Learning Collaborative #1 March 2017 National Immunization Partnership with the Academic Pediatric Association (NIPA) Wave 3 CDC Grant # 1H23IP000950

Agenda Attendance Diagnostic QI Tools HPV Vaccine Delivery Process Flow Maps and Fishbone Diagrams Past Participant Experiences LC schedule Baseline Chart Review Data Collection Reminder Contact Information Any questions?

Diagnostic QI Tools HPV Vaccine Delivery National Immunization Partnership with the Academic Pediatric Association (NIPA) Adapted from a presentation by Lory D. Harte, PharmD, CPHQ Children’s Mercy – Kansas City

Process Flow Maps and Fishbone Diagrams

Process Flow Maps Depicting the current and future state of a process

Key Points for Process Maps Observe the process Understand the current state Identify failure modes Determine your future state Making observations Understanding the baseline Distinguishing between QA vs QI Identifying failure modes

Why Map a Process?

Identify Steps in the Process Patient comes to clinic meets criteria to receive HPV Vaccine is ordered prepared Consent signed given monitored for side effects discharged Thinking of the points just highlighted (why map a process?) here is the process map for vaccines. It is high level. Much easier and quicker to construct than writing all the words needed to describe each step. Are there steps that people don’t think about? USE WORDS ON SLIDE/ POINT

How to Construct/Interpret a Process Map Clearly define the starting point and ending point Determine the steps in the process, then place them in sequence as they currently stand Walk through the chart with your team to test the accuracy Interpret Analyze the flow of events relative to the ideal flow Look for duplication of effort or unnecessary wait time Consider how it could be simplified Determine if there is variation in how different people follow the process

What is the process (flow map) for delivering immunizations in your continuity clinic?

Summer 2014 SPEND SOME TIME ON THIS/ USE POINTER POINT OUT RESIDENT INVOLVEMENT

Summer 2014 SPEND SOME TIME ON THIS/ USE POINTER POINT OUT RESIDENT INVOLVEMENT

Does the process map go deep enough to see these things? What elevation are you assessing?

Failure Modes Identify variations Assess gaps Determine inconsistencies “Failure modes” means the ways, or modes, in which something might fail.  Failures are any errors or defects, especially ones that affect the patient, and can be potential or actual. why attacking Failure Modes is helpful? Quality Improvement – identify a problem before it becomes a reality (Tackle the effects of a bad design)

Key Points Understanding the “Current State” allows for proper planning for the “Future State” Identifying “failure modes” will help in designing a “Future State” that can prevent them from occurring Matt: Understanding the “Current State” allows for proper planning for the “Future State.” And identifying “non-value added steps” and “failure modes” will help in designing the most meaningful project

Fishbone and 5 Whys Analyze the problem and the potential causes through the use of cause and effect tools

Key Points for Cause & Effect Tools You can’t fix what you don’t know is a problem 1st seek to understand, then work to improve Making observations Understanding the baseline Distinguishing between QA vs QI Identifying failure modes

Fishbone Diagram Kaoru Ishikawa , a Japanese statistician, pioneered quality management processes in the Kawasaki shipyards, and in the process became one of the founding fathers of modern management. It was first used in the 1960s, and is simply a diagram that closely resembles the skeleton of a fish and groups ideas about the causes of a problem. Also known as Ishikawa Diagrams, Cause &Effects Analysis, & Root Cause Analysis

Why use a Fishbone Diagram? Uses an orderly, easy-to-read format Helps determine root causes Indicates possible causes of variation Increases process knowledge Identifies areas for data collection

Building a Fishbone Start with a concise description of the “Effect” to which everyone agrees and place in the fish head Can be stated in the form of a question: Why do we have low rates of HPV vaccination? Can be phrased as a positive (objective or AIM) or negative (problem)

Building a Fishbone Brainstorm the Primary Causes influencing the Effect and list them for each category Secondary Causes may also be identified by continued brainstorming and asking “Why is this happening?” Add sub-factors under each segment and keep asking “Why” until you no longer obtain useful information

Building a Fishbone Analyze for “Most Likely Causes” where items appear in more than one category Identify “Most Probable Cause” by collecting data or surveying team members

Fishbone Diagram Use the words on the slide and pointer

Fishbone Diagram Use the words on the slide and pointer

Five Why’s Simply ask “Why” at least 5 times in a row. Problem Statement: Eligible patients do not receive the HPV vaccine series? 1. Why? Because the patient is unaware it is available   2. Why? Because the provider does not discuss it    3. Why? Because the provider does not remember to discuss it    4. Why? Because the provider was not prompted to remember    5. Why? Because the process did not work as designed   

Key Points Using cause and effect tools helps to determine the factors that contribute to the problem. These tools can also help you determine the most likely or most probable cause. Interventions targeted at preventing the factors will lead to improvement in your outcome.

Past Participant Experiences

Past Participant Experiences Who was involved in your team? What helped you to get started? What were you looking to change? Where did you notice your site’s greatest barriers? Successes? When did you start to notice your implementation strategies becoming part of your site’s routine? Why have you decided to continue with the project?

Next Learning Collaboratives: April 2017 Data Due: May Monthly Chart Review Data is due April 5th! If your site has IRB approval, Holly will send each site lead instructions, materials, and site-specific link to access REDCap. April 2017 Learning Collaborative Schedule: Tuesday 4/18 @ 8am ET/ 7am CT/ 6am MT/ 5am PT Tuesday 4/18 @ Noon ET/ 11am CT/ 10am MT/ 9am PT Friday 4/21 @ Noon ET/ 11am CT/ 10am MT/ 9am PT

Baseline Chart Review Data Collection If your site has IRB approval, each site lead will receive instructions and materials for completing Baseline Chart Review. Deadline: June 2017

Contact Information Please contact: Holly Tyrrell, MSSW Phone: 703/556 9222 x113 I Fax: 703/556 8729 Email: hollyce@academicpeds.org

Any questions?