1. California Chronic Care Learning Communities Initiative Collaborative Learning Session I Where Are We Going and How Will We Know We Are There? Model for Improvement Part 1: Aims & Measures Angela Hovis, Improvement Advisor

2. Session Objectives Participants will be able to: Describe the Model for Improvement and its utility in accelerating improvement initiatives Define a team’s aim and measures Understand the utility of annotated run charts

3. © 2004 Institute for Healthcare Improvement Set-up -Target population -Successful sites -Key groups who make the adoption decision -Initial strategy to reach all sites Successful Sites First: A Word About The Pilot Site and Spread Social System -Key messengers -Communities -Transition issues -Technical support Communication Strategies Knowledge Management Measurement and Feedback Leadership -Topic is a key strategic initiative -Goals and incentives aligned -Executive sponsor assigned -Day-to-day managers identified Better Ideas - Develop the case -Describe the ideas

4. © 2004 Institute for Healthcare Improvement Breakthrough Series Collaborative Select Topic (develop mission) Planning Group Develop Framework & Changes Participants (teams/pilot sites) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports EmailVisits PhoneAssessments Monthly Team Reports Congress, Guides, Publications etc. AD P S Expert Meeting

5. © 2004 Institute for Healthcare Improvement The First Law of Improvement “Every system is perfectly designed to achieve exactly the results it gets.”

6. Care Model Resources and Policies Community Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Health Care Organization Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Improved Outcomes HbA1c, LDL, BP ©McColl Institute

7. © 2004 Institute for Healthcare Improvement Key Elements of Breakthrough Improvement Will to do what it takes to change to a new system Ideas on which to base the design of the new system Execution of the ideas

8. Hagar Visits the Doctor

11. Fundamental Questions for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement?

12. 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? Model for Improvement ActPlan StudyDo ©Associates in Process Improvement

13. © 2004 Institute for Healthcare Improvement 1.What Are We Trying to Accomplish? Developing the Team Aim Statement Write a clear and concise statement of who, what, when, and where What does the team intend to do - use charter as a guide Who - patient population for collaborative Where - define pilot site and spread site(s) Align aim with strategic goals of the organization Make the target for improvement unambiguous – use numerical goals consistent with goals in the charter

14. © 2004 Institute for Healthcare Improvement The Team’s Aim Should Be: Strategic Relevant Compelling Important A Stretch Achievable Unambiguous Understandable to Everyone!

15. Example of an Aim statement ABC Hospital System will use the chronic care model to redesign care for patients with diabetes to help and empower them to reach their maximum health potential. We will begin our improvement work at the West Clinic with Dr. Grant’s and Dr. Moyen’s patients.

16. Example of an Aim statement (cont.) by September 30, 2005, our goals for this pilot population are:  Average HbA1c ≤7.0  At least 60% of patients with diabetes will have HbA1c <7.0  90% of patients with diabetes will have 2 HbA1c tests in the last 12 months  70% of patients will have LDL-c<100  50% of patients will have documented BP below 130/80  60% of appropriate patients on statins  50% of patients will have a current, documented self- management goal  90% of patients with diabetes will have a current foot exam

17. Example of an Aim statement-Complete ABC Physicians Group will use the chronic care model to redesign care for patients with diabetes to help and empower them to reach their maximum health potential. We will begin our improvement work with Dr. Grant’s and Dr. Moyen’s patients and by September 30, 2005, our goals for this pilot population are:  90% of patients with diabetes will have 2 HbA1c tests in the last 12 months  70% of patients with diabetes will have HbA1c <7.0  90% of patients will have at least one LDL test in the past 12 months  70% of patients will have LDL-c<100  50% of patients will have documented BP below 130/80  50% of patients will have a current, documented self-management goal  25% of patients who smoke will have ceased smoking  90% of patients with diabetes will have a current foot exam After successful implementation at the pilot practices, changes will be spread to other chronic conditions, other physicians in our clinic, and other clinics in our system.

18. © 2004 Institute for Healthcare Improvement What are we trying to accomplish? Team Aim Statement How will we know a change is an improvement? Measures What changes can we make that will result in improvement? Change Package Fundamental Questions for Improvement ActPlan StudyDo 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? Model for Improvement

19. © 2004 Institute for Healthcare Improvement This collaborative is about changing your organization’s approach to improving the care of patients It is not about measurement. 2. How Do We Know That a Change is an Improvement?

20. © 2004 Institute for Healthcare Improvement “You can’t fatten a cow by weighing it.” -- Proverb However….

21. © 2004 Institute for Healthcare Improvement Measurement Guidelines Need a family of measures reported each month to assure that the system is improved. These measures should clarify your aim statement & make it tangible These measures are used to guide improvement Integrate measurement into daily routine Plot data for the measures over time and annotate graph with changes

22. © 2004 Institute for Healthcare Improvement Some Measurement Assumptions The purpose of measurement in the collaborative is for learning not judgment. All measures have limitations, but the limitations do not negate their value. Measures are one voice of the system. Hearing the voice of the system gives us information on how to act within the system. Measures (especially as a family) tell a story; goals give a reference point.

23. Well Defined Measures

24. How are you getting the data for your measures? Share ideas for how to collect data How did you pick your optional measures?

25. © 2004 Institute for Healthcare Improvement Visual Display of Data: Annotated Run Chart Eliminates ink that does not add information Shows the data Makes good use of space Integrates words with the data

26. © 2004 Institute for Healthcare Improvement Annotated Run Chart Plot small samples frequently over time Time Order (e.g., Month) Observed Data Value (e.g., Infection Rate) Change 1 tested Change 2 tested

27. Effectiveness Annotated Time Series (Run Chart) - Iowa Health Systems 35

28. Family of Measures- Example

29. © 2004 Institute for Healthcare Improvement Reasons for Plotting Data Over Time In improvement efforts, changes are not fixed but are adapted over time. Time series graphs annotated with changes and other events provide evidence of sustained improvement - will guide you as to when you should implement and whether or not you are holding your gains. Will help generate support for your efforts. Will help sell spread to other parts of your organization Summary Statistics hide information (patterns, outliers).

30. Run Chart - a graphical record of a measure plotted over time Importance of Time Order Graph Changes made

31. © 2004 Institute for Healthcare Improvement Pre-Post Example: Cycle Time 35

32. © 2004 Institute for Healthcare Improvement Unit 2 - same pre and post averages Changes made

33. Cycle Time Results for Units 1, 2, and 3 Change

34. Team Meeting 1 Agenda 1. Review Your Aim Statement and Optional Measures: In light of what you have learned this today, you may wish to change your aim statement. Remember to: State your intent. Define your patient population, pilot site, target for spread, other specifics. List numerical goals for aims as outlined in the charter and any additional optional aims. 2. Review your Team 3. ACIC and Identify Ideas for Change

35. © 2004 Institute for Healthcare Improvement References The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey- Bass Publishers., San Francisco, 1996. Quality Improvement Through Planned Experimentation. 2nd edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998. “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990. A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997.