Improving Your Primary Care Practice: Part I

1. Improving Your PrimaryCare Practice: Part I Sue Butts-Dion Improvement Advisor Institute for Healthcare Improvement This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.

2. Learning Objectives By the end of this module you will be able to: • Describe the evolution of quality improvement • Describe key principles of quality improvement • Use the MFI to test a small improvement • Personal improvement • Primary Care improvement

3. PROMISES Project

4. Evolution of Quality (in Healthcare) 1820-1910 1910-1950 1950-1990 1990-Present Institute for Healthcare Improvement Founded (1991) The Institute for Family-Centered Care, founded (1992) QHR: Strategic Quality Management 1992 The Improvement Guide published (Model for Improvement MFI) 1996 IOM publishes “To Err is Human” (1999) NICHQ Founded (1999) Ryan White Program quality legislation (2000) IOM publishes Crossing the Quality Chasm (2001) AHRQ , CMS & DHHS partner to develop HCAHPS (2002) IHI launches Improvement Campaigns (2004) IPIP initiated (2005) NC CPHQ founded (2010) Structure Process Outcome Donabedian (1966) JCAHO Medical Audit & Performance Evaluation (1972) JCAHO Agenda for Change Announced—Use of Clinical Indicators (1986) ELI founded (1984) HCA 1st Healthcare client (FOCUS PDSA) (1987) Vermont Oxford Network (NICQ’s) (1988) Agency for Healthcare Research and Quality (AHRQ) Created (1989) QHR: Center for Continuous Improvement 1989 NCQA Founded (1990) American College of Surgeons/ Codman (1918) First Quality Manual Published (18 pages!) (1926) Deming and Juran become prominent figures in the field of quality management in industry (PDSA) (1945) JCAHO (1951) Florence Nightingale Uses Statistical Analysis and Plots the Incidence of Preventable Deaths in the Military (1820-1910) 4

5. Underlying QI Principles Focus on systems, not people Intervene iteratively using PDSAcycles Use measurementand data for decision making Remember thatcustomersare key Acknowledge that improvement requireschange

6. Improvement Requires Change “While all changes do not lead to improvement, all improvement requires change.” –IHI website The proposed freeway to remove the bottleneck created by the previous proposed freeway to remove the bottleneck created by… 6

7. Model for Improvement (MFI) Model for Improvement • What are we… • How will we… • What changes can we… PDSA = 7 Developed by: Associates in Process Improvement

8. How It Works…(or Doesn’t Work!) 8

9. How It Works…(or Doesn’t Work!) “I won’t do this anymore!” 9

10. How It Works…(or Doesn’t Work!) “I won’t do this anymore!” “I will work harder and faster!” 10

11. How It Works…(or Doesn’t Work!) “I will be more vigilant!” “I won’t do this anymore!” “I will work harder and faster!” 11

12. How It Works…(or Doesn’t Work!) “I will be more vigilant!” “I won’t do this anymore!” “I will work harder and faster!” I was doing things the same way: maybe a little faster, maybe with more attention, maybe with more intention… and expected different results. 12

13. What Had I Been Missing?

14. What Had I Been Missing? • Aim

15. What Had I Been Missing? • Aim • Measures

16. What Had I Been Missing? • Aim • Measures • Changes

17. What Are We Trying to Accomplish? (My Aim)

18. What Are We Trying to Accomplish? (My Aim) “Some is not a number.” Quotes from Don Berwick speech, 2004

19. What Are We Trying to Accomplish? (My Aim) “Some is not a number.” “Soon is not a time.” Quotes from Don Berwick speech, 2004

20. What Are We Trying to Accomplish? (My Aim) “Some is not a number.” “Soon is not a time.” “Hope is not a plan.” Quotes from Don Berwick speech, 2004

21. What Are We Trying to Accomplish? (My Aim) “Some is not a number.” My aim: By Thanksgiving of this year, I want to decrease the time spent working past 5:30 PM ET from 180 to 60 minutes per day. I want to increase my focus on: (1) improving systems for triaging emails, (2) improving systems for scheduling calls and meetings. “Soon is not a time.” “Hope is not a plan.” Quotes from Don Berwick speech, 2004

22. How Will We Know That the Change Is an Improvement? (My Measures) Outcome Measures: • Average number of minutes spent each week working past 5:30 PM ET. • Time spent on improving quality of life (e.g., my time spent with family, exercising, reading, etc.) • Family satisfaction/feedback (qualitative data). 22

23. What Changes Can We Make? (My Changes and Ideas) Sources for ideas: • Customers, suppliers • Colleagues, coworkers • Literature, experts • Internet (e.g., Google) • Generic Changes • The Improvement Guide, by Langley, et al. 23

24. The PDSA Cycle forLearning and Improvement Act Plan Adapt? Adopt? Abandon? What’s the next cycle? Objective Questions & predictions(why). Plan to carry out cycle (who/what/where/when). Next cycle? Study Do • Complete the • analysis of the data. • Compare data to • Predictions. • Summarize what • was learned. Carry out the plan (on a small scale). Document problems and unexpected observations. Begin analysis. W.E. Deming referred to this as the Shewhart Cycle

25. A PROMISES PRACTICE: ATKINSON FAMILY PRACTICE

26. Atkinson Family Practice “We have at least25 patients calling a day about prescription refills. Probably 25 a morning.” Karen – Clinical Team Leader “How can we reduce theses calls? It seems like that’s all our front desk staff do—take calls about refills from patients.” Tom – Practice Manager

27. What Are We Trying to Accomplish? Aim Does this answer…. By March 2012 ( in two months), our practice will: • Improve the Rx refill process • Reduce phone calls from patients or pharmacies to verify or check on prescription refills • Reduce the duplicate prescription requests • Reduce these events by 50% in this time frame

28. What Are We Trying to Accomplish? Aim Does this answer…. What to improve? By March 2012 ( in two months), our practice will: • Improve the Rx refill process • Reduce phone calls from patients or pharmacies to verify or check on prescription refills • Reduce the duplicate prescription requests • Reduce these events by 50% in this time frame

29. What Are We Trying to Accomplish? Aim Does this answer…. What to improve? For whom? By March 2012 ( in two months), our practice will: • Improve the Rx refill process • Reduce phone calls from patients or pharmacies to verify or check on prescription refills • Reduce the duplicate prescription requests • Reduce these events by 50% in this time frame

30. What Are We Trying to Accomplish? Aim Does this answer…. What to improve? For whom? By when? By March 2012 ( in two months), our practice will: • Improve the Rx refill process • Reduce phone calls from patients or pharmacies to verify or check on prescription refills • Reduce the duplicate prescription requests • Reduce these events by 50% in this time frame

31. What Are We Trying to Accomplish? Aim Does this answer…. What to improve? For whom? By when? By how much? By March 2012 ( in two months), our practice will: • Improve the Rx refill process • Reduce phone calls from patients or pharmacies to verify or check on prescription refills • Reduce the duplicate prescription requests • Reduce these events by 50% in this time frame

32. Key Point About Data: Improvement is Not Research • Quality improvement • Aim: improvement • Data: “just enough” data • Research • Aim: new knowledge • Data: “just in case” data

33. How Will We Know That a Change Is an Improvement? Measures • Number of duplicate requests for the same prescription refill. We’ll track: • Number of requests • Request method (i.e., calls, fax) Balancing Measures • Staff Satisfaction • Patient Satisfaction 33

34. What Changes Can We Make? • Identified changes to test • Test Idea: Pharmacy will… • Test Idea: Practice will… • Test Idea: Practice will educate patients to… 34

35. What Changes Can We Make? • Identified changes to test • Test Idea: Pharmacy will… • Test Idea: Practice will… • Test Idea: Practice will educate patients to… “We need to communicate more. Otherwise, we are all just irritating each other and getting upset.” --Karen, Clinical Team Leader 35

36. What Could You Do Today? Identify one area that needs improving • Write the first draft of an “aim” Choose one thing you could measure • Determine: Is it improving? Or not? List change ideas to test now • Choose a few, or just one 37

37. Thank You! Thank you for your time and attention today 38

38. Assessment Question 1: What was the first quality improvement in healthcare that we saw in the 1800s? • Deming became a prominent figure in industry • Ryan White Program quality legislation • F. Nightingale records preventable deaths • First quality manual published

39. Assessment Question 2: Improvement methodologies have common underlying principles, and recommend focusing on • Focus on people, not systems • Focus on systems, not people • Focus on systems and people • Focus on people to assess the blame

40. Assessment Question 3: Name one place you can access to get ideas for something to test or try in your practice • Customers/suppliers • Colleagues/experts • Literature/Internet • All of the above

41. A Few References • Langley et al, The Improvement Guide, 1996, 2011 • W. Edwards Deming, The New Economics, 2nd Edition, 2000 • www.ihi.org • www.deming.org

42. Want to Learn More? “Improving Your Primary Care Practice: Part 2” • Learn more about the benefits of testing things on a small scale • Learn about scaling up, sustaining, and spreading changes • Learn about two tools that all improvers should know about