Improving Adolescent and Young Adult Clinical Practice The Quality Improvement Process Rachel Wallace-Brodeur, MS, MEd Project Director and QI Coach, National Improvement Partnership Network May 10, 2017

Session Objectives Review fundamentals of quality improvement (QI) How to use the Patient Satisfaction Survey to improve quality of care

QI Principles Incremental change Data-driven Environment for shared learning Team Work and Communication Systems and Processes Individual and population health outcomes Sustainability QI principles are the same whether applied in public health or clinical care settings REVIEW

Changing Systems Every system is perfectly designed to achieve exactly the results it gets. If you want to improve, you must change your system! QI principles are the same whether applied in public health or clinical care settings REVIEW

QI: The Model for Improvement Aim Measurement Change We’ve presented the “Model for Improvement” Aim: stating as clearly as possible with a SMART framework exactly what it is that you are trying to accomplish To determine a measurement plan – I’m going to talk about some measures And then to identify and test strategies for change that you think will lead to the improvement you are seeking. From The Improvement Guide Langley, Nolan, Nolan, Norman and Provost

QI Project Steps Assemble your Change Team Develop aim statement Develop road map to achieve outcomes Determine measurement strategy Identify strategies to test & target populations Implement strategies using Model for Improvement

Convening a Change Team Cross-functional Team members have a stake in the outcome An effective improvement team is Flexible: willing to change and respond to the ongoing/unexpected Creative: solution-oriented No one individual has sufficient knowledge to solve the problem Cross functional: (proficient in relevant areas)

Aim Statements What do you want to ACCOMPLISH Picture the END RESULT

Aims Should be SMART

SMART Aim Statement By December 2018 the percentage of adolescents and young adults receiving well visits in Minnesota increases by 2%.

Key Driver Diagram Structured logic charts with ≥ 3 levels: Project Aim: SMART Key drivers: (elements, factors, influences) with direct contributions to the aim Primary Secondary Strategies: HOW to address the drivers to achieve the aim

QI Project Steps Assemble your Change Team Develop aim statement Develop road map to achieve outcomes Determine measurement strategy Identify strategies to test & target populations Implement strategies using Model for Improvement

Why Measure? How do we know which changes resulted in improvement? Which changes are most important to achieve our desired result? How do we know when we accomplish our aim? You can’t improve what you don’t measure. Why measure? We are now at the 2nd question in the Model for Improvement – How will we know that a change is an improvement? The purpose of measurement in QI projects is for learning not comparison or judgment. Project teams need measures to obtain feedback that the changes they are testing are having the desired outcome. As we will discuss a bit later, measures occur at two levels – the project level (these are measures tracked throughout your QI project and beyond) and a second level of measures which are developed on an as needed basis as part of the process of testing changes.

Data for Improvement Collected to: Observe process performance Obtain ideas Test changes Determine sustainability Data is (typically) already available and easy to obtain.

Measurement Measuring for improvement Short cycles “Just enough” data Learning vs. Judgment/Accountability Failure is good! Quick turnaround Run charts – view data over time

AYA Health Measures H.E.D.I.S. CHIPRA Core Measure Set State- and Health System-Specific measures (often adapted from above) NIPN Adolescent and Young Adult Health Measures (http://nipn.org/)

Two Levels of Measurement Project Level 1-3 core measures Takes time to develop data collection plan PDSA Level 2 Discrete measures used to inform individual PDSA cycles Quick to collect and feedback Often involve manual data collection Adapted from Associates in Process Improvement

QI Project Steps Assemble your Change Team Develop aim statement Develop road map to achieve outcomes Determine measurement strategy Identify strategies to test & target populations Implement strategies using Model for Improvement

Process Mapping Part of the “PLAN” step in PDSA Use to describe current process Use to improve process Design an entirely new process Tool to understand the process One of 7 core QI tools Current: how you get the job done Improve:

Flowcharts- from simple Tool to understand the process One of 7 core QI tools Current: how you get the job done Improve:

… to more complex For each step, ask: Can it be eliminated? Can it be done in a different order? Can it be done by someone else-more appropriate person? Are there unnecessary waits? Communication breakdowns? Is this value added for the patient? Is this value added for the staff?

Mapping the Process Define the process to be diagrammed Decide upon the boundaries of your process: Where/when does it start/end? What level of detail to include in the diagram? Get the right people there! Brainstorm the identified activities: Write each on a sticky note Arrange activities in proper sequence Draw arrows to show the flow of the process. Review flowchart with all involved for accuracy

Root Cause Analysis: Why??

The 5 Whys Repeatedly asking “why” is one way to get to the Root Cause Getting to the answer to the 5th why can be very surprising

Why don’t adolescents and young adults do well visits? 5 Whys Why don’t adolescents and young adults do well visits?

QI Project Steps Assemble your Change Team Develop aim statement Develop road map to achieve outcomes Determine measurement strategy Identify strategies to test & target populations Implement strategies using Model for Improvement

The Model for Improvement Aim (Goal) Measurement Change Ideas Many of us here at VCHIP and across our network use TMI we dicussed briefly in the project orientation wbinar. Many models for clinical QI exist. We like this model, but it does not matter what model you use. What really matters is that you choose a model, become comfortable with the elements and you apply them in your practice. We use the Model for Improvement as our basic framework Other models exist: selection may be drive by other constraints (e.g., if you are affiliated with an organization that has QI personnel, you may be familiar with other approaches. Choose one and become comfortable with it From The Improvement Guide Langley, Nolan, Nolan, Norman and Provost

How Improvement Happens: The PDSA Cycle So now we’re ready to revisit the model for change—the framework that we will use to test, measure, evaluate, adjust our strategy, and retest on a small scale before we can even think about scaling up.

Supporting Practices PDSA Log Measurement

Selecting and Testing Changes Use the PDSA Cycle for Testing or adapting a change idea Implementing a change Spreading the changes to the rest of your system AIM Training - April 11, 2013

Piloting vs. Implementation Pilot Phase Implementation Phase People Few Resistance low Many Stronger resistance Support Needed Low Changes not permanent High To make change part of routine operations Time Shorter Longer Tolerance for Failure Learn from mistakes Need high degree of confidence change will be an improvement Adapted from the Institute for Healthcare Improvement (IHI).

Repeated Use of the PDSA Cycle Changes That Result in Improvement A P S D D S P A A P S D Repeated use of PDSA Cycles Testing PDSA cycles in an iterative process. The completion of one cycle leads directly to the next on. You study and learn form each test, what worked, what didn’t and what needs to be tweaked, and use this knowledge to plan your next steps. Start small, keep it simple, measure just enough to inform your next step and ramp up the tests as you gain confidence they will lead to improvement. By repeating these tests of change overall as you move up the hill what we hope you see is that you move your system from its current level of performance to the improved level of performance. DATA A P S D Hunches Theories Ideas

Session Objectives Review fundamentals of quality improvement (QI) How to use the Patient Satisfaction Survey to improve quality of care

Case Study: Let’s Take a Closer Look Impact in Vermont

Project Impact: The Practices Geographical Target: Interested practice looking for help after a youth suicide Targeted recruitment to other sites in same geographical region Interventions: Initial site visit by faculty Gap in Care reports (Medicaid and BCBS VT) Environmental assessment by Youth Health Advisory Council (YHAC) members Small monetary stipend to make desired changes Coaching calls, technical assistance, webinars Tools and resources through website http://www.med.uvm.edu/vchip/yhii Use AYA Satisfaction Survey to collect data!

Project Impact: Youth Established a NEW Youth Health Advisory Council Used stakeholders and community partners to recruit widely Looked for AYA who were comfortable sharing ideas, concerns, and their experiences Struggled with communication, meeting times Struggled with diversity (HS students, College students, CYSHCN)

Environmental Assessment Environmental Assessment Tool Adolescent and Youth Friendly Resource Guide

AYA Satisfaction Survey: PDSA Cycles Pediatric Practice “A” Cycle 1: Started with one provider; gave tablet to all AYAs in age range for any visit – GREAT SUCCESS Cycle 2: Expanded to all providers Pediatric Practice “B” Cycle 1: Created flyer to passively promote survey in waiting room – not many returned Cycle 2: Continue doing the same

AYA Satisfaction Survey: PDSA Cycles Family Medicine Practice “C” Cycle 1: Created paper versions of survey and mailed to all AYAs in age range for Well Visit with all providers – return rate=5/50 Cycle 2: Give paper version of survey to all AYAs for Well Visit before leaving the office Family Medicine Practice “D” Cycle 1: Didn’t do anything (staff transitions) Cycle 2: Re-engaged: Considering purchasing tablets

Survey Return Practice A Practice B Practice C Survey Method Tablets Provider promoted Flyer in waiting area to passively promote survey Paper version (first mailed, then in office) Patient Satisfaction Survey’s returned 116 1 53 (5 from mailing)

Baseline & 1 Month: Practice A

Future PDSA Cycles Improve Private Time with Provider Examine data more closely to define problem: differences by age group or visit type? What do you want to change? Ensure private time for all AYAs >14 regardless of visit type

Baseline & 1 Month: Practice A

Future PDSA Cycles Know how to contact clinic/provider Give card with clinic info to all AYAs Waiting area is welcoming Use stipend to make some changes Know what services are confidential Info on practice website re: confidential services

Lessons Learned Offer supportive, flexible quality improvement strategies that fit each individual clinic’s needs Celebrate and share any and all successes with all engaged clinics Encourage data collection to quantify and track progress Discover and use creative ways to engage youth

Questions?