Using the Model for Improvement and PDSA Cycles to Create Regional Improvement

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Using the Model for Improvement and PDSA Cycles
to Create Regional Improvement

• Supporting Improvement and Innovation Learning
  Series
• Connie Sixta, RN, PhD, MBA

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Prerequisites of breakthrough improvement

• Will to do what it takes to change to a new
  system
• Ideas on which to base the design of the new
  system
• Execution of the ideas

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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
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Case study, frail elderly (Trail, B.C.)
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Three 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?

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The aim statement

• Through the introduction of a coordinated
  personal planned care approach, the initiative
  will support seniors-at-risk to remain in the
  home of their choice. The initial focus is on
  people who are mildly to moderately frail in
  Greater Trail and will result in a decrease in
  urgent management, as measured by a 25 decrease
  in urgent response by community services,
  hospital admissions and emergency room visits.
• Kenneth Rockwood, Xiaowei Song, Chris
  MacKnight, Howard Bergman, David B. Hogan, Ian
  McDowell, Arnold Mitnitski. A global clinical
  measure of fitness and frailty in elderly people.
  CMAJ Aug. 30, 2005 173 (5) 489-495.

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Target population
Pilot Population (Seniors at Risk) In Trail
Small-scale tests of change
The Total Population of Seniors in BC (spread
sites)
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Seniors at risk population foci?
Pilot Population (65 and older -vulnerable)
(Aim defines)
Small-scale tests of change
Moderately Frail Pts Pilot Population
Total Population of Patients 65 and older in
Trail (spread sites)
Mildly and Moderately Frail Patients Pilot
Population Focus for the Collaborative
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The target population defines

• Aim
• Scope of the work (size of registry)
• Specific measures
• Change package used
• Team of people that will make the changes

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Each target population has its own

• Set of Changes
• Community support organizations
• Level of care
• Continuum of care
• Type and scope of care providers (team)
• Outcomes (measures)
• Processes and procedures that support it

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Each component of the continuum will need to
write their own aim statement to guide their
improvement work
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Seniors At Home
Crisis Management
Quick Response Nurse
ER
Palliative or Hospice
Home Visit
End of Life Care
Physiotherapist Fall Prevention
Advanced Directives
Pharmacist Med Review
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
SAT
Medical Home
Plan of Care
Connie Sixta PhD, RN, MBA
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How do we know that a change is an improvement?

• Measurement!

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Cont
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Measurement guidelines

• Need a balanced set of 4 to 7 measures reported
  each month (or week) to assure that the system is
  improved.
• These measures should reflect your aim statement
  make it specific
• Measures are used to guide improvement and test
  changes
• Integrate measurement into daily routine
• Plot data for the measures over time and annotate
  graph with changes

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Types of measures

• Outcome Measures
• Process Measures
• Balancing Measures

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Measurement infrastructure

• Routine set of measures with clear definitions
• Processes and procedures for the collection and
  entry of data into an information system
• Creation of monthly run charts that display
  improvement ..or not
• Monthly improvement team meeting to review and
  evaluate the data plan tests of change to
  improve data

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What changes can we make that will result in an
improvement?
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Senior change package

• Community
• Develop community coalition to support Seniors
  at Risk
• Identify community resources for Seniors with
  cognitive needs
• Develop office to community continuum of care for
  Seniors with mobility problems (communication and
  documentation practices)

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Senior change package

• Organization of Health Care
• Develop Community Coalition Plan for Seniors
• Integrate fall prevention strategies into the
  annual improvement plans of community
  organizations and physician offices
• Communicate the Flu prevention plan to
  institutions and employees across the community

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Senior change package

• Clinical Information System
• Establish an office-based registry of Seniors
  patients
• Develop processes for data entry and report
  writing
• Designate personnel for data entry and registry
  maintenance
• Use the registry to generate reminders about
  patient follow-up

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Senior change package

• Decision Support
• Embed evidence-based guidelines in the care
  delivery system (office assessment form, flow
  sheet, progress notes.
• Provide a clinicians guide and protocol for
  cognitive assessment
• Train office staff about Senior measures and
  improvement plan
• Give Senior guidelines of care to each Senior

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Senior change package

• Delivery System Design
• Design a chart identification system for the
  office that helps staff recognize Seniors at Risk
• Assign roles and duties to office staff to
  accomplish planned Senior visits.
• Use the registry to plan visits.
• Implement chronic disease follow-up format (i.e.
  group visits, clinic, individual planned visits,
  or case management) based on patient needs

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Senior change package

• Self-management
• Use consistent Senior education tools that
  describe at risk situations (symptoms,
  medications, problems) and related patient
  responsibilities
• Use self-management tools
• Train staff to set self-management goals with
  patients, assign roles
• Establish goal follow-up process

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Using a concept to create an idea to test
Specific Idea to test A
Principle or Concept
Thought Process
Specific Idea to test B
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Innovative changes

• Cover Sheet (Problem List)
• SAT (Senior Assessment Tool)
• Careplan
• Med Review Sheet
• End of Life Packet (My Voice)
• GAT (determination of cognitive functioning)

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The PDSA CycleFour Steps Plan, Do, Study, Act

• Also known as
• Shewhart Cycle
• Deming Cycle
• Learning and Improvement Cycle

Act
Plan
Study
Do
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Why test?

• Increase the belief that the change will result
  in improvement
• Predict 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

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The PDSA cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• 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

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To be considered a PDSA cycle

• The test or observation was planned (including a
  plan for collecting data)
• The plan was attempted
• Time was set aside to analyze the data and study
  the results
• Action was rationally based on what was learned

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Do Study

• Reasons for failed tests
• 1. Change not executed well
• 2. Support processes inadequate
• 3. Hypothesis/hunch wrong
• Change executed but did not result in local
  improvement
• Local improvement did not impact our measures
• Collect data during the Do phase of the Cycle to
  help differentiate these situations

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Successful tests

• Do not try to get buy-in, consensus, etc.
• Be innovative to make test feasible
• Collect useful data during each test
• Test over a wide range of conditions
• Simulate the test

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Repeated use of the PDSA cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
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Overall aim improve chronic care
Specific Test Cycles
Self-management
Community Engagement
Delivery System design
Decision Support
Clinical Information System
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Acceleration of change

• Plan multiple cycles ahead
• Example Use of End of Life Packet test 4 times
  over 1 wk versus 4 times over 6 wks
• Quicker learning
• Maintained focus
• Easier revision of the test cycle you remember
  what worked, what didnt
• You maintain momentum
• Improvement happens quicker

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Acceleration of change

• Scale down size of test ( of patients, location)
• Test earlier if you think about testing
• next month do it next week
• Next week do it tomorrow
• Tomorrow do it today

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PDSA flow sheet end of life issues

• Aim Seniors and their care providers, including
  GPs,
• are routinely discussing and making plans for end
  of life
• Objective Develop an approach for GPs to discuss
  end of life issues with their patients. Test on
  MJs registry patients
• Plan List the tasks needed to set up this test
  of change
• Collect information on Representation
  Agreement.ActAgree which advance directive
  template to use
• Draft information sheet for GPs to go through and
  give to patients which sets out options and
  signposts where further information can be found
  on them
• Go through information sheet and give patients
  Representation Agreement information and advance
  directive form and instructions to 5 patients. Do
  this during care planning visit.
• Get feedback from patients and physician on
  whether the information and the form was useful.
  Obtain signed agreement from 3/5 patients??

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PDSA flow sheet end of life issues cont

• Prediction All of MJs registry patients will
  have the information they need to discuss and
  plan end of life issues
• Study Seven patients report information was
  useful and undertake their own end of life
  planning

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PDSA flow sheet medications review

• Aim Improve patient safety by regularly
  reviewing their
• medications to ensure that they are on the right
  meds and doses.
• Objective Develop a meds review form that will
  be authorised by the GP every six months. Test on
  Libby McCoids patients
• Plan Develop meds review form that can be filled
  out by a GP or a pharmacist, which allows drug
  related problems (drug-drug interaction) to be
  assessed against each medication. This form will
  be authorised by a GP and will constitute a
  prescription
• Discuss form and approach with other GPs (I would
  not do this until Libby has tested it and says
  that it works)
• Test form on Libby McCoids registry patients as
  part of care planning visit (how many patients
  will Libby test this on?--- 3).
• Discuss process and outcome with patients
  community pharmacist.

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PDSA flow sheet medications review cont

• Prediction Patients have their meds reviewed and
  adjusted using the form (to decrease drug-drug
  interactions). Patients community pharmacist
  involved in discussion
• Study 3 patients have meds reviewed, with form
  shared with their community pharmacist

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PDSAs tested to create processes that support the
Coordinated Care Planning Pathway

• Step 1. GP meets with patient and completes long
  term care referral
• Step 2. Community Care Nurse does client home
  assessment.
• Step 3. GP reviews meds
• Step 4. GP and CCN develop Coordinated Care Plan
• Step 5. CCN completes Health Binder visits
  patient at home.
• Step 6. GP meets with patient goes through care
  plan, problem list, meds list
• Step 7. Care plan is implemented
• Step 8. Care plan and meds reviews are reviewed
  and updated on ongoing basis

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Documentation/evaluation of changes tested
annotated time series
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Complexity of regional improvement

• Several pilot populations identified
• Stratification methodology for the population
• Many teams across continuum -home health, long
  term care, assisted living, pharmacy, physician
  offices, community
• Innovation of the change concepts
• Building of processes across continuum
• Testing of changes across continuum

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Questions