1. I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation. Model for Improvement Ruth S. Gubernick, MPH QI Advisor Newborn Screen Positive Infant ACTion Project Learning Session May 21-22, 2010

2. Objectives of this Session  Participants will be able to: Identify Model for Improvement Create an Aim statement for project with concrete goals Constitute Plan Do Study Act cycles to test improvements, using the project change package, tools and resources

3. The First Law of Improvement “Every system is perfectly designed to achieve exactly the results it gets.”

4. Measurement for Measurement for Learning and Research Process Improvement PurposeTo discover new knowledgeTo bring new knowledge into daily practice TestsOne large "blind" testMany sequential, observable tests BiasesControl for as many biases Stabilize the biases from test to test as possible DataGather as much data as Gather "just enough" data to learn possible, "just in case" and complete another cycle DurationCan take long periods of "Small tests of significant changes" time to obtain results accelerates the rate of improvement Research vs. Quality Improvement

5. 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?

6. 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 AIM MEASURES IDEAS

7. Compare the 3 questions to how we frame improvement  Aim  Measurement for learning  PDSA  What are we trying to accomplish?  How will we know a change is an improvement?  What changes can we make to bring about improvement?

8. 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 AIM MEASURE IDEAS

9. What Are We Trying to Accomplish? Aim:A written statement of the accomplishments expected from this improvement effort Key components: -A general description of aim – should answer, “what are we trying to accomplish?” - Some guidance for carrying out the work and rationale -Specific target population and time period -Measurable goals

10. Example (Poor)  Our practice teams will improve care for all infants with an out-of-range newborn screening result, by using the ACT sheet.

11. Sample Aim By November 30, 2010, our practice team will improve the processes for managing those infants identified with an out-of-range newborn screening result, using tools such as the ACTion sheets, so that:  100% of infants with an out-of-range newborn screening result have parents and family who receive condition-specific information and support.  100% of infants with an out-of-range screening result receive confirmatory testing and/or definitive consultation with subspecialists.  100% of false out-of-range newborn screening results are documented in the infant’s chart and discussed with parents.  100% of children given a diagnosis of a significant medical condition detected by newborn screening are identified as a child with special health care needs (i.e. entered into the practice’s children with special health care needs registry and chronic condition management initiated).

12. SMAART Aim  Specific: Understandable, unambiguous  Measurable: Numeric goals  Actionable: Who, what, where, when  Achievable (but a stretch)  Relevant to stakeholders and organization  Timely: with a specific timeframe

13. AIM Worksheet The (name of your team ) intend to accomplish By (date) For (population) because Our goals include: Special guidance that will help us stay on track:

14. 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 AIM MEASURE IDEAS

15. How will we know a change is an improvement?  Requires measurement  Build measurement into daily work routine Data should be easy to obtain and timely Small samples over time  Use qualitative & quantitative data Qualitative data is highly informative Qualitative data is easy to obtain

16. Measurement Guidelines Balanced set of 5 to 7 measures reported each month to assure that the system is improved Measures should reflect the aim and make it specific Measures are used to guide improvement and test changes Integrate measurement into daily routine Plot data measures over time and annotate graph with changes Outcome and process measures

17. Measures for Newborn Screen Positive Infant ACTion Project  Target population Infants seen by clinicians in participating practice  Numerator # infants with documentation that newborn screening was completed or declined; parents of out-of-range results received condition-specific information and support, infants received confirmatory testing, false results were discussed, children appropriately identified as CSHCN and followed in this medical home.  Denominator All infants seen in participating practice whose charts are reviewed during the month of interest.

19. 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 AIM MEASURE IDEAS

20. What Changes Can We Make That Will Result in Improvement? Tests of Change need 2 components: 1.Change concepts (ideas): ready for use or ready to adapt to your unique environment (**Use results from pre-work assessment to inform what you need to change) 2.PDSA test method

21. The PDSA Cycle for Learning and Improvement Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

22. PDSA: Break it Down/Simplify… Plan - Figure out the questions you want to answer, plan a way to answer the questions, and predict results Do - “Just do it” (i.e. do the plan) Study - What did you learn? Did your prediction hold? What assumptions need revision? Act - What will you do with the knowledge you learned? Adapt? Adopt? Abandon? What do you want to do next?

23. Use of the PDSA Cycles Multiple cycles Evidence Best Practice Testable Ideas Changes that Result in Improvement AP SD A P S D AP SD D S P A Data Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change

24. What are Tests? Putting a change into effect on a temporary basis and on a small scale and learning about the potential impact

25. Task or Test?  Task To do’s Meetings Posters Policy Committees  Test Question Prediction Data Usually involves patient

26. Why Test?  Increase your belief that the change will result in improvement  Opportunity for learning from “failures” without impacting performance  Document how much improvement can be expected from the change  Learn how to adapt the change to conditions in the local environment  Evaluate costs and side-effects of the change  Minimize resistance upon implementation

27. Decrease the Time Frame for a PDSA Test Cycle Years Quarters Months Weeks Days Hours Minutes Drop down next “two levels” to plan Test Cycle!

28. What Can We Do Now! By Next Week, By Tuesday, By Tomorrow That won’t harm a hair on the head of a patient?

29. Sequential Building of Knowledge Include a Wide Range of Conditions in the Sequence of Tests Breakthrough Results Theories, hunches, & best practices Learning and improvement AP SD Evidence & Data AP SD AP SD AP SD Test on a small scale Test a wider group Test new conditions Spread Implement

30. A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Out-of- range result information shared Practice-based Systems Index Overall Aim: Improving Newborn Screening Processes A P S D A P S D A P S D D S P A Confirmatory Testing Newborn Screening Documented

31. Fundamental Questions for Improvement What are we trying to accomplish? Team Aim Statement How will we know that a change is an improvement? Measures What changes can we make that will result in an improvement? Change Package 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 Stud y Do

32. Form for planning a PDSA cycle supports prediction and keeping one step ahead

33. The Care Model for Child Health in a Medical Home

34. Questions?

35. William Edwards Deming “It is not necessary to change. Survival is not mandatory.”

36. 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.  The Improvement Handbook, Model, Methods, and Tools for Improvement, Associates in Process Improvement, Austin, TX, 1997. Note: Special thanks to Carole Lannon, MD, MPH for some slides from her Safe and Healthy Beginning Model For Improvement presentation, 8/4/07