Quality Improvement The Model for Improvement, PDSA Cycles, and Accelerating Improvement

1. Quality Improvement The Model for Improvement, PDSA Cycles, and Accelerating Improvement Heather Maciejewski BEACON Quality Improvement Coordinator Ohio Chapter, AAP

2. Session Objectives • To describe the components of the Model for Improvement • To identify measures and goals for your participation in EASE • To develop a clear plan for your team to test a change idea • To identify future tests of change

3. Quality improvement structure, approach and roadmap

4. Structure is Based on Institute for Healthcare Improvement (IHI) Breakthrough Series Select a Quality Improvement Topic • Supports: • Experts • Learning Session • Action Period Calls • Telephone • Email • Monthly Reports • Monthly Data Conduct Expert Meeting Develop Framework and Changes Planning Group (Experts) Spread and Dissemination Participants (YOU!) Holding the Gains Learning Session Action Period Calls

5. Approach is Based on The Model for Improvement 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? Act Plan Study Do The Improvement Guide Associates in Process Improvement

6. Key Driver Diagram Medical Directors: Sarah Denny, MD and Michael Gittelman, MD Principal Investigator: Jamie Macklin, MD Updated: April 3, 2014 INTERVENTIONS KEY DRIVERS SMART AIM • CHEX Quality Board Tips • Nurse champions/RN care partners • Scripting for – and with – parents • Safe Sleep “Cheat Sheet” Nursing Education • By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position on random weekly audits. • A “safe sleep” position includes: • Sleeping in his/her own crib • Alone in the crib • Laying on his/her back Multi-Disciplinary (PCA, OT/PT) Education • Grand Rounds • Hospital pediatricians web module Physician Education • Safety Videos/Edutainment System (Franklin County/CPSC/NICHD) • Take-home magnets • Brochures • Safe Sleep posters Parent/Caregiver Education GLOBAL AIM Management of Environment • Sleep sacks • Safe Sleep Policy developed • Assess hospital policy on clothingallowed for patients • Mattresses on beds need evaluated • Potentially use fitted sheets on beds Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits. Key Driver Diagram adapted from Nationwide Children’s Hospital

7. The Model for Improvement

8. The Model for Improvement Part 1: Answers these three questions 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? Part 2: Guides change to see if there is an improvement Act Plan Study Do The Improvement Guide Associates in Process Improvement

9. The Model for Improvement Part 1: Answers these three questions Model for Improvement Set Aims What are we trying to accomplish? Establish Measures How will we know that a change is an improvement? What change can we make that will result in improvement? Select Changes Part 2: Guides change to see if there is an improvement Act Plan Test the Changes Study Do The Improvement Guide Associates in Process Improvement

10. The Model for Improvement Model for Improvement Aim 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? Act Plan Study Do The Improvement Guide Associates in Process Improvement

11. Aim Statements • Provides a focused rationale and vision for what your team plans to accomplish • Are SMART S: Specific M: Measurable A: Action-Oriented R: Relevant/Realistic T: Timely

12. Key Driver Diagram Medical Directors: Sarah Denny, MD and Michael Gittelman, MD Principal Investigator: Jamie Macklin, MD Updated: April 3, 2014 INTERVENTIONS KEY DRIVERS SMART AIM • CHEX Quality Board Tips • Nurse champions/RN care partners • Scripting for – and with – parents • Safe Sleep “Cheat Sheet” Nursing Education • By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position on random weekly audits. • A “safe sleep” position includes: • Sleeping in his/her own crib • Alone in the crib • Laying on his/her back Multi-Disciplinary (PCA, OT/PT) Education • Grand Rounds • Hospital pediatricians web module Physician Education • Safety Videos/Edutainment System (Franklin County/CPSC/NICHD) • Take-home magnets • Brochures • Safe Sleep posters Parent/Caregiver Education GLOBAL AIM Management of Environment • Sleep sacks • Safe Sleep Policy developed • Assess hospital policy on clothingallowed for patients • Mattresses on beds need evaluated • Potentially use fitted sheets on beds Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits. Key Driver Diagram adapted from Nationwide Children’s Hospital

13. Global vs. Specific Aim Statements Education and Sleep Environment (EASE): The Injury Prevention Learning Collaborative with Hospitalists • Global Aim: Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.

14. Global vs. Specific Aim Statements • Specific Aim: By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position during random weekly audits. • A “safe sleep” position includes a child who is: • Sleeping in his/her own crib • Sleeping alone in the crib • Laying on his/her back

15. The Model for Improvement Model for Improvement What are we trying to accomplish? Measures How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do The Improvement Guide Associates in Process Improvement

16. Why do we measure? Measures facilitate learning and are not for judgment or comparison • Recognize areas for improvement – define the gap between where we are and where we need to be • Provide feedback as a means to evaluate– are the changes we’re making having the desired impact? • Characterize the robustness of change – how does our system respond to the changes we’ve made?

17. Process vs. Outcome Measures • Process measures: represents the workings of the system • Proportion of patients with hemoglobin A1c levels measured at least twice within the past year • Proportion of children with asthma who receive asthma management plan • Outcome measures: represents the voice of the customer or patient • Reduction in BMI percentile • Hospitalizations or ED visits due to asthma • Patient satisfaction with time to getting an appointment

18. EASE Measures EASE process measures include: • > 90% of patients 1 year of age and younger will leave the hospital with information on safe sleep practices • Each hospital will show that > 90% of children ≤ 1 year of age will be in “safe sleep” position (own crib, nothing in crib and on back) on random weekly audits by the end of the 12-month project • This is a bundled measure of all three items for a safe sleep position

19. The Model for Improvement Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? Ideas/ Changes What change can we make that will result in improvement? Act Plan Study Do The Improvement Guide Associates in Process Improvement

20. The Model for Improvement 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? Act Plan P-D-S-A Cycle Study Do The Improvement Guide Associates in Process Improvement

21. Plan – Do – Study – Act Cycles

22. Act Plan Study Do The PDSA CycleFour Steps: Plan, Do, Study, Act • Also known as: • Shewhart Cycle • Deming Cycle • Learning and Improvement Cycle The Improvement Guide Associates in Process Improvement

23. Use PDSA Test Cycles for: • Testing or adapting a change idea • May answer a question related to the aim • Implementing a change • Spreading the changes to the rest of the system

24. Why Test? • Force us to think small • Increases your belief that the change will result in improvement • Opportunity for learning without impacting performance • Help teams adapt good ideas to their specific situation The Improvement Guide Associates in Process Improvement

25. The PDSA Cycle Act Plan • Objective (tie to • AIM or Key Driver) • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) Study Do

26. Do initial cycles on smallest scale possible Think baby steps…a “cycle of one” usually best “Failures” are good learning opportunities; can be better than “Successes” As move to implementation, test under as many conditions as possible Think about factors that could lead to breakdowns, supports needed, “naysayers” Different providers; different days of the week; different patient populations, etc. Key Points for PDSA Cycles

27. Key Points for PDSA Cycles • Do initial cycles on smallest scale and within shortest timeframe possible • Think baby steps…a “cycle of one” usually best • Years • Quarters • Months • Weeks • Days • Hours • Minutes Drop down “two levels” to plan Test Cycle!

28. The PDSA Cycle Act Plan • Objective (tie to • AIM or Key Driver) • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) Study Do • Carry out the plan • Document problems • and unexpected • observations

29. The PDSA Cycle Act Plan • Objective (tie to • AIM or Key Driver) • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) 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

30. The PDSA Cycle Act Plan • Objective (tie to • AIM or Key Driver) • 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

31. Common PDSA Pitfalls • Testing changes where link to overall aim or key driver is unclear • Failing to make a prediction before testing the change • Failing to execute the whole cycle • Plan, Plan, Plan-D-S-A (too much planning, not enough doing) • P-Do, Do, Do-S-A (too much doing, not enough studying)

32. Common PDSA Pitfalls • Not learning from “failures” • Lack of detailed execution plan • Failure to think ahead a few cycles

35. A P S D D S P A A P S D A P S D PDSA Cycle Ramps: Sequential Building of Knowledge Changes That Result in Improvement Successive tests of a change build knowledge AND create a ramp to improvement DATA Implementation of Change Wide-Scale Tests of Change Best Practice Evidence HunchesTheories Testable Ideas Follow-up Tests The Improvement Guide Associates in Process Improvement Very Small Scale Test

36. Plan Plan Plan Do Do Do Plan Do Act Act Act Act Study Study Study Study Example of Accelerating Improvement

37. “All improvements requires change, but not every change is improvement.” The Improvement Guide, 2009

38. Quality Improvement Videos • The Model for Improvement: http://www.youtube.com/watch?v=SCYghxtioIY • PDSA Cycles: http://www.youtube.com/watch?v=_-ceS9Ta820&feature=youtu.be

39. References Fuller, S. (2010). Model for Improvement. PowerPoint slides Griffin, F. (2004). The PDSA Cycle Testing and Implementing Changes. Retrieved from: www.njha.com/qualityinstitute/pdf/628200432756PM63.ppt · PPT file Langley, G., Moen, R., Nolan, K. , Nolan T., Norman, Provost, L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd edition. Jossey-Bass Publishers., San Francisco. Moen, R. and Norman, C. (2010). Circling back clearing up myths about the Deming cycle and seeing how it keeps evolving. Retrieved from www.qualityprogress. com NHS Institute for Innovation and Improvement. Quality and Service Improvement Tools: PDSA. Retrieved fromhttp://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html Provost, L., Murray, S. (2011). The Health Care Data Guide: Learning from data for Improvement. Jossey-Bass Publishers., San Francisco. Society of Hospital Medicine. Plan-Do- Study- Act. Retrieved from: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/Plan_study.cfm The Model for Improvement National Primary Care Development Team (2004). Retrieved from: www.npdt.org