Quality Improvement and

the Model for ImprovementHunter Gatewood, Improvement Advisor

Learning Session 1DSRIP RHP10 Learning Collaborative on

Behavioral Health – Primary Care Integration January 29, 2014

What is Quality Improvement?

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What is Quality Improvement?• Change at system level

– Work at the frontline level– By multi-disciplinary staff teams

• Regular, ongoing assessment and measurement• Reduction of variability• Process focus, not individual as good/badExamples

– Establish reminder system to reduce no shows– Develop system to identify patients needing LDL test

How do we do things better? 3

What is Quality Assurance?“The planned and systematic activities put in place to

ensure that (quality) requirements for a product or service will be fulfilled.”

• Ensure that requirements, guidelines, regulations met• Uses inspection (vs. regular measurement)• Also known as quality control• Examples:

– Health code for restaurants– Licensing of providers– Audits of clinical facilities

Are we (you) doing things right?4

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

From Associates in Process Improvement.

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AIM

MEASURES

CHANGES

RAPID TESTOF CHANGES

Model for Improvement, Part 1

Aim Statements

Monthly Measures and Run charts

but first, 3 more distinctions

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Diagram credit: hhs.gov, from original at www.ihi.org

Learning Collaboratives, DSRIP projects, and the Model for Improvement

Three DIFFERENT Uses of Numbers

Research

Judgment

Improvement

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Other Improvement Models

• Six Sigma

• LEAN (Toyota Production System)

• TQM

• CQI

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

From Associates in Process Improvement.

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AIM

Characteristics of Good Aim

• Focused: Sets a clear goal to focus the team

• Measurable: can develop clear measures to track progress toward aim– Defines success numerically

• Time specific: establishes time frame (6-12 months)

• Clinically relevant, compelling

• Defines patient population

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Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

Example Aims

• Within 12 months, decrease the percent of patients with >3 ER visits a year.

• Within six months, reduce waiting time for primary care appointments in SCC Clinic to Third-next Available Appointment Delay of 3 days or less.

• By December 2012, decrease the percentage of diabetic patients with HbA1c > 9 to ten percent.

• By {When}, increase/decrease {What} for {Whom}

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Assess the Aim: Example 1

• The QI team will meet five times in the next month

– Focused: Sets a clear goal to focus the team?

– Measurable and defines success numerically?

– Time specific?

– Clinically relevant?

– Defines patient population?

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Assess the Aim: Example 2

• By December 2014, increase by 50% the percentage of patients with diabetes who got an HbA1c test in the past 12 months AND have HbA1c < 9%.– Focused: Sets a clear goal to focus the team?

– Measurable and defines success numerically?

– Time specific?

– Clinically relevant?

– Defines patient population?

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

MEASURES

Measurement for Improvement

• Purpose: To track progress (improvement!) over time and to promote buy-in.

• Audience: QI Team, Front-line staff and providers, Senior sponsors

RHP10 shared BH-PC Integration measuresPre-work, Appendix D

1. % patients screened with cross-specialty tool

Ex. PHQ for depression in primary care, or diabetes

screening on behavioral health

2. % patients receiving integrated care intervention in past 12 months

Ex. shared care plan at both BH and PC sites

3. % patients receiving integrated care whose condition improved (tracked cross-specialty)

Ex. PHQ #s from + to – in primary care, or

HbA1c down and tracked/reported in BH

Characteristics of a Good Measure

• Directly relates to aim

• Specifies patient population

• Data are available

• Able to collect data frequently

• Worth measuring for at least 12 months

Example Measures

• Number of days until third next available appointment.

Aim: Within six months, reduce waiting time for primary care appointment to 3 days.

• Percentage of patients with HbA1c >9. Aim: By December 2012, decrease the

percentage of diabetic patients with HbA1c > 9 to 10% or less.

Assess the Measure: Example 1

• Number of times the QI team meets each month

– Directly relates to aim?

– Specifies patient population?

– Data are available?

– Able to collect data frequently?

Aim: The QI Team will meet 5 times in the next month

Assess the Measure: Example 2

• Number of improvements to the care of patients with diabetes– Directly relates to aim?

– Specifies patient population?

– Data are available?

– Able to collect data frequently?

Aim: Improve the care of diabetic patients over the next 12 months

Assess the Measure: Example 3

• Percentage of patients with HbA1c testing during past 12 months– Directly relates to aim?

– Specifies patient population?

– Data are available?

– Able to collect data frequently?

Aim: By December 2012, 90% of DM pts. will have had an A1c in the past 12 months.

Sample Run Chart

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11/12

11/17

11/22

11/27

12/212/7

12/12

12/17

12/22

12/27

1/1 1/61/1

11/1

61/2

11/2

61/3

12/5

2/10

2/15

2/20

2/25

3/1 3/60

20

40

60

80

100

120

Appointment Cycle Time (excludes physicals)

Appointment Cycle Time Mean Goal

Min

ute

s

Median

Run Charts

• Display ordered sequence of data and provide running record over time

• Can be used for any data that are sequenced over time (trending)

• Require no statistics

• Visually illustrate progress toward goal

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Adapted from, NHS Scotland Tutorial Guide on Statistical Process Control. http://www.indicators.scot.nhs.uk/SPC/SPC.html

Understanding Variation

• All sets of data demonstrate variation.• Two types of variation

–Random/common cause• normal, no impt change, NOT special

–Special cause• something going on

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Adapted from, NHS Scotland Tutorial Guide on Statistical Process Control. http://www.indicators.scot.nhs.uk/SPC/SPC.html

Detecting Special-Cause Variation

Four run chart rules • Astronomical point• Shift• Trend• Number of runs

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Did the change result in improvement?

Week 4 Week 110

1

2

3

4

5

6

7

8

9

Before and After ResultsChange made between Week 7 and

Week 8

Delay time (hours)

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1.

2.

3.

ChangeMade

ChangeMade

ChangeMade

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

Week 11

Week 12

Week 13

Week 14

0

2

4

6

8

10

Delay time (hours)

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

Week 11

Week 12

Week 13

Week 14

02468

1012

Delay time (hours)

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

Week 11

Week 12

Week 13

Week 14

0

2

4

6

8

10

Delay time (hours)

Benefits of Run Charts

• Tells story visually

• Focuses on the process

• Prevents jumping to unfounded conclusions about

what does/doesn’t work

• Motivates people to think like improvers

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Team Meeting 1:

Aim Statement and

Measures

Sample Aim+Measures for BH-PC Integration

By Dec 31, 2014,

Super BehavioralHealth Clinic will improve the integration of behavioral health and primary care

for our patients seen at Advanced Primary Care Clinic.

We will improve:

• Increase % patients with diabetes with a diabetes self-

mgt goal from 30% to 90%

• Increase % patients with a shared care plan at both SBHC

and APHC from 0% to 80%

• Decrease % patients with diabetes with HbA1c over 9

from 20% to 10%

Model for Improvement, Part 2

Test changes small, using the

Plan-Do-Study-Act Cycle

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

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From Associated in Process Improvement

Learning Objectives

• Learn the value of testing changes in care on a small

scale before implementing widely

• Learn how to turn your ideas into tests (PDSAs)

• Plan a PDSA test to complete when you return to work

Why do Small Tests of Change?

• Understand the likelihood that change will result in improvement

• Understand the extent and limitations of the change

• Learn to adapt the change to local environment

– Evaluate cost

– Address unexpected consequences• Gain buy-in and minimize resistance if change is

implemented and spread

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Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

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PDSA – Rapid Cycle Improvement

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Act

• Questions & predictions (why?)

• Plan to carry out the cycle

Plan

Study

Do

• Carry out plan• Document• Begin data

analysis

• Complete analysis

• Compare data to predictions

• Summarize what was learned

Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

AdaptAdopt

Abandon

PDSA STEP by STEP

1. Identify a daily process need/problem

2. Brainstorm possible solutions

3. Choose one to test

4. Write a PLAN for your test

5. DO it! Conduct the test and document the data.

6. STUDY the data to determine whether or not this test solved the problem

7. Take ACTion-your most logical next step to solve the problem or retest for effectiveness

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Example of PDSASubject: Diabetes: Planned visits for blood sugar management.

Plan: Ask one patient if he or she would like more information on how to manage his or her blood sugar. (Predict: Patient will say “yes”)

Do: Dr. J. asked his first patient with diabetes on Tuesday.

Study:  Patient was interested; Dr. J. was pleased at the positive response.

Act: Dr. J. will continue with the next five patients and set up a planned visit for those who say yes.

Source: ihi.org

Exercise

• Stand in groups of 8 • Get one tennis ball for your group• Pick team’s timekeeper • Name your team, quickly

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“HEY, LET’S GO SEE HOMER BLOW HIMSELF UP.”

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Video: “October Sky” Scene 6, “Rocket Roulette” (from 34:37 to 41:00)

Repeated Uses of PDSA Cycle

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Hunches Theories Ideas

Changes That Result in Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

Keys to Successful Small Tests of Change

• Scale down: do small tests• Collect useful data during each test• Test over a wide range of conditions

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Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

Adapted from the Institute for Healthcare Improvement Breakthrough Series College.

Run PDSAs in Parallel

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A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

Spec

ific Tes

t Cyc

les

Implement registry

Group Visits

Workflow redesign

Team care approach

Using a PDSA Worksheet

• PLAN: activities and timelines, including person responsible

• DO: describe what actually happened during test

• STUDY: review data collected during plan phase and compare to predictions

• ACT: determine what to change and what to keep based on previous plan cycle (this is a new PLAN)

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