1. Practice Improvement –
Making Quality Improvement Work for You
A series of Small Group Learning Sessions:
Session 4: Sustaining, Sharing, Spreading Improvements
Session Date
Presenters’ Name(s)

2. Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
Grants/Research Support: PharmaCorp ABC
Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
Consulting Fees: MedX Group Inc.
Other: Employee of XYZ Hospital Group
Please fill out all applicable areas (highlighted in red). One slide per speaker.

3. Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
[Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
[Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
Please fill out all applicable areas (highlighted in red).

4. Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to the College of Family Physicians of Canada’s “Quick Tips” document.
Please fill out all applicable areas (highlighted in red).
Please visit the following link for the CFPC’s “Quick Tips” document:

5. Introductions: Peer Mentor and RST
Please introduce yourselves and emphasize the working together/helping each other atmosphere, not just between Peer Mentor and RST but among each other (eg. Peer Mentor and audience)
Peer Mentor to provide example of case highlighting benefits to patients, practice and the physician experience. (ie your story about QI experience)

6. Agenda Welcome Action Plan Report out (30 min) Quick Recap
What changes to implement?
Break (10 min)
Sustainability
Spread
Action Planning
Here is our plan for the day. We will spend a full 30 minutes reporting out from your AP work – this is an opportunity to share challenges and successes and to learn from each other. Then we will do a quick recap of where we’ve come from to make sure we’re starting from similar places, and move into talking about how you decide whether to implement a change.
We’ll have a quick break, and talk about sustainability and spread in the context of your practice.
We’ll have discussion and activities throughout each section, and will finish with some structured time for Action Planning.

7. What is a SGLS?
Focus on application of knowledge and practical problem solving
Group of physicians and practice team members
Short &
Interactive
Session
Ongoing support
Action Plan
In-Practice visit with RST
Integrated Learning Package
Facilitators: Peer Mentors & Regional Support
Team Coordinators/Coaches
Small Group Learning Sessions (SGSL) are offered by the Practice Support Program (PSP) as a result of demand for short, accessible training sessions on priority content.
Small groups of physicians (and in some cases their teams) get together for short, interactive education sessions that are certified by the College of Family Physicians of Canada for group learning credits.
Peer Mentors guide participants through the content, encouraging questions and discussion throughout.
There is a focus on applying knowledge and lots of support for integrating session learnings and applying them in the practice.
Lots of options for ongoing support and learning
Sessions provide opportunity for both social and educational learning

8. Housekeeping www.gpscbc.ca/psp-learning/
Please put your cells on vibrate or turn them off. We appreciate that you may need to step out to take urgent calls. Please feel free to do so, but - as a courtesy to others - please keep your phones on vibrate.
Washrooms are here and there. We know emergencies sometimes come up so please feel free to leave the room if you need to take a call
We’ll be taking a 15 min coffee break at _____ and then there will be ______ when we finish at ______
Timing – We have two and half hours together today, and we’re going to work really hard to stick to this. We will be providing timelines for the activities and we ask for your help in keeping us all on track! We’ve tried to account for quite a lot of discussion and interaction time, so our hope is that we can achieve our timelines and get your questions answered. That being said, if we move on from a topic that you’d like to discuss further or get more information on, please make a note and let the RST know after the session; they can help make sure that you get what you need in an in practice visit.
We have a post session evaluation and ask that you fill it out carefully so that we can share it with the provincial office and try to integrate improvements to these sessions– in the true spirit of quality improvement!

9. Learning Objectives Determine when to adapt, adopt or abandon a change
Plan for sustaining improvement over time
Consider spread of improvements
At the close of this session, we hope you will feel very comfortable in doing these -

10. Action Plan Report Out Share your Action Plan work.
Challenges, learnings.
Turn and introduce yourself to your neighbor, and talk about the work they did in their Action Plan. You might discuss identifying opportunities for improvement in your practice or pain points identified by the team, what learnings from the last session that you integrated and why, how your office team responded to this work, and what challenges you encountered.
We are going to take extra time with this today – a full 30 minutes to talk about your first PDSA.

11. Review - Steps for QI project
Decide what needs to improve?
Build a team who knows about the process.
Clarify what the current process is.
Brainstorm ideas and test changes.
Implement sustainable changes.
Share learnings.
Hopefully this diagram looks familiar from prior sessions.
Today we’re going start after many of these steps have been done - just like where you are in your AP.
- you’ve figured out what needs to improve via problem and aim statements
- you’ve worked with your team to understand what the current processes impacting the problem are
- you’ve identified many change ideas with your team and have started to test some of them via PDSA cycles.
Now what? Where is all this going?
You want to implement changes, and you want them to be sustained. How will you know what changes to implement? We will talk about this today. First a quick recap about PDSA
Implement sustainable changes.
After you’ve tested your ideas and found which is most effective, you can move to implementing this change in your practice. It’s important to take the time to understand which ideas are worth implementing, and which should be abandoned altogether – or first adopted.
Share learnings.
When you find something that works, it’s important to celebrate this and share your learnings with others – colleagues, clinics, etc. If all the members of your team are engaged in improvement and share your successes with their peers – you will all have more opportunities to learn from each other.
QI is an iterative process – you may move onto brainstorming ideas with your team and realize you still need more data, that you are missing a key person on your team, or even that you still have different ideas about what needs to improve. That’s okay. This is just part of the process and shows you are working hard.

12. Model of Improvement & PDSA
Aim Statements
Measures
Change ideas
Each PDSA cycle repeats the questions for a very specific, narrow question.
Think back to the video – there are several core questions that it’s important to ask when starting out and thinking about making improvements in your practice.
The model of improvement and PDSA cycles provide a structure through which to operationalize many of the steps for QI projects we will continue to discuss.
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?
From this point, you start to run PDSA cycles, which repeat the questions for a very specific, narrow question.

13. PDSA A way to test a change in your practice:
Plan – Understand the problem. Describe how you will test an improvement strategy
Do – Implement your plan – test your improvement/change strategy
Study – Measure whether the test worked. Can it be improved in any way?
Act – Review your test and decide what to do – adapt, adopt, or abandon

14. Repeated use of the PDSA Cycle
Increasing:
- complexity
- # of people
- different situations
PDSA cycles start small and then get more complex over time, until you have tested changes that you are confident will work.
When the team’s predictions start to be right all the time, it is time to move to more sophisticated tests – with more people and under different conditions.
This is a PDSA ramp that shows how testing progresses from an idea to a change that results in improvement over time.
Time

15. PDSA Reality
While PDSA cycles seem straightforward, using them in a project is not necessarily a linear event. There can be multiple PDSAs going on at the same time, each at different stages.
The important thing is to keep track of the learning that comes from each cycle.

16. How do you decide to implement a change?
Discussion
Adapt
Adopt
Abandon
Ask the group how they think they’d decide to implement a change vs keep testing – brief discussion.
Click
The following slides can also be presented in handout form as well/instead.

17. When to Adapt? Default option – “Adapt with abandon!”
You should adapt a change strategy and re-test unless there is a clear indication that it will not work
You should have:
Completed at least 1 full PDSA
Developed a hypothesis
Measured something
Results = accurate hypothesis or suggestion that some tweaks can make it accurate
This is the default option.
Prototype phase; “Adapt” with abandon!
“You have evidence that your change strategy could get you the results you want. Tweak your strategy based on your testing and try again.”
You have:
done at least 1 full PDSA
developed a hypothesis
measured something
The results of your test (data) suggest that your hypothesis was correct or that, with adjustments, you will get there.
You should adapt a change strategy and re-test unless there is clear indication that it will not work.

18. When to Adopt? It worked!!! Hard-wire it into your practice.
Consider how to spread
You have:
Done several PDSA cycles
Developed and proven at least 1 hypothesis
Data and information showing your tests were successful
You have prototyped and perfected your change.
“It worked! You got the results you want! Hard-wire it into your program and consider spreading it beyond your practice.
You have:
Done several PDSA cycles
Developed and proven at least 1 hypothesis
Data and information showing your tests were successful
You have prototyped and perfected your change.
It is “obvious” to your team that this “new thing” or “strategy” should become a routine part of your program.
You want to tell the whole world what you have discovered.

19. When to abandon?
After multiple tests, accept that your change idea was not successful. Quit testing it and move onto a new idea.
You have:
Developed and tested a hypothesis
Adapted your change strategy several times.
Collected data that tell you it is not working.
After multiple tests, accept that your change strategy was not successful. Quit testing it. Move on to a new strategy.
You have:
Developed and tested a hypothesis;
Adapted your change strategy several times;
Collected data that tell you it is not working.
It can be difficult to abandon a change idea – maybe it was the one you were sure would work and you may be invested in it.
Remember that is not a failure but a success.
Avoid seeing it as “failure.” Why do you want to do something that clearly does not work / have the intended effect? It’s a learning opportunity - be thankful you will no longer waste time, energy, resources on trying it.

20. Partner Discussion Where does your PDSA cycle fit?
Should you adapt, adopt or abandon?
10 minutes each
Find a partner and analyze the status of your PDSA cycle – 10 minutes each – remind group when to switch.
Use the handouts to support discussion
Can have a group discussion if there’s time/interest (5 min)

21. When new ways of working and improved outcomes become the norm
Sustainability
When new ways of working and improved outcomes become the norm +
Not only have the process and outcome changed, but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed in support.
So – you’ve done all this work. You’ve clarified your problem, you’ve found a change idea that works, and you’ve implemented it in your practice. Ideally you’ve found a way to share this with others. Now what?
You will want to spend some time on sustainability so as to ensure the benefits of your work are actually realized!
Sustainability is -
‘when new ways of working and improved outcomes become the norm’. A more detailed version which includes the notion of ‘steady state’ in addition to promoting the desirability of continued improvement: “Not only have the process and outcome changed, but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed in support.
In other words it has become and integrated or mainstream way of working rather than something ‘added on’.
(NHS Institute for Innovation and Improvement 2005)

22. Holding the gains + evolving as necessary…
Sustainability
No reverting to the “old way”
Withstands challenge and variation
May have evolved and even improved!
Holding the gains + evolving as necessary…
As a result, when you look at the process or outcome one year from now or longer; you can see that at a minimum it has not reverted to the old way or old level of performance.
Additionally -
it has been able to withstand challenge and variation;
it has evolved alongside other changes in the context and perhaps has continued to improve over time.
Sustainability means holding the gains and evolving as required, definitely not going back”
(NHS Institute for Innovation and Improvement 2005)

23. Why Focus on Sustainability?
Up to 70% of change initiatives fail, impacting:
Best possible care
Staff and provider frustration
Reluctance to engage in future
Implementing a change in practice does not guarantee it will sustain long term. In order to continue to reap the benefits from your hard work you need to focus on how to ensure your change will ‘stick’.
The risk of failing to sustain your changes is not just clinical, but can effect provider and staff satisfaction and future change efforts.
(Daft and Noe, Beer and Nohria 2001).

24. Why don’t changes sustain?
Benefits for patients and staff are not clear
Changes are not credible
Changes are not part of the workflow
No one is monitoring over time
All staff have not be trained on changes
Key clinical leaders have not been engaged
The changes do not fit with the priorities of the clinic
Why don’t changes sustain naturally? There’s a range of reasons. Understanding these can help us better plan for sustainability and ensure we’ve worked to account for it in our quality improvement projects.

25. What Are You Trying to Sustain?
With your community team discuss what you would like to sustain in the practice and community, is it:
A specific change?
A measured outcome from your efforts?
An underlying culture of improvement?
Relationships established in the community?
A combination?
(10 min)
Before you focus on specific strategies to sustain your changes over time, you need to be clear on what it is you are trying to sustain. You may be trying to sustain:
A specific change you implemented
An outcome you have achieved through your work
An underlying positive culture and attitude towards improvement
Relationships you have established that contribute to your success now and into the future
Or a combination of these
In your team, discuss what your group would like to sustain.
Based on what exactly you are trying to sustain, how you apply these concepts will be different. It is important that the whole team is clear on what you are sustaining.
Source: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

26. Predictors of Sustainability
Staff, providers and patients can describe why they like the change and its impact
Providers and staff are confident and can assist in explaining to others
Job descriptions reflect new roles
Measurement is part of the practice and used to monitor progress
The change is no longer ‘new’, but ‘the way we do things around here’
Once you have made some changes towards sustaining your gains, how will you know that your work is paying off? There are some simple ways to tell if your change is more likely to sustain over time.
When you ask staff, providers and patients about the changes you have made they will be able to describe to you why the change is a good one and the impact it will have on both patient care and staff/provider experience in the clinic.
Providers and staff are confident that they could explain the new way of working to others and help to train new staff or providers.
Any effected job description has been changed to reflect changes in roles
Measurement is ongoing even after the change has been implemented. The measures are reviewed regularly to monitor progress and any changes indicating a loss in gains results in a correction.
People effected by the change do not describe it as ‘new’ or ‘being tested’ but accept it as the ‘new way of working’.
If you are interested in looking in more detail at the factors that have been demonstrated to affect sustainability - the NHS has a neat sustainability model that can help you understand these in more depth. The model can be extremely helpful in identifying areas that would adversely affect the likelihood of sustainability of your improvement work.
Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

27. What can you do? Clarify what you are sustaining Engage leaders
Involve and support front-line staff
Communicate the benefits of the improved process
Ensure the change is ready to be implemented and sustained
Embed the improved process in your electronic and human processes.
Build ongoing measurement
Take 10 minutes to discuss ideas about how to sustain improvements – what tangible steps can you integrate into your practice improvement work to ensure your efforts last and continue to be rewarded?
Run this as makes sense for the size of your group - can be done with smaller groups, by table, or partner activities.

28. Spread Learnings
“Means that the learning which takes place in any part of the organization is actively shared and acted upon by other/all parts of the organization.”
Now that we’ve talked about sustaining improvement, we will take a little time to think about potentially spreading your learnings.
When we think about spread, we often think big. While it’s important and wonderful to think broadly about sharing change, the “spread lens” can also be really useful to think about and employ internally or at a smaller level. Are there areas within your clinic or practice team that could benefit from the “spread” lens?
Quality Improvement Primer – Implementing and Sustaining Changes

29. Ready to Spread Learnings?
Ready when:
Clear ownership and leadership
Widespread acknowledgement that the project is important to the practice/team
Evidence that the ideas result in desired outcomes
How will you know when it’s a good time to start to spread learnings?
Clear ownership and leadership - leadership is engaged in and supportive of the work, and it’s clear which team members own what;
Widespread acknowledgement that the project is important to the practice/team;
Evidence that the ideas result in desired outcomes
A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper.

30. Spread
What infrastructure enhancements will assist in achieving the spread aim?
What communication channels will you use to reach out and engage?
How do you go about spread?
IHI has some great questions to ask when you think what how you might want to spread your learnings – these may well be applicable when working internally in your practice as well.
What communication channels will you use to reach out and engage?
How will you share the improvement story with new team members? Are there people who were less involved in the change process who should get information?
How will the spread efforts be transitioned to operational responsibilities?
A spread effort is only successful when the new ideas become engrained in the culture and part of the way that business is done. In planning for this, several key issues often need to be addressed: training and new skill development, supporting people in new behaviour that reinforce the new practices, problem solving, and assignment of responsibility.
What infrastructure enhancements will assist in achieving the spread aim?
Some changes rely on individual adoption decisions (ie prescription of new medication) while others may be more tied to infrastructure or system level changes (ex. roll out of new computer system) Most improvements lie somewhere between the two, but the more infrastructure changes can support adoption (ie. establishing an electronic decision-support for chronic disease management) the more quickly improvements can be spread throughout the target population.
How will the spread efforts be transitioned to operational responsibilities?

31. What might spread look like for your practice?
Share with other team members
Support other team members in sharing with their peers
Share informally with peers – both in and outside of your practice
Ask the group – “What might spread look like in the context of your practice?”
Have a brief discussion - click to show some prompts and ideas.

32. More on Sustainability & Spread
IHI – Spread and Sustainability “How to Guide”
ments/CourseraDocuments/13_SpreadSustainabilityHowTo Guidev14%5B1%5D.pdf
If you are interested in learning more about sustainability and spread – suggest checking out IHI’s How to guide. There’s some great tangible examples in here that may be helpful – unfortunately we don’t have more time to discuss more today!

33. Action Plan Intended to provoke thought and discussion with your team.
We’re going to talk briefly about the ongoing learning and supports offered.
We’ve handed out paper copies of the Action Plan. We hope you will be completing these with your office team, and we can compensate all of you for your time in working on this together (up to two hours). The Action Plan is a standard set of five questions that are core to the quality improvement process – you may recognize some of them from the model of improvement. You will learn more about this model as you progress through the QI SGLS sessions, and you may find that how you interpret the questions changes, or that you have more specific ways for the tools to help you answer the questions. This reflects your learning process and allows you to complete the Action Plan based on your current understanding and your comfort level with the concepts addressed.
You will start the AP today, work on it with your team back at the office, and then in a few weeks you will be ready to answer the final question, submit it and your sessional form.
Filling out the Action Plan is intended to provoke thought and discussion among your team about what you have learned, and your goals for practice improvement. There is no right or wrong here. The Plan may provoke questions and even be used to structure an in-practice visit with an RST or peer mentor. They will support you in working with your team to get everyone on the same page and get started.
Intended to provoke thought and discussion with your team.
5 questions core to the QI process.
The same for each SGLS.

34. Get Started on Action Plan
10 minutes to start – Go!
We’ve handed out paper copies of the Action Plans so you can take a few minutes to reflect while the ideas are still fresh, and discuss with your table today.
You now have 10 minutes to start work on your action plan. We are here to support you - please flag us down if you’d like to talk.
As AP is being completed, hand out the evaluation form. Leave this slide up until the 10 minutes is complete.

35. Ongoing Learning and Support
Who to lean on and work with going forward:
Your colleagues
Your office team
Peer Mentor(s)
Regional Support Team Coordinators/Coaches
We are nearing the close of the session. I hope you have found this time useful and that you have some learnings to take away and begin to apply to your daily operations in your practice. I want to highlight that you have lots of resources to draw on as you begin – the group here today is a valuable resource for hashing out challenges and learning from each other’s successes, however big or small. If there is interest, we can facilitate sharing of contact information today so you can keep in touch and further support each other.
Your office team will be a key support in planning for change, and the Action Plan includes work with your team in order to start this conversation.
There are also a number of PSP resources available to you – the peer mentor team, including myself, and the Regional Support Coordinators, all of whom are available to work with you one-on-one in your practice to help integrate ideas that you learned today, complete your Action Plan, and work towards realizing improvements in your practice.

36. Next Steps
Action Plan – start today, due in 8 weeks (trigger for sessional)
Post Activity Participant Questionnaire (PARQ) – in 8 weeks (trigger for Mainpro+ credits)
Integrated Learning Package (2 hours) Optional
In-Practice RST or Peer Mentor visit Optional
External Resources:
UBC/BCCFP - “Shine a Light on Your Learning”: A Self-directed Assessment Tool (Independent, online, up to 24 Mainpro+ credits).
Our next steps are:
Completing the action plan (we will take a few minutes shortly to start this). Please submit your completed AP to your RST within 8 weeks in order to receive up to two hours sessional payment for your time in doing this work.
After these 8 weeks, you will be asked to complete the Post Activity Participant Questionnaire (PARQ), which hopes to identify the impact of participating in this session. Submitting the PARQ triggers the receipt of your Mainpro+ certificate.
You also have the opportunity to have an in-practice visit with an RST, who can help you and your team complete the action plan and/or the integrated learning package if you choose, as well as help address any challenges you are experiencing. Please connect directly with your RST to get schedule an in practice visit. One of the things the RSTs can do with you is the PSP Practice Assessment Tool, which may help you decide where you’d like to focus your attention for the Action Plan.
Finally, we’ve included a link to a tool developed by UBC CPD and the BC College of Family Physicians that is complimentary to the learnings today, and will allow you to get credits in a different category. This is a self-assessment tool which focuses on making improvements in your practice and can walk you through the process in more detail, providing ideas and support. This tool is something you can work through step by step and get up to 24 Mainpro+ assessment credits.
A fourth session in the series could be developed based on demand so please let us know if you would be interested in this, and what you might be looking for.

37. Evaluation Please complete the Post Session Evaluation form
Your feedback informs improvements to this session and future SGLSs.
Thank you!
That’s it for learning today! We ask that everyone complete the post-session evaluation so that we can improve this session and make it more useful for your peers.
Thank you for your time, your attention, and your ideas. We hope the session has been of use, and look forward to working with you on planning and implementing improvements in your practice.