Performance Improvement --An Overview

1. Performance Improvement --An Overview Auxford Burks, MD Albert Einstein College of Medicine Department of Pediatrics/ Jacobi Medical Center

2. Thanks to: Daniel Hyman, MD, MMM Chief Medical Officer, Ambulatory Care Network New York Presbyterian Hospital Who provided all of this material

4. 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?

5. Model for Improvement Aim: What are we trying to accomplish? Measures: How will we know that the change is an improvement? Ideas: What changes can we make that will result in an improvement?

6. Model for Improvement Aim: What are we trying to accomplish?

7. What are we trying to accomplish? • Aim: A written statement of the accomplishments expected from each pilot team’s improvement effort • Different forms are useful: • A general description of aim • Specific patient population • Some guidance for carrying out the work

8. The Team’s Aim Should Be: • Strategic • Relevant • Exciting • Important • A stretch, not business as usual • Achievable, not impossible • Understandable

9. Sample Goals/Measures • 95% of patients with asthma will have symptom frequency documented in their record (day and night) – process measure • 95% of patients will have asthma severity specifically identified at all visits where asthma is addressed – process measure • 90% of patients with persistent asthma will be treated with an appropriate antiinflammatory medication, at an appropriate dose – process measure • 95% of patients with asthma will have a documented assessment of tobacco use or exposure and counseling to reduce risk if applicable – process measure • There will be an X% reduction in ED/hospitalization rate over Y period of time – outcome measure • Visit volume in clinic will be unchanged – balancing measure

10. AIM: Why the Change is Desired • A known performance deficiency in an important process • A gap between current performance and desired performance

11. Why an Aim Statement? • Answers and clarifies “What are we trying to accomplish? • Creates a shared language and shared methods • Facilitates organizational conversations and understanding • Supports accountability for team leaders

12. Developing the Aim Statement • Write a clear and concise statement stating the “who, what, when, and where “ • Who will undertake the work, and who will be affected by it • What does the team intend to do • When will the aim be accomplished • Where - define pilot site and spread site(s)

13. SMAART Aims • Specific: Understandable, unambiguous • Measurable: Numeric goals • Actionable: Who, what, where, when • Achievable (but a stretch) • Relevant to stakeholders and organization • Strategic, Compelling, Important • Timely: with a specific timeframe

14. Sample Aims • We will improve the care of patients with asthma by adhering to evidenced based guidelines for diagnosis, assessment and treatment, thereby reducing morbidity/mortality • By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 days or more in the 2-week period preceding a planned care visit.

15. Example of Elaborated Aim Statement • Aim: By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 or more in the 2-week period preceding a visit. To effect change, we will be guided by using the six components of the Care Model for Child Health. Intermediate aims are that: • 95% of children with persistent asthma will have severity classified at every visit. • 95% of children with persistent asthma will be treated with appropriate maintenance anti-inflammatory medication. • 90% of children will receive a written asthma management plan on which we will document family/self- management goals.

16. Act Plan Study Do Model for Improvement What are we trying to Aim accomplish? How will we know thata Measures change is an improvement? What change can we make that Ideas will result in improvement? Act Plan Study Do From: Associates in Process Improvement

17. A PDSA Cycle PDSA Objective:Test the use of encounter form to facilitate visit Will encounter forms facilitate severity classification?Dr. X will try form with severity class Qs with 3 patients on Thurs Revise form. Try new form with 3 patients tomorrow; MA will put form on chart. Dr. X found the form helpful for prompting; thought items on form should be in a different order. Need better process for getting form to provider. Dr. X tried with two patients. Couldn’t find a form for third patient.

18. Why Test? • Increase your belief that the change will result in improvement • Opportunity for learning from “failures” without impacting performance • Document how much improvement can be expected from the change • Learn how to adapt the change to conditions in the local environment • Evaluate costs and side-effects of the change • Minimize resistance upon implementation

19. Ideas: What Changes Can We Make That Will Lead to Improvement? • Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

20. Ideas: What Changes Can We Make That Will Lead to Improvement? • Change Concept: A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Promote clinical care that is consistent with scientific evidence and family preferences Use tool to classify severity at every visit

21. Vague, strategic, creative Specific, actionable, results Change Concepts vs.High Leverage Changes Improve care of asthma patients Share info w/ patients & families and encourage self-management Document asthma management plan and goals for self-management Begin discussion of self-management goals w/ 3 patients on Monday

22. 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? A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Improve asthma outcomes Changes That Result in Improvement Reduction in ED visits Change Pkg. DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Ideas Very Small Scale Test

23. PDSA example I • A pediatrician goes to a conference one October and learns all about Improvement, PDSA cycles, and how to improve care for patients with asthma. • He returns to his practice completely enthused and ready to do something new that will improve care. • We’ll call our protagonist in this story, Bill Caspe

24. PDSA example I • Bill decides to look at his 5 person practice’s assessment of children whose parents call for refills of asthma medications to see whether the children: • Need flu vaccines • Are having symptoms too frequently (i.e. are not being well controlled on their current medication regimen) • He develops a form and gives it to his nurse to use for one week when asthma meds are refilled

25. PDSA example I • Is this a good PDSA cycle? • Why? • Why Not? • What do you think happened?

26. PDSA example II • The pediatric residents in a community based clinic are taught about improvement, PDSA cycles, and how to improve care for patients with asthma. • They are provided with baseline data that shows that only 20% of children have a severity classification of their asthma in the practice’s medical records

27. PDSA example II • The residents develop a sticker that prompts the questions needing to be asked to determine symptom frequency • One resident on ambulatory block tries the sticker for 5 consecutive patients with asthma.

28. PDSA example II • Is this a good PDSA cycle? • Why? • Why Not? • What do you think happened?

29. PDSA Cycles “Negative results on the fish…Let’s try rubbing two sticks together.”

30. PDSA Key Points: • Make the Cycle SMALLER!!! • Break changes down into manageable parts • This also allows people to: • try things and give input • more easily adapt • feel included in decisions and development

31. D S P A A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle for Implementation Routine use of patient survey Cycles 5/6: Create orientation manual section on patient survey DATA Cycle 4: Use of survey for all patients Cycle 3: Try survey on other days with other providers and patients Cycle 2: Test - Use of new survey on two clinic days Test of patient survey Cycle 1: Introduce new survey form to one provider and staff

32. D S P A A P S D D S P A A P S D A P S D Multiple Cycles to Test and Implement Components of the Care Model Use of Flow sheet V.4 by all physicians and nurses Component: Decision Support From Chinatown, Asthma BTS, 2001 Learning Cycle 5: Implement use of V.4, do peer review of documentation and use Cycle 4: Trial of V.4 by all providers Cycle 3: Two week trail of V.3, review meetings Cycle 2: Try V.2 by two providers for a few days Will a flow sheet be useful for patients? Cycle 1: Gather sample flow sheets, try V.1with two patients

34. Things should be as simple • as possible but not simpler. • Albert Einstein