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Session Objectives

California Chronic Care Learning Communities Initiative Collaborative Learning Session I Where Are We Going and How Will We Know We Are There? Model for Improvement Part 1: Aims & Measures Angela Hovis, Improvement Advisor. Participants will be able to :

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Session Objectives

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  1. California Chronic Care Learning Communities Initiative CollaborativeLearning Session IWhere Are We Going and How Will We Know We Are There?Model for ImprovementPart 1: Aims & MeasuresAngela Hovis, Improvement Advisor

  2. Participants will be able to: Describe the Model for Improvement and its utility in accelerating improvement initiatives Define a team’s aim and measures Understand the utility of annotated run charts Session Objectives

  3. Measurement and Feedback Knowledge Management First: A Word About The Pilot Site and Spread Leadership -Topic is a key strategic initiative -Goals and incentives aligned -Executive sponsor assigned -Day-to-day managers identified Set-up -Target population -Successful sites -Key groups who make the adoption decision -Initial strategy to reach all sites Social System -Key messengers -Communities -Transition issues -Technical support Better Ideas -Develop the case -Describe the ideas Successful Sites Communication Strategies

  4. Breakthrough Series Collaborative Participants (teams/pilot sites) Select Topic (develop mission) Prework Congress, Guides, Publications etc. P P Develop Framework & Changes P A D A D A D Expert Meeting S S S LS 1 LS 2 LS 3 Planning Group Supports Email Visits Phone Assessments Monthly Team Reports

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

  6. Community Health System Resources and Policies Health Care Organization Self-Management Support DeliverySystem Design Decision Support ClinicalInformationSystems Care Model Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions ©McColl Institute Improved Outcomes HbA1c, LDL, BP

  7. Will to do what it takes to change to a new system Ideas on which to base the design of the new system Execution of the ideas Key Elements of Breakthrough Improvement

  8. 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? Fundamental Questions for Improvement

  9. Model for Improvement Act Plan Study Do 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? ©Associates in Process Improvement

  10. Write a clear and concise statement of who, what, when, and where • What does the team intend to do - use charter as a guide • Who - patient population for collaborative • Where - define pilot site and spread site(s) Align aim with strategic goals of the organization Make the target for improvement unambiguous – use numerical goals consistent with goals in the charter What Are We Trying to Accomplish?Developing the Team Aim Statement

  11. Strategic Relevant Compelling Important A Stretch Achievable Unambiguous Understandable to Everyone! The Team’s Aim Should Be:

  12. Example of an Aim statement ABC Hospital System will use the chronic care model to redesign care for patients with diabetes to help and empower them to reach their maximum health potential. We will begin our improvement work at the West Clinic withDr. Grant’s and Dr. Moyen’s patients.

  13. Example of an Aim statement (cont.) • by September 30, 2005, our goals for this pilot population are: •  Average HbA1c ≤7.0 •  At least 60% of patients with diabetes will have HbA1c <7.0 •  90% of patients with diabetes will have 2 HbA1c tests in the last 12 months •  70% of patients will have LDL-c<100 • 50% of patients will have documented BP below 130/80 • 60% of appropriate patients on statins •  50% of patients will have a current, documented self- management goal •  90% of patients with diabetes will have a current foot exam

  14. Example of an Aim statement-Complete • ABC Physicians Group will use the chronic care model to redesign care for patients with diabetes to help and empower them to reach their maximum health potential. We will begin our improvement work withDr. Grant’s and Dr. Moyen’s patients and by September 30, 2005, our goals for this pilot population are: •  90% of patients with diabetes will have 2 HbA1c tests in the last 12 months •  70% of patients with diabetes will have HbA1c <7.0 •  90% of patients will have at least one LDL test in the past 12 months •  70% of patients will have LDL-c<100 •  50% of patients will have documented BP below 130/80 • 50% of patients will have a current, documented self-management goal • 25% of patients who smoke will have ceased smoking • 90% of patients with diabetes will have a current foot exam After successful implementation at the pilot practices, changes will be spread to other chronic conditions, other physicians in our clinic, and other clinics in our system.

  15. 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 Fundamental Questions for Improvement • What are we trying to accomplish? Team Aim Statement • How will we know a change is an improvement? Measures • What changes can we make that will result in improvement? Change Package

  16. 2. How Do We Know That a Change is an Improvement? • This collaborative is about changing your organization’s approach to improving the care of patients • It is not about measurement.

  17. “You can’t fatten a cow by weighing it.” -- Proverb However….

  18. Need a family of measures reported each month to assure that the system is improved. These measures should clarify your aim statement & make it tangible These measures are used to guide improvement Integrate measurement into daily routine Plot data for the measures over time and annotate graph with changes Measurement Guidelines

  19. The purpose of measurement in the collaborative is for learning not judgment. All measures have limitations, but the limitations do not negate their value. Measures are one voice of the system. Hearing the voice of the system gives us information on how to act within the system. Measures (especially as a family) tell a story; goals give a reference point. Some Measurement Assumptions

  20. Well Defined Measures

  21. Share ideas for how to collect data How are you getting the data for your measures? How did you pick your optional measures?

  22. Eliminates ink that does not add information Shows the data Makes good use of space Integrates words with the data Visual Display of Data:Annotated Run Chart

  23. Plot small samples frequently over time Change 1 tested Change 2 tested Observed Data Value (e.g., Infection Rate) Time Order (e.g., Month) Annotated Run Chart

  24. Effectiveness Annotated Time Series(Run Chart) - Iowa Health Systems 35

  25. Family of Measures- Example

  26. • In improvement efforts, changes are not fixed but are adapted over time. • Time series graphs annotated with changes and other events provide evidence of sustained improvement - will guide you as to when you should implement and whether or not you are holding your gains. • Will help generate support for your efforts. • Will help sell spread to other parts of your organization • Summary Statistics hide information (patterns, outliers). Reasons for Plotting Data Over Time

  27. Importance of Time Order Graph Changes made Run Chart - a graphical record of a measure plotted over time

  28. Pre-Post Example: Cycle Time 35

  29. Unit 2 - same pre and post averages Changes made

  30. Cycle Time Results for Units 1, 2, and 3 Change Change Change

  31. 1. Review Your Aim Statement and Optional Measures: In light of what you have learned this today, you may wish to change your aim statement. Remember to: State your intent. Define your patient population, pilot site, target for spread, other specifics. List numerical goals for aims as outlined in the charter and any additional optional aims. 2. Review your Team 3. ACIC and Identify Ideas for Change Team Meeting 1 Agenda

  32. 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. References

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