The Model for Improvement: Advanced

1. The Model for Improvement: Advanced July 9, 2013 Steven Tremain, MD, FACPE Physician Advisor Cynosure Health

2. 2013: Perfect Care

4. Why the Global Failures? • Focus on outcomes, not processes • Dictating the what and the how • Identifying the ‘answers’ at the beginning • Not involving the process worker/owner in the design • Starting at scale • Knowing not Learning

5. Today’s Session • Review the Model for Improvement • Focus on Measurement • Types of Measurement • Improvement vsJudging • Improvement vs Creating new knowledge • Sampling vs ‘p values’ • Types of data elements • Displaying data effectively • Finding “First Followers”

6. Polling Question 1: Familiarity with the MFI • I fully understand the MFI, and successfully use it to implement change. • I have a partial understanding but still struggle with successful application • I have attended sessions about it but have never used it. • What’s the MFI?

7. Time to Share

8. Model For Improvement What are we trying to AIM accomplish? How will we know that a MEASURE change is an improvement? What change can we make that Selecting Change will result in improvement? Act Plan Small Tests of Change Study Do

9. BIG BOLD

10. WHAT? WHERE? HOW MUCH? BY WHEN?

11. Bold AIM Statements …this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth. John F. Kennedy

12. Model For Improvement What are we trying to AIM accomplish? How will we know that a MEASURE change is an improvement? What change can we make that Selecting Change will result in improvement? Act Plan Small Tests of Change Do Study

13. Why Measure? • How else will you know that the change(s) you made resulted in improvement? • Adopt? • Adapt? • Abandon?

14. Types of Measures • Process • Outcome • Balancing

15. Process Measures • Are the parts/steps in the system performing as planned? • Examples: • Does every patient receive a VTE risk assessment upon admission • Are insulin administration and meal delivery coordinated?

16. Outcome Measures • Are we getting the patient care results we want? • Examples: • Are we reducing VTE’s? • Are we avoiding hypoglycemia?

17. Balancing Measures • As we implement a process to improve an outcome, what might we make worse? • Examples: Your turn

18. Why Measure? • How else will you know that the change(s) you made resulted in improvement?

19. Moving the curve:Bad apple vs. performance improvement approach

20. Measurement:Improvement vs “New Knowledge” • New Knowledge: • Requires multiple studies • Power • P values • Meta-analyses • Improvement: • Are we headed in the right direction?

21. Measurement:Improvement vs “New Knowledge” “New Knowledge”

22. Measurement:Improvement vs “New Knowledge” Improvement

23. Measurement:Improvement vs “New Knowledge” • The Key advantages: • Size and complexity of ‘study’ • Sampling …not more than 20 • Real time • Integrate with work • Allows for rapid cycle improvement

24. The PDSA Cycle “What will happen if we try something different?” “What’s next? ” “Let’s try it!” “Did it work?”

25. Polling Question 2: Measurement for Improvement • I successfully use small samples as a key to my improvement efforts • I have a partial understanding but still struggle with successful application • I don’t get it. Why don’twe have to concernourselveswith ‘p values’ ?

26. Care to Share?

27. Type of data elements • Rates • % • Per 1000 patient days • Per 1000 vent days • Raw numbers • Individuals

28. Polling Question 3: Data Elements to Drive Change Which of the following is more likely to motivate people to work to improve care? • Our VAE rate is 1.8/1000 vent days • We have 2 VAE’s this year • A 51 y/o male accountant (H.G), husband and father of 2 had a VAE’s earlier this year.

29. What is “Data”? “factual information (as measurements or statistics) used as a basis for reasoning, discussion, or calculation” Merriam Webster Dictionary

30. What is “Information”? “Knowledge derived from study, experience, or instruction.” The Free Dictionary “The communication or reception of knowledge or intelligence.” Merriam Webster Dictionary

31. What is “Actionable Information”? “Information that can be acted upon, something that leads to action, something that makes things happen, starts a chain of action and reaction.” K-praxis.com

34. Adopters and Who to Persuade First Where Champions Work Where Champions Work Fertile Ground for Champions

35. What Does a Physician Champion Look Like?

37. Characteristics to Avoid

38. Polling Question 4: Engaging Physician Colleagues in Improvement Work • I find it easy to find other physicians to take the lead on improvement projects to to assist me with one. • It’s often difficult to engage colleagues in improvement work but I can usually find someone to help. • I often find myself to be the ‘lone nut’ amongst physicians in improvement work?

39. In Closing…. • Make the PDSA testing cycles small enough so that analysis and design of the next test can occur promptly • Start with the onesies and twosies • Always include the line staff • Test, test, test before implementation • Never spread until tested adquately • Beware of “perfect as the enemy of the good” • Make data visible to all engaged in the process

40. 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, 2009. • 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. • Patient Safety and Quality: An Evidence-Based Handbook for Nurses www.ahrq.gov/qual/nurseshdbk/