INTERPROFESSIONAL QUALITY IMPROVEMENT PROJECTS Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org Workshop 1 of 3 on Quality Improvement Facilitators Introduce themselves

Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org ZOMBIE ATTACK Improving quality, Building teams, Avoiding having your brain eaten Trainees introduce themselves using an icebreaker activity

WORKSHOP OF THE UNDEAD Why Zombies? Superordinate goals Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org WORKSHOP OF THE UNDEAD Why Zombies? Superordinate goals (Ergo – Zombie Attack!) Non-familiar terrain Why Teamwork? kill, l Unable to accomplish QI (or defeat zombies) without teamwork (One guy can’t ike, 50 zombies!) Use these questions to gauge the trainee's understanding of how QI and research defer. In our experience trainees conflate research and QI and need multiple reminders that they are not being asked to complete a research project with their team.

Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org ZOMBIE TRIVIA From what geographic area did the concept of a “Zombie” originate? West Africa (although Haiti more described) What was the name of the 1985 book which described an ethnobotanist’s exploration of the Haitian zombie myth? The Serpent and the Rainbow, by Wade Davis Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

RESEARCH VS. QUALITY IMPROVEMENT Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org RESEARCH VS. QUALITY IMPROVEMENT QI is the “democratization” of research Not single intervention w/ rigorous controls Local, iterative approach to problem With clear aim, measures, ideas And quick cycles of evaluation prior to implementation Research = created virus/mutation/chemical/etc. that CAUSED zombie apocalypse. Quality Improvement = only chance of stopping zombie attack and saving civilization as we know it. Further differentiation between QI and research.

ZOMBIE PANDEMIC Further differentiation between QI and research. Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org ZOMBIE PANDEMIC Further differentiation between QI and research.

Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org ZOMBIE & PUBLIC HEALTH "If you are generally well equipped to deal with a zombie apocalypse you will be prepared for a hurricane, pandemic, earthquake, or terrorist attack.“ Dr. Ali Khan, Office of Public Health Preparedness and Response, CDC “We have been overrun by zombies. We had to close the registration.” Univ. of Michigan’s School of Public Health preparedness exercise. Trainees introduce themselves using an icebreaker activity

QUALITY IMPROVEMENT & ZOMBIE QUOTES Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org QUALITY IMPROVEMENT & ZOMBIE QUOTES “Every system is perfectly designed to get the results it gets.” Paul Batalden “BLAAARHG blar mmaaaar Brains BrAIns…BRAINS – RRRRRAAAWRRR!” Zombie Saying Trainees introduce themselves using an icebreaker activity

Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org SCENARIO Zombie Apocalypse has struck Boise, Idaho. You and your team of survivors have holed up in an abandoned conference room. With dwindling supplies of stale donuts and tepid coffee, you must decide a means to survive the zombie attack, and minimize the number of humans you lose to zombification… Trainees introduce themselves using an icebreaker activity

PDSA Plan Identify the problem Analyze the problem Do Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org PDSA Plan Identify the problem Analyze the problem Do Develop solutions Implement a solution Study Evaluate the results – goal achieved? Act Standardize the solution & make it work Restart the cycle Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

UNDERSTANDING CAUSALITY Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org UNDERSTANDING CAUSALITY To understand the causes of problems, you have to understand the system. Causality by process map Causality (not casualties) by category & fishbone diagram Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

PROCESS MAPPING Understanding the Process… Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org PROCESS MAPPING Understanding the Process… “You don’t learn to process map, you process map to learn.” Dr. Myron Tribus Most are undocumented processes, especially those involving zombies (unless you work at CDC). Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

PROCESS MAPPING START Yes Activity Outcome Subsequent 1 No Alternate 2 Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org PROCESS MAPPING Activity START Outcome 1 Alternate Subsequent 2 Yes No Decision Point We provide quotes from the accreditation requirements or competencies for the procession that we train so that they are aware that their profession cares. Change this to fit your group of trainees.

ROLES & (LACK OF) RESPONSIBILITIES* Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org ROLES & (LACK OF) RESPONSIBILITIES* Roles in Zombie Attack ― Assign roles to each of the members of your team. Mad (or perhaps not so mad?) scientist ― advocates for scientific solutions Slightly annoyed physician ― wants to focus on curing zombies Compassionate optimist ― wants to fix zombies with lots of love Former special forces member ― wants to fix zombies with lots of bullets Lumberjack/chainsaw sales man ― wants to trim zombies into harmless packages Woody Harrelson ― wild card We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.

Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org GROUP ACTIVITY – PART A Develop a process map to understand how a human, facing Zombie Attack, might respond to maximize their chances of survival. Arrange pre-made process map pieces Make your own! 2 groups of 6 (bigger is more realistic) We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.

IF VETERAN ACCEPTED INTO Process Map: Transitions Of Care iQIP Team 2016-2017 ALCOHOL USE DISORDER WORK FLOW Medical Evaluation +/- BH Triage Monitoring 2M/MSDU Emergency Dept. Visit F/U with PCP Medically-Assisted DISCHARGE Medical SW ICT OSAT Drop-In Group IF VETERAN REQUESTS BH SERVICES FOR AUD IF NOT 2M/MSDU IF VETERAN ACCEPTED INTO RSAT BUT WAITING CAN BE SEEN BY ICT 1-5 VISITS BHIP RSAT Post Discharge from 2M *If Indicated ICT F/U Treatment Complete Each year, we provide the trainees with their list of QI topics to pick from KEY Inpatient Medical Team Primary Care Behavioral Health Dept.

GROUP ACTIVITY – PART B Return to Process Map Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org GROUP ACTIVITY – PART B Return to Process Map Highlight Possible Intervention Points Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

PROCESS MAP: SMOKING CESSATION iQIP TEAM 2015-2016 Check In Quit? + - Smoking Cessation Meds? Print Reminder Wed Tobacco Cessation Group Consult 1:1 visit Support Group Pharmacy Psychology PCP Discussion Warm handoff to psychology? Eileen Twomey & Sharlene Green 30% Attend Only 1 Meeting 21% Never Attend Stay Quit Coach Phone App Increased Engagement?? Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

FISHBONE DIAGRAM CAUSE & EFFECT Cause Effect Problem Material Method Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org FISHBONE DIAGRAM CAUSE & EFFECT Material Method Machine Manpower Measurement Environment Problem Effect Cause Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

FISHBONE DIAGRAM CAUSE & EFFECT More Zombies! EFFECT CAUSES Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org FISHBONE DIAGRAM CAUSE & EFFECT More Zombies! Government Conspiracy EFFECT Evil Scientists/ Experiment Awry Cosmic Rays Voodoo Curse Environmental Toxins CAUSES Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

FISHBONE DIAGRAM PRACTICE MANAGEMENT LEAD IQIP TEAM 2016-2017 EKGs Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org FISHBONE DIAGRAM PRACTICE MANAGEMENT LEAD IQIP TEAM 2016-2017 EKGs Veteran Drop In Note Call back request Information for action Med Requests Express Scripts Outside Pharmacy Choice Provider Form Requests Disability Medical Clearance FYI Discharge Summaries Consult results Outside provider notes Orders Home Health Vets Home ALF SNF0 Delayed Care Overwhelmed PCPs Frustrated Veterans CAUSES EFFECTS Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

PDSA Plan Identify the problem Analyze the problem Do Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org PDSA Plan Identify the problem Analyze the problem Do Develop solutions Implement a solution Study Evaluate the results – goal achieved? Act Standardize the solution & make it work Restart the cycle Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff Bottom up – refers to QI projects that come from the front lines We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

iQIP WORKS IN PROGRESS #1 Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org iQIP WORKS IN PROGRESS #1 Who: Your iQIP Team What: WiP #1 Background info, why you care Aim statement  More on this next time! Baseline data Bonus Understanding the Context Process Map Fishbone Diagram Possible interventions? When: Wednesdays in 12-1 December/January Where: Wednesday Interprofessional Noon Conference Room We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.

Boise VAMC Center of Excellence in Primary Care Education http://www.boisevacoe.org QUESTIONS? We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.