1. Performance Improvement
--An Overview
Auxford Burks, MD
Albert Einstein College of Medicine
Department of Pediatrics/ Jacobi Medical Center

2. Thanks to:
Daniel Hyman, MD, MMM
Chief Medical Officer, Ambulatory Care Network
New York Presbyterian Hospital
Who provided all of this material

4. Fundamental Questions for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an improvement?

5. Model for Improvement Aim: What are we trying to accomplish?
Measures: How will we know that the change is an improvement?
Ideas: What changes can we make that will result in an improvement?

6. Model for Improvement
Aim:
What are we trying to accomplish?

7. What are we trying to accomplish?
Aim: A written statement of the accomplishments expected from each pilot team’s improvement effort
Different forms are useful:
A general description of aim
Specific patient population
Some guidance for carrying out the work

8. The Team’s Aim Should Be:
Strategic
Relevant
Exciting
Important
A stretch, not business as usual
Achievable, not impossible
Understandable

9. Sample Goals/Measures
95% of patients with asthma will have symptom frequency documented in their record (day and night) – process measure
95% of patients will have asthma severity specifically identified at all visits where asthma is addressed – process measure
90% of patients with persistent asthma will be treated with an appropriate antiinflammatory medication, at an appropriate dose – process measure
95% of patients with asthma will have a documented assessment of tobacco use or exposure and counseling to reduce risk if applicable – process measure
There will be an X% reduction in ED/hospitalization rate over Y period of time – outcome measure
Visit volume in clinic will be unchanged – balancing measure

10. AIM: Why the Change is Desired
A known performance deficiency in an important process
A gap between current performance and desired performance

11. Why an Aim Statement?
Answers and clarifies “What are we trying to accomplish?
Creates a shared language and shared methods
Facilitates organizational conversations and understanding
Supports accountability for team leaders

12. Developing the Aim Statement
Write a clear and concise statement stating the “who, what, when, and where “
Who will undertake the work, and who will be affected by it
What does the team intend to do
When will the aim be accomplished
Where - define pilot site and spread site(s)

13. SMAART Aims Specific: Understandable, unambiguous
Measurable: Numeric goals
Actionable: Who, what, where, when
Achievable (but a stretch)
Relevant to stakeholders and organization
Strategic, Compelling, Important
Timely: with a specific timeframe

14. Sample Aims
We will improve the care of patients with asthma by adhering to evidenced based guidelines for diagnosis, assessment and treatment, thereby reducing morbidity/mortality
By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 days or more in the 2-week period preceding a planned care visit.

15. Example of Elaborated Aim Statement
Aim: By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 or more in the 2-week period preceding a visit. To effect change, we will be guided by using the six components of the Care Model for Child Health. Intermediate aims are that:
95% of children with persistent asthma will have severity classified at every visit.
95% of children with persistent asthma will be treated with appropriate maintenance anti-inflammatory medication.
90% of children will receive a written asthma management plan on which we will document family/self- management goals.

16. Ideas Aim Measures Model for Improvement Act Plan Study Do Act Plan
What are we trying to
Aim
accomplish?
How will we know that a
Measures
change is an improvement?
What change can we make that
Ideas
will result in improvement?
Act
Plan
Study Do
Act
Plan
Study Do
From: Associates in
Process Improvement

17. A PDSA Cycle
PDSA Objective: Test the use of encounter form to facilitate visit
Will encounter forms facilitate severity classification? Dr. X will try form with severity class Qs with 3 patients on Thurs
Revise form. Try new form with 3 patients tomorrow; MA will put form on chart.
Dr. X found the form helpful for prompting; thought items on form should be in a different order. Need better process for getting form to provider.
Dr. X tried with two patients. Couldn’t find a form for third patient.

18. Why Test?
Increase your belief that the change will result in improvement
Opportunity for learning from “failures” without impacting performance
Document how much improvement can be expected from the change
Learn how to adapt the change to conditions in the local environment
Evaluate costs and side-effects of the change
Minimize resistance upon implementation

19. Ideas: What Changes Can We Make That Will Lead to Improvement?
Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

20. Ideas: What Changes Can We Make That Will Lead to Improvement?
Change Concept: A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.
Promote clinical care that is consistent with scientific evidence and family preferences
Use tool to classify severity at every visit

21. Change Concepts vs. High Leverage Changes
Vague, strategic, creative
Specific, actionable, results
Improve care of asthma patients
Share info w/ patients & families and encourage self-management
Document asthma management plan and goals for self-management
Begin discussion of self-management goals w/ 3 patients on Monday

22. Repeated Use of the PDSA Cycle
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
Improve asthma outcomes
Changes That Result in Improvement
Reduction in ED visits
Change Pkg. A P S D
DATA D S P A
Implementation of Change A P S D
Wide-Scale Tests of Change A P S D
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test

23. PDSA example I
A pediatrician goes to a conference one October and learns all about Improvement, PDSA cycles, and how to improve care for patients with asthma.
He returns to his practice completely enthused and ready to do something new that will improve care.
We’ll call our protagonist in this story, Bill Caspe

24. PDSA example I
Bill decides to look at his 5 person practice’s assessment of children whose parents call for refills of asthma medications to see whether the children:
Need flu vaccines
Are having symptoms too frequently (i.e. are not being well controlled on their current medication regimen)
He develops a form and gives it to his nurse to use for one week when asthma meds are refilled

25. PDSA example I Is this a good PDSA cycle? What do you think happened?
Why?
Why Not?
What do you think happened?

26. PDSA example II
The pediatric residents in a community based clinic are taught about improvement, PDSA cycles, and how to improve care for patients with asthma.
They are provided with baseline data that shows that only 20% of children have a severity classification of their asthma in the practice’s medical records

27. PDSA example II
The residents develop a sticker that prompts the questions needing to be asked to determine symptom frequency
One resident on ambulatory block tries the sticker for 5 consecutive patients with asthma.

28. PDSA example II Is this a good PDSA cycle? What do you think happened?
Why?
Why Not?
What do you think happened?

29. PDSA Cycles
“Negative results on the fish…Let’s try rubbing two sticks together.”

30. PDSA Key Points: Make the Cycle SMALLER!!!
Break changes down into manageable parts
This also allows people to:
try things and give input
more easily adapt
feel included in decisions and development

31. Routine use of patient survey
Repeated Use of the PDSA Cycle for Implementation
Routine use of patient survey D S P A
Cycles 5/6: Create orientation manual section on patient survey A P S D
DATA D S P A
Cycle 4: Use of survey for all patients A P S D
Cycle 3: Try survey on other days with other providers and patients A P S D
Cycle 2: Test - Use of new survey on two clinic days
Test of patient survey
Cycle 1: Introduce new survey form to one provider and staff

32. Multiple Cycles to Test and Implement Components of the Care Model
Use of Flow sheet V.4 by all physicians and nurses
Component: Decision Support D S P A
From Chinatown, Asthma BTS, 2001 A P S D
Learning
Cycle 5: Implement use of V.4, do peer review of documentation and use D S P A
Cycle 4: Trial of V.4 by all providers A P S D
Cycle 3: Two week trail of V.3, review meetings A P S D
Cycle 2: Try V.2 by two providers for a few days
Will a flow sheet be useful for patients?
Cycle 1: Gather sample flow sheets, try V.1with two patients

34. Things should be as simple as possible but not simpler.
Albert Einstein