The Model for Improvement

1. The Model for Improvement Karen Scott Collins, MD, MPH VP, Quality and Patient Safety New York Presbyterian Hospital July 2008

2. 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

3. 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

4. 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

5. Three 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 improvement?

6. 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? Compare the 3 questions to how we frame improvement

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

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

9. 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

10. Aim: What Are We Trying to Accomplish? Your team’s aim statement should beconsistent 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

11. 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?

12. 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%)

13. 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 Does example meet these criteria?

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

15. 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

16. 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)

17. Types of Measures • Outcome Measures • Results – system level performance • How is the health of the patient affected? • Process Measures • Inform changes to the system • Are key changes being implemented in the system? • Balancing Measures • Signal “robbing Peter to pay Paul”

18. Measures - Examples • Outcome • Number symptom free days for asthma patients • ED asthma visits • Process • Patient and family have Asthma Action Plan • Appropriate medications prescribed • Balancing • Clinic cycle time

19. 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

20. Methods of Measurement • Clinical measures of patients’ health • Documentation of behaviors • Questionnaires • Assessments • Summary of databases • Chart audits • Observations

21. 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 datawith those who collect it

22. 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

23. GOAL Nurse Smith left Tried encounter forms QI Tools - Run Chart Implemented registry

24. Lessons from Baseline Data Collection • What worked? • What didn’t work? • What was difficult? • Why? • Ideas for successful measurement and data collection

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

26. 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

27. 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 SM goals w/ 3 patients on Monday Change Concepts vs.High Leverage Changes

28. Act Plan Study Do 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 Plan Study Do From:: Associates in Process Improvement

29. 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

30. 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

31. 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

32. Multiple cycles A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes that Result in Improvement Learning from Data, Tests Proposals, Theories, Ideas

33. 3 Principles for Testing a Change • 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

34. 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

35. 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

36. 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!

37. Global Collaborative Measures vs. PDSA Cycle Measures Achieving Aim 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 Adapting Changes During PDSA Cycles

38. 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 thata change is an improvement? What change can we make that will result in improvement? Act Plan Study Do

39. 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. • Jane Taylor, Improvement Advisor, IHI • Pat Heinrich, VP, NICHQ