1. Overview of Quality Improvement Terminology and Principles
86,408 PLWA – reported in the 8 states
At least 43,000 PLHIV – estimated
TOTAL POTENTIAL IMPACT:
IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States

2. IOM - Definition of Quality
“Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990)

3. ‘QI is not QA’ Motivation Measuring compliance with standards Means
Quality Assurance
Quality Improvement
Motivation
Measuring compliance with standards
Continuously improving processes to meet standards
Means
Inspection
Prevention
Attitude
Required, defensive
Chosen, proactive
Focus
Outliers: “bad apples”
Individuals
Processes
Systems
Scope
Medical provider
Patient care
Responsibility
Few
All

4. QI vs. Accreditation and Clinical Research
Aspect
Improvement
Accountability
(Accreditation)
Clinical
Research
Aim
Improvement of care
Comparison, reassurance, spur for change
New knowledge
Test observability
Test observable
No test, evaluate current performance
Test blinded
Sample size
“Just enough” data, small sequential samples
Obtain 100% of available, relevant, data
“Just in case” data
Testing strategy
Sequential tests
No tests
One large test
Solberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3.

5. Balance between Data Collection and Quality Improvement Activities
Infrastructure

6. Principles on the Quality Improvement Journey…

7. Success is achieved through meeting the needs of those we serve.

8. Most problems are found in processes, not in people.

9. Do not reinvent the wheel – Learn from best practices.

10. Achieve continual improvement through small, incremental changes.

11. Actions are based upon accurate and measured data.

12. Infrastructure enhances systematic implementation of improvement activities.

13. Set Priorities and Communicate clearly

14. Introduction of Quality Improvement Model: PDSA Cycle
86,408 PLWA – reported in the 8 states
At least 43,000 PLHIV – estimated
TOTAL POTENTIAL IMPACT:
IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States

15. Model for Improvement Improvement is about learning
trial and error (scientific method)
improvements require change, however not all changes are an improvement
Measure your progress
only data can tell you whether improvements are made
integrate measurement into the daily routine
Improvements thru continuous cycles of changes
Plan-Do-Study-Act approach
changes are initiated on a small scale to test them before implementation

16. In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment?
1602
1689
1757
1796
1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

17. In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment?
1602
1689
1757
1796 (195 years later)
1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

18. Treatment of Scurvy
Stephen J. Bown - Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail; St. Martin's Press, 2004
In 1601 lemon juice, as a protective against scurvy, is recorded by James Lancaster.
In 1612, Woodall recommended citrus fruit for protection against scurvy on sea voyages.
In 1753 James Lind published A Treatise on the Scurvy which portrays his experiment on-board the ship Salisbury in 1747.
From 1772 to 1775 sailors on historic voyages with Captain James Cook remained free from scurvy.
In 1796 lemon juice was officially introduced in the British Navy as a prophylactic against scurvy.
In 1865 British Board of Trade adopted the policy for the merchant marine.

19. How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article?
2 years
5 years
10 years
20 years
1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

20. How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article?
2 years
5 years
10 years
20 years
1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

21. Treatment of Ulcer – Dr Marshall
Timetable:
1979: Dr. Robin Warren, pathologist at Royal Perth Hospital, Australia found bacteria in stomach of patients
1981: Dr. Barry Marshall starts residency
1982: Marshall cultivates bacteria: Helicobacter pylori, 100% in Duodenal Ulcer and 77% in Gastric Ulcer
1984: first publication in Lancet; presents treatment of ulcer with common antibioticum
1994: National Institute of Health recommends treatment of ulcer as suggested by Dr. Marshall
Conclusio:
Too long to adapt proven concept - how can we adapt existing knowledge faster in daily actvities
New ideas come from outsiders
‘Early Adopter’ Diffusion of Innovation Everett Rogers
B) Neugeborenenstation in Honulu, Hawaii hat jährlich $120,000 Dollar für Schutzmasken, Plastik Handschuhe usw. ausgegeben. Nach 13 Studien wurde dort eine 14. Studie durchgeführt mit dem selben Ergebnis: es gibt keinen messbaren Unterschied der Ansteckungsrate zwischen der Vergabe von Schutzkleidern an Besuchern und der Nichtvergabe.
C) CQI Team: billinf Team, six months still trying to find causes, did not start to change things around.
HAND OUTS

22. In a recent article in the Journal of Quality Improvement 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot?
23 days
60 days
397 days
504 days
1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

23. In a recent article in the Journal of Quality Improvement 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot?
23 days
60 days
397 days
504 days
1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later

24. Survey of 92 Quality Improvement Projects in Journal of Quality Improvement
Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11):
504 days from problem identification to completion of first pilot
397 days from first team meeting to the end of first cycle
75 days to describe current situation in flowchart
62 days for data collection if change was improvement

25. How can we accelerate change and improvements in HIV programs?

26. Model for Improvement Act Plan Study Do Model for Improvement
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
Act
Plan
Study Do
MFI model for Improvement
How many have heard?
Elegantly simple model that is useful …
3 questions plus the PDSA cycle
Go over 3 questions and plan do study act ; pdsa

27. What are we trying to accomplish?
Model for Improvement
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?
Why this question is important … highly corelated with success of a team ..

28. that a change is an improvement?
Model for Improvement
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?
What is the second question … how will we know?
Why is this important ….

29. What change can we make that will result in improvement?
Model for Improvement
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?
So what is the third question?
The changes that you make should align with your aim and measures…
Where do they come from ? IHI change packages… chanes with a pedigree… have a high degree of belief they willwork .. Have worked .. Ideas in the op doc.. Op Doc.. Each other..

30. The PDSA cycle for learning and improvement
Act
Plan
Objective
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
What changes
are to be made?
Next cycle?
Study Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
Carry out the plan
Document problems
and unexpected
observations
Begin analysis of
the data

31. Why Test?
Increase your confidence that the change will result in improvement in your organization
Learn how to adapt the change to conditions in the local environment
Minimize resistance when you move to implementation
Basically, a PDSA cycle is a test. In a way, it’s like a high school biology experiment. You develop a theory (if we use an adherence screening tool with each client or patient, we’ll be able to help more patients adhere to treatment), and then run a small test to see if your theory is true.
Testing out improvement ideas is a tremendous help to implementation. From tests, you can
Know that your idea will work in your organization
Fine-tune an idea to meet the specific situation in your program or clinic
Show people that the idea can work, so they’ll be more likely to give it a try themselves.

32. How do tests lead to improvements?
You learn something from each test.
That knowledge gets incorporated into the next test.
Over time, as you build knowledge and expertise, you design a change that will result in improvement.
The answer lies in the repetitive nature of the tests. You run one PDSA cycle, and then another that is a little more complex (based on what you learned from the first), and then another that is still more complex.

33. The cycles build on each other…
Hunches Theories Ideas
Changes That Result in Improvement A P S D
DATA
Very small scale test
Follow-up tests
Wide-scale tests of change
Implementation of change
This diagram shows how the cycles build on each other. Eventually, you get to a wide-scale test of a change – trying a new screening tool in the entire clinic, for example. By the time you get to this point, when you’re involving all the staff – even those who are cranky and cynical – you’ve got a pretty good sense that the new tool will work. So, in a sense, you’ve taken the risk out of trying something new.

34. PDSA Cycle to incorporate the use of a new CM form
Improve Access to HIV Primary Care D S P A
DATA A P S D
Cycle 1E: Implement and
monitor the standards D S P A
Cycle 1D: Revise and test tool
with all clients for one week A P S D
Cycle 1C: Present refined tool to all 3
case managers and document feedback A P S D
Introduce new CM Intake/ Assessment Form
Cycle 1B: Revise tool and test with Karl’s
clients next Monday
Cycle 1A: Adapt new CM form and test with one of Joanne’s patients

35. Tips for PDSA Cycles
“What change could you implement by next Tuesday?”
Use the “Rule of 1”:
1 facility
1 office
1 provider
1 patient
We’ve learned:
Keep the first test small. Remember Dr. Smith and her 35-minute screening tool. Give yourself a chance to even to fail in this first test. Sometimes you learn the most from trying something that really doesn’t work. A common question to those starting their first PDSA cycle is: what change can you implement by next Tuesday? This question forces you to think small by reducing the sample size (‘just a few records’) and decreasing the implementation timetable (‘within a few days’) to a minimum.
One way to help you and your colleagues “keep it small” is to remember the Rule of 1. Design the first test for one facility, one office, one provider or one patient. See what happens, act on that knowledge, and then scale-up the test.

36. Useful, not perfect, data Use “huddles” to report
Tips for PDSA Cycles
Volunteers at first
Useful, not perfect, data
Use “huddles” to report
Learn from others (‘Steal shamelessly, Share senselessly’)
Just get started!
Here are three more important pointers for success:
Start out with your friends. Don’t try to convince the skeptics until you have proof. To get the proof, use volunteers – people who are interested in doing things differently.
This isn’t a randomized clinical trial. It’s a test. You don’t need double-blind data, you need information about how to make things work. Whether Dr. Smith’s test took 34.3 minutes or minutes doesn’t matter. The point is that it took about 35 minutes, and that was way too long.
Scheduling a formal meeting will take at least a week – pretty silly to do that to discuss the results of a one-day test. Grab people when you can, share information as it comes up. Dr. Smith could find Sally after the patient visit on Thursday morning and say, “Sally, that tool took 35 minutes, this will never work.” Sally might say, “Wow, you’re right. Joan and I found other tools, let me get her and we’ll come up with some others that might be better to try next.”
The important thing is to keep moving forward, because…

37. References
Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62
Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81
Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; “The Improvement Guide” San Francisco, CA; Jossey-Bass, 1996
Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55

38. PDSA Large Group Case Study
What PDSA do you suggest for the following scenario?
An agency wants to initiate a QI project to remind clients of their upcoming appointment.

39. PDSA Case Study Does your PDSA have the following three qualities?
Can you do the PDSA “by next Tuesday”?
Can you collect just enough data to know that this change will result in improvement?
Do you have a hypothesis?

40. National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street—13th Floor New York, NY NQC-QI-TA NationalQualityCenter.org