1. The Model For Improvement Part 1 Chapter Quality Network Asthma Pilot Project Asthma Learning Collaborative Peter Margolis, MD PhD

2. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Session Objectives To describe the components of the Model for Improvement To write a clear aim statement for your team. –To identify goals that you will measure to support your aim

4. Headlines: Previous Initiatives Sandhills Pediatrics reduces asthma admissions in Moore County to lowest among NC counties PHO cuts asthma admissions by 36%

5. Aggregate Total Pop Asthma (8 SE-PA practices, average of 600 patients per practice) (5,000 patients in total asthma population) 29 percentage point improvement

6. Multiple Barriers and Opportunities for Promoting Optimal Development What are some challenges you are facing in: –Eliciting parents’ concerns and addressing information needs –Helping parents enhance their child’s development –Identifying children at risk for developmental and behavioral problems –Linking families with needed community services

7. Barriers and Opportunities for Promoting Optimal Development Parent –Knowledge about development –Skills at managing behavior –Willingness/ability to as clinicians about concerns Provider –Time –Counseling resources and skills Practice –Routine process for eliciting concerns –Organized materials and resources to meet families’ needs –Ability to link families with community resources

9. 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 ActPlan StudyDo

10. Three 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?

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

12. Teams with clear aim and goals are more successful! Why Spend Time Refining Aim and Goals?

13. What Are We Trying to Accomplish? Aim: A written statement of the accomplishments expected from team’s improvement effort Key component: –A general description of aim (e.g., provide optimal asthma care) You may want to add: –Identification of specific patient population (e.g., all children under 5 years of age) –Some guidance for carrying out the work (e.g., can start with one physician/nurse team and spread to others)

14. I will give a talk about how to use QI to improve asthma care during LS 1. I will explain how to use the model for improvement By 3 pm on 9/17/09, 10 out of the 10 teams will have completed Aim statements for their work to improve asthma care. My Aim

15. The Best Aim Statements: Provide a rationale and point of shared vision for team’s efforts S.M.A.R.T S: SPECIFIC M: MEASUREABLE A: ACTION-ORIENTED R: RELEVANT T: TIMELY

16. We will increase the proportion of parents who whose asthma control is assessed. We will implement a planned care approach to provide reliable asthma care.

17. We will increase the proportion of parents who receive optimal asthma care from 10% to 90% by Sept, 2010. We will increase the proportion of patients with at least an annual assessment of asthma from 60% to 90% by Sept, 2010.

18. Global Aim What will we accomplish over 1 year, 2 years, 3 years? Allows the entire practice to understand and eventually buy-in to goal Keeps team focused and goal-oriented

19. Specific Aim Statement What is the work we are doing right now? What will we accomplish in the next 90 days? How do you run a marathon? ONE MILE AT A TIME

20. Goals Tell You When You’ve Reached Your Aim They define the way you expect your improved system to work They establish specific numeric targets for your work They describe the magnitude of change expected They should be challenging, but attainable –Stretch goals encourage creativity and innovation

21. Model Aim Statement ABC Pediatrics intends to improve preventive and developmental care for children by developing efficient practice-based systems to organize preventive and developmental care. We will integrate standardized screening tools and anticipatory guidance into the practice workflow, increase family involvement through the use of brief parent questionnaires to assist us in discussing their concerns. We will also increase our knowledge of community services by documenting each child’s early care providers and developing a community resource list. We will implement a standard letter for parents to share with ECE providers from ABC Pediatrics indicating our involvement with a specific child that includes contact information to reach our practice. By (date): Sept 1, 2009 for children up to 5 years of age and their families in our practice. Our goals are: 1. >90% of parents report needs met: AGPE and child’s development 2. >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening 3. >90% of parents report receiving information to address their concerns 4. >75% of parents read with child daily 5. > 90% of parents report screening about substance abuse and domestic violence 6. >12 Office System Inventory items in place

22. Model Aim Statement ABC Pediatrics intends to improve preventive and developmental care for children by developing efficient practice-based systems to organize preventive and developmental care. We will integrate standardized screening tools and anticipatory guidance into the practice workflow, increase family involvement through the use of brief parent questionnaires to assist us in discussing their concerns. We will also increase our knowledge of community services by documenting each child’s early care providers and developing a community resource list. We will implement a standard letter for parents to share with ECE providers from ABC Pediatrics indicating our involvement with a specific child that includes contact information to reach our practice. By (date): Sept 1, 2009 for children up to 5 years of age and their families in our practice. Our goals are: 1. >90% of parents report needs met: AGPE and child’s development 2. >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening 3. >90% of parents report receiving information to address their concerns 4. >75% of parents read with child daily 5. > 90% of parents report screening about substance abuse and domestic violence 6. >12 Office System Inventory items in place Gap this work is addressing

23. Model Aim Statement ABC Pediatrics intends to improve preventive and developmental care for children by developing efficient practice-based systems to organize preventive and developmental care. We will integrate standardized screening tools and anticipatory guidance into the practice workflow, increase family involvement through the use of brief parent questionnaires to assist us in discussing their concerns. We will also increase our knowledge of community services by documenting each child’s early care providers and developing a community resource list. We will implement a standard letter for parents to share with ECE providers from ABC Pediatrics indicating our involvement with a specific child that includes contact information to reach our practice. By (date): Sept 1, 2009 for children up to 5 years of age and their families in our practice. Our goals are: 1. >90% of parents report needs met: AGPE and child’s development 2. >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening 3. >90% of parents report receiving information to address their concerns 4. >75% of parents read with child daily 5. > 90% of parents report screening about substance abuse and domestic violence 6. >12 Office System Inventory items in place Goals Ambitious numeric targets

24. Model Aim Statement ABC Pediatrics intends to improve preventive and developmental care for children by developing efficient practice-based systems to organize preventive and developmental care. We will integrate standardized screening tools and anticipatory guidance into the practice workflow, increase family involvement through the use of brief parent questionnaires to assist us in discussing their concerns. We will also increase our knowledge of community services by documenting each child’s early care providers and developing a community resource list. We will implement a standard letter for parents to share with ECE providers from ABC Pediatrics indicating our involvement with a specific child that includes contact information to reach our practice. By (date): Sept 1, 2009 for children up to 5 years of age and their families in our practice. Our goals are: 1. >90% of parents report needs met: AGPE and child’s development 2. >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening 3. >90% of parents report receiving information to address their concerns 4. >75% of parents read with child daily 5. > 90% of parents report screening about substance abuse and domestic violence 6. >12 Office System Inventory items in place Guidance about how the work will be done

25. Team Exercise: Aim Statement Worksheet Name of Organization: Intends to: General Aim By: Timely (Global and Specific for next 90 days) For: Specific population Because: Rationale/Framework (clear for others) Goals: Measurable, Relevant Goals

27. The Model For Improvement Part 2 and Accelerating Improvement Chapter Quality Network Asthma Pilot Project Asthma Learning Collaborative Peter Margolis, MD, PhD

28. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

29. 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 improvement? ActPlan StudyDo Model for Improvement

30. How will we know that a change is an improvement?

31. Do a statistical test to rule out the null hypothesis

32. Measurement for Improvement Conduct repeated tests (PDSA cycles or planned experiments) to increase our degree of belief (provide evidence) that a change led to an improvement

33. Percentage of Parents Who Report Concerns Are Addressed % % % % % % Weeks

34. % % % % % % Change #1 Percentage of Parents Who Report Concerns Are Addressed

35. % % % % % % Weeks Change #1

36. Measures: Quantitative Data Monthly report of % parents report needs met: AGPE and child’s development Monthly report of % of appropriate encounters that include screening for depression, other pyschosocial issues and structured developmental screening Monthly report of % of parents who report receiving information to address their concerns Monthly report of % of parents who read with child daily

37. North Willow Grove Pediatrics, PC 2701 Blair Mill Road, Suite 10 Willow Grove, PA 19090 1010 Horsham Road, Suite 210 North Wales, PA 19454 Marie Smolenski, RN, MSN, CRNP Nancy Dockstader

39. Accelerating Improvement PDSA CYCLES

41. 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 improvement? Model for Improvement ActPlan StudyDo

42. Why Test? ActPlan StudyDo The PDSA Cycle Why Test?

43. Cycles for Testing Learn how to adapt change to local environment Increase belief that change will result in improvement Opportunity for “failures” without impacting performance Document how much improvement can be expected from change Evaluate costs and side-effects of change Minimize resistance upon implementation

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

45. ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes

46. ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes PLAN: Objective/Question Predict outcome of test Plan details of test (who, what, when?)

47. ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Do: Conduct the test and collect data Document observations – successes/failures Begin analysis Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?)

48. ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Do: Conduct the test and collect data Document observations – successes/failures Begin analysis Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?) Study: Complete analysis Compare predictions to test results Summarize what was learned

49. ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Do: Conduct the test and collect data Document observations – successes/failures Begin analysis Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?) Study: Complete analysis Compare predictions to test results Summarize what was learned Act: Take action based on new knowledge What changes will be made? Next test?

50. The Model Provides Structure for Repeated Tests Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA

51. Testing on a Small Scale Have others that have some knowledge about the change review and comment on its feasibility Test the new approach on the members of the team that developed the change before introducing it to others Incorporate comparison in the test by making the change side-by-side with the existing care system “Cycle of 1” - conduct the test in with one physician, with one patient, etc. Conduct the test over a short time period Test the change on a small group of volunteers Develop a plan to simulate the change in some way

52. Measurement for PDSA “Study” is specific to the PDSA –See implementation checklists –Usually not one of core measures –Usually begins and ends with PDSA cycle –Often qualitative (e.g., partner’s views) For PDSA Cycle measures, collect data only while you are testing or adapting a change to your system Identify/create tools to be used for data collection – make it simple and easy

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

54. Decrease the Time Frame for a PDSA Test Cycle Years Quarters Months Weeks Days Hours Minutes Drop down two levels to plan Test Cycle!

55. Do  Study Reasons for failed tests 1.Change not executed well 2.Support processes inadequate 3.Hypothesis/hunch wrong: Change executed but did not result in improvement Collect data during the Do phase of the Cycle to help differentiate these situations

58. Next Steps: Plan a Ramp of PDSA’s to Reach 90 Day Aim Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change

59. What Can We Do Now! By Next Week, By Tuesday, By Tomorrow

60. Learning from Each Other Transparent Sharing of Data Sharing Results of PDSA’s Learning from Successes and Failures

61. Report Your First PDSA on the Listserv by Friday, September 18th

62. Model for Improvement Measurement & PDSA QUESTIONS?