1. Model For Improvement: Aim Statements Chapter Quality Network Asthma Project Ohio Chapter, AAP Learning Session 1 Keith Mandel, M.D. Vice President of Medical Affairs, Physician-Hospital Organization Cincinnati Children’s Hospital Medical Center AAP/CQN Improvement Advisor October 9, 2009

2. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Session Objectives To describe components of Model for Improvement To write a clear aim statement for your team To identify measures and goals that support aim

4. How will the headline read……. ABC Pediatrics achieves Ohio’s lowest asthma admission rate ever!! ABC Pediatrics cuts asthma admissions by over 50%!! ABC Pediatrics eliminates asthma admissions and ED visits!!

5. Teams with clear aim and goals are more successful! Why Spend Time Refining Aim and Goals?

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. S - Specific M - Measurable A – Actionable R – Relevant T – Time bound

8. How will We Know a Change is an Improvement? What Changes will Result in Improvement?

9. Global vs. Specific Aim Statements (Examples) Global aim: to improve outcomes for asthma population across pilot practices through comprehensive “system” redesign, with 90% of population well-controlled and 90% of population receiving “optimal” care by December 31, 2010. Specific aim: to implement AAP/CQN encounter form at point of care across 100% of practice’s asthma population by June 30, 2010.

10. Team Exercise: Aim Statement Worksheet

11. Model For Improvement: PDSA Cycles Chapter Quality Network Asthma Project Ohio Chapter, AAP Learning Session 1 Keith Mandel, M.D. Vice President of Medical Affairs, Physician-Hospital Organization Cincinnati Children’s Hospital Medical Center AAP/CQN Improvement Advisor October 9, 2009

12. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

13. 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 improvement? ActPlan StudyDo Model for Improvement

14. PDSA Cycle Act Adapt, adopt, abandon? Another testing cycle? Plan Objective/ what trying to learn Prediction Plan to carry out the cycle and collect data (who, what, where, when) Study Analyze data/ compare to prediction Summarize learnings Do Conduct test Collect data Document observations, successes, failures PLAN DO STUDY ACT

15. Form for Planning a PDSA Cycle

16. 1.Opportunity to learn how to improve/adapt change to local environment, without “failures” impacting overall system performance 2.Increase degree of belief that the change will result in improvement, thus enhancing buy-in, reducing resistance, accelerating spread, and promoting sustainability 3.Determine how much improvement can be expected from the change. Why test?

17. 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

18. Scope of Next PDSA Cycle

19. Testing vs. Implementing Testing – Testing and adapting changes on a small scale. Learning what works in your system. Implementation – Embedding the change in day-to- day operations—not after just one test! More Tests over wide range of conditions

20. Key Points for PDSA Cycles Measures to assess impact of test are often PDSA- specific –Usually not part of global aim statement –Quantitative and qualitative data is important Make predictions Do cycles on smallest scale and within shortest timeframe possible “Failures” often provide more learning than “successes” Test ideas under different conditions (different patient populations, different physicians, etc.)

21. Tips for Accelerating Improvement

22. Smaller Scale Tests/ Shorten Timeframe Years Quarters Months Weeks Days Hours Minutes Drop down “two levels” to plan Test Cycle!

23. Smaller Scale Tests: The Power of “ one ” Conduct the test with one clinic day one physician one patient

24. Common PDSA Pitfalls 1.Testing changes where link to overall aim or key driver is unclear 2.Failing to make a prediction before testing the change 3.Failing to execute the whole cycle –Plan, Plan, Plan-D-S-A (too much planning, not enough doing) –P-Do, Do, Do-S-A (too much doing, not enough studying) 4.Not learning from “ failures 5.Lack of detailed execution plan

25. Watchful Eye Global Aim A6S will exceed Cincinnati Children ’ s Hospital Medical Center goals for patient safety

26. Watchful Eye - Specific Aim By establishing a standard assessment and action plan, A6S will increase to 365 days between codes by the end of FY07. Measure Number of days since last code on A6S.

27. Change Concept: Team believed to decrease risk of a code, there needed to be constant awareness of each patient ’ s risk. Checking the literature, they found a potential tool: Pediatric Early Warning Score (PEWS) Team also believed the risk awareness needed to lead to standard action and could not depend heavily on experience of the clinical staff.

28. Color and Number Coding PEWS Green=0-2 Score Orange=4 Score Red=5 or > Score Yellow=3 Score

29. PDSA Ramps

30. Early testing Initially one nurse and then three Gathered experience on the PEWS tool Linked PEWS to every 4 hour assessment Created a laminated board for less than $50 and started posting PEWS scores in color Posted “Days Between Codes”- got immediate feedback from staff and families

31. Learning from “ Failures ” 11 patients transferred to the PICU: Under controlled conditions Patient # 6: PEW Score = 2 Scheduled for surgery Transferred to PICU post-op Patient # 8: PEW Score = 1 (stable) Age: 9 day old neonate Diagnosis: HSV with new lesion

32. Learning from “ Every One ” PEWS Patients Transferred from A6S to B6W PEW Score Prior to Transfer 03/20/06 – 06/04/06

33. An example from Juvenile Arthritis

34. What are we trying to accomplish ? Global Aim: To design and implement a comprehensive delivery system for children Juvenile Rheumatoid Arthritis that is effective (evidence-based), efficient, family-centered, and safe, thus optimizing clinical status and quality of life. Population:500 patients with JRA Specific Aim:Increase the proportion of patients screened for iridocyclitis at appropriate intervals to 100% by July 1, 2005

35. How will we know a change is an improvement? Measure: % screened at appropriate intervals Baseline (March 2003) : 30%

36. What changes will result in improvement?

37. Plan Act Do Study Test 3 What: Continue Who (population): 23 additional patients Learning: 4th week problem due to one MD When: May 2004 Test 1 What: Test use of new clinic form to improve communication between ophthalmology & rheumatology Who (population): 38 JRA Patients over 5 days Learning: Improved documentation, 100% on 3 of 5 days When: March 2004 Test 2 What: Continue test of form Who (population): 25 additional JRA patients Learning: Last week of month a problem When: April 2004 Plan Act Do Study Plan Act Do Study

38. Results

39. QUESTIONS?

40. Team Exercise: PDSA Worksheet Potential areas for initial testing: –Reliability of using AAP/CQN asthma form at point of care. –Identifying revisions to AAP/CQN asthma form. –Engaging practice colleagues.