An Introduction to Methods Used in the Collaborative: The Model for Improvement

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An Introduction to Methods Used in the
Collaborative The Model for Improvement
Kelly Westfall (prepared with assistance from
Lloyd Provost, Associates in Process Improvement
and the Institute for Healthcare Improvement)
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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 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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Use the PDSA Cycle for

• Helping to answer the first two questions of the
  model
• Developing a change
• Testing a change
• Implementing an improvement
• Spreading an improvement

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The PDSA Cycle for Learning and Improvement

• What changes are to be made?
• Next cycle?

• Objective
• Questions and predictions (Why)
• Plan to carry out the cycle (Who, What, When,
  Where)

• 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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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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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Learning from Data
Proposals, Theories, 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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Q1 What are we trying to accomplish?

• A Aim statement
• Each aim statement should contain the following
• A general description of the goal
• A specific target population
• Numerical goals

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Examples of a Pilot Teams Aim

• State the aim clearly
• Implement the Chronic Care Model for
  cardiovascular disease (diabetes)...
• Use numerical goals
• so that the percentage of patients with CVD
  with an BP lt 140/90 will be greater than 95...
  or
• ... so that the percentage of patients with
  Diabetes with an HbA1c lt 7 will be greater than
  95
• State the site
• in Dr. Smiths practice.

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Points to remember...

• Senior leaders in the organization should support
  the aim, support implementation of successful
  changes, and prepare for spread.
• Base your aim statement goals on data or
  organizational needs.

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Examples of numerical goals appropriate for
pilot teams

• Diabetes
• 90 of the practices patients with diabetes who
  use tobacco will have a documented offer from
  their physician of smoking cessation counseling
• Clinic B will demonstrate 30 increase in ratings
  of patient satisfaction with chronic illness
  management
• Cardiovascular Disease
• The percentage of patients with an influenza
  vaccination will be greater than 80
• More than 70 of the patients with diabetes in
  Dr. Hs practice will have a documented
  self-management goal

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Different Populations
PILOT SITE System of Focus for the WSC
(defined by Aim)
Small-scale tests of change
The Total Health Care System (spread sites)
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Ingredients for an Effective WSC Team
System and/or Senior Leadership
Clinical Leadership
Day-to-day Leadership
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Q2 How Do We Know That Change is an Improvement?

• A Measurement
• Each PDSA cycle
• Each monthly measure
• Each spread measure

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Measurement Tips

• The monthly measures should clarify your teams
  aim statement and make it realistic
• Make use of your patient tracking database and
  administrative data for measurement
• Integrate measurement into the daily routine

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Measurement Tips continued

• Plot measures monthly
• Be careful about over-doing process measures
• Use a balanced set of five to seven measures to
  assure that the system is improved

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Diabetes Required Measures

• Most recent HbA1c lt 7.0
• Average HbA1c
• Most recent BP lt 130/80 mm Hg
• Most recent LDL lt 100 mg/dl or non-HDL lt 130
  mg/dl
• Average LDL value
• Documentation of self-management goal
• Tobacco-cessation counseling

A detailed description of the required measures
is provided in the Measures section of the
Handbook.
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Cardiovascular Disease Prevention Required
Measures

• Most recent LDL lt 160 mg/dl or non-HDL lt 190
  mg/dl
• Most recent BPlt 140/90 mmHg
• BMIgt25 kg/m2 with diabetes screening
• Documentation of self-management goal
• Tobacco cessation counseling

A detailed description of the required measures
is provided in the Measures section of the
Handbook.
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For Each of the Key Measures

• Define each of the measures for your pilot
  population (numerator and denominator)
• Begin reporting your measures immediately
• (Use the current administrative data as the means
  to obtain your measures each month whenever
  possible.)
• Develop run charts to display your measures each
  month throughout the Collaborative

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Minimum Standard for Monthly Reporting in the
CollaborativeAnnotated Run Chart
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Improvement in Glycemic Control of Patients
with HbA1c lt7.0 in Clinic A
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Improvement in Glycemic Control
of Patients with HbA1c lt7.0 in Clinic A
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Improvement in Glycemic Control of Patients
with HbA1c lt7.0 Clinics B and C
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Improvement in Glycemic Control
of Patients with HbA1c lt7.0 in Clinic B
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Improvement in Glycemic Control of
Patients with HbA1c lt7.0 in Clinic C
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Family of Measures for Diabetes
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Q3 What changes can we make that will result in
an improvement? A
Chronic Care Model
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Change Concepts from the Chronic Care Model

• Community
• - Resources to support patient care are
  identified and made easily accessible
• Health System
• - Organization goals for chronic illnesses are
  part of annual business plan
• - The system actively impacts the entire patient
  population with education and services
• Self-management Support
• - Patients assisted in setting personal
  goals and given aids to assist in changing
  behavior
• - Mechanisms for patient peer support and
  behavior change programs
• Decision Support
• - Evidenced-based guidelines and
  protocols are integrated into the practice
  systems
• - The system integrates the clinical
  expertise from generalists and specialists
• Delivery System Design
• - The practice anticipates problems and
  provides services to maintain quality of life
• - Systems are designed for regular
  communication and follow up
• Clinical Information System
• - A registry of patients with a chronic
  condition is maintained and utilized

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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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References

• The Improvement Guide A Practical Approach to
  Enhancing Organizational Performance. G. Langley,
  K. Nolan, T. Nolan, C. Norman, L. Provost.
  Jossey-Bass Publishers., San Francisco, 1996.
• Eleven Worthy Aims for Clinical Leadership of
  Health System Reform, Don M. Berwick, JAMA,
  September 14, 1994, Vol. 272, 10, p. 797-802.
• The Foundation of Improvement. Langley, G. J.,
  Nolan, K. M., Nolan, T. W., 1994. Quality
  Progress, ASQC, June,1994, pp. 81-86.
• A Primer on Leading the Improvement of Systems,
  Don M. Berwick, BMJ, 312 pp 619-622, 1996.