1. Paula Peyrani, MD Medical/Project Director, HIV Program at the 550 Clinic Assistant Director, Research Design and Development Clinical and Translational Research Support Center Division of Infectious Diseases University of Louisville p0peyr01@louisville.edu Strategies to Facilitate Performance Monitoring

2. Outline Quality improvement Model for improvement What can go wrong? Outline Quality improvement Model for improvement What can go wrong?

3. Outline Quality improvement Model for improvement What can go wrong? Outline Quality improvement Model for improvement What can go wrong?

4. Essential component of 21st century medicine. QUALITY IMPROVEMENT

5. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. QUALITY IMPROVEMENT

6. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. QUALITY IMPROVEMENT

7. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. Process measure quantifies compliance with the practices being implemented as part of an initiative. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. Process measure quantifies compliance with the practices being implemented as part of an initiative. QUALITY IMPROVEMENT

8. Essential component of 21st century medicine. Used to create safer systems and implement safer practices. Process measure quantifies compliance with the practices being implemented as part of an initiative. An outcome measure assess the impact of the initiative on a patient population or health-care system Essential component of 21st century medicine. Used to create safer systems and implement safer practices. Process measure quantifies compliance with the practices being implemented as part of an initiative. An outcome measure assess the impact of the initiative on a patient population or health-care system QUALITY IMPROVEMENT

9. Process QUALITY IMPROVEMENT Outcome

10. Outline Quality improvement Model for improvement What can go wrong? Outline Quality improvement Model for improvement What can go wrong?

11. MODEL FOR IMPROVEMENT

13. The aim has to be: Consistent with national goals and relevant to the length of the project The aim has to be: Consistent with national goals and relevant to the length of the project

14. MODEL FOR IMPROVEMENT The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations

15. MODEL FOR IMPROVEMENT The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations Clear with measurable targets The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations Clear with measurable targets

16. MODEL FOR IMPROVEMENT The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations Clear with measurable targets The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations Clear with measurable targets Outcome measure: To reduce the incidence of infections due to CRE

17. MODEL FOR IMPROVEMENT The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations Clear with measurable targets The aim has to be: Consistent with national goals and relevant to the length of the project Bold in its aspirations Clear with measurable targets Outcome: To reduce the incidence of infections due to CRE Process: timing of swabbing upon admission to the hospital Outcome: To reduce the incidence of infections due to CRE Process: timing of swabbing upon admission to the hospital

18. MODEL FOR IMPROVEMENT

19. Collect data to demonstrate whether changes result in improvement

20. MODEL FOR IMPROVEMENT Collect data to demonstrate whether changes result in improvement Graphs: “run charts” or statistical process control charts Collect data to demonstrate whether changes result in improvement Graphs: “run charts” or statistical process control charts

21. MODEL FOR IMPROVEMENT Collect data to demonstrate whether changes result in improvement Graphs: “run charts” or statistical process control charts Measures are tools for learning and demonstarting improvement, not for judgment. Collect data to demonstrate whether changes result in improvement Graphs: “run charts” or statistical process control charts Measures are tools for learning and demonstarting improvement, not for judgment.

22. MODEL FOR IMPROVEMENT

23. There are many potential changes that a team can make

24. MODEL FOR IMPROVEMENT There are many potential changes that a team can make There are a small number of changes that are most likely to result in improvement There are many potential changes that a team can make There are a small number of changes that are most likely to result in improvement

25. http://www.birdville.k.12.tx.us/staffdev/continuos_imprvmn.htmlt MODEL FOR IMPROVEMENT

26. WHY IS IMPORTANT TO ASSESS?

27. MODEL FOR IMPROVEMENT WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change

28. MODEL FOR IMPROVEMENT WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change Decide whether the change will work in the actual setting WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change Decide whether the change will work in the actual setting

29. MODEL FOR IMPROVEMENT WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change Decide whether the change will work in the actual setting Evaluate costs, social impact, and side effects from a proposed change WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change Decide whether the change will work in the actual setting Evaluate costs, social impact, and side effects from a proposed change

30. MODEL FOR IMPROVEMENT WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change Decide whether the change will work in the actual setting Evaluate costs, social impact, and side effects from a proposed change Minimize resistance upon implementation WHY IS IMPORTANT TO ASSESS? Evaluate how much improvement can be expected from the change Decide whether the change will work in the actual setting Evaluate costs, social impact, and side effects from a proposed change Minimize resistance upon implementation

31. http://www.birdville.k.12.tx.us/staffdev/continuos_imprvmn.htmlt MODEL FOR IMPROVEMENT

32. Plan

33. MODEL FOR IMPROVEMENT Plan Plan the test or observation, including a plan for collecting data Plan Plan the test or observation, including a plan for collecting data

34. MODEL FOR IMPROVEMENT Plan Plan the test or observation, including a plan for collecting data State the objective of the test Make predictions about what will happen and why Develop a plan to test the change (Who? What? When? Where? What data need to be collected?) Plan Plan the test or observation, including a plan for collecting data State the objective of the test Make predictions about what will happen and why Develop a plan to test the change (Who? What? When? Where? What data need to be collected?)

35. MODEL FOR IMPROVEMENT Do (test)

36. MODEL FOR IMPROVEMENT Do (test) Try out the test on a small scale Do (test) Try out the test on a small scale

37. MODEL FOR IMPROVEMENT Do (test) Try out the test on a small scale Carry out the test Document problems and unexpected observations Begin analysis of the data Do (test) Try out the test on a small scale Carry out the test Document problems and unexpected observations Begin analysis of the data

38. MODEL FOR IMPROVEMENT Study

39. MODEL FOR IMPROVEMENT Study Set aside time to analyze the data and study the results. Study Set aside time to analyze the data and study the results.

40. MODEL FOR IMPROVEMENT Study Set aside time to analyze the data and study the results. Complete the analysis of the data Compare the data to your predictions Summarize and reflect on what was learned. Study Set aside time to analyze the data and study the results. Complete the analysis of the data Compare the data to your predictions Summarize and reflect on what was learned.

41. MODEL FOR IMPROVEMENT Act

42. MODEL FOR IMPROVEMENT Act Refine the change, based on what was learned from the test. Act Refine the change, based on what was learned from the test.

43. MODEL FOR IMPROVEMENT Study Refine the change, based on what was learned from the test. Determine what modifications should be made Prepare a plan for the next test Study Refine the change, based on what was learned from the test. Determine what modifications should be made Prepare a plan for the next test

44. Outline Quality improvement Model for improvement What can go wrong? Outline Quality improvement Model for improvement What can go wrong?

45. WHAT CAN GO WRONG?

46. Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine WHAT CAN GO WRONG?

47. Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine Period of transformation by integrating QI principles into its clinical, educational, and research missions Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine Period of transformation by integrating QI principles into its clinical, educational, and research missions WHAT CAN GO WRONG?

48. Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine Period of transformation by integrating QI principles into its clinical, educational, and research missions Teams began working on PDSA cycles targeted at clinical and operational problems Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine Period of transformation by integrating QI principles into its clinical, educational, and research missions Teams began working on PDSA cycles targeted at clinical and operational problems WHAT CAN GO WRONG?

49. Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine Period of transformation by integrating QI principles into its clinical, educational, and research missions Teams began working on PDSA cycles targeted at clinical and operational problems Began looking for multiple ways to change previously well-established ways of working Palmetto Health Family Medicine Center (FMC), the teaching practice for the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine Period of transformation by integrating QI principles into its clinical, educational, and research missions Teams began working on PDSA cycles targeted at clinical and operational problems Began looking for multiple ways to change previously well-established ways of working WHAT CAN GO WRONG?

50. Signs of impairment after 18 months WHAT CAN GO WRONG?

51. Signs of impairment after 18 months Multitasking on various PDSA cycles Signs of impairment after 18 months Multitasking on various PDSA cycles WHAT CAN GO WRONG?

52. Signs of impairment after 18 months Multitasking on various PDSA cycles Not completing cycles Signs of impairment after 18 months Multitasking on various PDSA cycles Not completing cycles WHAT CAN GO WRONG?

53. Signs of impairment after 18 months Multitasking on various PDSA cycles Not completing cycles Fatigue Signs of impairment after 18 months Multitasking on various PDSA cycles Not completing cycles Fatigue WHAT CAN GO WRONG?

54. Signs of impairment after 18 months Multitasking on various PDSA cycles Not completing cycles Fatigue Lack of commitment to sustainability Signs of impairment after 18 months Multitasking on various PDSA cycles Not completing cycles Fatigue Lack of commitment to sustainability WHAT CAN GO WRONG?

55. to sustainability WHAT CAN GO WRONG? Planning was much easier than Doing Planning was much easier than Doing

56. WHAT CAN GO WRONG?

57. Treatment WHAT CAN GO WRONG?

58. Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. WHAT CAN GO WRONG?

59. Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) WHAT CAN GO WRONG?

60. Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Group accountability Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Group accountability WHAT CAN GO WRONG?

61. Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Group accountability Redirection of group members when they become distracted Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Group accountability Redirection of group members when they become distracted WHAT CAN GO WRONG?

62. Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Group accountability Redirection of group members when they become distracted Planning itself needs to be conducted in a purposeful manner to insure movement to the Do phase Treatment Because we cannot advocate for systematic education of organizational members, a focus on behavioral therapy is offered. Ensure proper motivation and buy-in among PDSA cycle participants (e.g. QI champion) Group accountability Redirection of group members when they become distracted Planning itself needs to be conducted in a purposeful manner to insure movement to the Do phase WHAT CAN GO WRONG?

63. Outline Quality improvement Model for improvement What can go wrong? Outline Quality improvement Model for improvement What can go wrong?

64. References Schriefer J, Leonard MS. Patient Safety and Quality Improvement: An Overview of QI. Pediatrics in Review 2012;33;353. http://www.institute.nhs.uk/quality_and_service_improvement_tools/q uality_and_service_improvement_tools/plan_do_study_act.html. Accessed on July 31, 2013. http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprove mentHowtoImprove.aspx Accessed on August 3, 2013. References Schriefer J, Leonard MS. Patient Safety and Quality Improvement: An Overview of QI. Pediatrics in Review 2012;33;353. http://www.institute.nhs.uk/quality_and_service_improvement_tools/q uality_and_service_improvement_tools/plan_do_study_act.html. Accessed on July 31, 2013. http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprove mentHowtoImprove.aspx Accessed on August 3, 2013.