Transcript The Model for Improvement

The Model for
Improvement
Karen Scott Collins, MD, MPH
VP, Quality and Patient Safety
New York Presbyterian Hospital
July 2008
Learning Objectives
Understand the Model for Improvement
 Discuss how to create aim statements that
are measurable and specific
 Review the measurement strategy and
identify how the key measures relate to
the improvement project
 Introduce Plan-Do-Study-Act cycles

Key Elements of
Breakthrough 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
The Model for Improvement
A simple way to frame, organize, execute
improvement work
 Useful for testing great ideas, trying
things that have worked for others,
implementing ripe ideas or actions, and
disseminating positive improvements
throughout organization
Three Fundamental
Questions for Improvement
1.
What are we trying to accomplish?
2.
How will we know that a change is an
improvement?
3.
What changes can we make that will
result in improvement?
Compare the 3 questions to how we
frame improvement

Aim

What are we trying to
accomplish?

Measurement for
learning

How will we know a
change is an
improvement?

PDSA

What changes can we
make to bring about
improvement?
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?
From: Associates in
Process Improvement
Act
Act
Plan
Plan
Study
Study
Do
Do
Aim
Measures
Ideas
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?
From: Associates in
Process Improvement
Act
Act
Plan
Plan
Study
Do
Do
Aim
Measures
Ideas
Question 1:
What Are We Trying to Accomplish?
Aim:
 A written statement of the
accomplishments expected from each pilot
team’s improvement effort.

Everyone on team has the same goals and
expectations
Aim:
What Are We Trying to Accomplish?
Your team’s aim statement should be
consistent with the mission of the
improvement work and include:
 What is expected to happen
The system to be improved
 The setting or (sub-)population of patients
 Specific numeric, stretch goals
 Time frame
 Guidance for activities, such as strategies for the
effort, or limitations

Exercise: Aims
Use the following criteria to evaluate the
following Aim statement example






Is it consistent with the mission of the
Collaborative/improvement initiative?
Is it clear what is expected to happen by when?
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 guidance indicated for the activities, such as
strategies for the effort, or limitations?
Aim Statement Asthma Example
The aim for our Clinic is to improve care provided to our pediatric
asthma patients using the Chronic Care Model so as to ensure the
Application of evidence based best practices to all patients and
improvement in clinical outcomes in the pilot population over the
next year. This will be accomplished by:






Providing follow up to an ED or hospital discharge within 7
days for > 80%
Documenting severity assessment for 95% of patients
Review management plans and provide written
management plan including shared goal for 85% pts
Appropriate medications for at least 90% of patients w/o
contraindications
Increasing symptom free days by at least 50%
Annual immunization against influenza (goal >90%)
Does example meet these criteria?






Is it consistent with the mission
of the initiative?
Is it clear what is expected to
happen and when?
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 guidance indicated for
the activities, such as strategies
for the effort, or limitations?
YES
NO
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?
From: Associates in
Process Improvement
Act
Act
Plan
Plan
Study
Study
Do
Aim
Measures
Ideas
Question 2: How will we know a change is
an improvement?
Requires measurement
 Can collect qualitative & quantitative data
 Test small first
 Test under a wide variety of conditions to
make sure idea is robust enough

Measurement for Improvement

Builds will/ Creates tension for change


Demonstrating performance gap overall
Demonstrating variability in performance

Focuses teams – “you can manage what you
measure”

Designed to help your improvement team learn
and establish improvement priorities

Like a growth curve: it’s not where you are, but
where you are going

Answers the question: Are changes an
improvement?

IS NOT:


Designed for criticism or punishment
Supposed to end (it should be sustainable)
Types of Measures
1.
Outcome Measures


2.
Process Measures


3.
Results – system level performance
How is the health of the patient affected?
Inform changes to the system
Are key changes being implemented in the
system?
Balancing Measures

Signal “robbing Peter to pay Paul”
Measures - Examples

Outcome



Process



Number symptom free days for asthma patients
ED asthma visits
Patient and family have Asthma Action Plan
Appropriate medications prescribed
Balancing

Clinic cycle time
Measurement Guidelines





Need a balanced set of 5 to 8 measures
reported each month to assure that the
system is improved
These measures should reflect your aim
statement & make it specific
Measures are used to guide improvement
and test changes
Integrate measurement into daily routine;
use patient population database
Plot data for the measures over time and
annotate graph with changes
Methods of Measurement
Clinical measures of patients’ health
 Documentation of behaviors
 Questionnaires
 Assessments
 Summary of databases
 Chart audits
 Observations

Integrate Data Collection for
Measures in Daily Work
Include the collection of data with
another current work activity
 Develop an easy-to-use data collection
form or make Information
Systems/registry input and output easy
for clinicians
 Clearly define roles and responsibilities
for on going data collection
 Set aside time to review data with those
who collect it

Plotting Data in Time Order
Summary statistics hide information
(patterns, outliers)
 In improvement efforts, changes are not
fixed, but are adapted over time
 Time series graphs annotated with
changes and other events provide
evidence of sustained improvement

QI Tools - Run Chart
Percent of Patients with Planned Care Visits
GOAL
Nurse
Smith
left
Tried
encount
er forms
Au
gu
Se
st
pt
em
be
r
O
ct
ob
er
No
ve
m
De ber
ce
m
be
r
Ju
ly
Ju
ne
M
ay
Implemented
registry
Ap
ril
Ja
nu
ar
y
Fe
br
ua
ry
M
ar
ch
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Lessons from Baseline Data Collection
What worked?
 What didn’t work?
 What was difficult?
 Why?
 Ideas for successful measurement and data
collection

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?
From: Associates in
Process Improvement
Act
Act
Plan
Plan
Study
Study
Do
Do
Aim
Measures
Ideas
Question 3: What Changes Can We
Make That Will Result in Improvement?

Use change concepts, models (Chronic
Care Model), literature, shared
experiences to develop specific changes

Test: good ideas, ready for use or ready
for adaptation to your environment
Change Concepts vs.
High Leverage Changes
Vague,
strategic,
creative
Improve care of asthma
patients
Share info w/ patients &
families and encourage
self-management
Document asthma
management plan and
goals for self-management
Specific,
actionable,
results
Begin discussion of SM goals
w/ 3 patients on Monday
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?
From:: Associates in
Process Improvement
Act
Act
Plan
Study
Study
Do
The PDSA Cycle for Learning and
Improvement
Act
Plan
• Objective
• What changes
• Questions and
are to be made?
• Next cycle?
Study
• Complete the
predictions (why)
• Plan to carry out the cycle
(who, what, where, when)
• Plan for data collection
Do
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize
• Begin analysis
what was
of the data
learned
Use the PDSA Cycle for:




Helping to answer the first two
questions of the Model for
Improvement
Developing a change
Testing or adapting a change idea
(from a component of the Care Model)
Implementing a change
Why Test?






Increase your belief that the change will
result in improvement
Opportunity for learning from “failures”
without impacting performance
Document 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
Repeated Use of the PDSA Cycle
Changes that
Result in
Improvement
Multiple cycles
A P
S D
A P
S D
Proposals,
Theories,
Ideas
3 Principles for Testing
a Change
1.
2.
3.
Test on a small scale
Collect data over time
Build knowledge sequentially
with multiple PDSA cycles for
each change idea. Include a
wide range of conditions in the
sequence of tests
To Be Considered a
PDSA Cycle:




The test or observation was planned (including a
plan for collecting data)
The plan was attempted (do the plan)
Time was set aside to analyze the data and study
the results
Action was rationally based on what was learned
Test on a Small Scale

Conduct the test in one facility or office
in the organization, or with one
customer

Test the change on a small group of
volunteers

Develop a plan to simulate the change
in some way
Decrease the Time Frame
for a PDSA Test Cycle







Years
Quarters
Months
Weeks
Days
Hours
Minutes
Drop down next
“two levels” to
plan Test Cycle!
Global Collaborative Measures vs.
PDSA Cycle Measures
Achieving
Aim
Adapting
Changes
During
PDSA Cycles
Project Measures:
Overall results related to the project aim
(core measures and teams’ additional and
balancing measures)
PDSA Measures
-PDSA-specific measures:
• Quantitative data on the impact of a
particular change
• Qualitative data to help refine the change
Fundamental Questions for
Improvement
 What
are we trying to
accomplish?
 Team Aim Statement
 How
will we know that a
change is an
improvement?
 Measures
 What
changes can we
make that will result in
an improvement?
 Change package
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?
Act
Study
Plan
Do
References
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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.
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.
Jane Taylor, Improvement Advisor, IHI
Pat Heinrich, VP, NICHQ