1. clinicalmicrosystem.org Next Steps in the Improvement Measurement Journey Driver Diagrams Cascading Measures Dashboards Registries Brant J. Oliver, PhD, MS, MPH, APRN-BC Randy Messier, MT, MSA, PCMH CCE

2. clinicalmicrosystem.org Presentation Highlights Teams are using data displays! (see dashboards in this session) Predominance of long-term outcome measures Need for balance with process measures leading up to the outcome of interest (see cascading measures in this session) Run charts/data over time (Yay!!!) The challenge of pie charts (beware the dark side…) Value of telling the story (see exercise in this session) Parallel PDSAs > Driver diagrams (see exercise in this session) “I feel your words, I understand your data… together they create a story I believe” - Randy

3. clinicalmicrosystem.org Next Steps on the Measurement Pathway…. DRIVER DIAGRAMS CASCADING MEASURES DATA DASHBOARDS REGISTRIES

4. Global Aim 1 2 3 Assessment Theme Global Aim Change Ideas Specific Aim Measures SDSA P DS A P D S A P DS A PDSA 1 3 2 Measurement is part of the DMIC ramp from start (Assessment) to finish (SDSA) 5P Specific Aim Measured Goal Conceptual |Operational Definitions Data Collection Data Review Data Monitoring Revisiting High Point

5. clinicalmicrosystem.org The Measurement Process We aim to improve the process of nutrition assessment, education and future planning. The process begins with patient education about their nutrition and identifying those who are underweight (BMI < 20). The process ends with all our patients with BMI’s less than 20 having a nutrition plan in place. By working on this process we aim to ensure that those at risk are appropriately assessed and treated. This is important because the clinic’s BMI is below the national average and this provides us with an opportunity to improve. Global Aim The ‘big picture ’ Specific Aim The ‘component parts’ Change Idea Conceptual Definition ‘The Measure’ Operational Definition ‘Specify & Quantify’

6. clinicalmicrosystem.org We will improve the percentage of adults with BMI <20 who are seen by the dietitian at every clinic to 100% by April 1, 2016 (four months from November 1, 2015) Global Aim The ‘big picture ’ Specific Aim The ‘component parts’ Change Idea Conceptual Definition ‘The Measure’ Operational Definition ‘Specify & Quantify’ The Measurement Process

7. clinicalmicrosystem.org 1.Increase # of adults seen by dietitian 2.Identify adults who are at risk (BMI<20) at pre-clinic meeting 3.Prioritize adults with BMI<20 to see dietitian 4.Create nutrition brochure for patient education 5.Create nutrition education for healthcare professionals 6.Create action plan for patients to follow between visits and lists weight goals 7.Create summary report that tracks and displays historical weights over time Global Aim The ‘big picture ’ Specific Aim The ‘component parts’ Change Idea Conceptual Definition ‘The Measure’ Operational Definition ‘Specify & Quantify’ The Measurement Process

8. clinicalmicrosystem.org 1.Survey patients on nutrition education and their understanding of treatments before and after given nutrition brochure 2.Track how many patients who are underweight are seen by dietitian 3.Track clinic frequency of each patient who are underweight Global Aim The ‘big picture ’ Specific Aim The ‘component parts’ Change Idea Conceptual Definition ‘The Measure’ Operation al Definition ‘Specify & Quantify’ The Measurement Process

9. clinicalmicrosystem.org 1.Develop survey that has 5 questions on a 10 point scale (1-poor to 10-best understanding) to assess patient nutrition knowledge. Give patient survey pre and post nutrition brochure. Average results and compare between pre and post nutrition education. Definition: Average likert scale score 2.For each clinic, count the number of patients who are underweight (defined as BMI < 20 kg/m 2 ) and seen by dietitian. Compare against the total number of underweight patients seen. Definition: # seen by dietician/total 3.Count the number of times each patient who are defined as underweight has a clinic visit per year to get clinic frequency. Identify those who have fewer than 4 visits a year. Definition: # less than 4 visits a year (frequency), # less than 4 visits a year/total. Global Aim The ‘big picture ’ Specific Aim The ‘component parts’ Change Idea Conceptual Definition ‘The Measure’ Operational Definition ‘Specify & Quantify’ The Measurement Process

10. clinicalmicrosystem.org What: Number of underweight patients seen by dietitian How: Keep a single global tracking sheet of underweight patients attending clinic and record that patient was seen by each healthcare professional after being seen At the end of clinic, count the total number of patients that attended clinic Who: The Nurse Coordinator will coordinate the measurement plan and the dietitian will be responsible for tracking (using ticks and tallies) all underweight patients seen Where: High Point Clinic A bright coloured neon green dot is put on the front of the chart to identify the underweight patients and the dietitian should prioritize to see them first When: All clinics (Friday afternoon) until April 2015 Global Aim The ‘big picture ’ Specific Aim The ‘component parts’ Change Idea Conceptual Definition ‘The Measure’ Operational Definition ‘Specify & Quantify’ Measurement Plan ‘The How’ The Measurement Process

11. Global Aim 1 2 3 Assessment Theme Global Aim Change Ideas Specific Aim Measures SDSA P DS A P D S A P DS A PDSA 1 3 2 Completed 5Ps and identified at risk group Microsystem Progress Report Improve nutrition status of patients who are classified as underweight We aim to improve the process of nutrition assessment and planning. The process begins with patient education about their nutrition and identifying those who are underweight (BMI < 20). The process ends with the patient being given an action plan with targets. Its important to work on this now because our clinics BMI is below the national average of 22.7 1.Track how many patients underweight patients are seen by dietitian 2.Survey patients on nutrition education 3.Track clinic frequency of underweight patients We will improve the percentage of patients who are underweight that are seen by the dietitian to 100% by April 2015 (5 months) 1.Increase # of patients seen by dietitian 2.Identify patients who are at risk at pre- clinic meeting 3.Prioritize patients who are underweight to see dietitian 4.Create nutrition brochure for patient education 5.Create nutrition education for healthcare professionals 6.Create action plan for patients to follow between visits and lists weight goals 7.Create summary report that tracks and displays historical weights over time 11

12. clinicalmicrosystem.org Variation & Run Charts Dietitian out Dietitian had to leave early Started giving education brochure. 1 st PDSA

13. clinicalmicrosystem.org Special Cause Variation A SHIFT is eight (8) or more consecutive points above or below the median.

14. clinicalmicrosystem.org Special Cause Variation A TREND is seven (7) or more consecutively increasing or decreasing points.

15. clinicalmicrosystem.org Global Aim 1 2 3 Assessment Theme Global Aim Change Ideas Specific Aim Measures SDSA P DS A P D S A P DS A PDSA 1 3 2 CFRD Screening is a “Pattern” Aspect of the 5P Assessment

16. clinicalmicrosystem.org Assessment Theme Global Aim Change Ideas Specific Aim Measures P DS A P D S A P DS A PDSA 1 3 2 CFRD Screening can also be a measure of improvement used in PDSA cycles…. Data sources include registry and tick and tally data collection….

17. clinicalmicrosystem.org Linking Short-Term Measures and Long-Term Measures Baseline Aim (Desired Outcome) Aim (Desired Outcome) SHORT-TERM PROCESS MEASURES P DS A P D S A P DS A PDSA 1 2 3

18. clinicalmicrosystem.org Macro-Level Initiation… Micro-Level Action Need Area (Baseline) Outcomes SHORT-TERM MEASURES (PDSA) Priority improvement areas can be identified and baseline performance levels established using macro- level measures (Registries) Microsystem improvement teams engaged to drive improvement from “bottom-up” (Front-line)

19. clinicalmicrosystem.org Baseline Status Longitudinal Outcome (Aim) Longitudinal Outcome (Aim) SHORT-TERM PROCESS MEASURES Cystic Fibrosis Care Example BMI often low in CF, r/t poor nutritional status. Longitudinal improvement goal. CFF SmartChange Ideas include increasing dietician access. Short-term process improvement measure. The longitudinal outcome measure improves slowly, “lagging behind” the process improvement measure…

20. clinicalmicrosystem.org Driver Diagram Exercise Revisited Global Aim Statement (Include registry data) Registry Data: Specific Aim Statements Measures (Operational Definitions) PDSA Cycles

21. clinicalmicrosystem.org Cascading Measures “Top Down” or “Bottom Up”

22. Cascading Measures… Microsystem Mesosystem Macrosystem Registry 2 or more related Microsystems “OneCF Center” Multiple Mesosystems “CFF LLC” Metasystem Multiple Macrosystems “All CF Centers” Smallest replicable unit of service delivery Registry and/or “Tick & Tally”

23. clinicalmicrosystem.org Center Report (Registry Data)

24. clinicalmicrosystem.org Center Specific Report

25. clinicalmicrosystem.org CF Registry Data This is an example of the type of report that can be created in PortCF. In this case we look at each patient’s most recent encounter during the past year where their BMI was <= 20 and if they were seen by an RD. The registry is a great source of data that can be utilized to facilitate your QI measurement work. For help in utilizing the registry contact Kris Petren at kpetren@cff.org or the registry help desk at RegHelp@cff.org kpetren@cff.orgRegHelp@cff.org

26. clinicalmicrosystem.org Moving towards Data Dashboards POPULATION DEMOGRAPHIC MEASURE #1POPULATION DEMOGRAPHIC MEASURE #2 CLINICAL OUTCOME MEASUREEXPERIENCE OUTCOME MEASURE PROCESS MEASURE #1PROCESS MEASURE #2

27. clinicalmicrosystem.org Demographic Measures DOMAINMEASURESHOW CAN I MEASURE IT? WHAT KIND OF DISPLAY CAN I USE? AGEAge distribution of the clinic population % in each age category Bar chart Pie Chart GENDERGender distribution% in each gender category Pie Chart ELIGIBLE FOR TRANSFER People with CF eligible for transfer % of total clinic population eligible for transfer in 90 and 180 days Bar chart PLANNED TRANSFERSWhen you are planning to transfer people with CF Frequency counts by season or quarter Bar chart COMORBIDITIESWhat other conditions are present besides CF? % of people with CF with each comorbidity Bar chart Pareto Chart

28. clinicalmicrosystem.org Outcome Measures DOMAINMEASURESHOW CAN I MEASURE IT? WHAT KIND OF DISPLAY CAN I USE? CLINICALFEV1 (respiratory status) % at goal Average FEV1 P Chart XmR Chart Run chart CLINICALBMI (nutritional status) % at goal Average BMI P Chart XmR Chart Run chart CLINICALEXACERBATIONS (“CF Flare” frequency) % with no flares Average # Flares P Chart XmR Chart Run chart EXPERIENCESATISFACTION EXPERIENCE OF CARE Average summary score by quarter (Questionnaires, QDM) Bar Chart XmR chart Run chart EXPERIENCEOTHER (Make your own)… QuestionnaireBar Chart XmR Chart Run chart

29. clinicalmicrosystem.org Process Measures DOMAINMEASURESHOW CAN I MEASURE IT?WHAT KIND OF DISPLAY CAN I USE? EFFICIENCYTime to transfer% transferred in 90 days Average transfer time p Chart XmR Chart Run chart READINESS1 st adult visit appt.% with 1 st adult visit scheduled at last Pedi appointment p Chart READINESSReadiness Assessment completed % with assessment completed at time of last pediatric visit P Chart PROBLEMSCategories of most common problems Frequency counts of problems by category Pareto Chart Bar Chart UTILIZATIONCategories of service utilization Frequency counts of utilization by category, e.g. ED, office visits, etc. Pareto Chart Bar Chart

30. clinicalmicrosystem.org Example: Dallas OneCF Center POPULATION DEMOGRAPHIC MEASURE #1POPULATION DEMOGRAPHIC MEASURE #2 CLINICAL OUTCOME MEASUREEXPERIENCE OUTCOME MEASURE PROCESS MEASURE #1PROCESS MEASURE #2

31. clinicalmicrosystem.org Credit: Dallas OneCF Center (OneCF LLC1, 2014) Excel template is available…

32. clinicalmicrosystem.org Telling the story… and quantifying it…. “Every story has a number.” - Brant Oliver “Every number has a story.” - Margie Godfrey Numbers and Stories

33. clinicalmicrosystem.org Create a story from this data… ? Numbers and Stories

34. clinicalmicrosystem.org Create a data display from this story… ? “We have been making some progress. Our clinical care satisfaction rate among people with CF went from 55% in January to 65% in February to 80% in April. We had a bit of a problem in March when we had some staff turnover and it dropped to 35%, but did an improvement intervention in April and now satisfaction is at 90% in May… not sure what our overall average is…” Numbers and Stories

35. clinicalmicrosystem.org Next Steps in the Improvement Measurement Journey Driver Diagrams Cascading Measures Dashboards Registries Brant J. Oliver, PhD, MS, MPH, APRN-BC Randy Messier, MT, MSA, PCMH CCE Thank You!