1. Systems Change Using Quality Improvement: From a “Good Idea” to a Practice Culture Artwork by Caroline S. © 2010 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2010 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

2. Objectives To understand the importance of creating a system to address tobacco use and secondhand smoke exposure in clinical practice To understand how to implement quality improvement changes in your clinical system using the Plan-Do-Study-Act Cycle

3. What is Quality Medical Care? The Institute of Medicine (IOM) defines healthcare quality as care that is: Safe Effective Patient Centered Efficient Timely Equitable

4. Barriers to Change The system is designed For patients with acute issues To provide preventive care and acute illness management To support a single service encounter Lack of time Reimbursement issues

5. What Can We Do? We have the tools and the knowledge Evidence-based treatments exist Unique opportunities to use treatments exist How do we incorporate this into the day-to-day operations of our practices? Implementation strategies exist

6. Think of Your Practice as a “System” Include all the parts that make the practice run Staff, clinical and administrative Records, paper and electronic Rooms, hallways, waiting rooms Resources in the community and beyond

7. Analyze System Flow Registration Waiting Room Check In Triage LAB Exam Check Out Patient checks in and goes to registration or waiting room Patient returns to waiting room after registration or to triage Vitals signs taken Diagnoses and lab results entered in chart Rx Prescription written and/or filled Labs drawn Follow-up appointments scheduled

8. Be Thoughtful In Your Implementation Understand the current system Research the areas most in need of change in your practice Start with the end in mind…how do you want your system to function?

9. Decision Support* is CRUCIAL You need support from the top AND the bottom Who’s in charge of Implementation? Supplies? Tracking outcomes? New tasks shouldn’t be added to anyone’s (already too long) list – make time and space for them *AKA “buy in”

10. Team Involvement Is CRITICAL Involve your staff early! First meet with key staff, then invite participation by staff at all levels Be sure to include: Front desk Nursing and clinical staff Administration

11. Get Input Brainstorm about implementation and barriers Invite ideas on logistics of asking and advising Develop implementation plans, using Plan-Do-Study- Act cycles

12. The PDSA Cycle

13. The PDSA Cycle: Plan, Do, Study, Act Prepare a plan for implementing one small step. Keep it very small!! Be very specific Include staff Prepare materials Set a time for the test (like today!)

14. Plans Have Components How will success be measured? What are we doing? Who will be the subject(s)? How will we start? Finish? Where will it be done? When will it be done?

15. The PDSA Cycle: Plan, Do, Study, Act Do it! Test it on ONE “sample” One family, visit, nurse, or doc Observe flow of program in the office Note places for improvement

16. The PDSA Cycle: Plan, Do, Study, Act Study it! How did it go? How was clinic flow affected? Were all materials available and easy to access? What adjustments need to be made?

17. The PDSA Cycle: Plan, Do, Study, Act Do another cycle Slightly improved or completely new Several cycles are typical Step back and take a look at the “big” picture

18. The PDSA Cycle: Plan, Do, Study, Act (Part 2) Implement in the entire practice. Inform staff Prepare materials Make needed changes to the office system Prepare a routine review cycle

19. Monitor and Feedback Are procedures working as intended? Are staff completing assigned tasks? Is documentation evident? Are patient materials kept up to date? Does the team receive timely feedback and support for a job well done?

20. Model for Improvement What changes can we make that will result in an improvement? What are we trying to accomplish? How will we know that a change is an improvement? Your Aim The Measures The Cycle for Learning and Improvement

21. Now What? Mobilize your team! Start with an Aim statement…what do you want to accomplish? Then develop small but measurable activities Create a PDSA (Plan, Do, Study, Act) cycle

22. www.aap.org/richmondcenter Need more information? American Academy of Pediatrics Julius B. Richmond Center of Excellence Audience-Specific Resources State-Specific Resources Cessation Information Coding & Payment Information Tobacco Control E-mail Lists Clinical Practice Change Resources American Lung Association www.lung.org/cessationta