The Model For Improvement Part 1

1. The Model For ImprovementPart 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. 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

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

6. 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

7. 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

8. 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

10. Act Plan Study Do Model for Improvement 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?

11. 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?

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

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

14. 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)

15. My Aim • 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.

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

17. 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.

18. 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.

19. 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

20. 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

21. By November 1st, 2008, we will have increased the frequency of age-appropriate structured developmental screening from 20% to 85%. 50% of staff will report that they identify and prompt clinicians about needed preventive services and the proportion of parents who report their concerns are addressed will increase to 60% by November 1, 2008

22. 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

23. Model Aim Statement ABC Pediatrics intends toimprove 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: • >90% of parents report needs met: AGPE and child’s development • >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening • >90% of parents report receiving information to address their concerns • >75% of parents read with child daily • > 90% of parents report screening about substance abuse and domestic violence • >12 Office System Inventory items in place

24. Gap this work is addressing Model Aim Statement ABC Pediatrics intends toimprove 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: • >90% of parents report needs met: AGPE and child’s development • >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening • >90% of parents report receiving information to address their concerns • >75% of parents read with child daily • > 90% of parents report screening about substance abuse and domestic violence • >12 Office System Inventory items in place

25. Model Aim Statement ABC Pediatrics intends toimprove 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: • >90% of parents report needs met: AGPE and child’s development • >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening • >90% of parents report receiving information to address their concerns • >75% of parents read with child daily • > 90% of parents report screening about substance abuse and domestic violence • >12 Office System Inventory items in place Goals Ambitious numeric targets

26. Model Aim Statement ABC Pediatrics intends toimprove 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: • >90% of parents report needs met: AGPE and child’s development • >95% of appropriate encounters include screening for depression, pyschosocial issues and structured developmental screening • >90% of parents report receiving information to address their concerns • >75% of parents read with child daily • > 90% of parents report screening about substance abuse and domestic violence • >12 Office System Inventory items in place Guidance about how the work will be done

27. EDSI Practice Goals • >90% of parents report needs met: AGPE and child’s development • >95% of appropriate encounters include screening for depression, other pyschosocial issues and structured developmental screening • >90% of parents report receiving information to address their concerns • >75% of parents read with child daily • > 90% of parents report screening about substance abuse and domestic violence • >90% of parents report family centered care • >12 Office System Inventory items in place

28. 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

30. The Model For ImprovementPart 2 Peter Margolis, MD, PhD Center for Health Care Quality September 12-13, 2008

31. Act Plan Study Do Model 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 improvement?

32. How will we knowthat a change isan improvement?

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

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

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

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

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

38. 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

39. 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

41. Quantitative Data of Key Processes Qualitative Data ADDITIONAL KEY MEASURES

42. Questions and CommentsAboutMeasurement for Improvement

43. Accelerating Improvement PDSA CYCLES

45. Act Plan Study Do Model 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 improvement?

46. Act Plan Study Do Why Test? The PDSA Cycle

47. 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

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

49. Act Plan Study Do Use PDSA Cycles to Test and Implement Changes

50. Act Plan Study Do Use PDSA Cycles to Test and Implement Changes PLAN: Objective/Question Predict outcome of test Plan details of test (who, what, when?)