QI in Action: Improving Preventive Care in Family Medicine Application Session – FM QI Curriculum

Purpose of this exercise Review core QI curriculum content from the 4 e-modules by examining a pneumococcal vaccination improvement project: Building a QI team Developing a problem statement Setting an aim Identifying measures Completing system diagnostics to support identification of change ideas Testing change ideas (PDSA cycle) The project that we will use throughout the presentation is pneumococcal vaccination in patients aged 65 and older.

Model for Improvement Specify and set the aim Establish measures Identify change ideas Turn ideas in action, action into learning We will use the Model for Improvement as our roadmap for the deconstruction. (review elements of MFI)

The Model and Your QI Project Page 10 of workbook Site QI Meeting / QI Project Idea Form QI Team Initiate project charter Define problem statement Complete stakeholder engagement Identify Aim and family of measures Describe data collection plan Set Aim Establish Measures Complete system diagnostic tools Select change ideas Identify Change Ideas PDSA change ideas Connect MFI to their Project Map Test Changes Project Poster and Guide Source: Paula Blackstien-Hirsch

Building a QI Team Stakeholders (page 24) Patrons Sponsors Champions Users of the QI Initiative Staff Patients Advisors on QI Specialists Data Support Our Pneumococcal Vaccine QI Team Residents Faculty / supervisors RN/vaccination program lead EMR administrator/ IT expert Administrative support Discuss example and compare to stakeholders in the workbook

Building your blueprint - the Charter (page 30) The Project charter: Is a “live” document to be used throughout the improvement project Helps plan the project, communicate with leadership and keep track of changes being made Is used at every meeting to provide a focus for discussion and record generated ideas Discuss example and compare to stakeholders in the workbook See Appendix in the workbook

Developing a problem statement Our Pneumococcal QI team found: Incidence of Invasive Pneumococcal Disease (IPD) = 10 cases per 100,000 Across Canada: Mean 3263 cases per year (2007-2011) Ontario: Mean 1130 cases/year (2007-2011) Pneumovax has been proven to reduce the risk of Invasive Pneumococcal Disease (IPD) and NACI recommends its use. However, many eligible patients have not been offered Pneumovax BUT…Is this their context?

Helpful hints… Remember, the problem is at your micro-system level Ask yourself… Why is this improvement important to your organization? Is there data or other evidence that helps to highlight the problem? Highlight the “pain” - to the patients, to the families, to the organization

Our Pneumococcal team’s approach…. (page 30) What is the problem you wish to address? Why is it a problem? (the pain) Where do we observe the problem? Who is impacted? When does it occur? (ongoing or recurrent?) Which quality dimensions are involved? Low rates of pneumococcal vaccination in those ages 65+ 39% vaccination rate in target pop. (source: EMR) Burden of preventable disease Impact on patient – hospitalization Cost to health care system Across the FHT but variation by providers Resident practices have lower rates of vaccination Patients, families, providers Ongoing problem Rates stable for last 3 years Patient-centered, Effective

A problem well stated, is a problem half-solved Our problem, at Sunshine FHT, is that only 39% of our clients aged 65 years or older were vaccinated in 2015. This is despite pneumovax being demonstrated as safe and effective and being publicly funded in Ontario. This low vaccination rate may lead to unnecessary disease burden for our patients and their families which may then require additional resources from our team.

Model for Improvement Specify and Set the Aim Aims help us… Inspire and motivate staff to engage in improvement work Know whether and when we’ve achieved our goal

Set and Specify and AIM (page 33) Ask yourself… What system is to be improved? Who is the population of focus? What is expected to happen? What is the timeframe? What is the goal? Helps us create Smart Aims Specific Measurable Attainable Relevant Time-bound

The pneumococcal QI team’s aim: Keep the scope manageable In the residents’ practices, we will increase pneumococcal vaccination rates for patients aged 65 and older from 39% to 70% by June 30, 2016. Specific Action Target population Measurable: From current to future state Attainable Relevant: Patient-centered Effective Time-Bound Timeline for change (months, days, years)

Model for Improvement Identify a Family of Measures To bring new knowledge into daily practice Stabilize the biases from test to test (accept consistent bias) Gather “just enough” data to learn

Helpful Hints Data for QI is different than data for research or data for accountability (page 34) Include outcome, process, and balancing measures Follow measures frequently and continually “Time is the teacher” Dr. Don Berwick

The Pneumococcal QI team’s Measures Type of measure Outcome measure: the voice of the patient (what is important to them) Process measure: the voice of the process; reflects system performance Balancing measure: unintended consequences The team’s measures Percentage of eligible patients who received pneumovax Percentage of eligible patients who came for a visit and are offered pneumovax Increased in days of the waitlist to see the RN

A picture is worth a thousand words Use run charts to: Plot data over time Learn from your data Share with stakeholders Key messages: as you move forward with your project and view the measurement modules, run charts will become clearer.

Model for Improvement Sources of Change ideas Diagnostic tools inform change ideas Knowledge experts The QI team – think logically Creativity tools and technology Copy, replicate, duplicate – “Steal with pride” Begin! Be open to learning from testing .

The Pneumococcal QI Team’s Diagnostics Fishbone Diagram:

The Pneumococcal QI Team’s Diagnostics Process Map:

The Pneumococcal QI Team’s change ideas

Model for Improvement Turns our ideas into action, and our action into learning

PDSAs All of the elements of the MFI are important. But if I had to choose one as the most important, the “heart of the Model”, it is the process of testing: the PDSA. Dr. Don Berwick

PDSAs are grounded in science

PDSA cycle (pg. 43)

The Pneumococcal QI Team’s PDSAs Cause from Diagnostics: Patients unaware Change Idea: Poster in waiting room PDSA worksheet (page 51) Objective: Develop a poster for the waiting room to increase awareness Who, What, When, Where? Team to decide on content and design Test with poster on Tuesday morning. Ask 10 clients if they saw poster (y/n data) and what information they recalled (tic sheet). Predict that 6 / 10 patients will see and recall info Decided to modify Changed design (more pictures / less info) 8 clients reported seeing poster 5 correctly reported to ask provider Results worse than prediction Carried out the test and collected the data.

The Pneumococcal Team’s PDSAs 6 cycles for the poster idea 3 to develop the poster (change content and colour) 3 to test under various conditions to find the best location Second change idea was EMR alert 5 cycles to learn the best way to use the EMR for the alerts

The Pneumococcal Team’s results

Do you have questions?