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  1. My Practice is Perfect So Why Are Some Of My Patients Unhappy and Unhealthy Developing a Provider Culture of Dynamic Quality Improvement

  2. Quality Health Care “Problems in health care quality are serious and extensive; they occur in all delivery systems and financing mechanisms. Americans bear a great burden of harm because of these problems, a burden that is measured in lost lives, reduced functioning, and wasted resources. Collectively, these problems call for urgent action.” Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001

  3. Quality Health Care “The Institute of Medicine outlines 6 aims for improving our nation’s health care system by stating that all health care should be safe, effective, patient-centered, efficient, equitable, and timely. “ Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001

  4. Quality Health Care The quality of health care is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Donald Berwick

  5. How Do We Define Health Care • Three Domains of Health Care • Structural • Processes • Outcomes

  6. How Do We Define Health Care • Three Domains of Health Care • Structural – tools available for care • Processes – activities we do • Outcomes - results

  7. How Do We Define Health Care Indicators Indicators are the metrics we use to measure the element of the three domains. As medical professionals, we are used to working with these. Vital signs are a outcome metric we use all the time.

  8. Types of Quality Problems • Overuse – risk of potential harm exceeds the possible benefit • Underuse – opportunity for likely favorable outcome missed  • Misuse - appropriate service causes a preventable complication and full potential benefit not acheived 

  9. Six Health Care Improvement Dimensions • Safe - Avoiding injuries to patients from the care • Effective - Providing services based on scientific knowledge • Patient-centered - respectful of and responsive to individual • Timely - reducing delays • Efficient - avoiding waste • Equitable – patient doesn’t impact the quality of service offered • Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

  10. I Wish My Practice Was This Simple

  11. A Better Model of My Practice Health Status Direct Effects of Practice Variables on Patient Outcome Gender Care Coordination Family Age Communication

  12. A Better Model of My Practice Numerous Direct and Indirect Effects of Practice Variables on Patient Outcome Health Status RHS RCC Care Coordination RF Family RP Age RA Communication R=Residual Error RC Blalock HM, Causal Models in the Social Sciences, Aldine Publishing Co., 1999.

  13. Building Blocks of Quality Improvement Focus on PROCESS Both internal and external CUSTOMER driven Use objective DATA to make decisions

  14. Building a Team for Quality Improvement • Multidisciplinary Team • MD Nursing • Lab IT • Billing Office Staff • Medical Records • Management • Clear involvement of leadership • Variable sponsorship • Efficient communication • Meet regularly • Foster “No Bad Suggestion” culture

  15. Quality Improvement Model The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].

  16. Quality Improvement Model The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].

  17. What Are We Trying To Accomplish? AIM Use quality indicators to make a list of problems faced by your practice or opportunities for change. Prioritize the problems or opportunities for change   Make goal improvement unambiguous and achievable Be clear on boundaries

  18. What Change Can We Make That Will Result in Improvement? Change Concepts Eliminate waste Improve work flow Optimize inventory – Vaccines Change the work environment Improve provider/customer experience Improve time efficiencies Decrease variation in the process Mistake proofing Improve product or service Langley G et al. The Improvement Guide. Josey-Bass Publishers, San Francisco, 1996; xxi, p295.

  19. What Are We Trying To Accomplish? AIM Use quality indicators to make a list of problems faced by your practice or opportunities for change. Prioritize the problems or opportunities for change   Make goal improvement unambiguous and achievable Be clear on boundaries

  20. What Are We Trying To Accomplish? AIM FOCUS on what is important to your organization not what is sexy STEAL shamelessly

  21. What Are We Trying To Accomplish? AIM Avoid AIM drift Be ready to refocus – always learn from current data set Pilot, try a panel of strategy and spread

  22. What Are We Trying To Accomplish? AIM HOW GOOD? BY WHEN?

  23. What Are We Trying To Accomplish? AIM HOW GOOD? BY WHEN? Highland Pediatrics will decrease mean registration to physician time by 20% in 18 months.

  24. What Are We Trying To Accomplish? AIM HOW GOOD? BY WHEN? Highland Pediatrics will offer 3 possible well care visits times within 48 hours of parental request within the next 6 months.

  25. What Are We Trying To Accomplish? AIM HOW GOOD? BY WHEN? Highland Patients will decrease ER or hospital admissions in known Asthma patients by 15% in 12 months.

  26. What Are We Trying To Accomplish? AIM HOW GOOD? BY WHEN? Highland Pediatrics babies will have completed maternal Edinburgh screens on the chart for the one and four months visits for 90% of patients in 12 months.

  27. Quality Improvement Model The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].

  28. How will we know a change is an improvement? Know that progression is vital BUT can be painful

  29. How will we know a change is an improvement? Challenges Adds work Threatening – I plead the 5th Difficultly with accuracy and consistency Using the data to take action Manual vs Automated Management’s reality conflicts with data Measured elements chosen inappropriately Lack of training in data collection and analysis

  30. How will we know a change is an improvement? Opportunity Healthier and more effective decision making process Progress (or lack of) can be followed Build a defined platform for improvement and areas of opportunity Build confidence in understanding of operations Everyone is talking a similar language Easier to see trends – move to proactive instead of reactive Focus on important items Data sells ideas and limits the power of dramatic anecdote

  31. How will we know a change is an improvement? Rules QI is for learning how well what you do correlates with what you want to do QI is not to build a case to punish someone “All measures have limits, but limitations do not negate value.” Use a “balanced set of measures” Focus on a VITAL FEW forget the common many Data plotted over time

  32. How will we know a change is an improvement? Steps AIM Statement Concept Measures Operational Definition Data Collection Analysis Test Change

  33. How will we know a change is an improvement? Operational Definition Clear and not ambiguous Measurement methods Measurement equipment Identifies criteria Specific measures Ends with numerator/ denominator

  34. How will we know a change is an improvement? Run Chart Measure over time Common and Special Causes

  35. Quality Improvement Model The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].

  36. What Change Can We Make That Will Result in Improvement? “All improvement will result in change. All change will not result in improvement” “Every system is perfectly designed to get the precise results that it gets”

  37. What Change Can We Make That Will Result in Improvement? Do a detailed analysis of your area of concern Review the current Evidence-Based Medicine Review Benchmarks (ie, learning from superior performers in the area chosen for improvement) Advice from experts or others who have attempted improvement in similar topics Brainstorming, critical thinking, and hunches about the current system of care Don’t reinvent the wheel

  38. What Change Can We Make That Will Result in Improvement? Change Concepts Eliminate waste Improve work flow Optimize inventory – Vaccines Change the work environment Improve provider/customer experience Improve time efficiencies Decrease variation in the process Mistake proofing Improve product or service Langley G et al. The Improvement Guide. Josey-Bass Publishers, San Francisco, 1996; xxi, p295.

  39. Quality Improvement Model The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].

  40. How To Use a PDSA Cycle • Plan • Describe the change to be tested. • What do you predict will happen? • When will you conduct the test? • Who will be involved? • Who needs to know about the test? • How will you conduct the test? • Do • Conduct the test. • Document what happened. • Study • Discuss the results of the test. • How do your results compare with your predictions? • What did you learn? • Act • Based on the results of the test adopt, adapt, or abort the change.

  41. Overview on Testing Change Must have a THEORY and a PREDICTION Test on small scale and collect data over time Build on your understanding with multiple PDSA cycles for each change idea Look at change over a wide range on circumstances as you sequence through your PDSA cycles

  42. How will we know a change is an improvement? Change Concept Testing Change Concept Applying Change Concept Universalization Theory and Prediction Test over a spectrum of conditions Become routine operation

  43. How will we know a change is an improvement? AIM: Improve infant care of depressed mothers by better screening mothers at one and four month visits Data Cycle 1: MD gives mom Edinburgh Screening Tool to complete during exam to 3 moms Cycle 2: MD gives screen to all moms for a month Cycle 3: RN introduces screen during rooming, MD grades Cycle 4: All staff oriented to use of Edinburgh Screen Tool 15% have EST Having moms fill out Edinburgh Screening Tool will help identify mothers at risk for severe post partum depression 90% have EST

  44. How will we know a change is an improvement? Change Concept Testing Change Concept Applying Change Concept Universalization Theory and Prediction Test over a spectrum of conditions Become routine operation

  45. PDSA Cycle Why did you succeed? Why did you fail? What further changes do you now need to make in order to succeed? Were there unintended consequences or harm created by your change attempts?

  46. Concept Triangle Change Concept- I want to minimize my vaccine inventory

  47. Concept Triangle Idea- Only order to replace what we have used that month Change Concept- I want to minimize my vaccine inventory

  48. Concept Triangle Idea Concept- Not overstock by over ordering Idea- Only order to replace what we have used that month Change Concept- I want to minimize my vaccine inventory