Practice-based Quality Improvement Session 1 PCFDP October 15, 2010 Sally Kraft, MD, MPH Stephanie Berkson, MPA

1. Practice-based Quality ImprovementSession 1PCFDPOctober 15, 2010Sally Kraft, MD, MPHStephanie Berkson, MPA

2. Exercise • In a small group, review the performance data on colorectal cancer screening. • Together discuss the following questions: • Does the data demonstrate variation in performance? What are the implications of the observed variation in performance? • What are potential causes of variation? • How would you use the data to achieve improvements in performance rates?

3. Session Objectives • Develop an understanding of health system levels and how these levels impact performance and improvement. • Develop an understanding of the core concepts of performance improvement. • Develop an understanding of the model of improvement. • Gain experience analyzing variation, using process maps, brainstorming and creating affinity diagrams.

4. Current UW Health Organizational Performance in WCHQ Size of the bubble is correlated to the number of eligible patients at each organization

5. UW Health Primary Care Clinics Performance in Colorectal Cancer Screening UW Health Colorectal Cancer Screening Rates by Clinic UW Health Colorectal Cancer Screening Rates by Clinic 5 Size of the bubble is correlated to the number of eligible patients at each clinic

6. Physician Screening RatesAt a Single Clinic *Screening rates based on panel age 50 – 75

7. Levels of improvement Performance at any level of the healthcare system, may be influenced by factors at another level in the system - Berwick. Health Affairs 2002 Patient/Family Microsystems Environment Organization Berwick. Health Affairs 2002

8. Quality Improvement: Improving Performance at the Frontline of Care Berwick. Health Affairs 2002

9. Institute of Medicine Definition of Quality The degree to which health services for individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge. Chassin and Galvin JAMA 1998: The Urgent Need to Improve Health Care Quality

10. What is Quality Improvement (QI)? • The combined and unceasing efforts of • everyone – health care professionals, patients • and their families, researchers, payers, • planners, educators – to make changes that • will lead to better: • patient outcomes • professional development • system performance • Practice based QI: focus on improving the quality of care delivered to a group of patients receiving care in a practice. (Presentation by Dr. Batalden IOM Workshop Jan 07)

11. Institute Of Medicine:Six Aims for Quality Health Care • Safety • Timely • Effectiveness • Efficiency • Equity • Patient-Centered STEEEP Berwick. Health Affairs 2002;21:80-90

12. Improving Performance by Understanding Variation • Variation in quality means that every patient is not receiving the best care every time. Our data demonstrates: • UW Health performs poorly compared to other Wisconsin provider groups on most of the publicly reported measures • There is significant variation in performance between UW Health primary care clinics • There is significant variation between physicians, even physicians practicing at the same clinic • Variation related to patient factors is appropriate. Our goal is to decrease inappropriate variation. • Inappropriate variation can be decreased by standardizing the clinical practices that produce superior performance (steal best practices from top performers!)

13. Which Process is Better? Which Will be Easier to Improve? Average

14. Managing Variation is Key to Improvement Ideal Quality/Process Improvement Scenario: 1. Assess need to address variation within the process 2. Decrease variation if necessary 3. Concentrate efforts on improving average of improved process

17. How do we understand variation in Colorectal Cancer screening data? • Start by defining the current process. • Improvement Tool: Process map Exercise: Define start and end points of the process Identify all current steps in the process

18. Definition Illustration of steps in a process using symbols and arrows Purpose Understand existing processes Identify non-value added steps Clarify complex processes Identify improvement opportunities Generate alignment and agreement Train new staff Process Map Basics

19. Where are the opportunities for improvement in this process? Problem Identification What do we do that is valuable? What do we do that isn’t valuable? Lean Thinking (from Toyota improvement model): Seeing and eliminating waste, i.e. eliminating anything that doesn’t add value to the process Eliminate Keep

20. Learning from Toyota “When my grandfather brought Toyota into the auto business in 1937, he created a set of principles that has always guided how we operate. We call it the Toyota Way, & its pillars are respect for people & continuous improvement.” - Akio Toyoda, president Toyota Motor Corporation But, when customers are overlooked …

22. Patient-centered = customers first!(making a U-turn for the better) “… I am convinced that the only way for Toyota to emerge stronger from this experience is to adhere more closely to (these core principles)… … Yet it is clear to me that in recent years we didn't listen as carefully as we should – or respond as quickly as we must – to our customers' concerns… … This is why I am taking the company back to basics. Across Toyota, we are putting our customers, & the values on which our company was founded, front & center… … We are listening more closely to our customers' concerns, gathering information faster, & responding more effectively when there's an issue.” - Akio Toyoda, president Toyota Motor Corporation

23. Types of waste Transportation Unnecessary movement of materials or patients from one place to another Over Production Producing more than is needed (ordering unnecessary tests) Waiting Patients waiting for providers, providers waiting for patients to be roomed, waiting for lab, x-rays, results etc. Intellect Any failure to fully utilize the time and talents of people (providers escorting patients through clinic) Motion Worker motion that does not add value (i.e. supplies kept in central cabinet rather than room) Over Processing Adding more value than the customer is paying for Inventory any more than the minimum to get the job done Defects/Rework Product or service not meeting customer requirement (Health ed materials only in English)

24. What steps does the patient value? Acute care appointment example Lead Time Reduction Chart

25. Example: Urgent Care Process Map • Identify non-value added steps then: • Eliminate • Combine • Simplify WASTE: Patient waits in room for provider WASTE: Patient waits in room for nurse New Process WASTE: Patient is re-roomed by nurse

26. Where is the waste in the Colorectal Cancer screening process? • Exercise: • 1. Indentify the value added steps that deliver satisfaction or value • 2. Identify the non-value added steps that generate costs or waste

28. QI foundation: Plan-Do-Check-Act

29. Multiple small improvement projects, each one building from the earlier project.

30. “FOCUS” - PDCA • 1: Find a process to improve • 2: Organize a team • 3: Clarify current knowledge • 4: Understand causes of problem • 5: Select the improvement Plan – Do – Check – Act

31. What are the causes of waste in Colorectal Cancer screening? Start by Finding a specific process to improve, then Organize your team. Improvement Tool: Brainstorming

32. How do we make sense of our brainstorming results? • Start by organizing your findings into themes. • Improvement Tool: Affinity Diagram

33. How do we choose what to improve in the process? • After you Clarify the situation and Understand the causes, Select a process to improve within your level of improvement.

34. Take Home Lessons • Levels of the health system • Understand the relationship between the levels and potential impact on improvement work • Inappropriate variation is an opportunity for improvement • Standardize care processes • Identify best practices • Our model for improvement FOCUS PDCA • Improvement tools • Process map • Brainstorming • Cause and effect diagrams/affinity diagrams

35. We’ll do a deeper dive into applying the PDCA cycle in Session 2. • Skills we will practice at the Nov session: • Writing a specific aim statement • Facilitating an improvement team • Collecting improvement data • Continuing the momentum to roll uphill