Support for Innovation and Improvement Learning Series

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Support for Innovation and Improvement Learning
Series

• Foundations Session 1
• The Model for Improvement
• Presenter Judy Huska, Director Health
  Improvement Action, Impact BC

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Interactivity

• This session is to be interactive a real
  opportunity to share and learn from each other
  please feel free to raise your hand at any time
  to ask a question or make a comment
• You can also use the chat pod if you have any
  questions, comments, contributions, etc. we will
  pick up on these as we go along

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The Model for Improvement (MFI)
Reference The Improvement Guide A Practical
Approach to Enhancing Organizational Performance-
2nd Edition. Langley GJ, Nolan KM, Nolan TW,
Norman CL, Provost LP. San Francisco
Jossey-Bass 2009
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What are we trying to accomplish?

• Understand the Model for Improvement
• Experience running PDSA cycles
• Start an improvement charter

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Prerequisites of transformational 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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Characteristics of the Model for Improvement

• Action-oriented What are you going to test
  next Tuesday
• Rapid-cycle testing of changes
• Evaluation and revision of all changes before
  implementation
• Testing and implementing the changes in small
  populations, then spreading then spreading to the
  larger population
• Impact evaluated using annotated run charts
• Monthly reporting of tests and outcomes

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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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What are we trying to accomplish?

• Develop an aim statement

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Establish the aim

• Involve senior leaders
• Focus on issues that are important to your
  organization
• Write a clear statement of aim with numerical
  goals
• Guidance include anything to keep the effort
  focused (location, strategies, client
  populations, office, spread plans, etc.)

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Template

• We aim to improve _________(name the process or
  topic) in _____(location) so that _________ (a
  numerical goal). By working on the process, we
  expect ____________(list benefits). It is
  important to work on this now because
  ________(list imperatives.) Some things we have
  to keep in mind as we work are _______ (guidance
  scope).

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Example aim statement

• Improve the patient partnership in our office so
  that in one year
• Decrease no-show rate by 50
• 80 of patients have a self-management goal
• 40 of patients have improved self-confidence
• 75 say they would recommend us to a friend
• Guidance
• Budget, personnel
• size start with 5 patients with diabetes and
  expand to all patients with diabetes in the
  practice

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How do we know that a change is an improvement?

• Measurement tells us whether or not we are
  hitting our target

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Measurement guidelines

• Need a balanced set of 4 to 7 measures report
  weekly or monthly to assure that system is
  improved
• Measures should reflect aim statement be
  specific
• Integrate measurement into routine
• Plot data for the measures over time and annotate
  graph with changes
• Post run charts where others can see update
  regularly

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Types of measures

• Outcome measures
• Results - system level performance
• Process measures
• Inform changes to the system
• Balancing measures
• Unintended consequences
• What you are afraid might happen to another
  part of the system

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Measurement example
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The improvement charter

• One or 2 page document
• Aim statement (answers question 1)
• Guidance
• 4-7 measures (answers question 2)
• Who is on the team leader, content experts,
  front line staff
• Can include run charts and be a record of what
  was accomplished

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Improvement Charter Template Team name here
Date What are we trying to accomplish? Our Aim
Statement is TEMPLATE We aim to improve
_________(name the process or topic) in
_____(location) so that _________ (a numerical
goal). By working on the process, we expect
____________(list benefits). It is important to
work on this now because ________(list
imperatives.) Some things we have to keep in
mind as we work are _______ (guidance
scope). How will we know that a change is an
improvement? Our measures are The recommended
number of measures is 4-7. A balanced
measurement set includes 1-3 process measures,
at least one outcome measure and a balancing
measure. Consider the triple aim, which is an
example of a balanced set of measures clinical
outcome, patient provider experience and cost.

• Team Members (Names and Roles)
• Who are the right people to make this happen?
  Look at the process you are improving and assure
  that those affected by the process are included.
• Organizational leadersnames
• Clinical Expertisenames
• Key staffnames
• Client representative--names
• Tips
• Try to keep charter to one page (front and back
  is okay)
• Should be understandable to anyone, including the
  public
• Reviewed and accepted by leadership
• If you want to make a report about your
  improvement effort, add the ideas you tested and
  the graphs of your results.

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What changes can we make that willresult in
improvement?

• The clinical ideas for excellent care
• Ideas about processes
• Models

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The PDSA cycle Plan, Do, Study, Act

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

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Use the PDSA cycle to

• Answer first two questions
• Develop a change
• Test a change
• Implement a change
• Spread a change

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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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Repeated use of the PDSA cycle
Changes that result in improvement
DATA
Implementation of change
Wide-scale tests of change
Hunches theories ideas
Follow-up tests
Very small scale test
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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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Measurement and data collection during PDSA
cycles

• Collect useful data, not perfect data - the
  purpose of the data is learning, not evaluation
• Use sampling as part of the plan to collect data
• Use qualitative data rather than wait for
  quantitative
• Record what went wrong during data collection
• Use paper pencil until information system is
  ready

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Successful cycles to test changes

• Plan multiple cycles for a test of a change
• Think a couple of cycles ahead
• Scale down size of test ( of patients, location)
• 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

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PDSA planning form
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Aim To improve the care of patients with mental
health problems
Improved outcomes
DATA
Cycle 5 Test 3 ways to access skills in
CBIS manual
Test (Patient B) Problem List/Action Plan
Cycle 4
Use of mental health screening tools will help
identify patients needing support.
Cycle 3
Test Diagnostic Assessment Interview (Patient B)
-Hand out Problem List
Cycle 2
Test the use of the PHQ9 with patients B and C
on Wednesday.
Cycle 1 Test use of PHQ9 with patient A on
Tuesday
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Frail Elderly Measures
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Implementation of coordinated care plan for all
patients
Cycle 5 RN to share plan as point person with
team members
Cycle 4 Plan to place RN from HCC IN primary
care one day/wk involves patient and GP in plan
Sequential learning
Cycle 3 Continue (S team felt this is not
sustainable temp. change agent to leave, no one
owns plan not clear how share change in plan)
How do we implement a coordinated care plan?
Cycle 2 Continued good team process (S need to
add professionals discovery of additional gaps
in care for other PDSA series)
Cycle 1 5 GPs, 32 clients avg. length 1.5 hours
(S takes less time than expected, participants
satisfied, invite new people
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Study results from chart review
Data quality suspect as no formal method is in
place to update this measure.
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Overall aim improve chronic care
Specific Test Cycles
Clinical Information System
Decision Support
Community Engagement
Delivery System design
Self-management
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Using the Model for Improvement for Youth
Depression and Anxiety

• Connie Sixta, RN, PhD, MBA

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What are we trying to accomplish?Aim Statement
Characteristics

• States that we are going to improve care for
  patients (knowledge, skills, and resource
  availability related to management of youth
  depression and anxiety in GP offices).
• Describes the target population for improvement
  (provider and patient).
• Describes in general terms changes we are going
  to use to improve care for the population (Youth
  Depression and Anxiety Change)
• Describes the most important outcomes (measures)
  that we want to improve for the population that
  define our success (Use of screening and
  diagnostic tools, treatment plans, support
  mechanisms, improved patient experience, etc.).

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The 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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What are we trying to accomplish?Youth
Depression Aim Statement

• Aim The care for youth with depression in the
  Killarney HS will be redesigned by increasing GP
  capacity in the provision of youth mental health
  services including a coordinated effort amongst
  GPs, school personnel, and community mental
  health providers. A youth depression change
  package will be used so that GPs increase the use
  of depression screening tools, diagnostic tools,
  treatment interventions, and coordinate care
  with school personnel and mental health
  specialists. Change will be evidenced by
  improved GP capacity, improved access for youth
  with depression, and improved youth /family
  experience.

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The 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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Possible Measures for Youth Depression

• of Youth screened for depression using KADS
• of Teens given Psychotherapeutic Support (PST)
  
• Youth who have appropriate pharmacological
  therapy.
• Youth/Family with positive experience with GP
  mental health care.
• of Youth with a wrap-around plan of care
  (GP-school-youth/family)
• GPs with improved confidence in giving
  treatment to youth for depression and/or anxiety.
  
• of Youth mental health care plans generated.
• of Youth referred to mental health specialists.
  

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Number of youths with being screened for
Depression using KADS
of Patients screened using KADS
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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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Youth Depression Change Package

• Diagnostic Tools (KADS)
• Psychotherapeutic Support for Teens (PST)
• Wrap-around mental health care plan
• Treatment (Self-care and/or Medications)
• Resource List
• Algorithm for screening, diagnosis and treatment

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Aim To improve the care of youth with depression
by using KADS screening tool.
Improved outcomes
DATA
Cycle 5 Educate staff in use of
the new tool.
Cycle 4 Standardize the tool in policy and
procedure.
Use of a mental health screening tool will
improve outcomes.
Cycle 3
Redesign approach to using the tool and retest.
Cycle 2
Test the screening tool with 2 patients
tomorrow.
Cycle 1 Identify youth depression screening tool
(i.e. KADS).
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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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Skills for Improvement

• Supporting change with data
• Developing a change
• Testing a change
• Implementing a change
• Spreading an improvement
• Human side of change

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References

• The Improvement Guide A Practical Approach to
  Enhancing Organizational Performance- 2nd
  Edition. Langley GJ, Nolan KM, Nolan TW, Norman
  CL, Provost LP. San Francisco Jossey-Bass 2009
• www.ihi.org, search for Model for Improvement
• Quality Improvement Through Planned
  Experimentation. 2nd edition. R. Moen, T. Nolan,
  L. Provost, McGraw-Hill, NY, 1998.
• Understanding Variation, Quality Progress, Vol.
  13, No. 5, T. W. Nolan and L. P. Provost, May,
  1990.
• A Primer on Leading the Improvement of Systems,
  Don M. Berwick, BMJ, 312 pp 619-622, 1996.
• Accelerating the Pace of Improvement - An
  Interview with Thomas Nolan, Journal of Quality
  Improvement, Volume 23, No. 4, The Joint
  Commission, April, 1997.

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Resources

• IHI Open School www.IHI.org
• An overview of the Model for Improvement
• Setting an Aim
• Measuring
• Developing changes
• Testing changes
• Impact BC website Charters, PDSA forms, Pocket
  Guide can be ordered from ImpactBC
• Please contact Avril Ullett aullett_at_impactbc.ca

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Next Supporting Innovation and Improvement Web
Conference

• Next call Oct 27, 2009
• Improvement Charters
• Change Packages
• Pre-reading Health Literacy Charter , SII
  charter , 3 Patients as Partners Charters, Nolan
  et al page 90, 91.
• Link to Patients as Partners information
• http//www.impactbc.ca/patientsaspartners/resource
  s4teams/webconferences
• SII Charter will be posted here shortly
• http//www.impactbc.ca/learningseries/resources
• For more information contact Avril Ullett
  aullett_at_impactbc.ca

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Coaching Sessions by Health Authority

• ½ hour coaching session 100pm-130pm
• Dial in locally at 604-899-2339 or toll free
  1-877-385-4099
• Participant Codes
• Fraser Health Authority 64461
• Northern Health Authority 5439894
• Interior Health Authority 7865959

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Questions for Coaching call

• 1.What improvement initiative are you currently
  working on or starting?
• 2.What is the aim of that initiative
• 3.How will you know a change is an improvement
  (what measures could you use)
• 4. What small test of change will you try first?
  How would you record this?
• 5. Imagine how a series of PDSA cycles/small
  tests might go. Anticipate how tests might
  succeed and/or fail
• 6.What might you do differently because of these
  learnings?

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Assignment

• If you wish, send the answers to the coaching
  questions and your PDSA cycle to your coach for
  feedback..
• We can discuss these at your coaching call the
  following week..