Why Quality Improvement(QI) and where do I begin? Alexander Singer MB BAO BCh, CCFP Associate Professor Quality Improvement and Informatics Postgraduate Lead Rady Faculty of Health Sciences, College of Medicine, Department of Family Medicine March 27, 2019

Faculty/Presenter Disclosure Relationships with financial sponsors: Grants/Research Support: Canadian Institute for Military and Veterans Health Research, IBM, Calian, Research Manitoba, Manitoba Medical Services Foundation, CIHR Speakers Bureau/Honoraria: None Consulting fees: None Patents: None

Disclosure of Financial Support The Practice Improvement Initiative has received financial support from the College of Family Physicians of Canada in the form of Institutional Support Potential for conflict(s) of interest: Alexander Singer has not received payment/funding from any organization supporting this program nor any organization whose product(s) are being discussed in this program. There are no products that will be discussed in this program

Mitigating Potential Bias The CFPC has no commercial interests in the success of promoting quality improvement among Family Physicians. Practice Improvement is a strategic priority for the CFPC.

QI is learning from our work… …and then improving it We have two Jobs Doing the work Improving the work This improvement work is about your practice rather than big system change. It’s about doing better. Famous quote by Baldtenden that everyone has two jobs – doing the work and improving the work. Need to adopt that culture.

What are the fundamentals of Healthcare Quality Improvement? What are we trying to accomplish (Aims)? How do we measure systems and change (Data)? How can we change effectively (ChangePDSA)?

#1 What is the Quadruple Aim? Improved patient experience Better health outcomes Lower healthcare costs Improved care team experience From Don Berwick article: The Triple Aim was the brainchild of two of IHI’s faculty, John Whittington and Tom Nolan, who came up with it in about 2006. It was a real breakthrough. The goal they had in mind was to articulate, in a very cogent way, the aims of health care from the viewpoint of the society it serves. You can’t define or pursue quality if you don’t know your aims. The proper way to think about goals is that they’re external to the organization, external to the industry. They lie in the world of the people we help, the customer, the patient, the consumer. So, what would society say it’s hiring health care to do? That’s the key initial question in quality. The fourth aim has been added more recently to include the need to reflect work/life balance of the care team. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014; 12(6): 573-576 Bodenheimer T, Sinsky C. Ann Fam Med 2014; 12(6): 573-576.

Don Berwick on the “Triple Aim”- “It’s an elegant way to name why we’re here: better care for individuals, better health for populations, and let’s not waste.”

The Six Dimensions or Domains of Quality Timely Efficient Equitable Safe Effective Patient-Centred The six dimensions of quality apply when patients need or use care – at the practice level. Those properties should be there in the individual experience of care when care is provided to clients. Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.

Is this high quality care? Think about the referral process:  Safety Avoid harm to patients Safe Effective Patient-centred Timely Efficient Equitable  Equity Care does not vary in quality because of personal characteristics  Effectiveness Provide evidence-based services to those who can benefit, refrain for those who will not  Efficiency Avoid waste of resources, ideas, and energy  Patient-centredness Provide respectful care responsive to patient preferences, needs, and values The Six Domains of Health Care Quality by the Institute of Medicine (IOM) Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.  Timeliness Reduce waits for those receiving and delivering care

#2 What can we measure?

#3 What is change? All improvement requires change, but not all change results in improvement Robust improvement work leads to fundamental change Making change only as a knee-jerk reaction - Will not achieve fundamental and sustained change Fundamental Change is change that permanently alters how things are done Produces visible positive difference Has a lasting effect

Practice improvement approaches A spectrum of approaches A simple change “Just do it!” Basic QI approaches and tools E.g. PDSA Cycle, Model for Improvement, process mapping Advanced QI approaches and tools E.g. LEAN, Six Sigma There are different approaches to practice improvement, depending on the nature of the change or improvement to be made. Some improvements or changes are straightforward. The idea of QI is to introduce some basic tools that can help, particularly when the change requires more effort. This diagram represents the spectrum of changes that can be made, depending on the need at hand. Some, as shown on the left hand side of the spectrum, simply require a straightforward change. However, for more complex problems at the practice level that involve other members of the team, a more planned approach may be required. Emphasize: The QI approaches and tools provided in these workshops (PIE Part 1 and Part 2) provide tools to help undertake quality improvement, from straightforward problems or change ideas to complex ones.

Model for Improvement What are we trying to accomplish? Specify and set an aim Establish measures Identify change ideas Small, iterative tests of change. Turns ideas into action and action into learning How will we know if a change is an improvement? What changes can we make that will result in an improvement? The Model for Improvement (MFI) is a basic approach to undertaking QI – often referred to as the QI roadmap. It consists of three simple questions followed by an action phase – the Plan, Do, Study, Act cycle (PDSA cycle). Note that the simplicity of the model does not necessarily mean that QI and change are always simple and straight forward. The application of the model that can be challenging. Primary care after-all is a complex system – a interdependent group of people, processes and equipment working together toward a common purpose. Improving in a complex system can be challenging. Emphasise the ‘WE’ in the MFI – QI is a team effort

Rapid Fire Improvement Ideas:

#1. Take a CFPC PIE course – Aim!

#2. MaPCReN – Measure!

#3. eConsult Manitoba – Change!