Quality Improvement: Reinforcing Foundations for Change Diane Liu, MD University of Utah, Department of Pediatrics Assistant Professor, Division General Pediatrics Co-Director, Utah Pediatric Partnership to Improve Healthcare Quality Quality Improvement & How to establish processes for change Welcome everyone If small group – make introductions

QI is founded upon science Main Focus QI is founded upon science It’s all about the kids Image by keepcalm-o-matic.co.uk Free image clipartpanda http://www.clipartpanda.com/categories/kids-clip-art

Objectives Understand the importance of quality improvement in current clinical practice (WHY do we care) Learn about some tools from QI methodology to implement in your own practice (HOW do I start?) Consider team-based strategies to support processes for change The most important reason – we know as Pediatricians giving highest quality care is the right thing to do. Beyond that ultimate reason, there are some other reasons we should consider as well Toolkit review Example of process improvement Answer questions like “What should I do to start? Where do I begin? Who do I need to enlist?” What tools are available. Which model or approach should I employ? Based on the approach, are there methods that I should be using more frequently or more familiar with than others? Why?

What is happening in healthcare? The AAP is committed to helping current and future Pediatricians navigate the ongoing and anticipated changes in healthcare The current issues provide some context for our conversation today

What is Happening in Healthcare now? Crossing the Quality Chasm - Institute of Medicine (IOM) 2001 Report (6 aims) Safe Patient-Centered Efficient Equitable Effective Timely Healthcare delivery and payment reform Population Management Triple Aim Value-based care CMS MACRA / MIPS / APM Slide slide represents some ideas that have been and are currently circulating in healthcare conversations. Our job is to make sure children are not left out of the conversation

Core perspectives of QI Focus on systems, not individuals Ideas/changes originate from customers (patients) & front-line staff Focus on small tests of change Frequent, ongoing measurement and data-driven decision-making Continuous! Never-ending process Helps, not hinder, staff in closing gap towards goals

QI TOOLS TO USE We decided not to obtain permission for reproduction but their tools are online for you to use. Many other organizations also have tools available online. We do not endorse one over another – there’s no bias on our end but we wanted to highlight just one organization so that you can begin using tools to help you Population Health Improvement Partners – open access online Institute for Healthcare Improvement – open access with free registration

Get started – HOW? Step 1 – Select a Project/Topic (sample statements) Improving Primary Care Management of Neurologic and Behavioral Health Conditions Increasing referral tracking and communication coordination Step 2 – Assemble your team You pick your team Step 3 – Use a roadmap UPIQ is here to help!

Step 1 – Choose a Focus Create a project Defines and formalizes your effort Shapes your scope about what area(s) you see as a problem Where is the quality gap? What is the goal for care? What care is your patient actually receiving? Understand the problem by using tools: Process mapping (great team exercise!) Observational walks (good for management to see the front-line) Data queries (your EMR should work for you!)

Step 2 – Assemble Your Team After selecting an area/topic for your project – assemble your team! Select your team members based on: Their knowledge of and involvement in the processes that you want to consider changing Roles to be filled (suggested examples) A project sponsor (Admin) A QI team lead (Clinician – therapist, nurse, physician) A QI expert and/or local experts (UPIQ and faculty advisors) A QI project manager Parent partner

Tuckman’s Stages of Team Development Source: Population Health Improvement Partners

Step 3 – Apply a Formal Model Now you have a topic and a team Consider the approach – the roadmap to help you move forward. Which one should you use?

Model For Improvement Tests and evaluates small changes before they are brought to scale Allows for a systematic analysis to determine the effect on an intervention Asks the learner 3 questions: What are we trying to accomplish? How will we know that our changes are an improvement? What changes can we make that will result in an improvement?

https://www.google.com/#q=not+all+change+leads+to+improvement http://www.ihi.org/resources/pages/howtoimprove/scienceofimprovementselectingchanges.aspx http://www.ihi.org/resources/Pages/Changes/default.aspx Put in a conceptual visual What are we trying to accomplish (AIM?) How will we KNOW that changes are actually an IMPROVEMENT? (MEASURES) What changes can we make that will result in an improvement (INTERVENTIONS/changes to test) PDSA to test ideas and changes with cycle for learning and improvement *Langley, GL. Nolan KM, Nolan TW, Norman CL, Provost LP

1st What are we trying to accomplish? Understand the problem first – learn together as a team What is the current process from point A to point B? I know what ‘the problem’ is but I don’t know what the root is of the problem or what is causing my problem. How much, if any, variation exists in the process I’m focusing on? In order to determine what tools or methods you should use for any improvement effort, you need to ask yourself ‘what do I really want to know?’ This table represents categorical areas of knowledge with matching methods and tools to help you characterize (or refine) the knowledge you’re seeking.

Visualize how you deliver care - Process Map!

Sometimes current-state process mapping leads us to the same endpoint from different flow areas

AIM STATEMENT Develop your aim once you understand your problem Defines the scope of your work Make it public or tape it to your office wall as a reminder WHAT? For WHOM? By WHEN? Over the next 6 months, 80% of children presenting with headaches will be screened for anxiety You can develop several aim statements if needed for a broader effort Keep an aim short and concise to help you remain focused

my change led to the improvement? 2nd – Measures How do I know if my change led to the improvement?

UPIQ Measurement Goals Limit the number of measures Keep data collection as simple as possible Measure frequently using small sample sizes

Percent of children screened for selected condition Measure #1 Percent of children screened for selected condition *Practices determine Denominator - population to screen Numerator – Selected screening tool used in appropriate patient Monthly chart review – 10 per provider Goal 80%

Measure #2 Percent of children screened for co-existing conditions in selected population *Practices determine Denominator - population to screen Numerator – Documentation +/- co-existing conditions noted Monthly chart review – 10 /provider Goal 80%

Measure #3 Percent of children REFERRED received instructions while waiting for specialty evaluation Denominator includes patients referred to either neurology or Behavioral Health Numerator – Documentation reflecting ‘to-do’ instructions for patients referred Monthly chart review – 10/provider Goal 80%

Measure #4 Referral Tracking Denominator – All patients referred to Neurology or Behavioral Health Numerator – Referred patients included in registry Monthly chart review – 10/provider Goal 100%

Structured referral communication from PCP to Specialist Measure #5 Structured referral communication from PCP to Specialist Denominator – All patients referred to Neurology or Behavioral Health Numerator – Referral communication includes the proposed minimum set of information Monthly chart review – 10/provider Goal 80% If we can get numbers of referrals per month, we can work with the practices to decide whether to assess just neuro and behavioral vs. all of their referrals to UU/PCH specialists; if we can’t get the numbers, then I’d suggest we ask each practice to choose the 4 or 5 most commonly referred-to specialists to track.  We propose a minimum set of information that should accompany the PCP to specialist (and specialist to PCP?) referral communication I would be OK with leaving it roughly outlined if consensus can’t be reached quickly and finalized with each practice within a week or so of the learning session

3rd question What changes can we make that will result in an improvement? Use your workshop time to brainstorm change ideas The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan) carrying out the test (Do) observing and learning from the consequences (Study) determining what modifications should be made to the test (Act) (source IHI.org)

Take Home Points Understand the problem Create your team Use the tools to help you Create your team Celebrate improving together Focus on a clear aim/goal All improvement requires change Not all changes lead to improvement Select a meaningful measure Guides your improvement cycles Reveals if you’re reaching your aim Develop a learning community culture among staff, partners, and participating clinicians and their teams

Celebrate IMPROVING! Image Source: University of Utah Accelerate

Thank You Remember - it’s about the kids QI coaches are here to help you Questions?