1. Quality Improvement: Reinforcing Foundations for Change
Diane Liu, MD
University of Utah, Department of Pediatrics
Assistant Professor, Division General Pediatrics
Co-Director, Utah Pediatric Partnership to Improve Healthcare Quality
Quality Improvement & How to establish processes for change
Welcome everyone
If small group – make introductions

2. QI is founded upon science
Main Focus
QI is founded upon science
It’s all about the kids
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3. Objectives
Understand the importance of quality improvement in current clinical practice (WHY do we care)
Learn about some tools from QI methodology to implement in your own practice (HOW do I start?)
Consider team-based strategies to support processes for change
The most important reason – we know as Pediatricians giving highest quality care is the right thing to do. Beyond that ultimate reason, there are some other reasons we should consider as well
Toolkit review
Example of process improvement
Answer questions like “What should I do to start? Where do I begin? Who do I need to enlist?”
What tools are available. Which model or approach should I employ? Based on the approach, are there methods that I should be using more frequently or more familiar with than others? Why?

4. What is happening in healthcare?
The AAP is committed to helping current and future Pediatricians navigate the ongoing and anticipated changes in healthcare
The current issues provide some context for our conversation today

5. What is Happening in Healthcare now?
Crossing the Quality Chasm - Institute of Medicine (IOM) 2001 Report (6 aims)
Safe Patient-Centered
Efficient Equitable
Effective Timely
Healthcare delivery and payment reform
Population Management
Triple Aim
Value-based care
CMS MACRA / MIPS / APM
Slide slide represents some ideas that have been and are currently circulating in healthcare conversations. Our job is to make sure children are not left out of the conversation

6. Core perspectives of QI
Focus on systems, not individuals
Ideas/changes originate from customers (patients) & front-line staff
Focus on small tests of change
Frequent, ongoing measurement and data-driven decision-making
Continuous! Never-ending process
Helps, not hinder, staff in closing gap towards goals

7. QI TOOLS TO USE
We decided not to obtain permission for reproduction but their tools are online for you to use. Many other organizations also have tools available online. We do not endorse one over another – there’s no bias on our end but we wanted to highlight just one organization so that you can begin using tools to help you
Population Health Improvement Partners – open access online
Institute for Healthcare Improvement – open access with free registration

8. Get started – HOW? Step 1 – Select a Project/Topic (sample statements)
Improving Primary Care Management of Neurologic and Behavioral Health Conditions
Increasing referral tracking and communication coordination
Step 2 – Assemble your team
You pick your team
Step 3 – Use a roadmap
UPIQ is here to help!

9. Step 1 – Choose a Focus Create a project
Defines and formalizes your effort
Shapes your scope about what area(s) you see as a problem
Where is the quality gap? What is the goal for care? What care is your patient actually receiving?
Understand the problem by using tools:
Process mapping (great team exercise!)
Observational walks (good for management to see the front-line)
Data queries (your EMR should work for you!)

10. Step 2 – Assemble Your Team
After selecting an area/topic for your project – assemble your team!
Select your team members based on:
Their knowledge of and involvement in the processes that you want to consider changing
Roles to be filled (suggested examples)
A project sponsor (Admin)
A QI team lead (Clinician – therapist, nurse, physician)
A QI expert and/or local experts (UPIQ and faculty advisors)
A QI project manager
Parent partner

11. Tuckman’s Stages of Team Development
Source: Population Health Improvement Partners

12. Step 3 – Apply a Formal Model
Now you have a topic and a team
Consider the approach – the roadmap to help you move forward. Which one should you use?

13. Model For Improvement
Tests and evaluates small changes before they are brought to scale
Allows for a systematic analysis to determine the effect on an intervention
Asks the learner 3 questions:
What are we trying to accomplish?
How will we know that our changes are an improvement?
What changes can we make that will result in an improvement?

14.
Put in a conceptual visual
What are we trying to accomplish (AIM?)
How will we KNOW that changes are actually an IMPROVEMENT? (MEASURES)
What changes can we make that will result in an improvement (INTERVENTIONS/changes to test)
PDSA to test ideas and changes with cycle for learning and improvement
*Langley, GL. Nolan KM, Nolan TW, Norman CL, Provost LP

15. 1st What are we trying to accomplish?
Understand the problem first – learn together as a team
What is the current process from point A to point B?
I know what ‘the problem’ is but I don’t know what the root is of the problem or what is causing my problem.
How much, if any, variation exists in the process I’m focusing on?
In order to determine what tools or methods you should use for any improvement effort, you need to ask yourself ‘what do I really want to know?’
This table represents categorical areas of knowledge with matching methods and tools to help you characterize (or refine) the knowledge you’re seeking.

16. Visualize how you deliver care - Process Map!

18. Sometimes current-state process mapping leads us to the same endpoint from different flow areas

19. AIM STATEMENT Develop your aim once you understand your problem
Defines the scope of your work
Make it public or tape it to your office wall as a reminder
WHAT?
For WHOM?
By WHEN?
Over the next 6 months, 80% of children presenting with headaches will be screened for anxiety
You can develop several aim statements if needed for a broader effort
Keep an aim short and concise to help you remain focused

20. my change led to the improvement?
2nd – Measures
How do I know if
my change led to the improvement?

21. UPIQ Measurement Goals
Limit the number of measures
Keep data collection as simple as possible
Measure frequently using small sample sizes

22. Percent of children screened for selected condition
Measure #1
Percent of children screened for selected condition
*Practices determine
Denominator - population to screen
Numerator – Selected screening tool used in appropriate patient
Monthly chart review – 10 per provider
Goal 80%

23. Measure #2
Percent of children screened for co-existing conditions in selected population
*Practices determine
Denominator - population to screen
Numerator – Documentation +/- co-existing conditions noted
Monthly chart review – 10 /provider
Goal 80%

24. Measure #3
Percent of children REFERRED received instructions while waiting for specialty evaluation
Denominator includes patients referred to either neurology or Behavioral Health
Numerator – Documentation reflecting ‘to-do’ instructions for patients referred
Monthly chart review – 10/provider
Goal 80%

25. Measure #4 Referral Tracking
Denominator – All patients referred to Neurology or Behavioral Health
Numerator – Referred patients included in registry
Monthly chart review – 10/provider
Goal 100%

26. Structured referral communication from PCP to Specialist
Measure #5
Structured referral communication from PCP to Specialist
Denominator – All patients referred to Neurology or Behavioral Health
Numerator – Referral communication includes the proposed minimum set of information
Monthly chart review – 10/provider
Goal 80%
If we can get numbers of referrals per month, we can work with the practices to decide whether to assess just neuro and behavioral vs. all of their referrals to UU/PCH specialists; if we can’t get the numbers, then I’d suggest we ask each practice to choose the 4 or 5 most commonly referred-to specialists to track. 
We propose a minimum set of information that should accompany the PCP to specialist (and specialist to PCP?) referral communication
I would be OK with leaving it roughly outlined if consensus can’t be reached quickly and finalized with each practice within a week or so of the learning session

27. 3rd question
What changes can we make that will result in an improvement?
Use your workshop time to brainstorm change ideas
The PDSA cycle is shorthand for testing a change by
developing a plan to test the change (Plan)
carrying out the test (Do)
observing and learning from the consequences (Study)
determining what modifications should be made to the test (Act)
(source IHI.org)

29. Take Home Points Understand the problem Create your team
Use the tools to help you
Create your team
Celebrate improving together
Focus on a clear aim/goal
All improvement requires change
Not all changes lead to improvement
Select a meaningful measure
Guides your improvement cycles
Reveals if you’re reaching your aim
Develop a learning community culture among staff, partners, and participating clinicians and their teams

30. Celebrate IMPROVING!
Image Source: University of Utah Accelerate

31. Thank You Remember - it’s about the kids
QI coaches are here to help you
Questions?