improvement? 4/21/2017 Why do we need a systematic model for improvement? “All improvements require change but not all change will result in improvement. A primary aim of the science of improvement is to increase the chance that a change will actually result in sustained improvement from the viewpoint of those affected by the change.” --The Improvement Guide, 1996 MCPP Healthcare Consulting

Rapid Cycle Improvement 4/21/2017 Rapid Cycle Improvement The idea behind rapid cycle improvement is to first try a change idea on a small scale to see how it works, and then modify it and try it again until it works very well for staff and customers. Then, and only then, does a change become a permanent improvement. MCPP Healthcare Consulting

Testing a Change: Why Test? 4/21/2017 Testing a Change: Why Test? Low -Smaller Scale Tests -More of them prior to implementation Confidence in success High Minor Level of risk Major Modified from Jane Taylor PhD MCPP Healthcare Consulting

Testing a Change: Why Test? 4/21/2017 Testing a Change: Why Test? Minimize risks of potential failure and of potential adverse or unanticipated side effects Predict 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 to implementation MCPP Healthcare Consulting

Rapid Cycle Improvement 4/21/2017 Rapid Cycle Improvement MCPP Healthcare Consulting

What Are We Trying to Accomplish? 4/21/2017 What Are We Trying to Accomplish? The first question is meant to establish an aim for improvement that focuses group effort. Aims should be as concise as possible – sometimes it takes a few trials of testing an aim before it becomes truly focused Focus on what matters to the organization, staff and patients Use numerical goals wherever possible Guidance and resources (e.g. tools to be used, methods and systems to be changed) MCPP Healthcare Consulting

How Will We Know That a Change is an Improvement? 4/21/2017 How Will We Know That a Change is an Improvement? Measures and definitions are necessary to answer this question. Data is needed to evaluate and understand the impact of changes designed to meet an aim. When shared aims and data are used, learning is further enhanced because it can be shared. In this way, superior performance and best practices are more quickly identified and disseminated through benchmarking. MCPP Healthcare Consulting

What Change Can We Make that Will Result in an Improvement? 4/21/2017 What Change Can We Make that Will Result in an Improvement? This step is also known as “How will we get there?” Formulate change concepts that may improve the process outcomes This is the who, what, when, and how of doing the actual test It compels the team to learn from the data collected, its effects on other parts of the system, and under different conditions MCPP Healthcare Consulting

Consolidation of Relevant Knowledge and Experience 4/21/2017 Consolidation of Relevant Knowledge and Experience Develop a set of change concepts Definition of Change Concepts - Ideas for interventions and actions for improvement with a greater likelihood of working based on evidence, quantitatively documented experience, and/or internal data. MCPP Healthcare Consulting

Some Sources for Improvement Interventions and Actions 4/21/2017 Some Sources for Improvement Interventions and Actions Published literature in scientific journals Documented (with data) experience from other public health agencies Internal qualitative analysis of work processes Use qualitative analysis tools (e.g. fishbone diagrams, root cause concepts) to identify barriers Internal quantitative analysis of work processes e.g. Pareto analysis National experts (e.g. IHI, NACCHO, PHF, ASQ, Goal/QPC, MLC states and many others) MCPP Healthcare Consulting

Learning and improvement 4/21/2017 Sequential Building of Knowledge Includes a Wide Range of Conditions in the Sequence of Tests Breakthrough Results A P Evidence & Data S D Spread Implement A P S D A P S D Test new conditions A P Learning and improvement Theories, hunches, & best practices S D Test a wider group Test on a small scale MCPP Healthcare Consulting

Sequential Testing….when do you move to implementation? 4/21/2017 Sequential Testing….when do you move to implementation? After each PDSA… Implement as is Abandon it Increase in scope e.g. more clients, more programs Modify it and test again Test under different conditions MCPP Healthcare Consulting

Testing Done in Multiple Change Areas in Parallel 4/21/2017 Testing Done in Multiple Change Areas in Parallel A P S D A P S D A P S D Aims: Productivity Quality Coordination Access A P S D A P S D A P S D A P S D RCI Team #4 Or 4th Change A P S D A P S D A P S D RCI Team #3 or 3rd Change A P S D A P S D A P S D A P S D - A P S D RCI Team #2 or 2nd Change A P S D A P S D A P S D A P S D RCI Team #1 Or 1st Change A P S D MCPP Healthcare Consulting

4/21/2017 Testing a Change Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system Testing is not permanent Often we have more failures than successes Test on a small scale over a short period of time Have experts comment on feasibility Anticipate a sequence of tests on one change idea MCPP Healthcare Consulting

Testing a Change: Tips Move from ideas to action quickly 4/21/2017 Testing a Change: Tips Move from ideas to action quickly Decrease the scope of the test Test of oneness One stakeholder, one program, one day As you are designing the test, ask ‘What design would enable us to do this test now, tomorrow or next week MCPP Healthcare Consulting

4/21/2017 Implementing a Change Implementation – Making this change a part of the day-to-day operation of the system Implement a change ONLY if it will lead to improvement Involves more people and conditions: you will run into more resistance and factors which require “design tweaks” MCPP Healthcare Consulting

… by Next Week, …by Tuesday, …by Tomorrow What Can We Do Now… 4/21/2017 What Can We Do Now… … by Next Week, …by Tuesday, …by Tomorrow …that we can learn from without harming clients or burdening staff? Modified from Jane Taylor PhD MCPP Healthcare Consulting

Rapid Cycle Improvement–Example 4/21/2017 Rapid Cycle Improvement–Example MCPP Healthcare Consulting

What are We Trying to Accomplish? 4/21/2017 What are We Trying to Accomplish? Increase accurate and complete reporting of CD to 80% or more of all reports by 10/07, and more than 95% by 2/08 with clear definition of complete reports. We do this in order to provide valid data for planning and program improvement MCPP Healthcare Consulting

How Will We Know When We Get There?: Measurements 4/21/2017 How Will We Know When We Get There?: Measurements Increase (trended) in percent of accurately completed CD reports Decrease in staff time to input incomplete information Trend in overall measures in right direction (direction of goodness indicated by arrow) Other CD reporting measures Other process measures MCPP Healthcare Consulting

What Changes Can We Make? 4/21/2017 What Changes Can We Make? Data analysis of reasons for incomplete reports. Identify reasons with definitions Assure that database can capture each reason Initiate data collection process Train staff and providers in definition and reporting process Address lack of knowledge of providers Create plan to identify high volume providers and target for extra training MCPP Healthcare Consulting

4/21/2017 RCI Team Planning Tool MCPP Healthcare Consulting

Data Analysis- Pareto Chart 4/21/2017 Data Analysis- Pareto Chart MCPP Healthcare Consulting

Data Analysis- Pareto Chart 4/21/2017 Data Analysis- Pareto Chart MCPP Healthcare Consulting

4/21/2017 Results – Error Rate MCPP Healthcare Consulting

4/21/2017 Results – Time Study MCPP Healthcare Consulting

Steps to Set Up a Rapid Cycle Improvement 4/21/2017 Steps to Set Up a Rapid Cycle Improvement Establish a multi-disciplinary RCI team Identify a positive opinion leader Align leadership and administrative support Consolidation of relevant knowledge and experience (national) for multiple changes Development of an overall aim statement (using the three questions at a high level) Decide where to start and develop a strategy for a series of rapid cycles. MCPP Healthcare Consulting

Guidance on Following the Steps 4/21/2017 Guidance on Following the Steps It is important not to try to write the perfect AIM statement and develop the most thorough rapid cycle strategy at the start. It is more important to start small, rapid tests of change through PDSA cycles as soon as possible. The AIM statement and strategy evolve continually as you learn from testing. The major objective is to build organizational learning from small tests of change. MCPP Healthcare Consulting

4/21/2017 Key Lessons from RCI The rapid improvement work must be seen as The Work and not a separate project Implementation and holding the gains requires integration into daily work and meetings Start work with those interested in change Communicate what is happening persistently Provide support to providers and staff who take on this new work MCPP Healthcare Consulting

What questions do you have? 4/21/2017 What questions do you have? MCPP Healthcare Consulting