Integrate QI Processes Into Daily Work at Every Level of the Organization

1. Integrate QI Processes Into Daily Work at Every Level of the Organization Create a Culture of Quality Janet Jorgenson-Rathke, PT, MA May 18, 2010

2. What is ICSI? Institute for Clinical Systems Improvement - Since 1993 A collaboration of 53 medical groups and hospitals, 7 health plans and growing ICSI Program supports: Collaborative work of our members, Bringing to the table; providers, payers, patients, and purchasers to improve care based on evidence and innovation

3. Session Objectives The participant will be able to: • Understand the essential components for creating and sustaining a quality culture • Apply the model for improvement within the organization in order to accelerate and sustain improvements in quality initiatives. • Understand how to involve physicians and other health care professionals for a team-based, multidisciplinary approach when implementing quality improvement initiatives

4. Collaboration at Every Level • Leadership • Improvement Teams • Process Improvement Cycle

5. RESULTS CQI Level of Commitment

6. RESULTS Infrastructure CQI Level of Commitment

7. Leadership/ Culture • RESULTS Infrastructure CQI Level of Commitment

8. Framework for Leadership 1 2 3 4 5 6 7 Focus the efforts Create sense of urgency Charter improvement teams Support the teams Monitor progress Celebrate success of change Sustain improvements Adapted from John Kotter, “Leading Change”

9. Step 1Focus the efforts • Continuously identify improvement opportunities • Focus on a few topics each year • Use formal criteria to select the topics • Review performance

10. Step 2Create urgency • For each topic, broadly communicate the organization’s goals • Clarify how reaching the goals will meet the needs of patients, clinicians, staff, and the organization • Communicate these connections many times and many ways

11. Step 3Charter improvement teams • For each topic, write a statement of scope and aim • Recruit a project sponsor, leader, change agent, and team • Negotiate refinement of the aim statement with the team • Establish a time line

12. Why Improvement Teams? • Quicker and more efficient improvements • Buy-in by more staff due to direct involvement • Harnesses the collective wisdom of all staff • Empowerment increases job satisfaction • Helps to control and manage change • Prevents manager/MD champion burn-out

13. Cast Of Characters Champions } Individuals who believe in and want the change and attempt to obtain commitment and resources for it, but lack sponsorship to drive it. Implementation can be accelerated when the other three roles are also Champions. Implement change. Agents have implementation responsibility through planning and executing implementation. At least part, if not all, of their performance is evaluated and reinforced on the success of this implementation. Authorize, legitimize and demonstrate ownership for the change: possess sufficient organizational power and/or influence to either initiate resource commitment (Authorizing Sponsor) or reinforce the change at the local level (Reinforcing Sponsor). Change behavior, processes, knowledge, perceptions, etc. } Agents Sponsors } Targets }

14. Step 4Support the teams • Provide staff for facilitation, measurement, and project management • Assure availability of physicians and other clinicians • Assure support of operational managers • Remove barriers identified by teams

15. Step 5Monitor progress • Receive reports from teams • Attend team meetings • Assess progress against aims • Revise charters, provide more support, or remove barriers as needed

16. Step 6:Celebrate success • Communicate short-term gains • Recognize and reward successes • Showcase achievements widely

17. Step 7Sustain the improvements • Stabilize the process changes • Provide continuing personal support for new behavior • Adjust rewards to reinforce the changes • Adjust organizational values if needed • Monitor for backsliding

18. People and Change

19. People and Change • People differ in reactions and receptivity to change • People can resist one change but be very interested in another • Different changes may elicit different patterns of response

20. Pimp My Wheels Tomorrow at 7:45 you get this! How do you feel about this change? Why might you be anxious? Why would you ride on this? • Comfortable • Reliable • Cheap • I know it will stop if I push backwards on the pedals • Minimal training • More power • Unfamiliar

21. Transitions – predictable nature • It’s an emotional roller coaster • What am I giving up or losing? • What’s in it for me? What’s going to happen to me? • It’s a group event, but an individual experience • Previous experience as context for change • The power of involuntary reaction

22. Essence of transitions • Letting go of one trapeze and grabbing another • Saying good-bye to the past • Safety nets • Clues from the past • Fitting in • It is important to help people move through the transition

23. The Transition Curve:Moving Through Attitudes & Feelings Change “S/he really made the effort to help us implement this change” “This way is more effective” “I’m not sure I know what’s going on” “This could be a better way of doing it” Confidence “I can handle this” “Actually, things might get better” “I feel overwhelmed” “We can’t do this. It won’t work. We’re not allowed” Time

24. Equation for Overcoming Resistance D x V x F > R (L + $) Dissatisfaction X Vision X First Steps > Resistance (Loss + Cost of change) Dissatisfaction x Vision x First steps > Resistance to change The motivation to change must be greater than the motivation to stay the same.

25. Tips to Overcome Resistance Actively listen to how people are experiencing the change Understand the situation from their perspective Involve members directly in the planning and implementation of the change Effectively communicate about the change and seek feedback

26. The Model for Improvement

27. Model for Improvement • Framework for connecting actions to learning • Answer three questions: • 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 improvement? • PDSA Cycle

28. The Model for Improvement Aim Measures Actions From The Improvement Guide. Langley & Nolan

29. What are we trying to accomplish? Aim Statement: • Captures the “vision” • States a desired end point • Clinically meaningful • Achievable in a time frame • Clear, numerical & measurable • Outcome & Process

30. Characteristics of a “Good” Aim Focused: answers the question: “What are we trying to accomplish?” Defines success: includes a numeric target/goal to be achieved within a specific time period Clinically meaningful: related to characteristics that providers and patients care about Specifies the patient population Measure is implied: aim directly drives the measures

31. Aim: Improve by 50% the % of patients ages 18-75 with Type II diabetes having HbA1c levels < 8.0 within 6 months • Answers: What are we trying to accomplish? • Is it clinically meaningful? • Is numeric target and timeframe specified? • Is patient population defined? • Is measure(s) implied and measurable?

32. How will we know that a change is an improvement? Measures: • Chosen as indicators of success in reaching aims • Directly related to the aim • Designed to accelerate improvement

33. Roles of Measurement for Improvement Measure to test changes and to learn, not to judge The purpose of data is to help understand, control, and improve processes and systems “Data do not improve processes, people do.”

34. Characteristics of a Measure Provides an answer to: “How will we know that a change is an improvement?” Directly relates to the aim Trending measurementover time reflects progress toward achieving the aim Clearly identifies the patient population Represents small, frequent samples expressed as %

35. Characteristics of a Measure (cont) Denominator: sample of cases observed Numerator: number of cases observed that meet specified criteria

36. Outcome Measure Clearly states how the result of the Aim will be measured Demonstrates whether an outcome has been impacted (% of pts with HbA1C <8, BP <130/80) Process Measure Assess the process changes that are needed to support improvement of the outcomes Demonstrates whether a process has been impact “Tells” the team which strategies are working (# of pts tested, # of pts who receive education) Outcome vs Process Measures

37. Numerator Reflects the number of cases from the sample that meet the measurement criteria. This number is divided by the denominator. Less than or equal to denominator. Example for diabetes: # of patients whose HbA1C < 8.

38. Denominator Reflects the total number of “tests” for a measure. The number (on bottom) by which the numerator is divided. Greater than or equal to the numerator. Example for diabetes: total # of patients who had a HbA1C completed.

39. Aim: Adult patients (ages 18 - 75) with heart failure will be discharged from the hospital with beta blocker.Measure: % of adult patients with heart failure, Classes II-IV, who are on a beta beta blocker. • Does it answer,“How will we know that a change is an improvement?” • Derived from the aim? • Defined patient population? • What is the numerator? • What is the denominator? • Able to measure frequently?

40. What changes can we make that will result in improvement? • Actions taken to change a process • Plan, Do, Study, Act phases (PDSA) • Combine with 3 questions • Turns the ideas into actions

41. Characteristics of a Actions • What can we do in the next few days? • Brainstorm small tests of change (PDSA cycles) that can be put into action in working towards achieving the Aim • Changes should be on a small scale • Changes should be tried with individuals whoa are willing to test the change

42. PDSA - Testing Change Why try small tests of change? May make improvements faster Troubleshoot possible problems earlier Gets more staff involvement in process improvement Lowers resistance to change Resource poor Will have more failures than successes but will learn more from that Helps to make choices for successful process changes

43. Cycle 5: One month following letter, measure the number of patients with diabetes coming in for testing. Cycle 4: Two weeks after letter was sent, follow-up phone calls made to those not responding Cycle 3: Nurses review charts of patients with Diabetes that have scheduled an appointment to identify which of those that are in need of the test Cycle 2: letter sent to patients from their primary physician prompting them to make a clinic appointment Cycle 1: Identify patients who have not received HgbA1c in the past 6 months. Cycles of Improvement

44. Evaluating PDSA Cycle • Answers the questions: What change can we make that will result in improvement? • Are changes small enough so that they can be easily tested within the next few days? • Can changes be tried on a small scale with someone interested in the idea? • Can changes be easily evaluated for effectiveness?

45. Now you try…

46. What is your Main Question or Concern? Take 3 minutes to consider then we will discuss…

47. What are we trying to accomplish? Based on your question or concern, write one aim statement that answers the above question.

48. Discussion… Evaluating an Aim statement… • Is it clinically meaningful? • Is numeric target and timeframe specified? • Is patient population defined? • Is a measure(s) implied and measurable?

49. How will we know a change is an improvement? Based on your question or concern, write one measure that answers the above question.

50. Discussion… Evaluating a Measure statement… • Does it answer,“How will we know that a change is an improvement?” • Derived from the aim? • Defined patient population? • What is the numerator? • What is the denominator? • Able to measure frequently?