Transcript BW Regulation - Albert Einstein College of Medicine

Performance Improvement
--An Overview
Auxford Burks, MD
Albert Einstein College of Medicine
Department of Pediatrics/ Jacobi Medical Center
Thanks to:
Daniel Hyman, MD, MMM
Chief Medical Officer, Ambulatory Care Network
New York Presbyterian Hospital
Who provided all of this material
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?
Model for Improvement
Aim:
What are we trying to accomplish?
Measures: How will we know that the change
is an improvement?
Ideas:
What changes can we make that
will result in an improvement?
Model for Improvement
Aim:
What are we trying to accomplish?
What are we trying to accomplish?
Aim: A written statement of the accomplishments
expected from each pilot team’s improvement effort
Different forms are useful:
– A general description of aim
– Specific patient population
– Some guidance for carrying out the work
The Team’s Aim Should Be:
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•
•
•
•
•
•
Strategic
Relevant
Exciting
Important
A stretch, not business as usual
Achievable, not impossible
Understandable
Sample Goals/Measures
• 95% of patients with asthma will have symptom frequency
documented in their record (day and night) – process measure
• 95% of patients will have asthma severity specifically identified at
all visits where asthma is addressed – process measure
• 90% of patients with persistent asthma will be treated with an
appropriate antiinflammatory medication, at an appropriate dose –
process measure
• 95% of patients with asthma will have a documented assessment of
tobacco use or exposure and counseling to reduce risk if applicable
– process measure
• There will be an X% reduction in ED/hospitalization rate over Y
period of time – outcome measure
• Visit volume in clinic will be unchanged – balancing measure
AIM: Why the Change is Desired
• A known performance deficiency in an important
process
• A gap between current performance and desired
performance
Why an Aim Statement?
• Answers and clarifies “What are we trying
to accomplish?
• Creates a shared language and shared
methods
• Facilitates organizational conversations and
understanding
• Supports accountability for team leaders
Developing the Aim Statement
• Write a clear and concise statement stating the
“who, what, when, and where “
– Who will undertake the work, and who will
be affected by it
– What does the team intend to do
– When will the aim be accomplished
– Where - define pilot site and spread site(s)
SMAART Aims
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•
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Specific: Understandable, unambiguous
Measurable: Numeric goals
Actionable: Who, what, where, when
Achievable (but a stretch)
Relevant to stakeholders and organization
– Strategic, Compelling, Important
• Timely: with a specific timeframe
Sample Aims
We will improve the care of patients with asthma by
adhering to evidenced based guidelines for diagnosis,
assessment and treatment, thereby reducing
morbidity/mortality
By the end of 2005, we will increase the average
number of symptom-free days for children in our
practice with persistent asthma to 10 days or more in
the 2-week period preceding a planned care visit.
Example of Elaborated Aim
Statement
• Aim: By the end of 2005, we will increase the average
number of symptom-free days for children in our practice
with persistent asthma to 10 or more in the 2-week period
preceding a visit. To effect change, we will be guided by
using the six components of the Care Model for Child Health.
Intermediate aims are that:
– 95% of children with persistent asthma will have severity classified at
every visit.
– 95% of children with persistent asthma will be treated with appropriate
maintenance anti-inflammatory medication.
– 90% of children will receive a written asthma management plan on
which we will document family/self- management goals.
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
Aim
Measures
Ideas
A PDSA Cycle
PDSA Objective: Test the use of encounter form to facilitate visit
Revise form. Try
new form with 3
patients
tomorrow; MA will
put form on chart.
Dr. X found the
form helpful for
prompting;
thought items on
form should be in a
different order.
Need better
process for getting
form to provider.
Will encounter forms
facilitate severity
classification?
Dr. X will try form
with severity class
Qs with 3 patients on
Thurs
Dr. X tried with two
patients. Couldn’t
find a form for third
patient.
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
Ideas: What Changes Can We Make
That Will Lead to Improvement?
Change Concept: a general notion or approach to change
that has been found to be useful in developing specific
ideas for changes that lead to improvement.
Concept
An opportunity to create
a new connection
Specific
idea A
Thought
process
Specific
idea B
Ideas: What Changes Can We Make
That Will Lead to Improvement?
Change Concept: A general notion or approach to change
that has been found to be useful in developing specific
ideas for changes that lead to improvement.
Concept
Promote clinical
care that to
is create
An opportunity
consistent withascientific
new connection
evidence and family preferences
Use
tool to
Specific
classify
idea A
severity at
every visit
Thought
process
Specific
idea B
Change Concepts vs.
High Leverage Changes
Vague, strategic,
creative
Specific, actionable,
results
Improve care of asthma
patients
Share info w/ patients &
families and encourage
self-management
Document asthma
management plan and
goals for self-management
Begin discussion of selfmanagement goals w/ 3
patients on Monday
Repeated Use of the PDSA Cycle
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?
Improve asthma outcomes
Reduction in ED visits
Change Pkg.
A P
S D
Changes That
Result in
Improvement
Implementation
of Change
A P
S D
Follow-up
Hunches
Theories Very Small Tests
Ideas Scale Test
Wide-Scale
Tests of Change
PDSA example I
• A pediatrician goes to a conference one
October and learns all about Improvement,
PDSA cycles, and how to improve care for
patients with asthma.
• He returns to his practice completely
enthused and ready to do something new
that will improve care.
• We’ll call our protagonist in this story,
Bill Caspe
PDSA example I
• Bill decides to look at his 5 person practice’s
assessment of children whose parents call for
refills of asthma medications to see whether the
children:
– Need flu vaccines
– Are having symptoms too frequently (i.e. are
not being well controlled on their current
medication regimen)
• He develops a form and gives it to his nurse to
use for one week when asthma meds are refilled
PDSA example I
• Is this a good PDSA cycle?
– Why?
– Why Not?
• What do you think happened?
PDSA example II
• The pediatric residents in a community based
clinic are taught about improvement, PDSA
cycles, and how to improve care for patients with
asthma.
• They are provided with baseline data that shows
that only 20% of children have a severity
classification of their asthma in the practice’s
medical records
PDSA example II
• The residents develop a sticker that prompts the
questions needing to be asked to determine
symptom frequency
• One resident on ambulatory block tries the
sticker for 5 consecutive patients with asthma.
PDSA example II
• Is this a good PDSA cycle?
– Why?
– Why Not?
• What do you think happened?
PDSA
Cycles
“Negative results on the fish…Let’s try rubbing two sticks together.”
PDSA Key Points:
• Make the Cycle SMALLER!!!
• Break changes down into manageable
parts
• This also allows people to:
– try things and give input
– more easily adapt
– feel included in decisions and development
Repeated Use of the PDSA Cycle for
Implementation
Routine use of
patient survey
A P
S D
Cycles 5/6: Create
orientation manual
section on patient
survey
Cycle 4: Use of survey for all patients
A P
S D
Test of
patient
survey
Cycle 3: Try survey on other days with other
providers and patients
Cycle 2: Test - Use of new survey on two clinic days
Cycle 1: Introduce new survey form to one provider and
staff
Multiple Cycles to Test and Implement
Components of the Care Model
Use of Flow sheet
V.4 by all
physicians and
nurses
Component:
Decision Support
From Chinatown, Asthma BTS, 2001
A P
S D
Cycle 5: Implement use
of V.4, do peer review of
documentation and use
Cycle 4: Trial of V.4 by all providers
A P
S D
Will a flow sheet
be useful for
patients?
Cycle 3: Two week trail of V.3, review meetings
Cycle 2: Try V.2 by two providers for a few days
Cycle 1: Gather sample flow sheets, try V.1with two patients
Things should be as simple
as possible but not simpler.
» Albert Einstein