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 Practicing Safety Learning Session May 30, 2009

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 PS Toolkit

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

4. 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?

5. 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

6. 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?

7. 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

8. 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

9. Example (Poor)  Our practice teams will improve care for all infants and toddlers, by using the Practicing Safety Toolkit.

10. Sample Aim By November 30, 2009, our practice teams will test the 3 Practicing Safety bundles (toolkit) to determine feasibility, as well as make improvements to the bundle set, so that:  100% of parents/caregivers receive assessment/screening regarding coping with crying at or by the 2-month well visit.  100% of parents/caregivers receive anticipatory guidance regarding coping with crying at or by the 2 month well visit.  100% of new mothers receive assessment/screening regarding maternal depression at or by the 2 month well visit.  100% of new mothers receive anticipatory guidance regarding maternal depression at or by the 2 month well visit.  100% parents/caregivers receive assessment/screening regarding discipline at or by the 18 month well visit  100% of parents/caregivers receive anticipatory guidance regarding discipline at or by the18 month well visit.  100% of parents/caregivers receive assessment/screening regarding toilet training at or by the 18 month well visit.  100% of parents/caregivers receive anticipatory guidance regarding toilet training at or by the 18 month well visit.

11. 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

12. 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:

13. 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

14. 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

15. 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

16. Measures for Practicing Safety  Target population Infants and Toddlers seen by PS clinicians in participating practice for well care visit  Numerator # infants or toddlers with documentation that parent/caregiver received anticipatory guidance, assessment/screening, referrals/follow up regarding crying, maternal depression, bonding/attachment (at or by 2 months); discipline and toilet training (at or by 18 months).  Denominator All infants and toddlers seen in participating practice for well care visit whose charts are reviewed.

18. 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

19. 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

20. 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

21. 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?

22. 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

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

24. 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

25. 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!

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

27. 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

28. 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 Mother/ Caregiver Bundle Practice-based Systems Index Overall Aim: Testing PS Toolkit A P S D A P S D A P S D D S P A Toddler Bundle Infant Bundle

29. 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? Practicing Safety Toolkit 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

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

31. Questions?

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

33. 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