1. Quality Improvement Clinical Workshop #1
FORGE AHEAD Program Transformation of Indigenous Primary Healthcare Delivery: Community-driven Innovations and Strategic Scale-up Toolkits
Quality Improvement Clinical Workshop #1

2. FORGE AHEAD

3. Funding Canadian Institutes of Health Research The Lawson Foundation
AstraZeneca Canada
This slide must be visually presented to the audience AND verbalized by the speaker. 3

4. Main Goal of FORGE AHEAD
To work with community healthcare providers and community members to develop and evaluate community-driven innovations/activities aimed to improve diabetes care and improve patient access to available services in First Nations communities
Clinical Team and Community Team in each community
Develop action plans and implement during action periods in the community

5. The FORGE AHEAD Team
Strong multi- disciplinary and cross-jurisdictional teams from 9 provinces
First Nations community representatives
Indigenous and non-Indigenous healthcare providers
Clinician scientists
Academic researchers reflecting a wide variety of disciplines from across Canada
Assembly of First Nations (AFN)
First Nations and Inuit Health Branch (FNIHB) of Health Canada
Canadian Diabetes Association (CDA)
Heart & Stroke Foundation

6. Program Activities Overview
National-level Activities
Preparatory Activities
- Community Profile Survey – all 617 First Nations Communities
- Best Practice and Policy Literature Review
- Readiness Tools Development
In-depth Community-level Activities (~ 14 First Nations Communities)
Intervention
Activities
Community Readiness Consultations
Community-driven Quality Improvement Initiative
Clinical Readiness Consultations
Clinical Quality Improvement Initiative
Diabetes Registry and Surveillance System
Wrap-up Activities
- Community and Clinical Readiness Consultations
- Readiness Tools Validation
- Cost Analysis - Common Indicators- Process Evaluation and Surveillance Data
- Scale-up Tool Kit Development

7. Community Participation
Each community has formed a Community Advisory Board to:
facilitate on-going community engagement
make community-level decisions
guide program activities to ensure community needs are met
share knowledge with the community
protect the interests, culture and ways of doing of the community in relation to FORGE AHEAD

8. Community Participation
Each community has a key contact person with joint decision-making power in planning the program and making decisions regarding their data
Each community has a Community Facilitator, a Community Data Coordinator and a Community and Clinical Team
Representatives on the Advisory Board, Steering Committee and in each of the FORGE AHEAD Working Groups

9. Community Facilitator and Data Coordinator
Your Community Facilitator will help guide you through your action plans and action periods
Community Facilitator will stay in constant communication with and support members of the Community and Clinical Team members during the program
Your Data Coordinator will help you prepare reports and graphs summarizing your community’s clinical data to evaluate your activities

10. Wave 1 Community Team Timeline
2014
Nov Dec
2015
Jan Feb Mar Apr
May Jun Jul Aug
Sep Oct Nov Dec
Workshop #1
Action period #1
Workshop #2
Workshop #3
Action Period #2
Action period #3
2016
Jan Feb Mar
Wrap-up Activities:
Readiness Questionnaire
Interviews
Complete Readiness questionnaire

11. Community and Clinical Teams
Two teams of people from each community are working in the program (Community and Clinical Teams)
The teams each complete surveys and participate in workshops to:
identify the community needs, strengths and challenges
find new ways to care for people with diabetes
After the program is done, the team members will be asked to share their experience in participating in the program and their perceptions of the impact of the program

12. Readiness Consultations
The goal of the Community and Clinical Readiness Consultations is to assess the degree of readiness to address diabetes care
You have all completed the readiness questionnaire to help identify factors that influence the development and adoption of innovations in the community
Your Community Facilitator will share the results of the questionnaire with you today and start the consultation component of this work

13. Registry and Surveillance
Contains an up-to-date diabetes registry and surveillance system of adult patients diagnosed with type 2 diabetes
Online system, accessible 24hrs a day, identifies diabetes incidence/prevalence rates and care gaps
Access to the registry will be determined by individual CABs
Western Team ONLY has access to aggregated, de- identified data from all participating communities
Your Data Coordinator is your key contact for the system
Securely house: name, gender, year of birth, type of diabetes, health card #, Band status #, diagnosis date, and other clinical information (e.g. labs, meds, complications…)
Note: The FORGE AHEAD team will work with communities to determine the completeness of existing registry and surveillance systems.

14. Quality Improvement (QI) Initiatives
There are 2 quality improvement initiatives in FORGE AHEAD
One for the Community Teams
One for the Clinical Teams
The reason for having 2 separate initiatives is that in many communities there exists a division between community programs and the medical clinic, in others where there is more integration, it will be hard to separate the 2 and team members may overlap

15. QI Workshops
The workshops for both the Community and Clinical teams include 3 workshops separated by action periods. They are an opportunity to:
build capacity and knowledge with expert presentations;
plan community specific innovation/changes to be tested during action periods; and
share lessons learned across teams.

16. QI Action Periods
During the Action Periods, you will go home to your regular job/work and try to figure out how to carve out some time to meet and to develop and test innovations (changes) in your community
Workshops will cover a variety of strategies to help you face the day-to-day challenges (e.g., small changes, working meetings, huddles, sub-groups in your team)

17. What to Expect?
Others who have participated in programs like this have told us that
they felt completely overwhelmed and lost after the first workshop and needed extra support from the Community Facilitator to stay motivated and committed
things get clearer and the second workshop helps to re-energize and get them back on-track
by the third workshop, most team members have a new way to think about making changes and trying new things

18. Clinical Readiness

19. Clinical Readiness Consultation
Purpose is to determine how your healthcare clinic functions to serve patients with diabetes, and how those functions can be improved
High quality care is characterized by:
ongoing care, ideally from a team of care providers (family physician, nurse, diabetes educator etc)
proactive healthcare - not reactive and responding only when an individual is sick
Readiness consultations are based on the idea that better functioning healthcare systems are more effective at producing the results they are designed to achieve, which in this case is improved chronic care for patients with diabetes

20. Clinical Readiness Questionnaire
The questionnaire assesses how ready a team is to address diabetes care
Questionnaire provides a team readiness score and helps
identify strengths and weaknesses in the clinic
set goals for QI
develop strategies
evaluate success
Learn about how a healthcare clinic functions, and in turn identify key components for improved chronic illness care for patients with diabetes
Will show the expanded chronic care model in the next slide

21. Clinical Readiness Questionnaire
The questions focus on the key components of health systems that can promote high quality care and are related to the Chronic Care model
Each question is on a scale from 0 to 11 with an opportunity to describe why you believe that number reflects the state of their health clinic.
Barr et al., 2003

22. Components
Information Systems & Decision Support
Local Health Centre Organizational Influence and Integration
Linkages with Community Resources & Other Health Services
Self-management Support
Delivery System Design
5 components of health systems have been identified to be influential for improving chronic care for patients with diabetes

23. Components
Each components has been defined and include a number of sub- components that are broken down into items
Components of clinical systems
Sub-components
1. Delivery system design
This component refers to the extent to which the design of the health center’s infrastructure, staffing profile and allocation of roles and responsibilities, patient flow and care processes maximize the potential effectiveness of the center
1.1 Team structure and function
1.2 Clinical leadership
1.3 Appointments and scheduling
1.4 Care Planning
1.5 Systematic approach to follow-up
1.6 Continuity of care
1.7 Patient access
1.8 Cultural competence/knowledge
1.9 Physical infrastructure
2. Information systems and decision support
This component refers to the clinical and other information structures (including structures to support clinical decision making) and processes to support the planning, delivery and coordination of care
2.1 Maintenance and use of electronic or paper diabetes registry
2.2 Evidence based guidelines for diabetes
2.3 Specialist and generalist collaboration
3. Self-management support
This component refers to structures and processes that support clients and families to play a major role in maintaining their health, managing their health problems, and achieving safe and healthy environments
3.1 Self-management support, assessment and documentation
3.2 Self-management education, behaviour risk reduction and peer support
4. Linkages with community resources and other health services
This component refers to the extent to which the health center uses external linkages to inform service planning, links clients to outside resources, works out in the community, and contributes to regional planning and resource development
4.1 Communication and cooperation of the health center and other community based organizations and programs
4.2 Linking health center patients to community resources
4.3 Community outreach
4.4 Regional health planning and development of health resources
5. Local health center organizational influence and integration
This component refers to the use of organisational influence to create and support organisational structures and processes that promote safe, high quality care; and how well all system components are integrated across the center
5.1 Organisational commitment
5.2 Quality improvement strategies
5.3 Integration of health system components to achieve high quality care for patients with diabetes

24. Clinical Readiness Questionnaire
The questionnaire will be completed 3 times:
Before the first QI workshop,
During the second QI workshop, and
After the last workshop
By completing it three times, we can capture changes in readiness over time
First QI session for wave 1 is in January (see slide 36ish)

25. Clinical Readiness Report
The report will include:
Summary of Component Scores
Sub-component scores with a summary of response descriptions and the associated item for discussion

26. Overall Scores Each score can range from 0 to 11
Each score can be linked to a ‘category’
Limited or no support
(not working)
Basic support
(working okay)
Good support
(working well but could improve)
Fully developed support
(working well)

27. Sample Component Scores
Delivery System Design: refers to: the physical layout of the health centre; staffing roles and responsibilities; and client flow and care support processes 5
Information Systems and Decision Support: refers to: clinical and other information structures (including structures to support clinical decision-making) 7
Self-management Support: refers to health centre structure and processes that support clients and their families to play a major role in maintaining their health, and managing their health problems 2
Linkages with Community Resources and Other Health Services: the appropriateness of population health programs and activities 4
Organizational Influence and Integration: refers to the use of organizational leadership to: create a positive workplace culture; support organizational structures and process that promote safe, high quality care; and ensure all the system components contribute to integrated care across the health centre. 3

28. Sample Sub-component Score
(0-11)
JUSTIFICATION
ITEMS FOR DISCUSSION
Team Structure and function 5
“The physicians are all too busy and not always here so the nurses make most of the decisions”
Team approach
Leadership
Definition of roles and responsibilities and lines of reporting
Communication and cohesion
Developing team members’
skills and roles

29. Take Home Message
The readiness report is meant to provide a snapshot of your community based on team members’ input
To help you succeed in improving care for people with diabetes, the changes you make must be appropriate for your clinic’s stages of readiness!

30. Identifying Community Priorities

31. 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?
References
1. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
2. The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." 3.
PLAN DO
STUDY
ACT

32. Things to Consider
The readiness results can support the identification of areas for improvement
Focusing on the areas with low readiness scores is often the best way to make successful improvements
Aligning priorities to existing mission statements or strategic plans in the community can make it easier to implement innovations/changes (i.e. buy-in and acceptance)
It is important for the team to reach consensus about what the areas of focus should be
Action plans, strategic plans, or mission statements that already exist in a clinic, or in community program
There may be strong interest by the community in certain areas for improvement (e.g., it is known that the community wants more access to face-to-face clinical services or that there is desire for more physical activity programming).
How easy will it be to accomplish the goal? How expensive will it be? For example, does it require expertise the clinic or community do not have?
Existing plans, strategic plans, missions statements, community goals that already exist
Building off of plans can ensure consistency, cooperation, and build off of already existing efforts/energies
There may be an existing interest by the community and/or patients for certain areas of improvement
(e.g., it is known that the community wants more access to face-to-face clinical services or that there is desire for more physical activity programming
How easy it will be to accomplish the goal or make improvements? How expensive will it be? Its it feasible?
How expensive will it be? For example, does it require expertise the clinic or community do not have?

33. Identify Potential Areas for Improvement
Encourage your team to identifying a small number of areas (2-4) to help focus improvement efforts (ensure the group is NOT trying to do too many things at once)
This whole process helps the team consider all relevant areas for improvement and supports decisions to focus on improvements that are most likely to be successful
Do not forget to use the readiness scores, the teams interpretation of the readiness scores, although it is up to the teams to decide which areas to focus on
Focusing on weaknesses of the readiness scores are often the best ways to make improvements
The list will be long, the prioritizing is critical and feasibility is important, it’s not about consensus but what is bugging the team the most what do you want to do in the next 2 weeks

34. Develop the Short List
Once the potential areas for improvement have been identified, the team can flag the areas that they believe are most likely to bring positive results
Consider feasibility at this point
how easy will it be to accomplish this?
how expensive will it be?
do we have the experts needed?
Do not forget to use the readiness scores, the teams interpretation of the readiness scores, although it is up to the teams to decide which areas to focus on
Focusing on weaknesses of the readiness scores are often the best ways to make improvements
The list will be long, the prioritizing is critical and feasibility is important, it’s not about consensus but what is bugging the team the most what do you want to do in the next 2 weeks

35. Quality Improvement Initiatives
PDSA Cycles

36. Key to Quality Improvement
Making things better requires making changes, but not all changes result in improvement
It is critical to identify the changes that are most likely to make things better
consider readiness consultation results

37. Key to Quality Improvement
Also, it is important to find out if a specific change actually resulted in improvement
think of the registry and surveillance information  how can this information be used to see if change made a difference?

38. The Model for Improvement
3 questions to set a time-specific and measurable goal to make changes for a specific population or an issue
Plan-Do-Study-Act (PDSA) cycles to test changes on a small scale
Designed to implement change more quickly than traditional quality improvement planning
References
1. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
2. The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." 3.

39. 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?
References
1. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
2. The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." 3.
PLAN DO
STUDY
ACT

40. Question#1: What are we trying to accomplish?
Improvement requires identifying priority areas and setting aims that are:
Clear and time-specific (date for achievement of goals)
Measurable
Define the specific population of patients or other system that will be affected
Should provide real value to community members
Mike, HQO had this statement listed on their website related to this question of the MFI, not sure if you want something like this on the slide. Aiming for small, incremental change (e.g., moving from below average to average, or changing by 10%) does not represent a real breakthrough in quality and may not justify the stakeholder’s time investment. For support in setting a stretch goal, it is helpful to review practices of leading organizations in the field. If there are no clear examples, aim to decrease i.e., suboptimal care, adverse events or undesirable wait times by half as a first step, or improve a measure by 50%.

41. Question#2: How will we know a change is an improvement?
Measures
Examples
Outcome measures:
what are the results?
infection rates or attendance in programs
Process measures
how did it work or not work?
program activities were always cancelled, or reminder s were always sent the day before an activity or appointment
Balancing measures
are changes in one area causing problems in another?
staff vs client satisfaction, or financial implications

42. Question# 3: What change can we make that will result in improvements?
Ideas for change may come from:
the insights of those who work in the system
change concepts or other creative thinking techniques
borrowing from the experience of others who have successfully improved.
Example, scheduling exercise classes on days of the week that have the least demand for the gym is a change idea.

43. Plan-Do-Study-Act (PDSA) Cycle
Is a tool to help test a change in a real world settings by planning it, trying it, observing the results, and acting on what is learned
Testing ideas quickly and on a small number of people/patients
Build from one cycle to the next until there is enough evidence and confidence to implement a change across the system
This process allows the improvement effort to increase belief the change will result in improvement, measure the amount of possible improvement and evaluate the costs and side effects of change before jumping to implementation

44. The PDSA Cycle ACT PLAN STUDY DO 4 1 3 2 Objective questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
What changes are to be made?
Next cycle?
Reference
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 data analysis 3 2

45. Why Test? Increase belief that the change will result in improvement
Document how much improvement can be expected from the change
Learn how to adapt the change to conditions in the local environment
Minimize resistance upon implementation
Evaluate costs and side-effects of the change

46. Examples
Foot exam protocol

48. What is your team trying to accomplish?
Scenario:
Readiness Score: 4 information systems and Decision Support and 2 for evidence-based guidelines for diabetes
Information: the registry and surveillance system shows that only 20% of patients with diabetes have had a foot exam last year.
Local Knowledge: the clinic team knows about the guidelines but are not sure how to go about getting a foot exam done when they are so busy with other things, and they do not know who needs one and who does not

49. Example: Foot Exam Protocol
CDA guidelines state that at minimum, a foot exam should be performed on patient with diabetes every 12 months
Aim Statement: Improve the care of patients with diabetes by implementing a foot exam protocol
Goal: Meet target guideline of a foot exam every 12 months for patients with diabetes
Result: A clinical protocol is in place within a month of initial testing demonstrating the power of rapid testing with small numbers to speed-up learning

50. Example: Foot Exam Protocol
Goal: Meet target guideline of a foot exam every 12 months for patients with diabetes
Plan: Best practice says that if the patient’s shoes and socks are off when the physician enters the room, a foot exam will be completed 100% of the time.
Do: The team begins with ideas to prompt the physician to remember to do the exam.
Study: After a single day of testing with a handful of patients it is clear that the physician does not have enough time to remove shoes and socks, conduct the exam and then record the exam results.
Act: Delegate work across the team to save physician time and retest.
Plan: Ensure that the person rooming the patient remove shoes and socks.

51. Multiple Cycles to Implement a Foot Exam Protocol
Foot exam protocol in place within one month of initial test
Cycle 5: Implement process for
all patients as a clinic protocol
Can implementing a foot exam protocol improve percentage of patients with a foot exam (target: once every 12 months for patients with diabetes)?
Cycle 4: Put foot care stamp in EMR or flag paper chart
to prompt RPN. Test. All patients received foot exam
Learning
Cycle 3: RPN rooming patient removes shoes and socks.
Test w/ 5 patients next day. 4 of 5 feet examined.
RPN forgot to remove shoes with one patient
Cycle 2: : Post sign to prompt patients to remove shoes and socks.
Test with 5 patients next day. Most patients did not understand.
Cycle 1: Monofilament placed on exam table to prompt provider.
Test with 5 patients on one day. No exams done. Provider ran out of time.

52. What Did We Learn?
We want failures during testing… not during implementation!
We want to learn reasons for failed tests
Change not executed well – or at all!
Support processes inadequate
Hypothesis was wrong:
Change did not result in local improvement
Or local improvement did not impact global measures
Need to collect information/data during testing
Sharing saves time!
Not all test are equal…

53. Measurement and Data Collection During PDSA Cycles
Collect useful data, not perfect data – the purpose of data is for learning and quality improvement, not evaluation
The FORGE AHEAD research team will take care of evaluation of the program as a whole

54. Measurement and Data Collection During PDSA Cycles
Use a pencil and paper until information system is ready (e.g. registry and surveillance)
Use qualitative data (feedback, experience, observation) rather than wait for quantitative data
Record what went wrong during the data collection

55. Activity: PDSA vs Task Have a meeting
Meet with a patient to set personal health goals
Having allied staff do a monofilament insensate test
Reading the registry/surveillance training manual
Obtaining a guideline for diabetes care
Have a huddle at the clinic to get ready for the day

56. Remember! Small tests Quick tests
Test now (versus waiting to get it right)
Test failures (the null hypothesis)
Consensus – No!
Don’t confuse tasking with testing
Testing is a team sport!

57. Quality Improvement Initiatives
Goal Setting

58. Getting the Info you need
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?
References
1. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
2. The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." 3.
PLAN DO
STUDY
ACT

59. Building on the Readiness Consultation Results
Remember to use the overall scores, the item scores, and the qualitative answers in your readiness reports
Think of the work you will have done with your team to integrate those results with local knowledge and experience

60. How are you going to do it? How will you know if it work?
What change can we make?
Specific Change Ideas
Broad – General Direction
Priority Area for Improvement
What is the goal?
Where do we start?
How are you going to do it?
How will you know if it work?
What are we trying to accomplish?
What is expected to happen?
How does the team know where to start?
How will we know a change is an improvement?

61. Goal Setting
Goals should be specific and worded in a way that helps identify how to measure success
It can be useful to use a series of goals – long, medium, and short term goals
It is important to monitor success and re-adjust future action to reach these goals
Making sure the goal isn’t too big
Clinic – I want to improve diabetes care – well which part of diabetes, which steps do you want to take

62. S – specific M – measurable A – attainable R – realistic T - timely
How to write a goal?
What is the goal?
System to be improved
Setting or sub- population of patients
Specific numerical goals to be attained
Timeframe
Anticipate outcomes
S – specific
M – measurable
A – attainable
R – realistic
T - timely
Educational materials presented at the educational workshops, clinical guidelines, best practices, trial and errors of other communities

63. How does the team know where to start?
How are you going to do it?
Readiness consultation results
Educational materials from workshops
Local knowledge
Registry and surveillance system
Consultation with experts, patients, family members, etc.
Educational materials presented at the educational workshops, clinical guidelines, best practices, trial and errors of other communities

64. How will we know a change is an improvement?
Measures
Outcome measures
what are the results?
Process measures
how did it work or not work?
Balancing measures
are changes in one area causing problems or benefits in another?

65. How are you going to do it?
Plan-Do-Study-Act (PDSA) Cycle
test a change: plan it, try it, observe the results, and act on what is learned
Testing ideas quickly and on a small number of people/patients
This process allows the improvement effort to increase belief the change will result in improvement, measure the amount of possible improvement and evaluate the costs and side effects of change before jumping to implementation
Build from one cycle to the next until there is enough evidence and confidence to implement a change across the system or community

66. Example: Goal to Action
Anticipated result: Diabetes Flow Sheet used by all clinicians in the clinic within 3 months
Cycle 5: Final version implemented across clinic within 2 months and guideline driven measures of care tracked.
Long Term Goal: Improved Planned Care for patients with diabetes ______________________________________Short – term Goal: Implement a diabetes flow sheet to improve delivery of guideline-based care
Cycle 4: V4 discussed at monthly all staff meeting
and V5 tested with providers new to the process
Learning
Cycle 3: V3 test with 3 providers for one week with 30
patients. Data on number of care gaps addressed is tracked
Cycle 2: : Revise flow sheet and test V2 with same provider on Thurs.
Cycle 1: Download CDA diabetes flow sheet and test with one provider
on Tuesday using all patients with diabetes coming in that day

67. Facilitation Tool: Goal to Action template
Anticipated result: ____________________________________________________________________________________
Cycle 5: ____________________________________________________________________________
Long Term Goal: ________________________________________________________________________Short – term Goal: ________________________________________________________________________
Cycle 4: ____________________________________
___________________________________________
Learning
Cycle 3: _________________________________________
________________________________________________
Cycle 2: : _______________________________________________
_______________________________________________________
Cycle 1: _____________________________________________________
____________________________________________________________

68. Activity: PDSA vs Task Have a meeting
Meet with a patient to set personal health goals
Having allied staff do a monofilament insensate test
Reading the registry/surveillance training manual
Obtaining a guideline for diabetes care
Have a huddle at the clinic to get ready for the day

70. Techniques to Accelerating Testing
Plan multiple cycles for a test of a change
Think of a couple of cycles ahead of time
Initially, scale down size of test (e.g. # of patients)
Test in parallel rather than sequentially – try more than one things at once (e.g. foot exam protocol and annual testing A1C)

71. Techniques to Accelerating Testing
Do not try to get buy-in or consensus for test cycles
Be innovative to make test feasible
Collect useful data during each test
Test with volunteers – people that embrace the idea of change and improvement

72. Facilitation Tool: Multiple PDSA Template
Goal 1: __________________________________________________________
Cycle 5: _________
Cycle 5: _________
Cycle 5: ______
Learning
Cycle 4: ________
Learning
Cycle 4: _______
Learning
Cycle 4: ________
Cycle 3: _________
Cycle 3: _________
Cycle 3: _________
Cycle 2: _________
Cycle 2: _________
Cycle 2: _________
Cycle 1: _________
Cycle 1: _________
Cycle 1: _________

73. Example: Multiple PDSAs
Goal 1: Proactive Outreach to Targeted Populations Using Registry
Cycle 5: Implement protocol
Cycle 5: Multi med rec strategy implemented
Cycle 5:
2 pronged care mgt strategy
Cycle 4:
MD calls non-responders
Cycle 4:
RN does med rec on phone
Cycle 4: MD visits home bound
Learning
Learning
Learning
Cycle 3:
RN calls lost to follow up
Cycle 3:
Pt. Re-scheduled if no meds
Cycle 3:
RN recruits pts at visit
Cycle 2:
MA calls lost to follow up
Cycle 2:
Front office calls to bring in meds
Cycle 2:
Letter to complex pts
Cycle 1:
Front office mails letter to lost to FU
Cycle 1:
Letter to bring in meds
Cycle 1:
Complex care risk identifier tested

74. Staying on track
Moving from broad areas for improvement to specific goals
Are you still working in line with your aim statement?

75. Registry and Surveillance System
First Nations Diabetes Surveillance System

77. Total number of adults (18 years and older) diagnosed with T2DM
Registry
Patient-level reports and graphs are accessed from the Patient Registry
Total number of adults (18 years and older) diagnosed with T2DM

78. Patient Reports & Graphs

79. Community Reports & Graphs
Click here…
…to see this
As a User you may view any “Predefined Reports” created by the FORGE AHEAD team at Western but you can only edit the “Start & End Date” fields

80. Community Reports & Graphs
…to see this
Click Print to print any report
Click here…
Clicking on individual patient StudyID will take you to the patient’s file in the Patient Registry

81. 5 Types of Graphs TARGET TREND CLINICAL MANAGEMENT
CLINICAL PERFORMANCE
COMPARISON

82. Target Graphs
Target graphs are used to display the number of people that meet a target, such as BMI

83. Trend Graphs
Trend graphs are used to display the change in values, such as BMI, HbA1c or LDL over time

84. Clinical Management Graphs
Clinical Management graphs are used to display a number of indicators about patients including screening, medication and lab result values

85. Clinical Performance Graphs
Clinical Performance graphs are used to display the number of patients on whom indicators were collected

86. Comparison Graphs
My community
FA communities
Comparison graphs are used to compare variables from one site with other sites. Only one variable can be displayed per graph

87. Creating Your Own Graph
You will see this screen
The New Graph screen allows the user to create one of five types of graphs:
1 .Target Graph
2. Trend Graph
3. Clinical Management
4. Clinical Performance
5. Comparative
Click New Graph in the Reports navigation

88. Scenario 1
To understand the patient characteristics of the community, Dr. Pink wants to know how many patients are at target for LDL-C
This is a snapshot of the practice, so Dr. Pink would want to…

89. Create a Target Graph

90. Link to Goal Setting and PDSA
Let’s say your team’s goal was to have 90% of your patients at target for LDL and entered in FNDSS by September 2014
What does this graph tell you?
Now that you have more information, do you need to adjust your goal?
What did your other measure tell you? - Outcome measures (what are the results), Process measures (how did it work or not work), Balancing measures
(are changes in one area causing problems in another)
What might be possible explanation for still having 20% of your patients with no data in the system?
Some patients have higher priorities for their health e.g. dealing with cancer
Do you need more PDSAs or should you implement the changes you made at a large scale?

91. Scenario 2
Dr. Pink wants to know if the changes his team has made over the last action period has improved A1Cs of patients with poor control (A1c > 8.5%) in his community
This is a time-sensitive graph, so Dr. Pink would want to…

92. Create a Trend Graph
Specify Timeframe
Interpret the results

93. Link to Goal Setting and PDSA
Let’s say your team’s goal was to see a reduction in your patients with an A1c>8.5% by 20% by April
What does this graph tell you?
Now that you have more information, do you need to adjust your goal?
What did your other measure tell you? - Outcome measures (what are the results), Process measures (how did it work or not work), Balancing measures
(are changes in one area causing problems in another)
What might be possible explanation for the spikes seen in this graph?
Understanding the data contained in FNDSS
Percents shown are percent of patients for whom an A1c is available at each month who have poor control
What does the graph show?
Large % in January – effects of holiday season
Small % in December – not many coming in for A1c
Need to communicate with other team members to help interpret and understand results
Do you need more PDSAs or should you implement the changes you made at a large scale?

94. FORGE AHEAD Program Transformation of Indigenous Primary Healthcare Delivery: Community-driven Innovations and Strategic Scale-up Toolkits
Tracking PDSA’s

95. Meeting agendas
Community facilitators will work with you to develop meeting agendas to help you track your ideas, progress and decisions
This will be really important to help you stay on track and not lose track of great ideas
Also, they will help the Western Team assess the impact of the program

96. Tracking PDSAs
Tracking PDSAs is a great way to remember what worked and did not work
This information will be invaluable when collaborating with fellow communities participating in FORGE AHEAD
Tracking will help the development of the scale up toolkits at the end of the program

97. Tracking Templates
The Community Facilitators have been provided with templates for the meeting agendas and for the PSDA development
You already started using these today in your breakout sessions
Continue to use the templates and share them with your Facilitators to help track your progress and ideas

98. Meeting Agenda Template

99. PDSA template
Anticipated result: ____________________________________________________________________________________
Cycle 5: ____________________________________________________________________________
Long Term Goal: ________________________________________________________________________Short – term Goal: ________________________________________________________________________
Cycle 4: ____________________________________
___________________________________________
Learning
Cycle 3: _________________________________________
________________________________________________
Cycle 2: : _______________________________________________
_______________________________________________________
Cycle 1: _____________________________________________________
____________________________________________________________

100. Tracking Templates
The Western Team will be using information on the agendas and PDSA forms to document where you focused your quality improvement efforts
They will use it to show how your efforts relate to changes in your readiness score and clinical processes and measures

101. Facilitator Support
It is not our expectation, that you be completely ready to go and completely clear about everything when you leave today
The Facilitators have been trained to help you during the whole program – during the workshop and back in the community
We suggest that you meet when you are back home on a regular basis particularly for the first few months to help you get started

102. Meetings Make some decisions and pre-book time! Format: 1 hour monthly
2 hours monthly
1 hour bi-weekly
Timing:
Day of the week?
Time of day?

103. Support from each other
It is important to work together, and make sure that all team members can contribute
Everyone here will experience some things that are the same and some things that are different…but we are all in this together!
Your Facilitators can share your questions or comments or concerns with the Western Team and the other communities participation in FORGE AHEAD

104. Support from each other
Sharing and learning from each other will be immensely beneficial and help accelerate troubleshooting
If you need help, if you have a burning question share with your Community Facilitator and we can share it with the whole group
There is a lot of support available
Communication is key in FORGE AHEAD

105. Collaborate with the Community Team
The Facilitators can:
help your team do quality improvement work
help your team bridge the gaps that often exist between clinical and community programs
facilitate sharing of ideas and efforts across the community and clinical team
point out ways to avoid duplication and take advantage of opportunities