Components of a Learning System David M. Williams, Ph.D. Improvement Advisor Institute for Healthcare Improvement

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The Early Years Collaborative “Scotland will be the best place to grow up.” Draws upon existing community infrastructure across the country Focused on age-based workstreams: 15% reduction in the rates of still-births and infant mortality by % of all children within each CPP will reached all of the expected developmental milestones at the time of the child’s month child health review, by end % of all children within each CPP have reached all of the expected developmental milestones at the time the child starts primary school, by end

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Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

Workstream 1 Aim To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015).

Workstream 2 Aim To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child’s 27‐30 month child health review, by end‐2016.

Workstream 3 Aim To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time the child starts primary school, by end‐2017.

Source: Brandon Bennett, IA Big Aims We are here!

Overall Project Measures vs. PDSA Cycle Measures Achieving Aim Data for Project Measures: - Overall results related to the project aim (outcome, process, and balancing measures) for the life of the project Adapting Changes During PDSA Cycles Data for PDSA Measures: - Just enough data - Quantitative data on the impact of a particular change - Qualitative data to help refine the change - Subsets or stratification of project measures for particular patients or providers - Collect only during cycles

Measure Time Run Chart - Data for Learning & Improvement

PDSA Measures Guide Learning about our testing. Process Measures Guide Learning about how our testing is improving reliability of the process. Outcome Measures Guide Learning about how the reliability of the process is achieving our aim.

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

Early Years Collaborative 2 day LS Expert meetings Cluster meetings Supports Expert QI & Early Years faculty Networking events Listserv Site Visits Phone conf Assessments Monthly Reports via web 2 day LS A P D S A D P S LS1 2 day Kickoff D S P A 2 day LS Key Changes Improvement Measures May 2013TBC Oct 2013 Jan 2013 Pre-work Oct 2012 Etc… TBC R

Reduce infant mortality Societal Issues Post-birth actions Pre-birth actions Smoking / Alcohol & Drug Misuse Improved sharing of information Improved management and quality of care Improved joint working Improved identification Aim 1⁰1⁰ 2⁰2⁰ Theory of what actions will reduce infant mortality Health Improved rate of breastfed babies Quicker diagnoses of Neonatal Abstinence Syndrome Nutrition Mental health & wellbeing AttachmentImproved stability / permanence for LAC Improved money management Improved access Improved family centred response Improved leadership, culture and planning Improved teamwork, communication, skills and collaboration Parenting skills Identification & reasons for current resilience WORKSTREAM 1 (conception to 1 year) Theory of what drives infant mortality Poverty Quality Of Home Environment Domestic Abuse & Violence Workforce Issues Transport, Community Capacity & Cultures Access To Services Employment Detailed aim: To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of: stillbirths (from 4.9 per 1000 births in 2010 to 4.3 per 1000 births in 2015) infant mortality (from 3.7 per 1000 live births in 2010 to 3.1 per 1000 live births in 2015) Version: 06/03/2013 R

Children have all the developmental skills and abilities expected of a month old Societal Issues Child’s physical & mental health and emotional development Carer’s physical & mental health and skills Level of education Improved sharing of information Improved joint working Improved early identification Detailed Aim: 85% of all children within each CPP have reached all of the expected developmental milestones at the time of the child’s month child health review by end-2016 Misuse of alcohol & drugs Health Improved child’s dental health Improving child nutrition Poverty Quality Of Home Environment Domestic Abuse & Violence Nutrition Disabilities & Mental health Attachment Improved stability / permanence for LAC Improved money management Improved management, planning and quality of services Improved family centred response Improved leadership, culture and planning Improved teamwork, communication, skills and collaboration Improving brain development and physical play Parenting skills & knowledge WORKSTREAM 2 (1 year to 30 months) Identification & reasons for current resilience Aim 1⁰1⁰ 2⁰2⁰ Theory of what drives developmental milestones Theory of what actions will ensure developmental milestones are reached Workforce Issues Transport, Community Capacity & Cultures Early Learning & Play Access To Services Employment Additional Support Version: 06/03/2013 R

Children have all the developmental skills and abilities expected at the start of primary school Societal Issues Child’s physical & mental health and emotional development Improved sharing of information Improved management, planning and quality of services Improved joint working Improved identification Detailed Aim: 90% of all children within each CPP have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017 Health Improved child’s dental health Improving child nutrition Attachment Improved stability / permanence for LAC Improved uptake of benefits Improved family centred response Improved leadership, culture & planning` Improved teamwork, communication and collaboration Improving brain development and physical play Early Learning & Play WORKSTREAM 3 (30 months to start of primary school) Identification & reasons for current resilience Aim 1⁰1⁰ 2⁰2⁰ Theory of what drives developmental milestones Theory of what actions will ensure developmental milestones are reached at the start of primary school Poverty Quality Of Home Environment Domestic Abuse & Violence Workforce Issues Transport, Community Capacity & Cultures Access To Services Employment Carer’s physical & mental health and skills Level of education Misuse of alcohol & drugs Nutrition Disabilities & Mental health Parenting skills & knowledge Additional Support Version: 06/03/2013 R

Provide the Leadership System to support quality improvement across the Early Years Collaborative Early Years Collaborative is a strategic priority & underpins all policy planning and operational activity Early Years Collaborative values, culture and behaviours are modelled by all leaders at all levels Infrastructure to support delivery of Early Years Collaborative Place quality issues at the top of senior leader meeting agendas Ensure that the senior team participates in Walk-rounds Display data that depicts progress towards aim Detailed Aim: Timely delivery of all three workstream “stretch aims” Early years executive and operational leads are identified Leaders can describe how they personally maintain early years focus within their working environment Ensure the development of a measurement system used to understand and drive quality indicators Build commitment with partners to focus on delivery CPPs communicate the EYC with enthusiasm and consistency Leaders illustrate how users are included in design, improvement, and delivery of Early Years Measurement plan and priorities are established and triangulation with other key data Leaders demonstrate their ability to set direction and engage and mobilise staff to constantly improve quality of service Meet regularly with the Implementation Committee to track progress and remove barriers Ensure a feedback mechanism for issues raised in Walk-rounds Establish Programme Management and remove barriers Add Early Years Collaborative and outcomes to the CPP agenda Establish an EYC Implementation Committee Assign a senior leader to each improvement area (Workstreams 1-3 and measurement) Spread plan is in place for core and innovative work Leaders facilitate change by cultivating innovation from intelligence, insights and wisdom of people working together WORKSTREAM 4 (Leadership) Aim 1⁰1⁰ 2⁰2⁰ Theory of what drives leadership support Theory of what actions will ensure leadership support Strategy for capturing, celebrating and spreading innovation Version: 06/03/2013 R

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system… Note: The size of the rectangles is meant to be indicative of population size, not cost.

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. People who have “fallen through the cracks” of our “rescue-care” system. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Note: The size of the rectangles is meant to be indicative of population size, not cost. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. Sub-groups, people from the high cost high utilization sub- population that can be stratified based upon relatively similar needs. People who have “fallen through the cracks” of our “rescue-care” system. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Sub-groups based more on needs and less on conditions. Note: The size of the rectangles is meant to be indicative of population size, not cost. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. Sub-groups, people from the high cost high utilization sub- population that can be stratified based upon relatively similar needs. People who have “fallen through the cracks” of our “rescue-care” system. Interventions intended to address the needs of high cost high utilization sub- groups, Plan Do Study Act cycles. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Sub-groups based more on needs and less on conditions. Some interventions will work and some will not. All should result in learning and start on the smallest practical scale. Note: The size of the rectangles is meant to be indicative of population size, not cost. An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

Repeated Use of the PDSA Cycle for Testing Changes That Result in Improvement Hunches Theories Ideas DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change Sequential building of knowledge under a wide range of conditions Spreading Sustaining the gains 48 Mini-measure tracks improvement cycles

Scottish Borders - Run chart of run charts! R

Scottish Borders - PDSAs completed R

Test! Test! Test! Burt Sandeman’s Story Post LS1: Burt Sandeman’s Story Post LS1 – The Challenge To Be Quick Burt Sandeman’s Story Post LS2: Burt Sandeman’s Story Post LS2 – The F-Word Looked after two-year olds: – My Prediction Was Wrong 30

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

Act with the Individual Dad’s Care Asset Based Community Development in N. Ayrshire Asset Based Community Development in N. Ayrshire 32

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

Things to Consider to “Scale-up” Determine full scale at project setup and milestones to reach full scale Different changes may require different scale-up strategies Consider different dimensions of structure – Information technology – Physical (e.g. space, equipment, capacity) – Human resources (workforce organization and capabilities) – Financial – Learning system Use “5x” ( ) thinking to predict/define the structural issues and set a path forward for testing – (What is working when testing with x that probably won’t work with 5x,...?) Standardize processes (e.g. training, referral) Understand oversight requirements as the system grows

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

Period Review

You are here!Aim The Work Remaining to Do Keeping an eye on the journey

Components of a Learning System 1.System level measures 2.Explicit theory or rationale for system changes 3.Segmentation of the population 4.Learn by testing changes sequentially 5.Use informative cases: “Act for the individual learn for the population” 6.Learning during scale-up and spread with a production plan to go to scale 7.Periodic review 8.People to manage and oversee the learning system From Tom Nolan PhD, IHI

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