The Model for Improvement A Method to Adapt, Implement, and Spread Changes Heard lots of great concepts and ideas Now it's time to put them into action Turning to the methodology for how we will put them into action Connie Davis September 14, 2000 (prepared with assistance from Lloyd Provost, Associates in Process Improvement and the Institute for Healthcare Improvement)

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 an improvement? Reviewing pre-work Many different QI models. We'll use this one. Minimize jargon. Your job is to answer these three questions First is about your AIM Second is about MEASURES Third is about CHANGES 17

The PDSA Cycle for Learning and Improvement Act Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) 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 You have this as a worksheet to use when you plan PDSA's.

Repeated Use of the PDSA Cycle Changes That Result in Improvement A P S D Learning from Data D S P A A P S D Doing multiple PDSA cycles, possibly over a hundred in the course of the year. A P S D Proposals, Theories, Ideas 31

Model for Improvement 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 Here's our model. Now start working on the form.

What are we trying to accomplish? Aim (also called Charter) A written statement of the accomplishments expected from each pilot team’s improvement effort Contains useful information: A general description of the goal Specific population Numerical goals Guidance for carrying out the work. Review what you determined from your pre-work.

Different Populations PILOT SITE System of Focus for the BTS (defined by Aim) A P S D A P S D A P S D Small-scale tests of change The Total Health Care System (spread sites) Your job is to work in the pilot site. Your senior leader will be addressing the total health care system. You will be providing valuable information the senior leader needs for spread.

How Do We Know That a Change is an Improvement? This collaborative is about changing your organization’s approach to caring for patients. It is not about measurement. But …… Population management and measurement are key components of clinical care. Key outcome measures are required to assess progress on your pilot team’s aim. Specific measures are required for learning about concepts tested during PDSA cycles. Second question. More detail on measurement in breakout session tomorrow.

Measurement Guidelines The key measures plotted and reported each month should clarify your team’s aim and make it tangible. Be careful about over-doing process measures. Make use of your patient population data base (registry) and administrative data for measurement. Integrate measurement into the daily routine. Plot data on the key measures each month during the Collaborative. The question - How will we know that a change is an improvement? usually requires more than one measure. A balanced set of five to seven measures helps assure that the system is improved.

For Each of the Key Measures Define each of the measures for your pilot population (numerator and denominator). Begin reporting your measures immediately. Use the current administrative and registry data as the means to obtain your measures each month whenever possible. Develop run charts to display your measures each month throughout the Collaborative. What you will need to do in upcoming team meeting.

Minimum Standard for Monthly Reporting Annotated Time Series Here's the method of data display we will use in the collaborative. Why?

Improvement in Glycemic Control Percent of (Patients with HbA1c >9 Improvement in Glycemic Control Percent of (Patients with HbA1c >9.5 in Clinic A) Clinic A, before and after

Improvement in Glycemic Control (% of Population with HbA1C >9 Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic A) Clinic A run chart. Look at the timing of the improvement. Are the results related to the improvement?

Improvement in Glycemic Control (% of Population with HbA1C >9 Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic B) Clinic B. Was the change responsible for the improvement?

Improvement in Glycemic Control (% of Population with HbA1C >9 Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic C) Clinic c: What's going on here? All three had the same before and after bar graph, but the run charts with annotations really showed us valuable information about what was happening.

Family of Measures for Diabetes You'll have multiple measures.

What changes can we make that will result in an improvement? Chronic Care Model The third question has been answered by the planning group.

Change Concepts from the Chronic Care Model Community - Resources to support patient care are identified and made easily accessible. Health System - Organization goals for chronic illnesses are part of annual business plan. - The system actively impacts the entire patient population with education and services. Self-management Support - Patients assisted in setting personal goals and given aids to assist in changing behavior. - Mechanisms for patient peer support and behavior change programs. Decision Support - Evidenced-based guidelines and protocols are integrated into the practice systems. - The system integrates the clinical expertise from generalists and specialists. Delivery System Design - The practice anticipates problems and provides services to maintain quality of life. - Systems are designed for regular communication and follow-up. Clinical Information System - A registry of patients with a chronic condition is maintained and utilized. I've selected a few of the change concepts. The entire list can be found in your handouts....

Change Concepts vs. High Leverage Changes Vague, strategic, Improve care of chronic population creative Provide effective behavioral change interventions. Documented patient receipt of self- management support Specific, actionable, Begin documenting collaborative results goals during next week’s visits Today the faculty has been focusing on the levels in the middle. Your job in the rest of today and tomorrow is to get to the botton level, things you can try in your setting.

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. “Eleven Worthy Aims for Clinical Leadership of Health System Reform,” Don M. Berwick, JAMA, September 14, 1994, Vol. 272, #10, p. 797-802. “The Foundation of Improvement.” Langley, G. J., Nolan, K. M., Nolan, T. W., 1994. Quality Progress, ASQC, June,1994, pp. 81-86. “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.

Washington State Diabetes Collaborative #2 Joint effort of Dept. of Health, PRO-West and ICIC Health plans and provider teams from around the state work together for 12 months Begins Feb. 2001, sign up by December Contact LaDon Kessler, PRO-West, 364-9700