1. Quality Improvement Tools for Intervention Determination Presenters: Kris Hartmann, MS Healthcare Analyst, Performance Improvement Projects Don Grostic, MS Biostatistician, Performance Improvement Projects

2. Objectives of the Workshop 2 To share the latest knowledge on quality improvement tools. To address identified opportunities for improvement from prior Florida PIP validations. To support current efforts in determining interventions for ongoing PIPs. To provide a systematic, step-by-step approach that can be used to select impactful interventions.

3. Summary of Objectives 3 To empower you, your team, and your organization to answer the question: “What changes can we make that will result in improvement?”

4. Quality Improvement Tools 4 Team Building Process Mapping Failure Modes and Effects Analysis (FMEA) Pareto Diagram Failure Mode Priority Ranking

5. Building a PIP Team Including the right people on the PIP team is critical to a successful improvement effort. Teams may vary in size and composition. Team composition should be driven by the PIP topic. 5

6. Building a PIP Team: Senior Management A Sponsor from Senior Management: Is critical to support the PIP team efforts. Serves to link the PIP team with senior management and assure alignment with the organizational strategy. Provides resources and assists with overcoming organizational barriers on behalf of the team. Enables the PIP Team to make the changes necessary to improve the process. 6

7. Building a PIP Team: Clinical Support A clinical leader: Is critical to the PIP team efforts. Provides insight into the clinical implications of potential interventions and can anticipate the impact of system changes. Should come from the areas of the organization that are relevant to the PIP topic. 7

8. Building a PIP Team: Analytical Support Analytical Support: Should be included from the beginning of the project. Provides sound methodology upon which the project is based. Ensures that outcomes are accurately measured. 8

9. Building a PIP Team: Step-by-Step Approach Steps to develop an effective team: 1.Review the PIP topic. 2.Consider the process being targeted for improvement. 3.Include team members who are knowledgeable about the different levels and steps of the process. 4.Include analytical support from the beginning of the project. 9

10. Building a PIP Team: Step by Step Approach 5.Identify an executive sponsor who takes responsibility for the success of the project. 6.Consider including partners from external organizations that are part of the process. 10

11. Process Mapping 11 A process map is: A quality improvement tool that illustrates how a current process is being administered. A global view of all the steps in the current process to determine where improvement efforts are most needed. Most effective if it is documented from the perspective of the person most affected by the overall process, typically the enrollee.

12. Building A Process Map: Step-by-Step Approach 12 1.Determine the beginning and ending points. 2.Involve the individuals responsible for the different steps of the process. 3.Determine 3–5 prominent phases that occur for the process to work. 4.List the activities for each phase of the process. 5.Obtain feedback from all team members before finalizing the process map.

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14. Questions and Answers 14 Questions on Team Building and Process Mapping

15. Quality Improvement Tools 15 Team Building Process Mapping Failure Modes and Effects Analysis (FMEA) Pareto Diagram Failure Mode Priority Ranking Presenter: Don Grostic, MS Biostatistician, Performance Improvement Projects

16. Failure Modes and Effects Analysis 16 A Failure Modes and Effects Analysis (FMEA) is: A systematic, proactive method for evaluating a process. A quality improvement tool that helps identify where and how a process is failing or might fail in the future. Useful to pinpoint specific steps most likely to affect the overall process so interventions can have the desired impact on PIP outcomes.

17. Failure Modes and Effects Analysis 17 Failure Modes: What could go wrong? Any scenario that could go wrong (failing now or can go wrong in the future). Failure Causes: Why would the failure happen? Explanation of why the failure mode would occur; what is the root cause of the failure? Failure Effects: What is the consequence of the failure? What is the aftermath of the failure?

18. Steps for Conducting FMEA 18 1.Determine up to three sub-processes from the process map that will have the most impact on improving the PIP outcomes. 2.Include all individuals responsible for the chosen sub-processes. 3.Brainstorm all failure modes that can occur for each sub-process.

19. Steps for Conducting FMEA 19 4.Brainstorm failure causes and effects for each failure mode. 5.Evaluate the results and determine the priority ranking for each failure mode. 6.Obtain feedback from all individuals before finalizing the FMEA.

20. Failure Modes and Effects Analysis Priority Ranking 20 Priority ranking allows for the highest ranked failure modes to take precedence when determining the interventions to be tested. The highest priority failure modes are those that have the most leverage on affecting the PIP Outcomes. The priority ranking should be based on MCO data and experience.

21. Pareto Diagram 21 A Pareto diagram is another method to identify specific areas in the overall process that warrant interventions. When to use a Pareto chart: Analyzing data about the frequency of problems or causes in a process. There are many problems or causes and you must focus on the most significant. Analyzing broad causes by looking at their specific components. Communicating to others about your data.

22. Pareto Diagram Example: Preventive Dental Visits 22 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cumulative Percentage

23. Priority Ranking: Risk Priority Number (RPN) 23 The RPN is a numeric assessment of risk or impact of each sub-process. The RPN has three basic components: Likelihood that the failure would occur. Likelihood that the failure would not be detected. The amount of harm or damage the failure mode may cause. Each Component is ranked on a scale of 1 to 5: (Low Risk) 1--------------------------------------5 (High Risk)

24. FMEA Example with RPN: Preventive Dental Visits 24 Sub-processesFailure ModesFailure CausesFailure Effects Likely to Occur Likely to go Undetected Amount of Damage Priority Ranking Number Scheduling the preventive dental visit appointment Parent/caregiver and enrollee do not see the importance of preventive dental visits. No educational materials available. Parent/caregiver takes no action to obtain preventive dental visit for child. 33545 Scheduling outreach not provided by dental office. No process in place for dental provider to provide outreach for scheduling a preventive dental visit. Parent/caregiver does not have the guidance to schedule an appointment. 44232 Attending the preventive dental visit appointment Parent/caregiver and enrollee do not have transportation to keep appointment. No process to assess and assistance with transportation barriers for dental appointments. Enrollee is unable to attend scheduled appointment. 35575 Dental offices do not offer convenient hours. Appointment is scheduled at a time that is difficult to attend. Enrollee is unable to attend scheduled appointment. 455100

25. Failure Mode Ranking Example: Preventive Dental Visits 25 Priority (Highest to Lowest) Priority Ranking Score Failure Modes 1100Dental offices do not offer convenient hours. 275 Parent/caregiver and enrollee do not have transportation to keep appointment. 345Parent/caregiver does not see the importance of preventive dental visits. 432Scheduling outreach not provided by dental office.

26. Intervention Determination 26 The ranked failure modes should be used as a guide to determine the interventions to be tested. The failure modes with the higher ranking need more attention.

27. Intervention Determination Example: Preventive Dental Visits 27 FailuresPotential InterventionsConsideration for Reliability Dental offices do not offer convenient hours. Partnering with dental offices to offer Saturday and/or evening preventive dental appointments. Offering Saturdays and evening appointment times will decrease the difficulty working parents/caregivers may have in attending appointments with their children. Parent/caregiver and enrollee do not have transportation to keep appointment. Hosting a mobile dental service van at various locations. Bringing a mobile dental unit near the enrollee’s residence will reduce the structural transportation barrier that makes it difficult to access preventive dental services. Parent/caregiver does not see the importance of preventive dental services. Partnering with pediatrician offices to provide education to parents/caregivers on importance of preventive dental care, recommended frequency of visits. Messages provided during pediatric well or sick visits will capitalize on the opportunity to provide face-to-face education and help parents/caregivers to understand how dental care fits into the overall health of children.

28. Questions and Answers 28 Discussion and Breakout Sessions