Improving Your PrimaryCare Practice: Part ISue Butts-DionImprovement Advisor Institute for Healthcare Improvement

*This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.

Baker, Butts-Dion, Crowe, Heinrich, & Taylor (2011)

*Learning ObjectivesBy the end of this module you will be able to: Describe the evolution of quality improvementDescribe key principles of quality improvementUse the MFI to test a small improvementPersonal improvementPrimary Care improvement

PROMISES Project*

*Evolution of Quality (in Healthcare)

*

*Underlying QI Principles

Focus on systems, not peopleIntervene iteratively using PDSA cyclesUse measurement and data for decision makingRemember that customers are keyAcknowledge that improvement requires change

Improvement Requires ChangeWhile all changes do not lead to improvement, all improvement requires change. IHI website The proposed freeway to remove thebottleneck created by the previousproposed freeway to remove the bottleneckcreated by*

Model for Improvement (MFI)Model for ImprovementWhat are weHow will weWhat changes can we*

How It Works(or Doesnt Work!)*

How It Works(or Doesnt Work!)I wont do this anymore!*

How It Works(or Doesnt Work!)I wont do this anymore!I will work harder and faster!*

How It Works(or Doesnt Work!)I wont do this anymore!I will work harder and faster!I will be more vigilant!*

How It Works(or Doesnt Work!)I wont do this anymore!I will work harder and faster!I will be more vigilant!I was doing things the same way:maybe a little faster, maybe with more attention, maybe with more intentionand expected different results.

*

What Had I Been Missing?*

What Had I Been Missing?Aim*

What Had I Been Missing?AimMeasures*

What Had I Been Missing?AimMeasuresChanges*

What Are We Trying to Accomplish? (My Aim)*

What Are We Trying to Accomplish? (My Aim)*Some is not a number.Quotes from Don Berwick speech, 2004

What Are We Trying to Accomplish? (My Aim)*Some is not a number.Soon is not a time.Quotes from Don Berwick speech, 2004

What Are We Trying to Accomplish? (My Aim)*Some is not a number.Soon is not a time.Hope is not a plan.Quotes from Don Berwick speech, 2004

What Are We Trying to Accomplish? (My Aim)My aim: By Thanksgiving of this year,I want to decrease the time spent workingpast 5:30 PM ET from 180 to 60 minutes per day. I want to increase my focus on:(1) improving systems for triaging emails, (2) improving systems for scheduling calls and meetings.*Some is not a number.Soon is not a time.Hope is not a plan.Quotes from Don Berwick speech, 2004

How Will We Know That the Change Is an Improvement? (My Measures)Outcome Measures:Average number of minutes spent each week working past 5:30 PM ET.Time spent on improving quality of life (e.g., my timespent with family, exercising, reading, etc.)Family satisfaction/feedback (qualitative data).

**

What Changes Can We Make? (My Changes and Ideas)Sources for ideas:Customers, suppliersColleagues, coworkersLiterature, expertsInternet (e.g., Google)Generic ChangesThe Improvement Guide, by Langley, et al.

**

The PDSA Cycle forLearning and Improvement*ActAdapt? Adopt? Abandon? Whats thenext cycle?PlanObjective Questions& predictions (why).Plan to carry out cycle(who/what/where/when). Next cycle?StudyDoW.E. Deming referred to this as the Shewhart Cycle

ATKINSON FAMILY PRACTICEA PROMISES PRACTICE:*

*

Atkinson Family PracticeWe have at least 25 patients calling a day about prescription refills. Probably 25 a morning. Karen Clinical Team LeaderHow can we reduce theses calls? It seems like thats all our front desk staff dotake calls about refills from patients. Tom Practice Manager

What Are We Trying to Accomplish?AimBy March 2012 ( in two months), our practice will:Improve the Rx refill processReduce phone calls from patients or pharmacies to verify or check on prescription refillsReduce the duplicate prescription requestsReduce these events by 50% in this time frameDoes this answer.*

What Are We Trying to Accomplish?AimBy March 2012 ( in two months), our practice will:Improve the Rx refill processReduce phone calls from patients or pharmacies to verify or check on prescription refillsReduce the duplicate prescription requestsReduce these events by 50% in this time frameDoes this answer.What to improve?*

What Are We Trying to Accomplish?AimBy March 2012 ( in two months), our practice will:Improve the Rx refill processReduce phone calls from patients or pharmacies to verify or check on prescription refillsReduce the duplicate prescription requestsReduce these events by 50% in this time frameDoes this answer.What to improve?For whom?*

What Are We Trying to Accomplish?AimBy March 2012 ( in two months), our practice will:Improve the Rx refill processReduce phone calls from patients or pharmacies to verify or check on prescription refillsReduce the duplicate prescription requestsReduce these events by 50% in this time frameDoes this answer.What to improve?For whom?By when?*

What Are We Trying to Accomplish?AimBy March 2012 ( in two months), our practice will:Improve the Rx refill processReduce phone calls from patients or pharmacies to verify or check on prescription refillsReduce the duplicate prescription requestsReduce these events by 50% in this time frameDoes this answer.What to improve?For whom?By when?By how much?*

Key Point About Data: Improvement is Not Research*Quality improvementAim: improvementData: just enough dataResearch Aim: new knowledgeData: just in case data

How Will We Know That a Change Is an Improvement?MeasuresNumber of duplicate requests for the same prescription refill. Well track:Number of requestsRequest method (i.e., calls, fax)Balancing MeasuresStaff SatisfactionPatient Satisfaction*

What Changes Can We Make?Identified changes to testTest Idea: Pharmacy willTest Idea: Practice willTest Idea: Practice will educate patients to*

What Changes Can We Make?We need to communicate more.Otherwise, we are all just irritatingeach other and getting upset.--Karen, Clinical Team LeaderIdentified changes to testTest Idea: Pharmacy willTest Idea: Practice willTest Idea: Practice will educate patients to*

The PDSA Cycle forLearning and Improvement*ActAdapt? Adopt? Abandon? Whats thenext cycle?PlanObjective Questions& predictions (why).Plan to carry out cycle(who/what/where/when). Next cycle?StudyDoW.E. Deming referred to this as the Shewhart Cycle

What Could You Do Today? Identify one area that needs improvingWrite the first draft of an aimChoose one thing you could measureDetermine: Is it improving? Or not?List change ideas to test nowChoose a few, or just one*

Thank You!Thank youfor your timeand attention today*

Assessment Question 1:What was the first quality improvement in healthcare that we saw in the 1800s?

Deming became a prominent figure in industry Ryan White Program quality legislation F. Nightingale records preventable deaths First quality manual published*

Assessment Question 2:Improvement methodologies have common underlying principles, and recommend focusing on

Focus on people, not systems Focus on systems, not people Focus on systems and people Focus on people to assess the blame*

Assessment Question 3:Name one place you can access to get ideas for something to test or try in your practice

Customers/suppliers Colleagues/experts Literature/Internet All of the above*

A Few ReferencesLangley et al, The Improvement Guide,1996, 2011W. Edwards Deming, The New Economics,2nd Edition, 2000www.ihi.orgwww.deming.org

Want to Learn More?Improving Your Primary Care Practice: Part 2Learn more about the benefits of testingthings on a small scaleLearn about scaling up, sustaining, andspreading changesLearn about two tools that all improversshould know about

*******************************************