1. QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM – 2017-18
INTRODUCTION TO QI
QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM –

2. CONFLICT AND DISCLOSURE INFORMATION
Speaker:
Program:
Financial Disclosure:
Grants/Research Support:
Speakers Bureau/Honoraria:
Consulting Fees:
Other:
This disclosure slide will be displayed with every module. The main message is that this program is unbiased - there is no industry funding.

3. After this session you will be able to…..
Define quality improvement
Differentiate the quality drivers in health care
Describe the CanMEDS 2015 ‘key competencies’ related to QI
Set the Triple AIM as the target for improvement efforts
Differentiate the methodology of science of improvement from traditional research and quality assurance methodologies
Outline the QI curriculum
This first module is the introductory slide series for the 4 modules that comprise the in-class element of the FM resident QI curriculum. In this module we define QI; highlight quality as an important driver in healthcare; set the Triple Aim as the target for improvement efforts; differentiate quality improvement from research and quality assurance and outline the broader FM resident curriculum for the PGY1 learner.
These 4 learning objectives build on the Prework that you completed (viewing the YouTube videos and reading the articles) and your site-based discussions surrounding identification of QI projects.

4. QUALITY IMPROVEMENT Definition:
“the combined and unceasing efforts of everyone - - to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”
adapted Batalden and Davidoff, 2007
QI SIMPLY DEFINED IS A METHOD OF CONTINUOUSLY FINDING BETTER WAYS TO PROVIDE BETTER PATIENT CARE AND SERVICE
PRINCIPLES:
Customer focused (patient)
Continuous improvement of all processes
Involvement of all
Use of data and knowledge to improve decision making
WHAT QI IS NOT IS “QUALITY CONTROL”. i.e. “looking for bad apples” and and getting rid of them, NOR QUALITY ASSSURANCE, i.e. the process of trying to reduce and/or minimize the factors that lead to errors or defects
AND IT IS NOT RESEARCH where all variation is controlled to allow the testing of one variable; requires large numbers and does not reflect the reality of messy day-to-day life
QI AIMS for GOOD ENOUGH not PERFECT

5. WHY DO WE NEED QI?
“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it”
A.A. Milne
Illustration E.H.Shepard
Winnie the Pooh provides a light-hearted perspective on why we need QI – “…. If we could stop bumping for a moment and think of it.”
In our healthcare careers we often tolerate processes and practices that we know could be better. Quality improvement skill and knowledge provides us with the tools to do things differently.

6. QI is learning from our work, and improving it
Two Jobs
Doing our work
Improving our work
Recalling the YouTube videos that you viewed as an element of the Prework, you will recall the focus that Deming made on learning or building knowledge about the systems we work within. With quality improvement skill and knowledge we focus on learning from our work and improving it.
An important perspective that is often commented on related to quality improvement is that we have 2 jobs – 1 to do our work and the second and equally important job to improve our work. 6

7. IMPROVEMENT DRIVERS QUALITY ASSURANCE KNOWLEDGE TRANSLATION RESEARCH
CONTINUING
EDUCATION
PROFESSIONAL
DEVELOPMENT
QUALITY
IMPROVEMENT
When we think about the various improvement drivers that you will connect with during your medical careers, we would like you to think beyond quality improvement and recognize that quality can be achieved across many drivers that you will encounter… the next few slides will address each of these drivers and provide examples that relate to medical education.

8. GOAL – CONTINUING EDUCATION
To maintain professional knowledge and skills after the completion of formal education
Example?
Foundation for Medical Education, McMaster University,
Problem Based Small Group Learning
Read the slide

9. GOAL – PROFESSIONAL DEVELOPMENT
To attain new knowledge and skills now applicable to one’s professional practice
Example?
Learning Cognitive Behavioural Therapy because of the prevalence of mental health issues in your practice
Read the slide

10. GOAL - KNOWLEDGE TRANSLATION
To apply new knowledge into one’s professional practice in the most effective way possible
Example?
(Academic Detailing) DATIS, Drug and Therapeutics Information Service
Australia
Read the slide

11. GOAL – QUALITY ASSURANCE
To judge that a system meets an identified set of standards of performance
Example?
Quality Book of Tools
Read the slide

12. GOAL – QUALITY IMPROVEMENT
To better processes, systems, and outcomes To improve
Read the slide
Highlight that a system includes the people, processes, items/equipment that are working together towards a common purpose (the outcome).

13. IMPROVEMENT DRIVERS - SUMMARY
Continuing Education – maintain
Professional Development – attain
Knowledge Translation – apply
Research – create
Quality Assurance – judge
Quality Improvement - better
In summary, improvement drivers are varied and seek to address quality in many ways. Quality Improvement specifically focuses on the improvement perspective – seeking ‘better’ than current performance or current state.

14. QI is included as key competencies in the following roles:
CanMEDS 2015
QI is included as key competencies in the following roles:
Medical Expert - Actively contribute, as an individual and as a member of a team providing care, to the continuous improvement of health care quality and patient safety
Leader - Contribute to the improvement of health care delivery in teams, organizations, and systems
- Demonstrate leadership in professional practice
Scholar - Engage in the continuous enhancement of their professional activities through ongoing learning
Frank JR, Snell L, Sherbino J, editors. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015.
The CanMEDS 2015 Physician Competency Framework addresses QI in 3 of the 7 roles – Medical Expert, Leader and Scholar. As depicted on this slide, there are 4 key competencies that directly reference quality improvement in the respective roles. The presence of QI as a key competency for physicians signals the legitimacy of the knowledge and skills for change for your careers.
Note: reference the pre-reading article – Improvement science and the future of family medicine.

15. WHAT DO WE WANT TO IMPROVE?
IHI Triple AIM
Patient & Provider
Experience
Population Health
Value ≈ f(Q/$)
The Institute for Healthcare Improvement (IHI) developed a framework – the Triple Aim that describes the 3 foci of quality improvement efforts.
There is a focus on population health which allows for segmenting the population to address specific areas requiring improvement.
Enhancing the patient and provider care experience includes specific foci on quality parameters, access and reliability and also speaks to the overall realm of patient centeredness.
The focus on value is related to the goal of reducing, or at least controlling, the
per capita cost of care. Value is framed as a function of QUALITY/COST implying that an increase in quality while maintaining cost improves value as does a reduction in cost and maintenance of quality.

16. THERE IS SCIENCE TO QI O-X-O
Often singular intervention with control of influencers
RCT
C+M=O
Interventions often complex, multicomponent that are sensitive to complex environmental factors
Social science
Berwick, Don. The Science of Improvement. JAMA, March 12, Vol 299, No. 10.
Building on the Prework article that we asked you to review, the science of improvement incorporates social science and acknowledges the complex, multicomponent interventions that exist within equally complex environments.
O-X-O refers to
O – observe a system
X – introduce a change or a perturbation and
O – observe again
“Properly measured, the changes in outcome are, with a calculable degree of certainty, attributable to the perturbation.”
This resembles a traditional RCT approach and the control of influencers over related processes/systems.
Contrast this with C + M = O where complexity in the system is represented as CONTEXT + MECHANISM (the change) = outcome
“Programs work (have successful ‘outcomes’) only insofar as they introduce the appropriate ideas and opportunities (‘mechanisms’) to groups in the appropriate social and cultural conditions (‘contexts’).”
The Science of Improvement, Dr. Don Berwick
Berwick, Don. The Science of Improvement. JAMA, March 12, 2008—Vol 299, No. 10,

17. IS ALL CHANGE AN IMPROVEMENT?
Every improvement, involves change!
Read the slide.
Reflect on examples where change was not an improvement!

18. ADAPTING TO CHANGE 16% Majority: Early: 34% Late: 34% Early Adopters:
Rogers E.M. Lessons for guidelines from the diffusion of innovations. Joint Commission
Journal on Quality Improvement 21(7):
Majority:
Early:
34%
Late:
34%
Early Adopters:
13.5%
Laggards:
16%
Innovators:
2.5%
TIME
You may be familiar with Rogers curve relating to diffusion of innovations. Adapting to change is an important construct to think about related to quality improvement.
The innovators will be keen to test change; the early adopters will follow the innovators lead with a receptive lens to testing and spreading change; the early and late majority will be watching what is happening and cautiously testing changes once they are reassured that it is relevant and beneficial to do so; laggards will be watching what is happening and will be the last to change. This does not mean that laggards are negative team players – they are often the ‘natural risk managers’ and can lend an interesting and important perspective on the possible impact of specific change.
Keep in mind that individuals play different roles across this curve for different changes. Reflect on how you adapt to change such as a new technology versus a new environment.

19. ENGAGING YOUR COLLEAGUES
Use data to generate light, not heat
Time is a strong driver, give back time
Make physicians partners, involve them where necessary, and involve them early
Identify leaders, champions, laggards etc.
Studies show increased satisfaction with work life if involved with QI work
Use a proven methodology……
As family physicians, you will play a leadership role in the engaging of your colleagues in positive change.
Using date to generate light, not heat illuminates the opportunity for change and frames the current state in a non-judgmental lens.
Time is important to everyone in healthcare; focus on change that focuses on efficiency and giving back time.
Physician engagement is critical to quality improvement success.
Identify where your colleagues are with respect to adapting to change – each player on the Rogers diffusion curve plays an important role in change and supports learning about your system in addition to targeting specific change ideas that are best suited for improvement.
Having the skill and knowledge to drive positive change surrounding your work environment has been proven to increase job satisfaction.
Use a methodology such as the Model for Improvement that is proven to drive improvement.

20. QI CURRICULUM MAP

21. QI PROJECT MAPPING & MILESTONES

22. So now you know, how to….. Define quality improvement
Differentiate the quality drivers in health care
Describe the CanMEDS 2015 ‘key competencies’ related to QI
Set the Triple AIM as the target for improvement efforts
Differentiate the methodology of science of improvement from traditional research and quality assurance methodologies
Outline of the QI curriculum
Review learning objectives

23. QUESTIONS?
Your table group facilitator will be happy to answer any questions.