1. QI in Action: Improving Preventive Care in Family Medicine
Application Session – FM QI Curriculum

2. Purpose of this exercise
Review core QI curriculum content from the 4 e-modules by examining a pneumococcal vaccination improvement project:
Building a QI team
Developing a problem statement
Setting an aim
Identifying measures
Completing system diagnostics to support identification of change ideas
Testing change ideas (PDSA cycle)
The project that we will use throughout the presentation is pneumococcal vaccination in patients aged 65 and older.

3. Model for Improvement Specify and set the aim Establish measures
Identify change ideas
Turn ideas in action, action into learning
We will use the Model for Improvement as our roadmap for the deconstruction. (review elements of MFI)

4. The Model and Your QI Project
Page 10 of workbook
Site QI Meeting / QI Project Idea
Form QI Team
Initiate project charter
Define problem statement
Complete stakeholder engagement
Identify Aim and family of measures
Describe data collection plan
Set Aim
Establish Measures
Complete system diagnostic tools
Select change ideas
Identify Change Ideas
PDSA change ideas
Connect MFI to their Project Map
Test Changes
Project Poster and Guide
Source: Paula Blackstien-Hirsch

5. Building a QI Team Stakeholders (page 24) Patrons
Sponsors
Champions
Users of the QI Initiative
Staff
Patients
Advisors on QI
Specialists
Data Support
Our Pneumococcal Vaccine QI Team
Residents
Faculty / supervisors
RN/vaccination program lead
EMR administrator/ IT expert
Administrative support
Discuss example and compare to stakeholders in the workbook

6. Building your blueprint - the Charter (page 30)
The Project charter:
Is a “live” document to be used throughout the improvement project
Helps plan the project, communicate with leadership and keep track of changes being made
Is used at every meeting to provide a focus for discussion and record generated ideas
Discuss example and compare to stakeholders in the workbook
See Appendix in the workbook

7. Developing a problem statement
Our Pneumococcal QI team found:
Incidence of Invasive Pneumococcal Disease (IPD) = 10 cases per 100,000
Across Canada: Mean 3263 cases per year ( )
Ontario: Mean 1130 cases/year ( )
Pneumovax has been proven to reduce the risk of Invasive Pneumococcal Disease (IPD) and NACI recommends its use.
However, many eligible patients have not been offered Pneumovax
BUT…Is this their context?

8. Helpful hints… Remember, the problem is at your micro-system level
Ask yourself…
Why is this improvement important to your organization?
Is there data or other evidence that helps to highlight the problem?
Highlight the “pain” - to the patients, to the families, to the organization

9. Our Pneumococcal team’s approach…. (page 30)
What is the problem you wish to address?
Why is it a problem? (the pain)
Where do we observe the problem?
Who is impacted?
When does it occur? (ongoing or recurrent?)
Which quality dimensions are involved?
Low rates of pneumococcal vaccination in those ages 65+
39% vaccination rate in target pop. (source: EMR)
Burden of preventable disease
Impact on patient – hospitalization
Cost to health care system
Across the FHT but variation by providers
Resident practices have lower rates of vaccination
Patients, families, providers
Ongoing problem
Rates stable for last 3 years
Patient-centered, Effective

10. A problem well stated, is a problem half-solved
Our problem, at Sunshine FHT, is that only 39% of our clients aged 65 years or older were vaccinated in This is despite pneumovax being demonstrated as safe and effective and being publicly funded in Ontario. This low vaccination rate may lead to unnecessary disease burden for our patients and their families which may then require additional resources from our team.

11. Model for Improvement Specify and Set the Aim Aims help us…
Inspire and motivate staff to engage in improvement work
Know whether and when we’ve achieved our goal

12. Set and Specify and AIM (page 33)
Ask yourself…
What system is to be improved?
Who is the population of focus?
What is expected to happen?
What is the timeframe?
What is the goal?
Helps us create Smart Aims
Specific
Measurable
Attainable
Relevant
Time-bound

13. The pneumococcal QI team’s aim:
Keep the scope manageable
In the residents’ practices, we will
increase pneumococcal vaccination rates for patients aged 65
and older from 39% to 70% by June 30, 2016.
Specific
Action
Target population
Measurable:
From current to future state
Attainable
Relevant:
Patient-centered
Effective
Time-Bound
Timeline for change
(months, days, years)

14. Model for Improvement Identify a Family of Measures
To bring new knowledge into daily practice
Stabilize the biases from test to test (accept consistent bias)
Gather “just enough” data to learn

15. Helpful Hints
Data for QI is different than data for research or data for accountability (page 34)
Include outcome, process, and balancing measures
Follow measures frequently and continually
“Time is the teacher”
Dr. Don Berwick

16. The Pneumococcal QI team’s Measures
Type of measure
Outcome measure: the voice of the patient (what is important to them)
Process measure: the voice of the process; reflects system performance
Balancing measure: unintended consequences
The team’s measures
Percentage of eligible patients who received pneumovax
Percentage of eligible patients who came for a visit and are offered pneumovax
Increased in days of the waitlist to see the RN

17. A picture is worth a thousand words
Use run charts to:
Plot data over time
Learn from your data
Share with stakeholders
Key messages: as you move forward with your project and view the measurement modules, run charts will become clearer.

18. Model for Improvement Sources of Change ideas
Diagnostic tools inform change ideas
Knowledge experts
The QI team – think logically
Creativity tools and technology
Copy, replicate, duplicate – “Steal with pride”
Begin! Be open to learning from testing .

19. The Pneumococcal QI Team’s Diagnostics
Fishbone Diagram:

20. The Pneumococcal QI Team’s Diagnostics
Process Map:

21. The Pneumococcal QI Team’s change ideas

22. Model for Improvement
Turns our ideas into action, and our action into learning

23. PDSAs
All of the elements of the MFI are important. But if I had to choose one as the most important, the “heart of the Model”, it is the process of testing: the PDSA. Dr. Don Berwick

24. PDSAs are grounded in science

25. PDSA cycle (pg. 43)

26. The Pneumococcal QI Team’s PDSAs
Cause from Diagnostics: Patients unaware
Change Idea: Poster in waiting room
PDSA worksheet (page 51)
Objective: Develop a poster for the waiting room to increase awareness
Who, What, When, Where?
Team to decide on content and design
Test with poster on Tuesday morning. Ask 10 clients if they saw poster (y/n data) and what information they recalled (tic sheet).
Predict that 6 / 10 patients will see and recall info
Decided to modify
Changed design (more pictures / less info)
8 clients reported seeing poster
5 correctly reported to ask provider
Results worse than prediction
Carried out the test and collected the data.

27. The Pneumococcal Team’s PDSAs
6 cycles for the poster idea
3 to develop the poster (change content and colour)
3 to test under various conditions to find the best location
Second change idea was EMR alert
5 cycles to learn the best way to use the EMR for the alerts

28. The Pneumococcal Team’s results

29. Do you have questions?