Model for Improvement

1. Model for Improvement Ruth S. Gubernick, MPH QI Advisor Florida Pediatric Medical Home Demonstration Project Learning Session I September 23-24, 2011

2. Objectives of this Session • Participants will be able to: • Identify Model for Improvement • Create an Aim statement for project with concrete goals • Constitute Plan Do Study Act (PDSA) cycles to test improvements, using the project change package, tools and resources

3. The First Law of Improvement “Every system is perfectly designed to achieve exactly the results it gets.”

4. Research vs. Quality Improvement Measurement for Measurement for Learning and Research Process Improvement Purpose To discover new knowledge To bring new knowledge into daily practice Tests One large "blind" test Many sequential, observable tests Biases Control for as many biases Stabilize the biases from test to test as possible Data Gather as much data as Gather "just enough" data to learn possible, "just in case" and complete another cycle Duration Can take long periods of "Small tests of significant changes" time to obtain results accelerates the rate of improvement

5. 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?

6. Act Plan Study Do Model for Improvement What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES What change can we make that IDEAS will result in improvement?

7. Compare the 3 questions to how we frame improvement • Aim • Measurement for learning • PDSA • What are we trying to accomplish? • How will we know a change is an improvement? • What changes can we make to bring about improvement?

8. Act Plan Study Do Model for Improvement What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES What change can we make that IDEAS will result in improvement?

9. What Are We Trying to Accomplish? Aim: A written statement of the accomplishments expected from this improvement effort Key components: - A general description of aim – should answer, “what are we trying to accomplish?” - Some guidance for carrying out the work and rationale - Specific target population and time period - Measurable goals

10. Example (Poor) Our practice teams will improve care for all children and youth, including those with special health care needs (CYSHCN) by using the Medical Home toolkit.

11. Sample Aim By March 2012, XYZ Pediatrics will aim to improve our medical home by focusing on potential ways to improve our processes for enhancing access to care. Our team will focus on testing the suggested strategies and tools related to enhancing access to care. We will achieve this aim by using the Medical Home tools and resources so that we: 1. Identify the primary care pediatrician or physician‐led care team for 90% or more of all patients 2. Ensure that 90% or more of all patients receive their health supervision visits from their primary care pediatrician or physician‐led team members 3. Work on system level changes such as offering expanded appointment hours, procedures for urgent care after hours, offering alternate ways to interact with patients, and pre‐arranging special accommodations for patients who need them in order to achieve the goal of 90% of care being delivered by the PCP or physician‐led care team member

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

13. AIM Worksheet • The (name of your team ) intend to accomplish • By (date) • For (population) • because • Our goals include: • Special guidance that will help us stay on track:

14. Act Plan Study Do Model for Improvement What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES What change can we make that IDEAS will result in improvement?

15. How will we know a change is an improvement? Requires measurement Build measurement into daily work routine Data should be easy to obtain and timely Small samples over time Use qualitative & quantitative data Qualitative data is highly informative Qualitative data is easy to obtain

16. Measurement Guidelines Balanced set of 5 to 7 measures reported each month to assure that the system is improved Measures should reflect the aim and make it specific Measures are used to guide improvement and test changes Integrate measurement into daily routine Plot data measures over time and annotate graph with changes Outcome and process measures

17. Measures for Florida Pediatric Medical Home Demonstration Project: Example Target population Percent of patients with an identified primary care pediatrician or physician-led care team (Process) Numerator Total number of patients with an identified primary care pediatrician or physician-led care team Denominator Total number of charts in chart set

18. Act Plan Study Do Model for Improvement What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES What change can we make that IDEAS will result in improvement?

19. What Changes Can We Make That Will Result in Improvement? Tests of Change need 2 components: 1. Change concepts (ideas): ready for use or ready to adapt to your unique environment (**Use results from pre-work assessment to inform what you need to change) 2. PDSA test method

20. The PDSA Cycle for Learning and Improvement Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • 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

21. PDSA: Break it Down/Simplify… Plan - Figure out the questions you want to answer, plan a way to answer the questions, and predict results Do - “Just do it” (i.e. do the plan) Study - What did you learn? Did your prediction hold? What assumptions need revision? Act - What will you do with the knowledge you learned? Adapt? Adopt? Abandon? What do you want to do next?

22. Use of the PDSA Cycles Multiple cycles A P S D D S P A A P S D A P S D Changes that Result in Improvement Data Implementation of Change Wide-Scale Tests of Change Evidence Best Practice Testable Ideas Follow-up Tests Very Small Scale Test

23. What are Tests? Putting a change into effect on a temporary basis and on a small scale and learning about the potential impact

24. Task or Test? Task To do’s Meetings Posters Policy Committees Test Question Prediction Data Usually involves patient

25. 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

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

27. What Can We Do Now! By Next Week, By Tuesday, By Tomorrow That won’t harm a hair on the head of a patient?

28. Sequential Building of Knowledge Include a Wide Range of Conditions in the Sequence of Tests BreakthroughResults A P Evidence & Data S D A P S D A P S D A P Learning and improvement Theories, hunches,& best practices S D Spread Implement Test new conditions Test a wider group Test on a small scale

29. Overall Aim: To strengthen medical home capacity to provide high quality, family-centered care for all children and youth, including those with special health care needs (CYSHCN). P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Access to Care Family-centered care Planned, proactive, comprehensive care Coordinated care, across all settings

30. Fundamental Questions for Improvement What are we trying to accomplish? Team Aim Statement How will we know that a change is an improvement? Measures What changes can we make that will result in an improvement? Change Package Model for Improvement What are we trying to accomplish? How will we know thata change is an improvement? What change can we make that will result in improvement? Act Plan Study Do

31. Form for planning a PDSA cycle • supports prediction • and keeping one step ahead

32. The Care Model for Child Health in a Medical Home

33. Questions

35. William Edwards Deming “It is not necessary to change. Survival is not mandatory.”

36. References The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. Quality Improvement Through Planned Experimentation. 2nd edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998. “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990. A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997. The Improvement Handbook, Model, Methods, and Tools for Improvement, Associates in Process Improvement, Austin, TX, 1997. Note: Special thanks to Carole Lannon, MD, MPH for some slides from her Safe and Healthy BeginningModel For Improvement presentation, 8/4/07