Successfully negotiating bumps in the road The Principles of Quality Improvement and Structured Coll

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Successfully negotiating bumps in the roadThe
Principles of Quality Improvement and Structured
Collaboratives

• Neil Baker M.D.
• GPSC Practice Support Program
• April 12, 2007

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(No Transcript)
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Reflection

• Think of a barrier/stuck point that was
  significant for you in your improvement effort.
• What was the underlying reason?
• What helped you to overcome it?

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Goals

• Learn the principles of Quality Improvement that
  can be applied to help deal with barriers
• Learn the principles of structured Collaboratives
  so that you can adapt them within different
  structures

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1. Quality Culture

• 85 of poor quality is a result of poor work
  processes, not of staff doing a bad job.
• Deming stated Of all changes Ive observed,
  about 5 were improvements, the rest, at best,
  were illusions of progress
• Don Berwick The three foundations of quality are
  reliability, teamwork, and transparency.

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1. Quality Culture

• Non judgmental
• Process driven
• the underlying problems are systems and work
  process design and not the fault of an individual
• Patient/customer driven
• Data driven
• Evidence and experience driven
• Based on learning in small steps through planned
  experimentation

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1. Quality Culture

• Everyone learns everyone teaches.
• There are no experts. Everyone has expertise.
  Expertise must be shared for the best outcomes.
• Share generously, steal shamelessly.
• Failures are just as important as successes.
  Celebrate failures.
• Celebrate successes as a team.
• When in doubt always refer back to The Three
  Questions.

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2. Leadership and champions

• Physician and administrative champions
• Accountable leaders who own the process
• Designate process ownership and accountability
• They buy-in and help others buy-in
• Make decisions balancing local autonomy with
  direction
• Establish infrastructure (e.g. job descriptions,
  IT, HR policies, performance goals)
• Remove barriers
• Own the communication process through stories and
  celebration

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3. Quality and Project Teams

• Defined teams guiding quality and specific
  projects
• Designated team leaders and project management
• Meet regularly
• Create an agenda and follow-up plan with tasks
  and assigned roles
• Mutual respect and understanding of roles
• Set performance goals and plan action steps
• Create continuous improvement loops

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4. Model for Improvement
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4. Model for Improvement

• The idea behind rapid cycle improvement is to
  first try a change idea on a small scale to see
  how it works, and then modify it and try it again
  until it works very well for staff and customers.
  Then, and only then, does a change become a
  permanent improvement.

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4. Model for Improvement

• Question one establishing the Aim, What are we
  trying to accomplish?
• Is it clear what is expected to happen and by
  when?a written statement of the accomplishments
  expected from the improvement effort.
• Can you determine the system to be improved?
• Can you distinguish the setting or sub-population
  of patients?
• Are specific numeric goals clearly stated?
• Is there a time frame?
• Is there guidance indicated for the activities,
  such as strategies for the effort, or
  limitations?

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4. Model for Improvement

• Question two How will we know that a change is
  an improvement? OR How will we know when we get
  there?
• Measures and definitions are necessary to answer
  this question.
• Data is needed to evaluate and understand the
  impact of changes designed to meet an aim.
• When shared aims and data are used, learning is
  further enhanced because it can be shared. In
  this way, superior performance and best practices
  are more quickly identified and disseminated
  through benchmarking.

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4. Model for Improvement

• Question three What change can we make that
  will result in an improvement? OR How will we
  get there?
• This is the who, what, when, and how of doing the
  actual test
• Uses Change Concepts (see next section)

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4. Model for Improvement

• Why small tests of change?
• Minimize risks of potential failure and of
  potential adverse or unanticipated side effects
• 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 to implementation

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4. Model for Improvement

• Options after each small test of change (PDSA
  cycle)
• Implement as is
• Abandon it
• Increase in scope
• e.g. more patients, more physicians
• Modify it and test again
• Test under different conditions

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4. Model for Improvementsequential testing
BreakthroughResults
A
P
Evidence Data
S
D
Spread Implement
A
P
S
D
A
P
S
D
Test new conditions
A
P
Learning and improvement
Theories, hunches, best practices
Test a wider group
S
D
Test on a small scale
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4. Model for Improvement

• Small tests of change tips
• Move from ideas to action quickly. (e.g. Are you
  in disagreement? Then test and see the results!)
• Decrease the scope of the test
• If it feels like too much work or too burdensome,
  go back to design and make it doable. Downsize
  it, shorten it, minimize burden. Make it as
  doable as possible with minimal effort in the
  course of day to day work.
• Test of oneness
• One patient, one doctor, one day
• As you are designing the test, ask What design
  would enable us to do this test now, tomorrow or
  next week

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4. Model for Improvement

• Testing Trying and adapting existing
  knowledge on small scale. Learning what works in
  your system.
• Testing is not permanent
• Often we have more failures than successes
• Implementation Making this change a part of
  the day-to-day operation of the system.
• Implement a change ONLY if it will lead to
  improvement
• Involves more people and conditions you will run
  into more resistance and factors which require
  design tweaks.

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5. Change Concepts

• Ideas for improvement with a greater likelihood
  of working based on
• evidence,
• quantitatively documented experience
• qualitatively documented experience
• internal data.
• GPSC change concepts
• Advanced access, Group visits, Chronic Disease
  Management, Self management

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6. Implementation and holding the gains

• Old System
• We rely on hard work, vigilance, and memory
• We accept mediocre or average gains
• We allow variation in work processes because
  autonomy is so important
• We accept failures because they are
  non-catastrophic (i.e. no death or severe injury
  within hours of the failure)

• New System
• pulled to the old
• way of doing things

From Ginna Crowe, PhD
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6. Implementation and holding the gains

• New System
• We decide what is optimal
• We intend to reach that level
• and review performance regularly to hold gains
• We standardize work processes where ever needed
• We identify and fix all failures and constantly
  improve design

• Old System
• Pulled to the new
• way of doing things

From Ginna Crowe, PhD
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7. Dissemination and spread
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Structured Collaboratives
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Principles of Structured Collaboratives

• Self efficacy
• Successful learning through small steps
• Taking the leap and building confidence
• Modeling and social persuasion
• Sharing stories, especially connected to data
  (run chart formats can be very effective)
• Ongoing communication
• Reinterpretation of barriers and stuck points
• Learning and applying Quality Principles
• The Three Questions

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1. Quality Culture

• Everyone learns everyone teaches.
• There are no experts. Everyone has expertise.
  Expertise must be shared for the best outcomes.
• Share generously, steal shamelessly.
• Failures are just as important as successes.
  Celebrate failures.
• Celebrate successes as a team.
• When in doubt always refer back to The Three
  Questions.

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20 primary care clinics
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Physician and staffing cuts Advanced access
initiative
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What might be happening? What would you do?

• A clinic says they tried out a visit planner for
  patients prior to the appointment. It worked good
  but somehow never got used.
• A physician working on improvement of diabetes
  care increased HbA1c testing levels to over 90
  but simply has not time to improve levels of
  foot, eye and nephrology screening.
• A clinic working on Advanced Access started
  backlog plans 7 months ago but still has a 4 week
  waiting time.
• A clinic tries a depression screening tool but
  feels that it just takes too much time.

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References

• Institute for Healthcare Improvement, ihi.org
• Clinicalmicrosystems.org
• Excellent resource for office practice redesign
• Improvingchroniccare.org
• Excellent resource on the Care Model
• The Improvement Guide A Practical Approach to
  Enhancing Organizational Performance, Langley,
  Nolan, Nolan, Norman, Provost, 1996.