Model for Improvement

1. Model for Improvement AF4Q SCPA Planned Care Collaborative May 12, 2011

2. Model 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 improvement?

3. What are we trying to accomplish? • Improvement requires setting goals/aims • Aim Statement • A written statement of the accomplishments expected from improvement effort • “SMART” • Specific • Measurable • Actionable • Realistic • Time-bounded

4. Example • By April 30, 2012, Somewhere Family Medicine will improve care for all patients with diabetes by implementing x components of PCMH to: • Ensure that x% of patients have annual monofilament foot exams • Improve cholesterol control such that x% of patients have an LDL<2.0

5. How will we know that a change is an improvement? • Measure, measure, measure • Measures need to be well defined • Data is needed to assess and understand the impact of changes • Shared aims and data can be used to enhance learning • Can be shared with other teams, both internal and external • Best practices more quickly identified

6. What changes can we make that will result in an improvement? • Test the change using the PDSA cycle • Analyze the results and decide if the test was an effective and efficient way to change the process and satisfy the goal • The cycle is modified and repeated until the change is ready for broader implementation “All improvement requires change, but not all change results in improvement.” Donald Berwick, M.D.

7. Model 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 improvement?

8. State the objective of the test • Predict what will happen and why • Develop the action plan to test the change. (Who? What? When? Where? What data need to be collected?)

9. Carry out the plan on a small scale • Document problems and unexpected observations • Begin analysis of the data

10. Complete analysis of the outcome data • Compare the results to your predictions • Summarize what was learned

11. Refine the change based on what was learned from the test • Determine what modifications needs to be made • Prepare a plan for the next test cycle, if needed

12. PDSA Cycles Changes that result in improvement DATA Implementation of Change Wide-scale Tests Hunches, theories, & ideas Follow-up Tests Small Scale Test

13. PDSA Cycles • Testing changes is an iterative process • The completion of each PDSA cycle leads directly into the start of the next cycle • Teams learn from the test – What worked? What didn’t work? What should be kept, changed, or abandoned?

14. PDSA Cycles • Team continues testing and refining until ready for broader implementation • Linking small tests of change helps overcome natural resistance and gain buy-in • People are more willing to test a change when they know that changes will be modified as needed.

15. Tips for Success • Stay a cycle ahead • When designing a test, imagine at the start what the subsequent test or two might be, given various possible findings in the "Study" phase of the Plan-Do-Study-Act cycle. • Scale down the scope of tests • Dimensions of the tests that can be scaled down include the number of patients, doctors, and others involved in the test ("Sample the next 10" instead of "Get a sample of 200"), and the location or duration of the test ("Test it in Exam Room #1 for one week"). • willing volunteers • Work with those who want to work with you. ("I know Dr. Jones will help us" instead of "How can we convince Dr. Smith to buy in?") • Avoid the need for consensus, buy-in, or political solutions • Save these for later stages. When possible, choose changes that do not require a long process of approval, especially during the early testing phase. • Don’t reinvent the wheel • Instead, replicate changes made elsewhere.

16. Tips for Success • Pick easy changes to try • Look for the concepts that seem most feasible and will have the greatest impact. • Reflect on the results of every change • After making a change, a team should ask: What did we expect to happen? What did happen? Were there unintended consequences? What was the best thing about this change? The worst? What might we do next? Too often, people avoid reflecting on failure. Remember that teams often learn very important lessons from failed tests of change. • Be prepared to end the test of a change • If the test shows that a change is not leading to improvement, the test should be stopped. Note: "Failed" tests of change are a natural part of the improvement process. If a team experiences very few failed tests of change, it is probably not pushing the boundaries of innovation very far. • Consider downstream affect on other practice processes • Pay attention to preserving productivity

17. References • Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove. Accessed 05/10/11. • Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/testingchanges.htm. Accessed 05/10/11. • Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/tipfortestingchanges.htm. Accessed 05/10/11. • Florida Association of Community Health Centers. http://www.fachc.org/health-dc-performance.php. Accessed 05/10/11. • Berwick DM. Harvesting knowledge from improvement. JAMA 1996;275:877–8.