The Model for Improvement Karen Scott Collins, MD, MPH VP, Quality and Patient Safety New York Presbyterian Hospital July 2008

Learning Objectives Understand the Model for Improvement Discuss how to create aim statements that are measurable and specific Review the measurement strategy and identify how the key measures relate to the improvement project Introduce Plan-Do-Study-Act cycles

Key Elements of Breakthrough Improvement Will to do what it takes to change to a new system Ideas on which to base the design of the new system Execution of the ideas

The Model for Improvement A simple way to frame, organize, execute improvement work Useful for testing great ideas, trying things that have worked for others, implementing ripe ideas or actions, and disseminating positive improvements throughout organization

Three Fundamental Questions for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

Compare the 3 questions to how we frame improvement Aim Measurement for learning PDSA What are we trying to accomplish? How will we know a change is an improvement? What changes can we make to bring about improvement?

Aim Measures Ideas Model for Improvement Act Plan Study Do Act Plan What are we trying to Aim accomplish? How will we know that a Measures change is an improvement? What change can we make that Ideas will result in improvement? Act Plan Study Do Act Plan Study Do From: Associates in Process Improvement

Aim Measures Ideas Model for Improvement Act Plan Study Do Act Plan What are we trying to Aim accomplish? How will we know that a Measures change is an improvement? What change can we make that Ideas will result in improvement? Act Plan Study Do Act Plan Study Do From: Associates in Process Improvement

Question 1: What Are We Trying to Accomplish? Aim: A written statement of the accomplishments expected from each pilot team’s improvement effort. Everyone on team has the same goals and expectations

Aim: What Are We Trying to Accomplish? Your team’s aim statement should be consistent with the mission of the improvement work and include: What is expected to happen The system to be improved The setting or (sub-)population of patients Specific numeric, stretch goals Time frame Guidance for activities, such as strategies for the effort, or limitations

Exercise: Aims Use the following criteria to evaluate the following Aim statement example Is it consistent with the mission of the Collaborative/improvement initiative? Is it clear what is expected to happen by when? Can you determine the system to be improved? Can you distinguish the setting or sub-population of patients? Are specific numeric goals clearly stated? Is there guidance indicated for the activities, such as strategies for the effort, or limitations?

Aim Statement Asthma Example The aim for our Clinic is to improve care provided to our pediatric asthma patients using the Chronic Care Model so as to ensure the Application of evidence based best practices to all patients and improvement in clinical outcomes in the pilot population over the next year. This will be accomplished by: Providing follow up to an ED or hospital discharge within 7 days for > 80% Documenting severity assessment for 95% of patients Review management plans and provide written management plan including shared goal for 85% pts Appropriate medications for at least 90% of patients w/o contraindications Increasing symptom free days by at least 50% Annual immunization against influenza (goal >90%)

Does example meet these criteria? Is it consistent with the mission of the initiative? Is it clear what is expected to happen and when? Can you determine the system to be improved? Can you distinguish the setting or sub-population of patients? Are specific numeric goals clearly stated? Is there guidance indicated for the activities, such as strategies for the effort, or limitations? YES NO

Aim Measures Ideas Model for Improvement Act Plan Study Do Act Plan What are we trying to Aim accomplish? How will we know that a Measures change is an improvement? What change can we make that Ideas will result in improvement? Act Plan Study Do Act Plan Study Do From: Associates in Process Improvement

Question 2: How will we know a change is an improvement? Requires measurement Can collect qualitative & quantitative data Test small first Test under a wide variety of conditions to make sure idea is robust enough

Measurement for Improvement Builds will/ Creates tension for change Demonstrating performance gap overall Demonstrating variability in performance Focuses teams – “you can manage what you measure” Designed to help your improvement team learn and establish improvement priorities Like a growth curve: it’s not where you are, but where you are going Answers the question: Are changes an improvement? IS NOT: Designed for criticism or punishment Supposed to end (it should be sustainable)

Types of Measures Outcome Measures Process Measures Balancing Measures Results – system level performance How is the health of the patient affected? Process Measures Inform changes to the system Are key changes being implemented in the system? Balancing Measures Signal “robbing Peter to pay Paul”

Measures - Examples Outcome Process Balancing Number symptom free days for asthma patients ED asthma visits Process Patient and family have Asthma Action Plan Appropriate medications prescribed Balancing Clinic cycle time

Measurement Guidelines Need a balanced set of 5 to 8 measures reported each month to assure that the system is improved These measures should reflect your aim statement & make it specific Measures are used to guide improvement and test changes Integrate measurement into daily routine; use patient population database Plot data for the measures over time and annotate graph with changes

Methods of Measurement Clinical measures of patients’ health Documentation of behaviors Questionnaires Assessments Summary of databases Chart audits Observations

Integrate Data Collection for Measures in Daily Work Include the collection of data with another current work activity Develop an easy-to-use data collection form or make Information Systems/registry input and output easy for clinicians  Clearly define roles and responsibilities for on going data collection Set aside time to review data with those who collect it  

Plotting Data in Time Order Summary statistics hide information (patterns, outliers) In improvement efforts, changes are not fixed, but are adapted over time Time series graphs annotated with changes and other events provide evidence of sustained improvement

QI Tools - Run Chart GOAL Nurse Smith left Tried encounter forms Implemented registry 75

Lessons from Baseline Data Collection What worked? What didn’t work? What was difficult? Why? Ideas for successful measurement and data collection

Ideas Aim Measures Model for Improvement Act Plan Study Do Act Plan What are we trying to Aim accomplish? How will we know that a Measures change is an improvement? What change can we make that Ideas will result in improvement? Act Plan Study Do Act Plan Study Do From: Associates in Process Improvement

Question 3: What Changes Can We Make That Will Result in Improvement? Use change concepts, models (Chronic Care Model), literature, shared experiences to develop specific changes Test: good ideas, ready for use or ready for adaptation to your environment

Change Concepts vs. High Leverage Changes Vague, strategic, creative Specific, actionable, results Improve care of asthma patients Share info w/ patients & families and encourage self-management Document asthma management plan and goals for self-management Begin discussion of SM goals w/ 3 patients on Monday

Model for Improvement Act Plan Study Do Act Plan Study Do What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do Act Plan Study Do From:: Associates in Process Improvement

The PDSA Cycle for Learning and Improvement Act Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection What changes are to be made? Next cycle? Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data

Use the PDSA Cycle for: Helping to answer the first two questions of the Model for Improvement Developing a change Testing or adapting a change idea (from a component of the Care Model) Implementing a change

Why Test? Increase your belief that the change will result in improvement Opportunity for learning from “failures” without impacting performance Document how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation

Repeated Use of the PDSA Cycle Changes that Result in Improvement Multiple cycles A P S D Learning from Data, Tests D S P A A P S D A P S D Proposals, Theories, Ideas 31

3 Principles for Testing a Change Test on a small scale Collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea. Include a wide range of conditions in the sequence of tests 29

To Be Considered a PDSA Cycle: The test or observation was planned (including a plan for collecting data) The plan was attempted (do the plan) Time was set aside to analyze the data and study the results Action was rationally based on what was learned 2 27

Test on a Small Scale Conduct the test in one facility or office in the organization, or with one customer Test the change on a small group of volunteers Develop a plan to simulate the change in some way

Decrease the Time Frame for a PDSA Test Cycle Years Quarters Months Weeks Days Hours Minutes Drop down next “two levels” to plan Test Cycle!

Global Collaborative Measures vs. PDSA Cycle Measures Achieving Aim Project Measures: Overall results related to the project aim (core measures and teams’ additional and balancing measures) PDSA Measures -PDSA-specific measures: Quantitative data on the impact of a particular change Qualitative data to help refine the change Adapting Changes During PDSA Cycles

Fundamental Questions for Improvement What are we trying to accomplish? Team Aim Statement How will we know that a change is an improvement? Measures What changes can we make that will result in an improvement? Change package Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do 17 2

References The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. Quality Improvement Through Planned Experimentation. 2nd edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998. “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990. A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997. Jane Taylor, Improvement Advisor, IHI Pat Heinrich, VP, NICHQ