The M odel for Improvement A Method to Adapt, Implement, and Spread Changes

1. The Model for ImprovementA Method to Adapt, Implement, and Spread Changes Connie Davis September 14, 2000 (prepared with assistance from Lloyd Provost, Associates in Process Improvement and the Institute for Healthcare Improvement)

2. 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?

3. The PDSA Cycle for Learning and Improvement 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 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

4. A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes That Result in Improvement Learning from Data Proposals, Theories, Ideas

5. 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?

6. What are we trying to accomplish? Aim (also called Charter) A written statement of the accomplishments expected from each pilot team’s improvement effort Contains useful information: • A general description of the goal • Specific population • Numerical goals • Guidance for carrying out the work.

7. A P S D A P S D A P S D Different Populations PILOT SITE System of Focus for the BTS (defined by Aim) Small-scale tests of change The Total Health Care System (spread sites)

8. How Do We Know That a Change is an Improvement? • This collaborative is about changing your organization’s approach to caring for patients. • It is not about measurement. But …… • Population management and measurement are key components of clinical care. • Key outcome measures are required to assess progress on your pilot team’s aim. • Specific measures are required for learning about concepts tested during PDSA cycles.

9. Measurement Guidelines • The key measures plotted and reported each month should clarify your team’s aim and make it tangible. • Be careful about over-doing process measures. • Make use of your patient population data base (registry) and administrative data for measurement. • Integrate measurement into the daily routine. • Plot data on the key measures each month during the Collaborative. • The question - How will we know that a change is animprovement? usually requires more than one measure. A balanced set of five to seven measures helps assure that the system is improved.

10. For Each of the Key Measures • Define each of the measures for your pilot population (numerator and denominator). • Begin reporting your measures immediately. • Use the current administrative and registry data as the means to obtain your measures each month whenever possible. • Develop run charts to display your measures each month throughout the Collaborative.

11. Minimum Standard for Monthly ReportingAnnotated Time Series

12. Improvement in Glycemic Control Percent of (Patients with HbA1c >9.5 in Clinic A)

13. Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic A)

14. Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic B)

15. Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic C)

16. Family of Measures for Diabetes

17. What changes can we make that will result in an improvement? Chronic Care Model

18. Change Concepts from the Chronic Care Model • Community - Resources to support patient care are identified and made easily accessible. • Health System - Organization goals for chronic illnesses are part of annual business plan. - The system actively impacts the entire patient population with education and services. • Self-management Support - Patients assisted in setting personal goals and given aids to assist in changing behavior. - Mechanisms for patient peer support and behavior change programs. • Decision Support - Evidenced-based guidelines and protocols are integrated into the practice systems. - The system integrates the clinical expertise from generalists and specialists. • Delivery System Design - The practice anticipates problems and provides services to maintain quality of life. - Systems are designed forregular communication and follow-up. • Clinical Information System - A registry of patients with a chronic condition is maintained and utilized.

19. Change Concepts vs. High Leverage Changes Vague, strategic, Improve care of chronic population creative Provide effective behavioral change interventions. Documented patient receipt of self- management support Specific, actionable, Begin documenting collaborative results goals during next week’s visits

20. 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. • “Eleven Worthy Aims for Clinical Leadership of Health System Reform,” Don M. Berwick, JAMA, September 14, 1994, Vol. 272, #10, p. 797-802. • “The Foundation of Improvement.” Langley, G. J., Nolan, K. M., Nolan, T. W., 1994. Quality Progress, ASQC, June,1994, pp. 81-86. • “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.

21. Washington State Diabetes Collaborative #2 • Joint effort of Dept. of Health, PRO-West and ICIC • Health plans and provider teams from around the state work together for 12 months • Begins Feb. 2001, sign up by December • Contact LaDon Kessler, PRO-West, 364-9700