Testing and Implementing Change Learning Session 2 November 14, 2002 Vicki Grant & Ron Moen

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 ActPlan StudyDo

What are we trying to accomplish? Maximize enrollment and retention of adults and children in Medicaid, SCHIP and Food Stamps (where applicable) by improving county and state eligibility processes ·

M1= Caseload Cases beginning of month + approvals in month - closures in the month M2= % Approvals 100 x approvals in the month/total application decisions made in the month M3= % Denials 100 x denials in the month/total application decisions made in the month M3.1= Denials by reason 100 x denials by reason /total denials M4= % Closures 100 x closures in the month/cases at beginning of month + approvals M4.1 Closures by reason 100 x closures by reason /total closures 100 x renewal closures in month / cases up for renewal in month M4.2 % Closed Renewals How will we know that a change is an improvement?

 Improve Customer service  Improve Policy/Procedures  Improve Work Flow  Change Work Environment  Improve Intra-system Communications  Error Proofing  Eliminate Waste  Focus on Variation What changes can we make that will result in an improvement?

PDSA Cycles Plan: Plan a test (change, theory, prediction Test plan and data collection Record plan on team report Do: Conduct the test of change. Build the plane. Conduct 3 test flights. Study: Plot data, interpret results. What did you learn? Act: Keep the change in your design, modify or abandon?

Aim: Improve the notification system Redesigning the Medicaid notice will improve communication Improved communication AP SD A P S D AP SD D S P A DATA D S P A Cycle 1:Test on employees Cycle 2:Field test on customers in 1 office in 1 week Cycle 3:Field test at a different site for 1 week Cycle 4: Field test at pilot site for 1 month Cycle 5: Implement and spread to county/state

Project:Cycle #: 2Date: Sept. 6, 2002 Objective: Determine if the redesign of the Medicaid notice will improve communication to our customers Plan QuestionsPredictions 1. Did we simplify the sentences? (Yes, because we “unpacked” them) 2. Did we simplify the vocabulary?(Yes, used a language they can read) 3. Is the new format easier to understand? (Yes, better organization makes the text less busy) What data will be collected during this time? (Forms to be used) Preference scale (Which is better: current or new) Who: Next customer after 8:00, 9:00, 10:00, etc Administered and observation by Bob from our team What: Preference test with the new Medicaid notice When: Tues-Thursday collect data, Team will analyze data on Friday Where: Field test at the Glendale site

Use the PDSA Cycle for :  Testing or adapting a change idea  Implementing a change  Holding the gains  Spreading the changes to the rest of your system

3 Principles for Testing a Change  Test on a small scale  Collect data over time  Build knowledge sequentially and include a wide range of conditions in the sequence of tests

Testing on a Small Scale Have others that have some knowledge about the change review and comment on its feasibility Test the new product or the new process on the members of the team that developed the change before introducing it to others Incorporate redundancy in the test by making the change side-by-side with the existing process or product

Testing on a Small Scale (Cont.) Conduct the test in one facility or office in the organization, or with one customer Conduct the test over a short time period Test the change on a small group of volunteers Develop a plan to simulate the change in some way

Decrease the Time Frame for a PDSA Test Cycle Years Quarters Months Weeks Days Hours Minutes Drop down next “two levels” to plan Test Cycle!

Conserve Measurement Resources Integrate into daily work Use sampling

Length of Stay for Main ED Discharged Patients n=1 per week Avg=180, SD=50 Avg=135, SD=35

Median Length of Stay for Main ED Discharged Patients n=14 per week

Median Length of Stay for Main ED Discharged Patients n=28 per week

Median Length of Stay for Main ED Discharged Patients n=300 per week

Team examples of testing Use teams reports and story boards to fill in here Minnesota: Use of credit card payments Delaware: Test verification check-list Nassau County: Telephone survey of mail recertification process

Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system. Implementation – Making this change a part of the day- to-day operation of the system (Not after just one test!) Testing vs. Implementation

Cycles for Implementation  The change is permanent - need to develop all support processes to maintain change.  High expectation to see improvement (no failures).  Increased scope will lead to increased resistance.  Generally takes more time than tests.

Approaches to Implementation  Parallel  Changes run parallel as current processes are running  When old processes “turn off”, the new ones “turn on”  Sequential  Incorporates changes over time (completeness) or by location (coverage)  “Just Do It”  One cycle to study the effect of the change  Used for simple changes only

Holding the Gains  Communicate  As soon as aim is chosen  Continuing as project progresses through storyboards, newsletters, etc.  Successes and learning  Standardization  Documentation  Measurement  Training

Spread  Spread means making improvements beyond the scope of the Collaborative Team  Readiness  Success of collaborative team  Intention  Organizational priority  Leadership responsibility

Target Population for Spread Population of Focus for your BTS Aim Spread - Other offices - Other departments - Other counties - Other key systems