© 2004 Institute for Healthcare Improvement The Model for Improvement A Method to Test, Implement, and Spread Change Ideas for Improving Care for People Living with HIV and AIDS

© 2004 Institute for Healthcare Improvement Objectives  List the three improvement questions  Describe the PDSA Cycle  Identify one tip to improve:  Use of aims  Use of measures  PDSA cycles  Team practice

© 2004 Institute for Healthcare Improvement Introduction (15 minutes)  Name  Where you work  What you do  Expectations for the session

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 improvement? Model for Improvement ActPlan StudyDo © 2004 Institute for Healthcare Improvement The Model for Improvement was developed by Associates in Process Improvement.

© 2004 Institute for Healthcare Improvement First Question What are we trying to accomplish?  AIM content:  Explicit statement  Specific actions  Stretch goals  AIM characteristics:  Time specific  Measurable  Define participants

© 2004 Institute for Healthcare Improvement Example The clinic will improve care of HIV/AIDS patients by making changes in the following areas: self–management and adherence support; decision support for clinicians; clinical information systems; delivery system design; community linkages; and leadership. Focusing on education, prevention, and early intervention, our goals include:

© 2004 Institute for Healthcare Improvement Example  80% of patients with at least one visit every 3 months  85% of patients with documented medication education/adherence counseling  90% of applicable patients with PCP/MAC prophylaxis

© 2004 Institute for Healthcare Improvement AIM Tip #1 Achieve agreement and write the aim clearly

© 2004 Institute for Healthcare Improvement AIM Tip #2 Include numerical goals

© 2004 Institute for Healthcare Improvement AIM Tip #3 Set stretch goals

© 2004 Institute for Healthcare Improvement AIM Tip #4 Avoid aim drift

© 2004 Institute for Healthcare Improvement AIM Tip #5 Be prepared to refocus the aim

© 2004 Institute for Healthcare Improvement Pairs Discussion (10 minutes)  With a partner, discuss your experience with aim statements. What has worked? What has not worked? (3 minutes)  Next, join another pair. Briefly share the highlights of both discussions. Then develop a few tips you would give regarding the development and use of aim statements. (4 minutes)  Last, be prepared to tell the large group one of these tips. (3 minutes)

© 2004 Institute for Healthcare Improvement Second Question How will we know that a change is an improvement?

© 2004 Institute for Healthcare Improvement Measurement for Learning and Process Improvement Measurement for Research Purpose To bring new knowledge into daily practice To discover new knowledge Tests Many sequential, observable tests One large "blind" test Biases Stabilize the biases from test to test Control for as many biases as possible Data Gather "just enough" data to learn and complete another cycle Gather as much data as possible, "just in case" Duration "Small tests of significant changes" accelerates the rate of improvement Can take long periods of time to obtain results

© 2004 Institute for Healthcare Improvement A Family of Measures  Outcome measures  Process measures  Balance measures

© 2004 Institute for Healthcare Improvement Outcome Measures Measures of the customer or patient

© 2004 Institute for Healthcare Improvement Process Measures Measures of the workings of the system

© 2004 Institute for Healthcare Improvement Balance Measures Measures of the other parts of the system

© 2004 Institute for Healthcare Improvement Measurement: Types and Time Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Process Measures Harm Outcome Measures

© 2004 Institute for Healthcare Improvement Tips for Measurement #1 Plot data over time  Tracking a few key measures over time is the single most powerful tool a team can use. % Patients with a Visit in Past Three Months

© 2004 Institute for Healthcare Improvement Tips for Measurement #2 The perfect is the enemy of the good.

© 2004 Institute for Healthcare Improvement Tips for Measurement #3 Sampling

© 2004 Institute for Healthcare Improvement Tips for Measurement #4 Integrate measurement into the daily routine

© 2004 Institute for Healthcare Improvement Tips for Measurement #5 Use both words and numbers

© 2004 Institute for Healthcare Improvement Third Question What changes can we make that will result in improvement?

© 2004 Institute for Healthcare Improvement Change Concept While all changes do not lead to improvement, all improvement requires change

© 2004 Institute for Healthcare Improvement Change Ideas Changes to improve care for people living with HIV disease Topics/HIVAIDS/ HIVDiseaseGeneral/ Changes/

© 2004 Institute for Healthcare Improvement Reflect Back To … (10 minutes total)  The project of which you are most proud, something you were involved with that really improved the situation for patients or for staff. It comes readily to mind because it was/is important to you.

© 2004 Institute for Healthcare Improvement Reflect Back To …  Make a few notes in answer to these questions:  What was the project?  Who was involved?  What changes were made that resulted in an improvement?  What did you learn?

© 2004 Institute for Healthcare Improvement Reflect Back To …  Turn to someone at your table, preferably someone you don’t know or have not yet spoken with.  Introduce yourselves and share your stories.

© 2004 Institute for Healthcare Improvement Debrief  What happened?  Collaborative learning  Networking  Good ideas ready for change

© 2004 Institute for Healthcare Improvement What is the PDSA Cycle? Act What changes are to be made? Next cycle ? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when ) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

© 2004 Institute for Healthcare Improvement Repeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A Learning from Data Very small scale test Follow-up tests Wide-scale tests of change Implementation of change

© 2004 Institute for Healthcare Improvement Why Test?  Increase degree of belief  Document expectations  Minimize resistance  Learn and adapt  Evaluate costs and side effects

© 2004 Institute for Healthcare Improvement Start Small and Do More Use of flowsheet will improve care to known standards Improved Decision Support AP SD A P S D AP SD D S P A DATA D S P A Cycle 1A: Adapt Clinic X Standard’s based flow sheet and test with one of Joanne’s patients Cycle 1B: Revise flowsheet and test with Dr. Burton’s patients next Monday Cycle 1C: Present refined flowsheet to all 3 clinicians and document feedback Cycle 1D: Revise and test flow- sheet with all patients for one week Cycle 1E: Implement and monitor the standards

© 2004 Institute for Healthcare Improvement PDSA Tip #1: Scale Down  Years  Quarters  Months  Weeks  Days  Hours  Minutes “Drop 2”

© 2004 Institute for Healthcare Improvement PDSA Tip #2: “Oneness”

© 2004 Institute for Healthcare Improvement A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Community Resources Self- Manage- ment Support Delivery System Design Clinical Information Systems A P S D A P S D A P S D D S P A LeadershipDecision Support PDSA Tip #3: Changes in Parallel

© 2004 Institute for Healthcare Improvement PDSA Tip #4 © 2004 Institute for Healthcare Improvement

PDSA Tip #5 Current Situation ResistantIndifferentReady Low Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Very Small Scale Test Small Scale Test High Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Small Scale Test Large Scale Test Cost of failure small Small Scale Test Large Scale Test Implement

© 2004 Institute for Healthcare Improvement Ideas for Change (10 minutes)  At your table, develop a small PDSA cycle based on one of the good ideas you heard from our sharing a few minutes ago.  Use the grid from Tip #5 to determine and justify the size of your cycle.

© 2004 Institute for Healthcare Improvement Teams “A team is a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable.” --Jon R. Katzenbach

© 2004 Institute for Healthcare Improvement Teams  Team Composition  System  Technical  Day-to-day

© 2004 Institute for Healthcare Improvement Team Practice: Tip #1  Team Time  Huddles

© 2004 Institute for Healthcare Improvement Team Practice: Tip #2  Simplify Team Reports  Good bullets; not paragraphs  Smaller, more frequent?  Other ideas?

© 2004 Institute for Healthcare Improvement Team Practice: Tip #3 Ask forgiveness, not permission

© 2004 Institute for Healthcare Improvement Team Practice: Tip #4 Learning with others

© 2004 Institute for Healthcare Improvement Closing The Model for Improvement  List the three improvement questions  Describe the PDSA Cycle  Identify a method (tip) to improve:  Use of aims  Use of measures  PDSA cycles  Team practice

© 2004 Institute for Healthcare Improvement Web Resources  ImprovementMethods provides information on improvement methods, strategies, and changes

© 2004 Institute for Healthcare Improvement References  Deming WE. Out of the Crisis. Cambridge, Massachusetts: Massachusetts Institute of Technology Center for Advanced Engineering Study;  Deming WE. The New Economics. Cambridge, Massachusetts: Massachusetts Institute of Technology Center for Advanced Engineering Study;  Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco, California: Jossey-Bass; 1996.