1. INTERPROFESSIONAL QUALITY IMPROVEMENT PROJECTS
Boise VAMC Center of Excellence in Primary Care Education
Workshop 1 of 3 on Quality Improvement
Facilitators Introduce themselves

2. Boise VAMC Center of Excellence in Primary Care Education
ZOMBIE ATTACK
Improving quality, Building teams, Avoiding having your brain eaten
Trainees introduce themselves using an icebreaker activity

3. WORKSHOP OF THE UNDEAD Why Zombies? Superordinate goals
Boise VAMC Center of Excellence in Primary Care Education
WORKSHOP OF THE UNDEAD
Why Zombies?
Superordinate goals
(Ergo – Zombie Attack!)
Non-familiar terrain
Why Teamwork?
kill, l Unable to accomplish QI (or defeat zombies) without teamwork
(One guy can’t ike, 50 zombies!)
Use these questions to gauge the trainee's understanding of how QI and research defer. In our experience trainees conflate research and QI and need multiple reminders that they are not being asked to complete a research project with their team.

4. Boise VAMC Center of Excellence in Primary Care Education
ZOMBIE TRIVIA
From what geographic area did the concept of a “Zombie” originate?
West Africa (although Haiti more described)
What was the name of the 1985 book which described an ethnobotanist’s exploration of the Haitian zombie myth?
The Serpent and the Rainbow, by Wade Davis
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

5. RESEARCH VS. QUALITY IMPROVEMENT
Boise VAMC Center of Excellence in Primary Care Education
RESEARCH VS. QUALITY IMPROVEMENT
QI is the “democratization” of research
Not single intervention w/ rigorous controls
Local, iterative approach to problem
With clear aim, measures, ideas
And quick cycles of evaluation prior to implementation
Research = created virus/mutation/chemical/etc. that CAUSED zombie apocalypse.
Quality Improvement = only chance of stopping zombie attack and saving civilization as we know it.
Further differentiation between QI and research.

6. ZOMBIE PANDEMIC Further differentiation between QI and research.
Boise VAMC Center of Excellence in Primary Care Education
ZOMBIE PANDEMIC
Further differentiation between QI and research.

7. Boise VAMC Center of Excellence in Primary Care Education
ZOMBIE & PUBLIC HEALTH
"If you are generally well equipped to deal with a zombie apocalypse you will be prepared for a hurricane, pandemic, earthquake, or terrorist attack.“
Dr. Ali Khan, Office of Public Health Preparedness and Response, CDC
“We have been overrun by zombies. We had to close the registration.”
Univ. of Michigan’s School of Public Health preparedness exercise.
Trainees introduce themselves using an icebreaker activity

8. QUALITY IMPROVEMENT & ZOMBIE QUOTES
Boise VAMC Center of Excellence in Primary Care Education
QUALITY IMPROVEMENT & ZOMBIE QUOTES
“Every system is perfectly designed to get the results it gets.”
Paul Batalden
“BLAAARHG blar mmaaaar Brains BrAIns…BRAINS – RRRRRAAAWRRR!”
Zombie Saying
Trainees introduce themselves using an icebreaker activity

9. Boise VAMC Center of Excellence in Primary Care Education
SCENARIO
Zombie Apocalypse has struck Boise, Idaho. You and your team of survivors have holed up in an abandoned conference room. With dwindling supplies of stale donuts and tepid coffee, you must decide a means to survive the zombie attack, and minimize the number of humans you lose to zombification…
Trainees introduce themselves using an icebreaker activity

10. PDSA Plan Identify the problem Analyze the problem Do
Boise VAMC Center of Excellence in Primary Care Education
PDSA
Plan
Identify the problem
Analyze the problem Do
Develop solutions
Implement a solution
Study
Evaluate the results – goal achieved?
Act
Standardize the solution & make it work
Restart the cycle
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

11. UNDERSTANDING CAUSALITY
Boise VAMC Center of Excellence in Primary Care Education
UNDERSTANDING CAUSALITY
To understand the causes of problems, you have to understand the system.
Causality by process map
Causality (not casualties) by category & fishbone diagram
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

12. PROCESS MAPPING Understanding the Process…
Boise VAMC Center of Excellence in Primary Care Education
PROCESS MAPPING
Understanding the Process…
“You don’t learn to process map, you process map to learn.”
Dr. Myron Tribus
Most are undocumented processes, especially those involving zombies (unless you work at CDC).
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

13. PROCESS MAPPING START Yes Activity Outcome Subsequent 1 No Alternate 2
Boise VAMC Center of Excellence in Primary Care Education
PROCESS MAPPING
Activity
START
Outcome 1
Alternate
Subsequent 2
Yes No
Decision
Point
We provide quotes from the accreditation requirements or competencies for the procession that we train so that they are aware that their profession cares. Change this to fit your group of trainees.

14. ROLES & (LACK OF) RESPONSIBILITIES*
Boise VAMC Center of Excellence in Primary Care Education
ROLES & (LACK OF) RESPONSIBILITIES*
Roles in Zombie Attack ― Assign roles to each of the members of your team.
Mad (or perhaps not so mad?) scientist ― advocates for scientific solutions
Slightly annoyed physician ― wants to focus on curing zombies
Compassionate optimist ― wants to fix zombies with lots of love
Former special forces member ― wants to fix zombies with lots of bullets
Lumberjack/chainsaw sales man ― wants to trim zombies into harmless packages
Woody Harrelson ― wild card
We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.

15. Boise VAMC Center of Excellence in Primary Care Education
GROUP ACTIVITY – PART A
Develop a process map to understand how a human, facing Zombie Attack, might respond to maximize their chances of survival.
Arrange pre-made process map pieces
Make your own!
2 groups of 6 (bigger is more realistic)
We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.

16. IF VETERAN ACCEPTED INTO
Process Map: Transitions Of Care iQIP Team
ALCOHOL USE DISORDER WORK FLOW
Medical
Evaluation
+/-
BH Triage
Monitoring
2M/MSDU
Emergency
Dept. Visit
F/U with PCP
Medically-Assisted
DISCHARGE
Medical SW
ICT
OSAT
Drop-In Group
IF VETERAN REQUESTS
BH SERVICES FOR AUD
IF NOT 2M/MSDU
IF VETERAN ACCEPTED INTO
RSAT BUT WAITING CAN BE
SEEN BY ICT 1-5 VISITS
BHIP
RSAT
Post Discharge from 2M
*If Indicated ICT F/U
Treatment
Complete
Each year, we provide the trainees with their list of QI topics to pick from
KEY
Inpatient Medical Team
Primary Care
Behavioral Health Dept.

17. GROUP ACTIVITY – PART B Return to Process Map
Boise VAMC Center of Excellence in Primary Care Education
GROUP ACTIVITY – PART B
Return to Process Map
Highlight Possible Intervention Points
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

18. PROCESS MAP: SMOKING CESSATION iQIP TEAM 2015-2016
Check In
Quit? + -
Smoking
Cessation
Meds?
Print
Reminder
Wed Tobacco Cessation Group
Consult
1:1 visit
Support
Group
Pharmacy
Psychology
PCP
Discussion
Warm handoff to psychology?
Eileen Twomey & Sharlene Green
30% Attend Only 1 Meeting
21% Never Attend
Stay Quit Coach Phone App
Increased Engagement??
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

19. FISHBONE DIAGRAM CAUSE & EFFECT Cause Effect Problem Material Method
Boise VAMC Center of Excellence in Primary Care Education
FISHBONE DIAGRAM
CAUSE & EFFECT
Material
Method
Machine
Manpower
Measurement
Environment
Problem
Effect
Cause
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

20. FISHBONE DIAGRAM CAUSE & EFFECT More Zombies! EFFECT CAUSES
Boise VAMC Center of Excellence in Primary Care Education
FISHBONE DIAGRAM
CAUSE & EFFECT
More
Zombies!
Government Conspiracy
EFFECT
Evil Scientists/ Experiment Awry
Cosmic Rays
Voodoo Curse
Environmental Toxins
CAUSES
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

21. FISHBONE DIAGRAM PRACTICE MANAGEMENT LEAD IQIP TEAM 2016-2017 EKGs
Boise VAMC Center of Excellence in Primary Care Education
FISHBONE DIAGRAM
PRACTICE MANAGEMENT LEAD IQIP TEAM
EKGs
Veteran Drop In Note
Call back request
Information for action
Med Requests
Express Scripts
Outside Pharmacy
Choice Provider
Form Requests
Disability
Medical Clearance
FYI
Discharge Summaries
Consult results
Outside provider notes
Orders
Home Health
Vets Home
ALF
SNF0
Delayed Care
Overwhelmed PCPs
Frustrated Veterans
CAUSES
EFFECTS
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

22. PDSA Plan Identify the problem Analyze the problem Do
Boise VAMC Center of Excellence in Primary Care Education
PDSA
Plan
Identify the problem
Analyze the problem Do
Develop solutions
Implement a solution
Study
Evaluate the results – goal achieved?
Act
Standardize the solution & make it work
Restart the cycle
Top down – refers to QI projects that come from mandates that are outside f the front line clinical staff
Bottom up – refers to QI projects that come from the front lines
We suggest that the trainees consider both as they are developing their project and what they would like to work on in their team. Also, highlight how once they are practicing providers, they may experience being asked to be a part of a QI team due to either top down or bottom up approaches.

23. iQIP WORKS IN PROGRESS #1
Boise VAMC Center of Excellence in Primary Care Education
iQIP WORKS IN PROGRESS #1
Who: Your iQIP Team
What: WiP #1
Background info, why you care
Aim statement  More on this next time!
Baseline data
Bonus
Understanding the Context
Process Map
Fishbone Diagram
Possible interventions?
When: Wednesdays in December/January
Where: Wednesday Interprofessional Noon Conference Room
We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.

24. Boise VAMC Center of Excellence in Primary Care Education
QUESTIONS?
We provide the trainees with an overview of their expectations. As much as we can, we fill in the dates above – it will change depending on your program and overall schedule.