Applying the Collaborative Improvement & Innovation Network (CoIIN)

1. Applying the Collaborative Improvement & Innovation Network (CoIIN) Pediatric Nutrition Obesity CoIIN Iran Naqvi Chief of Integrated Services Branch Division of Services for Children with Special Healthcare Needs Maternal and Child Health Bureau January 15, 2015

2. What is a CoIIN? • A CoIN, or Collaborative Innovation Network, has been described as a team of self-motivated people with a collective vision, enabled by the Web to collaborate in achieving a common goal by sharing ideas, information, and work.1 • Key Elements of a CoIN • Collaborative learning • Common benchmarks • Coordinated strategies • Rapid test cycles • Real-time data to drive improvement • Being a “cyber-team” (i.e. most CoIN work will be distance-based) • Innovation comes through rapid and on-going communication across all levels • Work in patterns characterized by meritocracy, transparency, and openness to contributions from everyone • Adapted to reflect focus on both innovation and improvement yielding a Collaborative Improvement & Innovation Network 1Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford University Press, 2006.

3. CollN Purpose • Disseminate practices known to work • Innovate • Achieve results faster • Build leaders of QI - Sustainability • Demonstrate effectiveness of strategies/changes in large scale implementation

4. CoIIN Theory

5. Learning Collaborative A method of improvement for the extension and adaptation of existing knowledge to facilitate multiple adjustments with the goal of achieving a common goal.

6. Breakthrough Series Learning CollaborativeApproximately 18-24 months, refer to timeline Recruit Participants (30-40 Teams) Topic Areas (Key constructs) P P P Pre-work D D D A A A Develop “Technical Content” S S S Expert Meeting LS 1 LS 2 LS 3 Holding the Gains Planning Group AP1 AP2 Expert Faculty Support LS – Learning Session AP – Action Period Source: Adapted from Institute for Healthcare Improvement, BTS Collaborative.

7. Knowledge for Improvement and Articulating the Gap Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Subject Matter Knowledge Profound Knowledge IG: 76

8. Design to Action Using the Model for Improvement Use the Model for Improvement to guide Strategy Team work, including: Identify a Quality Improvement Aim. (Plan) Use Team members (Expert Leads and State Representatives) to identify strategies that work. (Plan) Identify process and outcome measures based on chosen Strategies. (Plan) Implement strategies to “test” change. (Do) Measure progress (outcomes and processes). (Study) Adjust strategies as needed. (Act) Goals Measures Ideas

9. Steps to Create a CoIIN

10. CoIIN Steps Step 1 • Project Leads and Organizers Articulate the Topic(s) Step 2 • Hold Expert Meeting/Technical Content to Create a Charter with Aim Statement Step 3 • Create a Driver Diagram Step 4 • Draft a Change Package • Begin State Application Process Step 5 Step 6 • Teams Engage in Pre-work • Hold Learning Session 1 Step 7 Step 8 • Engage in Action Period 1/Continue PDSA at Locales Step 9 • Teams Report Results Steps 10, 11, 12 • Hold Learning Session 2, Action Period 2, and Learning Session 3 Step 13 • Implement and Spread

11. Planning Stage 1. Define Gap, Scope and Nature of the Problem 5. Build and Sustain Cyberteams

12. Step 1: Project Leads and Organizers Articulate Topic(s) • Articulate the “possible” topic(s) of focus by considering: • Resources • Time • Priorities (national, state, local) • Evidence-based support • Ripe for improvement • Discuss gap in what is happening • Define the problem • Determine the scope • Scan evidence and experience based examples of quality • Select individuals to participate in the Expert Group

13. Step 2. Hold Expert Meeting/Technical Content to Create a Charter (see form) • Document written on behalf of a quality improvement team which builds understanding, consensus, and clarity • Defines the project and organizes critical pieces of information about a project in one, concise place • Components: • Project title • What are we trying to accomplish? (SMART Aim statement) • What is the problem that we are addressing? • What is the reason for the effort? • What are the expected outcomes or benefits of the project? • How do we know that a change is an improvement? • Outcome, process and balancing measures • What changes can we make that will lead to improvement? • Initial changes, barriers, key stakeholders Source: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Langley, G., Nolan, K., Moen, R., Norman, C., and Provost, L. 2009.

14. State Aim clearly: • Achieve agreement to maintain progress • Be specific/discrete and describe current state • Include numerical goals requiring fundamental change to the system • Clarifies the goal • Creates tension for change • Directs measurement from current to ideal state • Set stretch goals • Reach within a certain time that cannot be met by tweaking the existing system • Look for ways to overcome barriers and achieve the stretch goals • Avoid Aim drift • Do not back away from the aim unconsciously • Repeat aim continually and start each meeting stating with it • Be prepared to refocus aim • Every team needs to recognize when to refocus/revise its aim • Acceptable to work on a smaller/manageable part of the system Tips for Writing Aim

15. Example: Breastfeeding Aim • Measures • Total Number of enrolled women. • % of women who initiate breastfeeding. • Among all enrolled women, the % of women exclusively breastfeeding at 3 months. • Among women who initiated breastfeeding, the % of women exclusively breastfeeding at 3 months. • Among all enrolled women, the % of women breastfeeding some at 3 months. • Among women who initiated breastfeeding, the % of women breastfeeding some at 3 months. • Among all enrolled women, the % of women exclusively breastfeeding at 6 months. • Among women who initiated breastfeeding, the % exclusively breastfeeding at 6 months. • Among all enrolled women, the % breastfeeding some at 6 months. • Among women who initiated breastfeeding, the % breastfeeding some at 6 months. • % of women who report intention to breastfeed. • % of women with a need for breastfeeding support identified this month, who received peer or professional breastfeeding support. • % of home visitors who have been trained in breastfeeding “Increase by 20% from baseline, the % of women exclusively breastfeeding at 3 and 6 months within the HV CoIIN timeframe (24 months).” Increase by 20% mothers enrolled prenatally. 80% of mothers with an identified need for breastfeeding support will receive professional or peer breastfeeding support. 80% of mothers with the intention to breastfeed, initiate breastfeeding. Increase by 40% the number of home visits in which breastfeeding goals are reviewed and documented. 100% of home visitors are trained in lactation and breastfeeding. Smart Aim Process Aims

16. Start Here Step 3: Create a Driver Diagram Continuous Learning Loop

17. Driver Diagram Model Source: www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html

18. AIM PRIMARY DRIVERS SECONDARY DRIVERS KEY CHANGES Example Driver Diagram: Improving Outcomes for Home Visiting Clients Improve within 18- 24 months maternal depression, child developmental screening, breastfeeding and family engagement outcomes through home visitation by while reducing or maintaining program costs. Monthly data reporting feedback available to home visitors and supervisors Data-driven supervisory and clinical practice Home visitors and supervisors have access to real-time performance data Train home visitors on standardized, evidence-based protocols for core activities with clients Evidence-based, quality care delivery LIA has standardized service delivery processes based on evidence and best practices Standardize internal processes for commonly performed activities with clients Family centeredness Negotiated shared decision making process with clients LIA has established and effective operational linkages to community resources State and/or LIA leadership supports quality care and system Systematically document provision of referrals Systematically document follow up and completed on referrals Standardize referral pathways to community resources

19. Step 4: Draft a Change Package • Definition: Tool to enable grouping of changes into a logical whole and enable a team to work at the issue or task level. Team may move, copy, modify, merge or revert the change package. • Include the global and specific aims from Driver Diagram • Review the primary drivers. • Are these the WHAT that will help QI teams achieve the aim? • Are they clear, or do they need to be made more specific? • Are they sufficient, or are any missing? • Note activities that will achieve the changes.

20. Example: Breastfeeding Change Package

21. Step 5: Begin State Application Process • Planning team creates application • Potential State participants apply to CoIIN with selected strategy topics • Applicants awarded following review process of all applications

22. Step 6: Teams Engage in Pre-work • Collaborative Teams: Local staff, community partners, other stakeholders • Discuss aims and focus work • Engage the senior leader • Initiate measurement and other information gathering • Identify resources and develop a budget • Storyboard This is a different type of learning experience

23. Step 7: Hold Learning Session 1 with Planning Committee, QI Advisor, Project Lead, Awarded Applicants, Experts and Other Invited Team Members • Participants meet with teams • Learn quality improvement theory • Review driver diagram and change packages • Begin initial stages of PDSA (Plan Stage)

24. Plan PDSAs • After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. • If improvement, expand the tests and gradually incorporate larger and larger samples until confident that the changes should be adopted more widely. www.ihi.org

25. P is for Plan • List the tasks needed to set up this test of change • Person responsible • When to be done • Where to be done • Predict what will happen when the test is carried out • Measures to determine if prediction succeeds • Plan the test or observation, including a plan for collecting data. • State the objective of the test. • Make predictions about what will happen and why. • Develop a plan to test the change. (Who? What? When? Where? What data need to be collected?) www.ihi.org

26. Outcome: Changes in individuals and populations attributed to healthcare (can be end results or intermediate outcomes) • Example: Reduce infant mortality • Process: Interactions between practitioner and patient; series of actions, changes, or functions bringing about a result • Example: Increase home visits; percent of mothers receiving prenatal care prior to 12 weeks gestation • Structure: Measures of organizational characteristics (staffing ratios, number of beds) • Example: Availability of physicians providing obstetric care • Balancing: Shows whether the changes you are making are inadvertently affecting another part of the system. • Example: Customer satisfaction of grantees with new process introduced Determine Measures Source: http://patientsafetyed.duhs.duke.edu/module_a/measurement/measurement.html

28. Step 8: Action Period 1 - Teams Return to their Field Locations and continue PDSA • Planning Committee and Project Lead hold sessions during this Action Periods for teams to meet, share and learn virtually with experts and each other • Teams continue the Do, Study and Act steps of the PDSA

29. D is for Do • Describe what actually happened when you ran the test • Try out the test on a small scale. • Carry out the test. • Document problems and unexpected observations. • Begin analysis of the data. www.ihi.org

30. Categorize Change • Eliminate Waste: Eliminate activity or resource that is non-value added to an external customer. • Improve Work Flow: Improve processes to improve the products/services. • Optimize Inventory: Understand where inventory is stored in a system to find improvement opportunities. • Change the Work Environment: Can be a high-leverage opportunity to make all other process changes more effective.  • Producer/Customer Interface: To benefit from improvements in quality of products and services, the customer must recognize and appreciate the improvements. • Manage Time: Gain advantage by reducing time to develop new products, waiting times for services, lead times, and cycle times for all functions in the organization. • Focus on Variation: Reduce variation to improve outcome predictability and to help reduce the frequency of poor results.  • Error Proofing: Redesign the system to make it less likely for people in the system to make errors. • Focus on the Product or Service: Address improvement of products and services, not just processes. www.ihi.org

31. Test/Pilot the Change • Increase belief that the change will result in improvement. • Decide which of several proposed changes will lead to the desired improvement. • Evaluate how much improvement can be expected from the change. • Decide whether the proposed change will work in the actual environment of interest. • Decide which combinations of changes will have the desired effects on the important measures of quality. • Evaluate costs, social impact, and side effects from a proposed change. • Minimize resistance upon implementation. www.ihi.org

32. Determine Scale and Scope of the Change • Scale: Time span or number of events included in a cycle. When scale up test of change, think about more. • The “Five Times (5X) Rule” - when scaling up the number of encounters or events, multiply the number of events used in the last cycle by five. • PDSA Cycle5X Rule: Events involved in the cycle 1                    12                    53                    254                   1255                   625 • Scope : Variety of conditions under which tests occur. When change the scope of test, think about difference . • A useful rule of thumb when designing early test cycles is to build a “1:1:1” test, which means your test will involve “1 person, 1 program, 1 event” as the smallest unit of testing. • A small-scale test of change enables observing the test without using up lots of time and resources. IHI Open School

33. S is for Study • Describe the measured results and how they compared to the predictions • Set aside time to analyze the data and study the results. • Complete the analysis of the data. • Compare the data to your predictions. • Summarize and reflect on what was learned. www.ihi.org

34. Reasons for Failed Test • Do not shy away from test failures, but grasp the opportunity to learn. • If you start with a focused test and expanded scale and scope appropriately, then you have contained the risk of large-scale failure while making the conditions for success clearer. • There are different possible reasons for failed tests:  • Change was not executed well. • Support processes were inadequate. • Hypothesis of your “good change idea” was just wrong. IHI Open School

35. A is for Act • Describe what modifications to the plan will be made for the next cycle from what you learned • Refine the change, based on what was learned from the test. • Determine what modifications should be made. • Prepare a plan for the next test. www.ihi.org

36. Step 9: Teams Report Results • Plot data over time using a run chart or other graphs to determine whether the changes you are making are leading to improvement. • Use a Dashboard which is limited to show summaries, key trends, comparisons, and exceptions of your measurement data.

37. Step 10-12: Hold Learning Session 2, Action Period 2, and Hold Learning Session 3 Recruit Participants (30-40 Teams) Topic Areas (Key constructs) P P P Pre-work D D D A A A Develop “Technical Content” S S S Expert Meeting LS 1 LS 2 LS 3 Holding the Gains Planning Group AP1 AP2 Source: Adapted from Institute for Healthcare Improvement, BTS Collaborative.

38. Step 13: Implement and Spread Change • Implementing a change at the broader scale/spreading usually comes after a series of successful PDSA tests. It requires that teams and leaders build the change into formal plans. • Implementation is a permanent change to the way work is done and, as such, involves building the change into the organization. • Spreading has implications that need to be addressed that are not heavily engaged in the testing phase such as written policies, hiring, training, compensation, and infrastructure. IHI Open School

39. Challenges and Strengths of CoIINs

40. CoIIN: Challenges • Logistics! • Inter- and intra-State differences (policy) • Strategy-specific challenges • Adoption of collaborative practices under challenging logistical circumstances.

41. CoIIN: Strengths • People • Commitment • Partners • Momentum

42. Lessons LearnedFrom Infant Mortality CoIIN Participants • QI approach should be flexible • Policy changes may not be as amenable to Rapid Cycle timelines • Support participants in their work! • Make participants (and their leadership) aware of the time and resource commitment • Help them focus staff energies on a few topics • Engage all relevant partners • In this case of the Infant Mortality CoIIN, Medicaid & Medicare, Hospital Associations strengthened the collaboration Sharing data and ideas with states and partners was participant’s favorite aspect of the CoIIN.

43. CoIIN: Summary • Designed to help States: • Innovate andimprove their approaches to public health issue through communication and sharing across state lines. • Use the science of quality improvement and collaborative learning to improve your strategy topics.

44. Contact Information Iran Naqvi, MHS, MBA Chief of Integrated Services Branch Division of Services for Children with Special Healthcare Needs Maternal and Child Health Bureau Health Resources and Services Administration 301-594-4429 INaqvi@hrsa.gov