1. Improving Your Primary Care Practice: Part 2 Sue Butts-Dion Improvement Advisor Institute for Healthcare Improvement This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.

2. Learning Objectives By the end of this module you will be able to: Describe several benefits of “testing small” Describe scaling up tests of change Identify 2 tools all improvers need in their toolkits 2

3. Model for Improvement (MFI) Developed by: Associates in Process Improvement Model for Improvement What are we… How will we… What changes can we… 3

4. Act Adapt? Adopt? Abandon? What’s the next cycle? Plan Objective Questions & predictions (why). Plan to carry out cycle (who/what/where/when). Next cycle? Study Do Complete the analysis of the data. Compare data to Predictions. Summarize what was learned. Carry out the plan (on a small scale). Document problems and unexpected observations. Begin analysis. The PDSA Cycle W.E. Deming referred to this as the Shewhart Cycle 4

5. Task (www.thefreedictionary.com) task (tsk) n. 1. Piece of work assigned or done as part of one's duties. 2. Difficult or tedious undertaking. 3. Function to be performed; an objective. 5

6. Test (www.thefreedictionary.com) test 1 (tst) n. 1. Procedure for critical evaluation; means of determining the presence, quality, or truth; a trial: test of one's eyesight; subjecting a hypothesis to a test; test of an athlete's endurance. 2. Series of questions, problems, or physical responses designed to determine knowledge, intelligence, or ability. 3. Basis for evaluation or judgment: "A test of democratic government is how Congress and the president work together." (Haynes Johnson) 6

7. Learning Your Way to Big Results (“Scaling Up”) 7 Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change

8. Benefits of “Testing Small” 8

9. Simple (easy to learn and adapt) 9

10. Benefits of “Testing Small” Simple (easy to learn and adapt) Rapid (short timeframe—minimize resistance) 10

11. Benefits of “Testing Small” Simple (easy to learn and adapt) Rapid (short timeframe—minimize resistance) Doable (doesn’t impact daily work as much as a large test or implementation does-make it part of the work) 11

12. Benefits of “Testing Small” Simple (easy to learn and adapt) Rapid (short timeframe—minimize resistance) Doable (doesn’t impact daily work as much as a large test or implementation does-make it part of the work) Immediate (results available immediately) 12

13. Change Idea 1 Change Idea 3 Change Idea 4 Change Idea 2 Change Idea 5 Testing Changes in Multiple Areas 13

14. ATKINSON FAMILY PRACTICE A PROMISES PRACTICE: 14

15. Atkinson Family Practice: 4 Simultaneous Test Ideas 15

16. Atkinson Family Practice: 4 Simultaneous Test Ideas 16 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent)

17. Atkinson Family Practice: 4 Simultaneous Test Ideas 17 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Test Idea #2: Practice will write on maintenance scripts: “11 refills” (or 90 days if insurance mandates 90 days)

18. Atkinson Family Practice: 4 Simultaneous Test Ideas 18 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Test Idea #2: Practice will write on maintenance scripts: “11 refills” (or 90 days if insurance mandates 90 days) Test Idea #3: Practice will educate patients that if they are told the “script is not there” to ask the pharmacy clerk to check their “patient profile”.

19. Atkinson Family Practice: 4 Simultaneous Test Ideas 19 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Test Idea #2: Practice will write on maintenance scripts: “11 refills” (or 90 days if insurance mandates 90 days) Test Idea #3: Practice will educate patients that if they are told the “script is not there” to ask the pharmacy clerk to check their “patient profile”. Test Idea #4: Practice will educate patients that if they call for auto refill and get an automated voice that says “not authorized” to hang up and call pharmacy back and talk to a live person

20. Plan: Question, Prediction, Measure 20 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent)

21. Plan: Question, Prediction, Measure 21 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Prediction: This agreement would result in:

22. Plan: Question, Prediction, Measure 22 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Prediction: This agreement would result in: Reduced work for the pharmacy

23. Plan: Question, Prediction, Measure 23 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Prediction: This agreement would result in: Reduced work for the pharmacy Reduced duplicate refill requests at the practice

24. Plan: Question, Prediction, Measure 24 Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent) Prediction: This agreement would result in: Reduced work for the pharmacy Reduced duplicate refill requests at the practice Measure: Number of duplicate script requests

25. Plan: The 5 Ws 25 Who – Pharmacy Manager, Michelle What – Pharmacy changed script request protocol from 3 to 24 hrs When – Monday through Wednesday Where – In both call-protocol and fax-protocol Why – Practice protocol filled non-urgent scripts within 24 hours; sending additional requests added unnecessary paperwork

26. Do: Everyone’s Tasks 26 Karen, Michelle, Tom: Tried 4 test ideas for 3 days Karen: Tracked duplicate script requests (those 3 days) All: Agreed to regroup and share findings (Maybe there were other ideas to test?)

27. Study: The Findings 27

28. Study: The Findings Calls from local pharmacy dropped by >50% 28

29. Study: The Findings Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% 29

30. Study: The Findings Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% Patients were not upset by the new system 30

31. Study: The Findings Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% Patients were not upset by the new system Staff was not confused by the new system 31

32. Study: The Findings Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% Patients were not upset by the new system Staff was not confused by the new system Everyone had less work 32

33. Act: Abandon, Adapt, Adopt? Actions: Changed workflow with the pharmacy Removed duplicate pharmacy #s from EMR Results: Duplicate script requests dropped ≥90% ACTION? 33

34. Act: Abandon, Adapt, Adopt? Actions: Changed workflow with the pharmacy Removed duplicate pharmacy #s from EMR Results: Duplicate script requests dropped ≥90% 34 ADOPT!

35. Two PDSA Tips 35  Years  Quarters  Months  Weeks  Days  Hours  Minutes Hamilton Consulting, LLC & Performance Management Group ONE-NESS SCALE DOWN (by 2)

36. Scaling Up Tests 4. Implementation testing 1. Early tests are simple and designed to learn then succeed 2. Then test over a variety of conditions to understand scalability and identify weaknesses 3. Later tests are designed to predict and prevent failures AP SD A P S D AP SD D S P A DATA 36

37. Your Toolkit: Essential Tools Flow Mapping: How things work now Brainstorming: Improvement ideas 37

38. Flow Mapping “You can’t improve something you can’t draw a picture of.” -- W. Edwards Deming 38

39. Brainstorming Group decision-making technique… Designed to generate many ideas… Through interaction among team members. 39

40. Brainstorming: How to 40

41. Brainstorming: How to 1.Clarify the brainstorming objective 41

42. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 42

43. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 3.Record each idea (flip chart, white board, stickies, etc.) 43

44. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 3.Record each idea (flip chart, white board, stickies, etc.) 4.Build on and expand the ideas of others 44

45. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 3.Record each idea (flip chart, white board, stickies, etc.) 4.Build on and expand the ideas of others 5.Pass when an idea does not come quickly to mind 45

46. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 3.Record each idea (flip chart, white board, stickies, etc.) 4.Build on and expand the ideas of others 5.Pass when an idea does not come quickly to mind 6.Generate as long a list as possible 46

47. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 3.Record each idea (flip chart, white board, stickies, etc.) 4.Build on and expand the ideas of others 5.Pass when an idea does not come quickly to mind 6.Generate as long a list as possible 7.Resist stopping when ideas slow 47

48. Brainstorming: How to 1.Clarify the brainstorming objective 2.Call out ideas in turn around the group 3.Record each idea (flip chart, white board, stickies, etc.) 4.Build on and expand the ideas of others 5.Pass when an idea does not come quickly to mind 6.Generate as long a list as possible 7.Resist stopping when ideas slow 8.Clarify ideas; eliminate duplicates 48

49. What Could You Do Today? Try this change? TEST IT! Plan * Do * Study * Act Can test be done in 1 hour with 1 patient? What is your current flow? MAP IT! Brainstorm list of changes. SELECT ONE! 49

50. Thank You! Thank you for your time and attention today 50

51. Assessment Question 1: Name the benefits of testing things on a small scale. a) Rapid b) Simple c) Immediate d) All of the above 51

52. Assessment Question 2: What is the suggested chronological order of “scaling up your tests of change”? w - Implementation, x - Wide scale test y - Very small scale test, z - Follow up test a) wxyz b) xywz c) yzxw d) zyxw 52

53. Assessment Question 3: List the two tools all improvers need in their toolkit (according to this module). a) Mind mapping and Flow charting b) Flow Mapping and Brainstorming c) Brainstorming and Mind Mapping d) Flow Charting and Brainstorming 53

54. Want to learn more? Be sure to refer to Part 1 54