Model for Improvement

1. Model for Improvement Breakthroughs in Patient Centered Medical Homes Safety Net Clinic QI Collaborative Chaminade Resort, May 27 2011

2. Session Objectives • Understand the Model for Improvement • Learn the Three Questions of the model and how they will apply to your work. • Introduce Plan-Do-Study-Act cycles

3. 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

4. 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

5. Setting the Aim • The Aim should clearly state what you are trying to achieve. • The Aim should be: • measureable and • time-specific • And define the population of patients that will be affected. What are we trying to achieve, for whom, by when

6. Examples of good Aim statements What are we trying to achieve, for whom, by when • For all patients, reduce waiting time to see providers to less than 15 minutes within 9 months • Within 9 months, ensure all patients have access to same-day appointments with their PCP • Reduce time to next appoint to see a urologist by 50% within 6 months

7. What’s missing? • Reduce the number of medical unit patient complaints about the admission process by 50% • Increase the score on patient and staff satisfaction surveys within 6 months • Increase satisfaction with the referral process to home health by 50% in 8 months.

8. 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

9. How Will We Know That a Change is an Improvement? • By Measuring • Measurement tells us where we are at any point in time, and if we are making progress toward our Aim • Measurement tell a team whether the changes they are actually resulting in improvement. • Measures may reveal the unexpected, and often serve as staff motivators

10. Three Kinds of Measures • Outcome Measures = voice of the patient Are patients getting better/more satisfied? • Process Measures = voice of the system Are the steps in the system performing as planned? • Balancing Measures unintended outcomes? “robbing Peter to pay Paul”?

11. Measurement Guidelines for BTS • Need a balanced set of measures reported each month to asses your progress • Outcome measure(s) should reflect your aim statement & make it specific • Process measures are will guide improvement and reveal results of test changes • Integrate data collection for measurement into daily routine (<10%) • Plot data for the measures over time and annotate graph with changes

12. Document your progress • Progress Measures (are steps in the system performing as planned?) • Outcome Measure (improved patient experience/ quality of care) In Last 6 months, how often did your health care team:

13. 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 changes can we make that Ideas will result in improvement? Act Plan Study Do From: Associates in Process Improvement

14. Ideas: selecting changes Where can we find good ideas for change? • Think about your system in relation to the Change Concepts • Use your Change Package. • Faculty is great resource • Look within your Team • Listen to your Patients, walk in their shoes

15. 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

16. 7th Inning Stretch… http://www.youtube.com/watch?v=CX1z2ocWDok

17. Putting Ideas into Action The Model for Improvement Part II Testing changes with PDSA Cycles

18. Session Objectives • Learn about PDSA cycles and how to use them effectively • See PDSAs in action

19. Act Plan Study Do Model for Improvement What are we trying to Aim accomplish? How will we know that a Measures change is an improvement? What change can we make that Ideas will result in improvement? Testing “putting ideas into action”

20. What is PDSA? The idea behind PDSA cycles is to first try a change idea on a small scale to see how it works, and then modify it and try it again and again until it works well Then, and only then, is a change ready to be implemented to become a permanent improvement.

21. Small Tests The PDSA Of Change Cycle Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • 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 • Begin analysis • of the data

22. Why test on a small scale? • Opportunity to try things out on a small scale where the risk of failure is low • Allows you make refinements and move ahead quickly • Gives you a chance to try out the change in different conditions and adapt local environment • Helps to evaluate potential costs and side-effects of the change A small test ≠ a small change! Reaching Children Initiative Learning Collaborative

23. What happens at the end of a PDSA Cycle? Review results of test (change): • Was the change tested as planned? • Was the change successful in achieving the goal? Options for next PDSA cycle • Abandon the change • Modify it and test again • Test under different conditions • Increase in scope • e.g. more patients, more providers

24. PDSA Objective:Test the use of a verbal script to introduce depression screening to Student Health Center patients Will the script for introducing the screening tool and questionnaire with students be helpful and useful? Ann will try the script with 5 patients on Thurs Script revised to describe the tool and questionnaire process up front. Ann observed that students understood the screening tool but responded with annoyance when given f/u questionnaire. Ann used the script to explain the screening tool and questionnaire with 5 patient.

25. Failure is an attitude, not an outcome I have not failed, not once.  I’ve discovered 700 ways that don’t work. It’s all about learning

26. A P S D D S P A A P S D A P S D Plan multiple cycles for a test of change Changes That Result in Improvement Learning from DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Ideas Very Small Scale Test

27. D S P A A P S D D S P A A P S D A P S D Multiple cycles to test introduction of screening tool to new counseling patients Learning Cycle 5: Implement use of PHQ 9 for all new patients Cycle 4: Trial PHQ9 for all new patients Cycle 3: V.3 Ann tries PQH9 script for 5 patients Cycle 2: Ann V.2 explains process up front for 5 patients Will a script for introducing the screening tool with students be helpful and useful? Cycle 1: Ann tries PHQ2/PHQ9 script with 5 patients

28. Testing tips • Move from ideas to action quickly. (e.g. Are you in disagreement? Then test and see the results!) • Those who develop the PDSA do itfirst: Test the change with improvement team members before introducing the change to others • Decrease the scope of the test • If it feels like too much work or too burdensome, go back to design and make it doable. • Test of oneness • One patient, one doctor, one day • Decrease the time frame • ‘What design would enable us to do this test now, tomorrow or next week?’

29. P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Consider testing in several areas… Script for PHQ in new counseling pts Script for PHQ in new medical pts Expand access to individual/ group psych Improve referral process to community resources Developing multiple strategies for full implementation

30. Measurement for PDSA • Collect useful data, not perfect data - the purpose of the data is learning, not research • Usually not one of core measures • Usually begins and ends with PDSA cycle • Often qualitative • Identify/create tools to be used for data collection – make it simple and easy • Use a pencil and paper until the information system is ready • Record what went wrong as well as what went right

32. Don’t forget to document your PDSAs “Negative results on the fish…Let’s try rubbing two sticks together.” Reaching Children Initiative Learning Collaborative

33. Form for planning a PDSA cycle

34. Initial PDSAs say “Improvement” Now what? Is it time to “roll it out”?

35. Understand testing vs. implementation Testing • Trying a change on small scale to see if and how it works. • The change is temporary. • Many failures are expected. Implementation • Making a change a part of day-to-day operations. • The change is intended to be permanent. • There is high confidence that the change will lead to improvement. • Low resistance

36. The Human Side of Change • People react differently to change—expect that it will be hard for some • Let people know why change is needed • Gather input from those affected by the change • Keep people informed of the progress during testing • Share “how the change will affect you” • Build belief in the change

37. October Sky

38. October Sky • What did you observe about testing? • What did you observe about the team? • What else?

39. Meet with your teammates… • Review your project--can you answer the 3 MFI questions? • What are we trying to accomplish • How will we know a change is an improvement • What change can we make that will result in an improvement? • Plan your first PDSA cycle “What can you test by Tuesday” Need assistance? Ask the experts!