2. Accelerating Improvement Learning Session 2 February, 2005 Angela Hovis Improvement Advisor California Chronic Care Learning Communities Initiative Collaborative

3. © 2005 Institute for Healthcare Improvement Objectives of Session Learn how we can accelerate improvement by: Doing more testing with PDSA cycles for learning Understanding the difference between testing and implementation Designing smaller tests of change Designing multiple tests of change Using measurement for learning Communicating and working as a team

4. 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 © 2005 Associates in Process Improvement

5. 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 for Patients © ICIC, Ed Wagner et al

6. © 2005 Institute for Healthcare 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 The PDSA Cycle

7. © 2005 Institute for Healthcare Improvement Why Test?

8. © 2005 Institute for Healthcare Improvement Why Test? Increase belief that change will work Document how much improvement can expect from change Learn to adapt change to other conditions/your environment Evaluate costs/side-effects of change Minimize resistance to implementation

9. © 2005 Institute for Healthcare Improvement Form for planning a PDSA cycle

10. PDSA Example - Arrowhead Regional Medical Center Plan: Objective of this test: Develop a process for documenting self- management goals Questions: Will the form “My Action Plan” work? Will the patient be willing to participate? Will Cindy have the time to question the patient? Prediction: We will be able to find a patient to participate and it will work. Who, what, where, when, how: - Cindy will use the form, My action Plan with one patient in the pilot population by Friday, Nov. 5, 2004. - The patient will be questioned during the portion of the clinic visit while waiting for the provider to come into the exam room. - The team will meet on Monday, November 8 to discuss the results.

11. PDSA Cycle (cont.) Do : Cindy was able to meet on Thursday with one patient. The form worked well, she was able to complete the questionnaire in 5-10 minutes. Study : The form worked well, it was easy to complete in 5-10 minutes. Documentation of the goal setting exercise will be done on the pink clinic note.. Act : Will test the form on the other group of patients on Wednesday, Nov 10. Cindy will call the patients that she interviewed to follow up.

12. © 2005 Institute for Healthcare Improvement Learning the Sequence - Prediction Game Application of PDSA Cycle What are we trying to accomplish? We found a new technology represented by a sequence that can help our organizations to improve health care. We want to discover the rule (or theory) that generated this sequence. Each improvement team should run tests to determine the rule. When they are sure that they have the rule (based on enough tests), then implement the technology in their organization.

13. © 2005 Institute for Healthcare Improvement Learning the Sequence How will we know that a change is an improvement? 1.Correct prediction of result of test 2. A statement of the correct rule upon implementation

14. © 2005 Institute for Healthcare Improvement PDSA Cycle for Learning the Sequence

15. CycleRule (or Theory) for Sequence Sequence to Test on this Cycle YesNo 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 PDSA Test Results Confirming?

16. What did we learn? 1.Had to run cycles to learn 2.Planning requires prediction 3. A single observation may require us to modify our theory (can learn a lot from a test of “1” 4.Multiple cycles necessary 5.Can test for judgement samples -e.g. cultural diversity - sure it worked for numbers, but what about our friends a,b,c,d. We could have tested for them to to see if worked for them before we implement. 6. “Failures” helped (trial and learn) 7.More than one way or set of tests to get to same results (concensus not necessary for testing) 8.Collaborative advantage 9.Importance of theory 10.If have questions left before implementing-run another cycle

17. © 2005 Institute for Healthcare Improvement Do more testing -How? Smaller scale tests that build towards implementation

18. © 2005 Institute for Healthcare Improvement Smaller scale tests Years Quarters Months Weeks Days Hours Minutes Drop down next “two levels” to plan Test Cycle!

19. © 2005 Institute for Healthcare Improvement Smaller Scale Tests: The power of “one” Conduct the test with one facility one office one doc one patient

20. Testing vs. Implementing Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system. Implementation – Making this change a part of the day-to-day operation of the system in the pilot site. Not after just one test! More Tests: Wide range of conditions Judgement samples

21. © 2005 Institute for Healthcare Improvement Planned Grouping Set up two groups that have different conditions. Test new process in each group. If the change shows improvement from both groups, the change is robust against the different conditions. If the change shows improvement from one planned group but not in other, further test cycles are needed to better understand the relationship between the change being tested and the different conditions. Opportunities for groups: Different days of week Different shifts

22. © 2005 Institute for Healthcare Improvement Wide Range of Conditions: Judgment Samples Instead of selecting a random sample of patients, select patients to be included in the test of change that are more extreme based on the judgment of an expert. Example: Before implementing the use of a self-assessment tool, test with patients with low literacy.

23. © 2005 Institute for Healthcare Improvement Implementation Increased scope will lead to increased resistance (Value of evidence from successful tests) High expectation to see improvement (no longer testing for failures) Generally takes more time than tests The change is permanent - need to develop support processes to maintain change: Planning sheet with test(s) can help

24. PROJECT TEAM WORKSHEET: Redesign of Support Processes for Implementation of Change Change Implemented: Date: Cycle No. Change Tested or Implemented LeadJune July August September October November 24 1 8 15 22 29 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25 Policies Documentation Hiring Procedures Staff education/training Job descriptions Information Flow Equipment Purchases

25. Appropriate Scope for next PDSA Cycle Current Situation ResistantIndifferentReady Low Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Very Small Scale Test Small Scale Test High Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Small Scale Test Large Scale Test Cost of failure small Small Scale Test Large Scale Test Implement Staff/Physician Readiness to Make Change

26. © 2005 Institute for Healthcare Improvement Repeated Use of the PDSA Cycle Hunches Theories 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

27. Example-One cycle of tests… (building on earlier Arrowhead Regional Medical Center PDSA) Can use a tool to help set goals Improved Foundation for Self-Management for both doctors and patients AP SD A P S D AP SD D S P A Data D S P A Cycle 1: Test “My Action Plan with one provider, one patient Cycle 2: Test form and pink clinic note with more patients Cycle 3: Test progress of patients who used form with follow-up call Cycle 4: Test with other provider(s)/pts Cycle 5: Implement tool and monitor its use

28. © 2005 Institute for Healthcare Improvement Do more testing -How? Smaller scale tests Do tests in parallel

29. 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 A P S D A P S D A P S D D S P A AssessAdviseArrange (Follow-Up) Example of Parallel Tests Agree (set goals) Aim: Self- Manage ment Support A P S D A P S D A P S D D S P A Assist

30. © 2005 Institute for Healthcare Improvement 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 A P S D A P S D A P S D D S P A Community Resources Self- Manage- ment Support Delivery System Design Clinical Information Systems Testing in Each Component of the Care Model Overall Aim: Implement the Care Model for the pilot population of patients 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 Health Care Organization Decision Support

31. Use Measurement for Learning - How? Let Your Data Do the Talking (or at least start a conversation) Example: Chinatown Public Health Center

32. © 2005 Institute for Healthcare Improvement Team Practice Skills Getting the most from team time Use change package for planning and test/implement high leverage concepts Use PDSA/Plan for multiple cycles Agenda, plans, next agenda Huddles vs. meetings Learning from other teams: Listserv activity Other’s reports Shared Documents Site visits

33. © 2005 Institute for Healthcare Improvement Ways teams bog down Wait for all physicians to agree Skip team meetings Got to write a Policy Forms Committee too soon Forgetting to invite Senior Leaders Getting frustrated by: other department, VP, personality Other?

34. © 2005 Institute for Healthcare Improvement Ways to Overcome Barriers Test often before going through committee and forms approval process Ask a patient for feedback Identify and utilize the early adopters Find VP or Sr. Leader who can become excited Feed senior leaders results-especially small ones Build on passion Recognize and reward people for trying