Academic Pediatric Association QUALITY IMPROVEMENT TRAINING: Module #3 Initiating a QI project This work is supported by a grant from The Centers for Disease Control & Prevention.

National Partnership for Adolescent Immunization PI: Peter Szilagyi Coordinators: Christina Albertin, Nui Dhepyasuwan Ed Marcuse (communication expert) Cindy Rand Jan Schriefer (QI expert) Stanley Schaffer Janet Serwint William Stratbucker Donna D'Alessandro William Atkinson Paul Darden Sharon Humiston (moderator) Keith Mann (QI expert) FACULTY & CONSULTANTS

This is part of the APA series on Quality Improvement. The examples focus on adolescent immunization, but the principles are widely applicable. The series includes: 1. Overview: The Model for Improvement and Deming’s System of Profound Knowledge 2. Improvement cycles and the psychology of change 3. Initiating a QI project 4. More tools to better understand the system 5. How will we know that a change is an improvement? An introduction to QI measurement 6. Changes we can make that will result in improvement

Module 3 Objectives After viewing this segment, you will be able to: 1. Identify roles and responsibilities of QI team members 2. Draft an Aim Statement (Describe your problem, timeline, scope, and target population) 3. Complete a charter 4. Build a driver diagram

1. Identify roles & responsibilities of QI team members “Including the right people on a process improvement team is critical to a successful improvement effort.” Institute for Health Improvement

When putting together a QI team… How to choose team members: Review the general mission  What system will be affected by the improvement efforts? Invite members familiar with different parts of the process Size: 5-7 people at most Executive sponsor: takes responsibility for the success of the project

Possible Team Members & Their Roles Project sponsor/champion – oversee QI project (e.g., goal setting, data collection & analysis), advocate for & find resources to get project done Clinical technical expert -- knows the subject intimately, understands the processes of care Day to day leader – plan & deliver all training needed to implement the project; managing the implementation and testing the change System leader -- advocate Other team members – “voice of experience” Outsider? QI expert if available

Some characteristics that make a good team member: Good knowledge of process, product, and customer Access to data about the process or product Willingness to work cooperatively with other team members Ability to devote 3-4 hours/week to data collection and team meetings Ability to challenge the status quo From The Six Sigma Way: Team Fieldbook PS Pande, RP Neuman, RR Cavanagh

QUESTION #1 True or False? When developing your QI team, the project champion should emphasize that the project will take almost no time in order to attract important (i.e., busy) team members.

QUESTION #1 (Answer) False! When developing your QI team, the project champion should acknowledge that QI takes time in order to attract team members prepared for the commitment.

2. Draft an Aim Statement

AIM Statement What are we striving to accomplish (measurable goal(s))? When will this occur? (what is the timeline)? How much? What is the specific, numeric improvement we wish to achieve? For whom? Who is the target population? Why is it important? See Jean Meeks on “Developing Clear Aim Statements” at

QUESTION #2: Name at least 1 component (What, When, How much, For Whom, Why) that is missing from each of the following first draft AIM statements. A. Within the next 12 months we will increase our first dose HPV vaccination rates by 50%. B. We will strive to achieve 100% HPV vaccination of all adolescent patients in our clinic. C. Between January 1 - June 30, 2014 we will improve HPV vaccination coverage among our patients (both males and females) who are 11 or 12 years of age as of January 1, 2014.

QUESTION #2: Name at least 1 component (What, When, How much, For Whom, Why) that is missing from each of the following first draft AIM statements. A. Within the next 12 months we will increase our first dose HPV vaccination rates by 50%. Missing: For whom? B. We will strive to achieve 100% HPV vaccination of all adolescent patients in our clinic. Missing: When? C. Between January 1 - June 30, 2014 we will improve HPV vaccination coverage among our patients (both males and females) who are 11 or 12 years of age as of January 1, Missing: How much?

A Sample AIM Statement for HPV Vaccination

From Not so high that it paralyzes people because they know they can’t succeed But it shouldn’t be so low that it just barely exceeds the status quo “The measure of goodness is as much improvement as you can possibly accomplish.” How high should we set our goals?

3.Complete a charter for the project committee

What is in a project charter? AIM Statement (includes goal and timeline) Members and their responsibilities Meetings --Timing (e.g., every Tuesday 12:00-12:50, expectation to start & end on time) --Who will take notes, document decisions? (see template based on

Why use a project charter? Defines the project and organizes critical pieces of info about a project in one place Emphasizes approval by leadership Builds understanding, consensus, and clarity Is a living document that evolves using a structured approach

4. Build a driver diagram

Driver Diagram The system can be described through a graph called a driver diagram. Purpose: to show the factors that cause an outcome The outcome we are interested in is our Aim, so let’s start there.

Improve HPV immunization rate from 30% to 80% in 12 months Desired Outcome (Aim)

Improve HPV immunization rate from 30% to 80% in 12 months System: The providers have to remember to order the HPV vaccine Variation: The providers all use different HPV vaccination schedules and the nurses can’t keep them straight Knowledge: Physicians don’t know how they are doing and tend to assume the best Psychology: A lot of the team members believe that it’s better to give HPV vaccine right before college (“when sex is more likely”) Desired Outcome Primary Drivers (Aim)

Improve HPV immunization rate from 30% to 80% in 12 months Desired Outcome Primary Drivers2ndary Drivers (Aim)

Improve HPV immunization from 30% to 80% in 12 months Providers forget to order it Use standing orders Add vaccination to check list Use EMR prompt Nurses can’t remember/guess who will order what, when Agree on standard schedule Post standard in clinic “I’m sure I vaccinate 80% of my patients.” Monthly data reviews “Let’s wait.” Education Desired Outcome Primary Drivers Interventions (Aim)

Improve HPV immunization from 30% to 80% in 12 months Providers forget to order it Use standing orders Add vaccination to check list Use EMR prompt Nurses can’t remember/guess who will order what, when Agree on standard schedule Post standard in clinic “I’m sure I vaccinate 80% of my patients.” Monthly data reviews “Let’s wait.” Education Desired Outcome Primary Drivers Interventions (Aim)

QUESTION #3: Match the term on the left with the phrase on the right. Aim statement Project charter Driver diagram Graphic display of a system with the outcome of interest and the major influences on the outcome An AIM Statement, the team’s members and their responsibilities, expectations for the meetings A careful description of a desired outcome with respect to its importance, the desired measurable goal(s), the timeline, the target population

QUESTION #3 (Answer) A. Driver diagram – Graphic display of a system with the outcome of interest and the major influences on the outcome B. Project charter – An AIM Statement, the team’s members and their responsibilities, expectations for the meetings C. Aim statement – A careful description of a desired outcome with respect to its importance, the desired measurable goal(s), the timeline, the target population

Summary QI teams should include 5-6 people familiar with different parts of the problem plus an executive sponsor. An Aim Statement should explicate the measurable goal, the timeline, the numeric improvement you plan to achieve, the target population and why the issue is important. Your team charter should include the AIM Statement, team members and their responsibilities, and details of meetings such as timing and note taking. A driver diagram depicts the problem, the primary drivers, possibly the secondary drivers, and potential interventions to address the drivers.

The End of Module #3 IHI. Science of Improvement: How to Improve ScienceofImprovementHowtoImprove.aspx