1. Improving Adolescent and Young Adult Clinical Practice
The Quality Improvement Process
Rachel Wallace-Brodeur, MS, MEd
Project Director and QI Coach, National Improvement Partnership Network
May 10, 2017

2. Session Objectives Review fundamentals of quality improvement (QI)
How to use the Patient Satisfaction Survey to improve quality of care

3. QI Principles Incremental change Data-driven
Environment for shared learning
Team Work and Communication
Systems and Processes
Individual and population health outcomes
Sustainability
QI principles are the same whether applied in public health or clinical care settings
REVIEW

4. Changing Systems
Every system is perfectly designed to achieve exactly the results it gets.
If you want to improve, you must change your system!
QI principles are the same whether applied in public health or clinical care settings
REVIEW

5. QI: The Model for Improvement
Aim
Measurement
Change
We’ve presented the “Model for Improvement”
Aim: stating as clearly as possible with a SMART framework exactly what it is that you are trying to accomplish
To determine a measurement plan – I’m going to talk about some measures
And then to identify and test strategies for change that you think will lead to the improvement you are seeking.
From The Improvement Guide
Langley, Nolan, Nolan, Norman and Provost

6. QI Project Steps Assemble your Change Team Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for Improvement

7. Convening a Change Team
Cross-functional
Team members have a stake in the outcome
An effective improvement team is
Flexible: willing to change and respond to the ongoing/unexpected
Creative: solution-oriented
No one individual has sufficient knowledge to solve the problem
Cross functional: (proficient in relevant areas)

8. Aim Statements
What do you want to ACCOMPLISH
Picture the END RESULT

9. Aims Should be SMART

10. SMART Aim Statement
By December 2018 the percentage of adolescents and young adults receiving well visits in Minnesota increases by 2%.

11. Key Driver Diagram Structured logic charts with ≥ 3 levels:
Project Aim: SMART
Key drivers: (elements, factors, influences) with direct contributions to the aim
Primary
Secondary
Strategies: HOW to address the drivers to achieve the aim

12. QI Project Steps Assemble your Change Team Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for Improvement

13. Why Measure? How do we know which changes resulted in improvement?
Which changes are most important to achieve our desired result?
How do we know when we accomplish our aim?
You can’t improve what you don’t measure.
Why measure? We are now at the 2nd question in the Model for Improvement – How will we know that a change is an improvement?
The purpose of measurement in QI projects is for learning not comparison or judgment. Project teams need measures to obtain feedback that the changes they are testing are having the desired outcome.
As we will discuss a bit later, measures occur at two levels – the project level (these are measures tracked throughout your QI project and beyond) and a second level of measures which are developed on an as needed basis as part of the process of testing changes.

14. Data for Improvement Collected to: Observe process performance
Obtain ideas
Test changes
Determine sustainability
Data is (typically) already available and easy to obtain.

15. Measurement Measuring for improvement Short cycles “Just enough” data
Learning vs. Judgment/Accountability
Failure is good!
Quick turnaround
Run charts – view data over time

16. AYA Health Measures H.E.D.I.S. CHIPRA Core Measure Set
State- and Health System-Specific measures (often adapted from above)
NIPN Adolescent and Young Adult Health Measures (

17. Two Levels of Measurement
Project Level
1-3 core measures Takes time to develop data collection plan
PDSA Level 2
Discrete measures used to inform individual PDSA cycles
Quick to collect and feedback
Often involve manual data collection
Adapted from Associates in Process Improvement

18. QI Project Steps Assemble your Change Team Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for Improvement

19. Process Mapping Part of the “PLAN” step in PDSA
Use to describe current process
Use to improve process
Design an entirely new process
Tool to understand the process
One of 7 core QI tools
Current: how you get the job done
Improve:

20. Flowcharts- from simple
Tool to understand the process
One of 7 core QI tools
Current: how you get the job done
Improve:

21. … to more complex For each step, ask: Can it be eliminated?
Can it be done in a different order?
Can it be done by someone else-more appropriate
person?
Are there unnecessary waits?
Communication breakdowns?
Is this value added for the patient?
Is this value added for the staff?

22. Mapping the Process Define the process to be diagrammed
Decide upon the boundaries of your process:
Where/when does it start/end?
What level of detail to include in the diagram?
Get the right people there!
Brainstorm the identified activities:
Write each on a sticky note
Arrange activities in proper sequence
Draw arrows to show the flow of the process.
Review flowchart with all involved for accuracy

23. Root Cause Analysis: Why??

24. The 5 Whys Repeatedly asking “why” is one way to get to the Root Cause
Getting to the answer to the 5th why can be very surprising

25. Why don’t adolescents and young adults do well visits?
5 Whys
Why don’t adolescents and young adults do well visits?

26. QI Project Steps Assemble your Change Team Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for Improvement

27. The Model for Improvement
Aim (Goal)
Measurement
Change Ideas
Many of us here at VCHIP and across our network use TMI we dicussed briefly in the project orientation wbinar. Many models for clinical QI exist. We like this model, but it does not matter what model you use. What really matters is that you choose a model, become comfortable with the elements and you apply them in your practice.
We use the Model for Improvement as our basic framework
Other models exist: selection may be drive by other constraints
(e.g., if you are affiliated with an organization that has QI personnel, you may be familiar with other approaches.
Choose one and become comfortable with it
From The Improvement Guide
Langley, Nolan, Nolan, Norman and Provost

28. How Improvement Happens: The PDSA Cycle
So now we’re ready to revisit the model for change—the framework that we will use to test, measure, evaluate, adjust our strategy, and retest on a small scale before we can even think about scaling up.

29. Supporting Practices
PDSA Log Measurement

30. Selecting and Testing Changes
Use the PDSA Cycle for
Testing or adapting a change idea
Implementing a change
Spreading the changes to the rest of your system
AIM Training - April 11, 2013

31. Piloting vs. Implementation
Pilot Phase
Implementation Phase
People
Few
Resistance low
Many
Stronger resistance
Support Needed
Low
Changes not permanent
High
To make change part of routine operations
Time
Shorter
Longer
Tolerance for Failure
Learn from mistakes
Need high degree of confidence change will be an improvement
Adapted from the Institute for Healthcare Improvement (IHI).

32. Repeated Use of the PDSA Cycle
Changes That Result in Improvement A P S D D S P A A P S D
Repeated use of PDSA Cycles
Testing PDSA cycles in an iterative process. The completion of one cycle leads directly to the next on.
You study and learn form each test, what worked, what didn’t and what needs to be tweaked, and use this knowledge to plan your next steps.
Start small, keep it simple, measure just enough to inform your next step and ramp up the tests as you gain confidence they will lead to improvement.
By repeating these tests of change overall as you move up the hill what we hope you see is that you move your system from its current level of performance to the improved level of performance.
DATA A P S D
Hunches Theories Ideas

33. Session Objectives Review fundamentals of quality improvement (QI)
How to use the Patient Satisfaction Survey to improve quality of care

34. Case Study: Let’s Take a Closer Look
Impact in Vermont

35. Project Impact: The Practices
Geographical Target:
Interested practice looking for help after a youth suicide
Targeted recruitment to other sites in same geographical region
Interventions:
Initial site visit by faculty
Gap in Care reports (Medicaid and BCBS VT)
Environmental assessment by Youth Health Advisory Council (YHAC) members
Small monetary stipend to make desired changes
Coaching calls, technical assistance, webinars
Tools and resources through website
Use AYA Satisfaction Survey to collect data!

36. Project Impact: Youth Established a NEW Youth Health Advisory Council
Used stakeholders and community partners to recruit widely
Looked for AYA who were comfortable sharing ideas, concerns, and their experiences
Struggled with communication, meeting times
Struggled with diversity (HS students, College students, CYSHCN)

37. Environmental Assessment
Environmental Assessment Tool
Adolescent and Youth Friendly Resource Guide

38. AYA Satisfaction Survey: PDSA Cycles
Pediatric Practice “A”
Cycle 1: Started with one provider; gave tablet to all AYAs in age range for any visit – GREAT SUCCESS
Cycle 2: Expanded to all providers
Pediatric Practice “B”
Cycle 1: Created flyer to passively promote survey in waiting room – not many returned
Cycle 2: Continue doing the same

39. AYA Satisfaction Survey: PDSA Cycles
Family Medicine Practice “C”
Cycle 1: Created paper versions of survey and mailed to all AYAs in age range for Well Visit with all providers – return rate=5/50
Cycle 2: Give paper version of survey to all AYAs for Well Visit before leaving the office
Family Medicine Practice “D”
Cycle 1: Didn’t do anything (staff transitions)
Cycle 2: Re-engaged: Considering purchasing tablets

40. Survey Return Practice A Practice B Practice C Survey Method Tablets
Provider promoted
Flyer in waiting area to passively promote survey
Paper version (first mailed, then in office)
Patient Satisfaction Survey’s returned
116 1 53
(5 from mailing)

41. Baseline & 1 Month: Practice A

42. Future PDSA Cycles Improve Private Time with Provider
Examine data more closely to define problem:
differences by age group or
visit type?
What do you want to change?
Ensure private time for all AYAs >14 regardless of visit type

43. Baseline & 1 Month: Practice A

44. Future PDSA Cycles Know how to contact clinic/provider
Give card with clinic info to all AYAs
Waiting area is welcoming
Use stipend to make some changes
Know what services are confidential
Info on practice website re: confidential services

45. Lessons Learned
Offer supportive, flexible quality improvement strategies that fit each individual clinic’s needs
Celebrate and share any and all successes with all engaged clinics
Encourage data collection to quantify and track progress
Discover and use creative ways to engage youth

46. Questions?