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Model for Improvement. Ruth S. Gubernick, MPH Practicing Safety Learning Session May 30, 2009. Objectives of this Session. Participants will be able to: Identify Model for Improvement Create an Aim statement for project with concrete goals

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Model for improvement

Model for Improvement

Ruth S. Gubernick, MPH

Practicing Safety Learning Session

May 30, 2009


Objectives of this session

Objectives of this Session

  • Participants will be able to:

    • Identify Model for Improvement

    • Create an Aim statement for project with concrete goals

    • Constitute Plan Do Study Act cycles to test improvements, using the PS Toolkit


The first law of improvement

The First Law of Improvement

“Every system is perfectly designed to achieve exactly the results it gets.”


Fundamental questions for improvement

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

Act

Plan

Study

Do

Model for Improvement

What are we trying to

accomplish?

AIM

How will we know that a

change is an improvement?

MEASURES

What change can we make that

IDEAS

will result in improvement?


Compare the 3 questions to how we frame improvement

Compare the 3 questions to how we frame improvement

Aim

Measurement for learning

PDSA

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make to bring about improvement?


Model for improvement

Act

Plan

Study

Do

Model for Improvement

What are we trying to

accomplish?

AIM

How will we know that a

change is an improvement?

MEASURE

What change can we make that

IDEAS

will result in improvement?


What are we trying to accomplish

What Are We Trying to Accomplish?

Aim:A written statement of the accomplishments

expected from this improvement effort

Key components:

-A general description of aim – should answer, “what are we trying to accomplish?”

- Some guidance for carrying out the work and rationale

-Specific target population and time period

-Measurable goals


Example poor

Example (Poor)

  • Our practice teams will improve care for all infants and toddlers, by using the Practicing Safety Toolkit.


Sample aim

Sample Aim

By November 30, 2009, our practice teams willtest the 3 Practicing Safety

bundles (toolkit) to determine feasibility, as well as make improvements to the

bundle set, so that:

  • 100% of parents/caregivers receive assessment/screening regarding coping with crying at or by the 2-month well visit.

  • 100% of parents/caregivers receive anticipatory guidance regarding coping with crying at or by the 2 month well visit.

  • 100% of new mothers receive assessment/screening regarding maternal depression at or by the 2 month well visit.

  • 100% of new mothers receive anticipatory guidance regarding maternal depression at or by the 2 month well visit.

  • 100% parents/caregivers receive assessment/screening regarding discipline at or by the 18 month well visit

  • 100% of parents/caregivers receive anticipatory guidance regarding discipline at or by the18 month well visit.

  • 100% of parents/caregivers receive assessment/screening regarding toilet training at or by the 18 month well visit.

  • 100% of parents/caregivers receive anticipatory guidance regarding toilet training at or by the 18 month well visit.


Smaart aim

SMAART Aim

  • Specific: Understandable, unambiguous

  • Measurable: Numeric goals

  • Actionable: Who, what, where, when

  • Achievable (but a stretch)

  • Relevant to stakeholders and organization

  • Timely: with a specific timeframe


Model for improvement

  • AIM Worksheet

  • The (name of your team ) intend to accomplish

  • By (date)

  • For (population)

  • because

  • Our goals include:

  • Special guidance that will help us stay on track:


Model for improvement

Act

Plan

Study

Do

Model for Improvement

What are we trying to

accomplish?

AIM

How will we know that a

change is an improvement?

MEASURE

What change can we make that

IDEAS

will result in improvement?


How will we know a change is an improvement

How will we know a change is an improvement?

  • Requires measurement

  • Build measurement into daily work routine

    • Data should be easy to obtain and timely

    • Small samples over time

  • Use qualitative & quantitative data

    • Qualitative data is highly informative

    • Qualitative data is easy to obtain


Measurement guidelines

Measurement Guidelines

  • Balanced set of 5 to 7 measures reported each month to assure that the system is improved

  • Measures should reflect the aim and make it specific

  • Measures are used to guide improvement and test changes

  • Integrate measurement into daily routine

  • Plot data measures over time and annotate graph with changes

  • Outcome and process measures


Measures for practicing safety

Measures for Practicing Safety

  • Target population

    • Infants and Toddlers seen by PS clinicians in participating practice for well care visit

  • Numerator

    • # infants or toddlers with documentation that parent/caregiver received anticipatory guidance, assessment/screening, referrals/follow up regarding crying, maternal depression, bonding/attachment (at or by 2 months); discipline and toilet training (at or by 18 months).

  • Denominator

    • All infants and toddlers seen in participating practice for well care visit whose charts are reviewed.


Model for improvement

Act

Plan

Study

Do

Model for Improvement

What are we trying to

accomplish?

AIM

How will we know that a

change is an improvement?

MEASURE

What change can we make that

IDEAS

will result in improvement?


What changes can we make that will result in improvement

What Changes Can We Make That Will Result in Improvement?

Tests of Change need 2 components:

1.Change concepts (ideas): ready for use or ready to adapt to your unique environment (**Use results from pre-work assessment to inform what you need to change)

2.PDSA test method


Model for improvement

The PDSA Cycle for Learning and Improvement

Act

Plan

  • Objective

  • Questions and

  • predictions (why)

  • Plan to carry out the 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


Pdsa break it down simplify

PDSA: Break it Down/Simplify…

Plan - Figure out the questions you want to answer, plan a way to answer the questions, and predict results

Do - “Just do it” (i.e. do the plan)

Study - What did you learn?

Did your prediction hold?

What assumptions need revision?

Act - What will you do with the knowledge you learned?

Adapt? Adopt? Abandon?

What do you want to do next?


Use of the pdsa cycles

Use of the PDSA Cycles

Multiple cycles

A

P

S

D

D

S

P

A

A

P

S

D

A

P

S

D

Changes that Result in Improvement

Data

Implementation of

Change

Wide-Scale Tests of Change

Evidence

Best Practice

Testable Ideas

Follow-up Tests

Very Small Scale Test


What are tests

What are Tests?

Putting a change into effect on a temporary basis and on a small scale and learning about the potential impact


Why test

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


Decrease the time frame for a pdsa test cycle

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!


What can we do now

What Can We Do Now!

By Next Week,

By Tuesday,

By Tomorrow

That won’t harm a hair on the head of a patient?


Sequential building of knowledge include a wide range of conditions in the sequence of tests

Sequential Building of Knowledge Include a Wide Range of Conditions in the Sequence of Tests

BreakthroughResults

A

P

Evidence & Data

S

D

A

P

S

D

A

P

S

D

A

P

Learning and improvement

Theories, hunches,& best practices

S

D

Spread

Implement

Test new conditions

Test a wider group

Test on a small scale


Model for improvement

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

Overall Aim: Testing PS Toolkit

Infant

Bundle

Mother/

Caregiver Bundle

Toddler

Bundle

Practice-based

Systems Index


Fundamental questions for improvement1

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?

    • Practicing Safety Toolkit

  • Model for Improvement

    What are we trying to

    accomplish?

    How will we know thata

    change is an improvement?

    What change can we make that

    will result in improvement?

    Act

    Plan

    Study

    Do


    Model for improvement

    • Form for planning a PDSA cycle

      • supports prediction

      • and keeping one step ahead


    Questions

    Questions?


    William edwards deming

    William Edwards Deming

    “It is not necessary to change. Survival is not mandatory.”


    References

    References

    • 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.

    • The Improvement Handbook, Model, Methods, and Tools for Improvement, Associates in Process Improvement, Austin, TX, 1997.

      Note: Special thanks to Carole Lannon, MD, MPH for some slides from her Safe and Healthy BeginningModel For Improvement presentation, 8/4/07


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