AIM Statements for Improvement: Understanding Aims, Measures, and Ideas

1. Aim Statements(Break-out Session) “If you aim at nothing, you will hit it every time” - Zig Ziglar Bob Martin, PsyD June 13, 2018 Materials modified from IHI, Association for Process Improvement, and UCLA Fielding School of Public Health (Dr. Moira Inkelas)

2. Intro Recap Cavemen Stormtroopers Spiders Innovative Baby Clothes Sheep & Wolves Video! Important Words

3. Objectives for the “AIM” break-out session • Understand how Aims, Measures, and Ideas relate • Understand how it is incorporated into PDSA • Identify good & bad Aim Statements • Write an Aim Statement

4. Theory of Knowledge – Partial (Deming) Knowledge that is basic to the things we do in life. Professional knowledge (Medicine, Dentistry, Nursing, etc.) Subject Matter Knowledge The interaction of the theories of systems, variation, knowledge, and psychology. Profound Knowledge Source: Langley, G., Nolan, K., Nolan, T., Norman C., Provost, L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 2009.

5. Theory of Knowledge & Improvement – Deming Improvement: Combining subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. This is why trying to accomplish improvement is not easy… Subject Matter Knowledge Improvement Improvement This is also why you need a structured approach Profound Knowledge • Source: Langley, G., Nolan, K., Nolan, T., Norman C., Provost, L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 2009.

6. Model for Improvement (Structured Approach) Act Plan Study Do What are we trying to accomplish? Aim How will we know thata change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan PDSA Cycle Cycles of small-scale tests, building sequentially on a promising idea. The goal is to learn what works, without disrupting the system or requiring consensus to get started Study Do • Source: Langley, G., Nolan, K., Nolan, T., Norman C., Provost, L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 2009.

7. Model for Improvement: Aim Act Plan Study Do Aim What are we trying to accomplish? How will we know thata change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do

8. Aim Statements & Lean Principles • The output should be defect free. • The product or service is delivered in response to customer need (pull, on demand). • The response is immediate. • 1:1 binary communication and hand-offs • Work is done without waste. • Work is done safely. • Work is done securely

9. Aim Statements without Lean Principles A small car drives into the water. What is our Aim?

10. Aim Statements without Lean Principles So far so good…what could possibly go wrong?

11. Aim Statements without Lean Principles …

12. Aim Statements without Lean Principles So a new crane is brought in…

13. Aim Statements without Lean Principles Whoops! Disclaimer (sadly, according to Snopes.com, this last one was photoshopped) https://www.snopes.com/fact-check/a-series-of-unfortunate-events/

14. Aim Statements What they should include: • What is expected to happen • The system to be improved or the population of patients • Specific numerical goals • Time frame • Guidance for activities, such as strategies for the effort, or limitations What they do: • Answers and clarifies “What are we trying to accomplish?” • Creates a shared language to communicate about the project • Facilitates a framework for experimentation, understanding, and learning

15. Aim Statements – use the SMAART Method Do to WhatFrom X to Y By When (Simple Version) IncreasePatient Satisfaction from 75 to 80%by December 2018 (Detailed Version) In order to improve Patient Satisfaction, we will conduct PDSA cycles to increaseCG-CAHPS “Recommend This Provider” Top Box (9 or 10) at Clinic X from 75 to 80%by December 15th, 2018 • Specific • Measurable • Actionable • Achievable • Relevant • Timely or

16. Now it is your turn! • Think of a clinical quality or operational improvement that you would like to make • Work with your peers or table • You will have 5 minutes • Then we will share Do to WhatFrom X to Y By When (Simple Version) IncreasePatient Satisfaction from 75 to 80%by December 2018 (Detailed Version) In order to improve Patient Satisfaction, we will conduct PDSA cycles to increaseCG-CAHPS “Recommend This Provider” Top Box (9 or 10) at Clinic X from 75 to 80%by December 15th, 2018

17. Model for Improvement: Measures Act Plan Study Do Aim What are we trying to accomplish? How will we know thata change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do

18. Measures tell us: • If we are making progress toward our overall Aim • Whether or not something we are trying (PDSA cycles) will lead to improvement • If improvement in one area is negatively impacting another part of the system • Ways to focus improvement and refine changes

19. Measures: Research vs. Improvement Adapted from Solberg,Mosser, McDonaldJt Comm J Qual Improv. 1997 Mar;23(3):135-47.

20. Measures: Types to Include • Outcome Measures • Are the patients better? • Are the patients having a better experience? • Process Measures • Are we doing the work we are supposed to be doing to improve outcomes? • Balancing Measures • As we do our improvement work, what is our impact on the rest of the system? (and identification of unintended consequences) Adapted from Solberg,Mosser, McDonaldJt Comm J Qual Improv. 1997 Mar;23(3):135-47.

21. Measures: Asthma Example Use of appropriate Anti-Inflammatory Meds Written Action Plan Symptom Free Days Adapted from Solberg,Mosser, McDonaldJt Comm J Qual Improv. 1997 Mar;23(3):135-47.

22. Model for Improvement: Ideas Act Plan Study Do Aim What are we trying to accomplish? How will we know thata change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do

23. Ideas: • The best available evidence • Knowledge & creativity of front line workers (engage them!) • Experiences of experts and those in the field • Ask your clients • Identify something that really bothers everyone • Identify something that everyone is excited about • Observe where there are bottle necks in the process • Successes of other organizations (adapt them)

24. Model for Improvement: PDSA Plan Act • Plan to carry out the ideas cycle (who, what, where, when) • Plan for Data Collection • What changes • are to be made? • Next cycle? Study Do • 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

25. How many PDSA Cycles? How did WD-40 get its name? In 1953, chemist Norm Larsen created, on his 40th try, a formula to stop corrosion by displacing moisture. Hence the name “Water Displacement, 40th attempt).

26. How many PDSA Cycles? “Negative results on the fish. Let’s try rubbing two sticks together.”

27. How many PDSA Cycles? “I have not failed 1,000 times. I have successfully found 1,000 ways not to do it.” “Negative results are just what I want. They’re just as valuable to me as positive results. I can never find the thing that does the job best until I find the ones that don’t.” - Thomas Edison

28. PDSA Cycles https://www.youtube.com/watch?feature=player_embedded&v=jsp-19o_5vU

29. Remember…it is about learning Changes that result in improvement A P Evidence & Data S D Implement the change A P S D A P S D Test new conditions Learning and improvement A P Theories, hunches,& best practices More Testing S D Small Scale

30. Where should you start? Readiness to Make the Change Source: The Improvement Guide, Langley et al. 2009, p 10

31. Questions? “If you aim at nothing, you will hit it every time” - Zig Ziglar

32. Example

33. Example of a Testing Cycle Los Angeles County Departments of Public Social Services Child Support Services Children and Family Services City of Los Angeles

34. What are parents experiencing now? % of parents reporting depression: 19% % of parents reporting being asked about depression in past year: 50% (Source of information: Community survey) Change Idea: Ask our clients if they need support for depression Are we ready to implement? • How do we raise the topic of depression? • How do we fit this question into our workflow? • How can we reliably respond (have something to offer) if the parent wants support?

35. Are We Ready to Implement? Deciding on the Scale of the Testing Readiness to Make the Change Source: The Improvement Guide, Langley et al. 2009, p 10

36. P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Planning for Multiple PDSA Cycles Testing and adaptation Other questions How to ask the question How to respond (linkage) When to ask the question Source: The Improvement Guide, Langley et al. 2009, p 10

37. Question: Will clients react well to being asked about depression? Prediction: Clients will not mind being asked. Plan: One staff member from each of two departments will ask clients one of the two items from the PHQ-2 depression screener. Do: Each staff member will ask one client, next Tuesday. Study: Both clients answered the question readily. One client shared that it showed we care about how she’s doing. The wording of the item seemed formal instead of conversational so it didn’t really fit into the nature of the discussions we were having. Act: We will create a 2 sentence script to explain why we are asking about depression. Instead of reading the item, we will put the question into our own words. Also, we will ask the question at the end of the encounter, not at the beginning or middle, as more of a “wrap up” question. We predict that this way, the question will seem more empathic. On Thursday, two staff members will each test with 2 clients.

38. Examples of learning cycles for asking clients if they need support for depression 90% of clients are asked about depression 7 6 5 3 4 2 1 Our measure tracks the impact of improvement cycles Cycle 7: All staff begin the protocol; analyze failures Learning from data Cycle 6: All staff begin the protocol Cycle 5: Week 5: Document the protocol (2 sentence script, and question wording) Cycle 4: Week 4: Test variation for asking the question – to ask in the same and “best” way IDEA: Asking all clients about depression will identify people needing support Cycle 3: Week 3: Client responds but flow isn’t right; two staff asks clients at end of the visit Cycle 2: Week 2: Two staff ask clients, using a 2-sentence script and a question in their own words Cycle 1: Week 1: Two staff ask one client each, using PHQ-2 item

39. % asked about depression % discussed local resources for social support

40. Example: Los Angeles County departments