An Introduction to Quality Improvement

for MINTiesConnie Davis, MN, ARNP

cld@conniedavis.caCentre for Comprehensive Motivational Interventions

www.centreCMI.caSeptember 13, 2012

Fort Wayne, IN

Who is in the room?

Where is everyone from?

What did you hope to accomplish?

What I prepared

• Describe prerequisites for improvement

• Describe the Model for Improvement

• Design PDSA cycles for testing a change

• Demonstrate rapid-cycle improvement

• Describe the measurement family

• If we have time, a creative thinking exercise

Prerequisites for Improvement

• WILL - to do what it takes for improvement

• IDEAS - for changes that will result in improvement

• EXECUTION - a framework for action to adapt the changes to achieve improvement

Building will• Patient

engagement• Leadership• Data• Stories

Great Wall of China, JinShanLing

Ideas

• Literature• Exemplars• Ourselves• Creative exercises

Execution is often the barrier• The Lens of Profound

Knowledge• Model for Improvement• Learning models

near Scandal Beck, UK

The Lens of Profound Knowledge

The Science of ImprovementTwo Types of Knowledge

SubjectMatter

Knowledge

ProfoundKnowledge

The Lens of Profound Knowledge

The Improvement Guide, page 77

The Science of ImprovementTwo Types of Knowledge

SubjectMatter

Knowledge

ProfoundKnowledge

Increased capability to improve

The Improvement Guide, Langley et al, John Wiley and Sons, 2009

• 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?

Three Questions for Improvement

Act Plan

Study Do

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Proposals, Theories, Ideas

Changes That Result in

Improvement

A PS D

APS

D

A PS D

D SP A

Learning fr

om Data

Repeated Use of the PDSA Cycle

Proposals, Theories, Ideas

Changes That Result in

Improvement

A PS D

APS

D

A PS D

D SP A

Learning fr

om Data

PDSA cycles for increasing attendance at webinars

1) Send invite in newsletter

2) Send reminder

3) Poll about topics of interest

4)

Certainty About Results

Agr

eem

ent

On

The

Cha

nge

Project

Management

Chaos

High Low

Low

Model for Improvement & Project Management

Model

for

Improvement

Based on Plsek

Learning Model

Practice Coaching

• Coaches with topic and QI expertise work with health care teams/organizations over time.

• Based on agricultural extension agent model

• Often used in conjunction with other learning models

• Used in TransforMED medical home with better results for those who were coached.

Collaborative Learning Institute for Healthcare Improvement, www.ihi.org

Model for Improvement Simulation

Improving a Process

• Aim: Pass the tennis ball as fast as possible without dropping it through a team of 7 people.

• Measures: Time and drop rate

• Work in groups of 8• One person is the measurement

captain• Seven people are the passers• They stand in a circle by number

order• Each group has a tennis ball• They pass the tennis ball in a

certain order

1

2

3

45

6

7

• Ball must start and end with the same person (person #1)

• Ball must touch each person in the process

• Only one person can touch the ball at a time

• Follow the exact order each time

• When I tell you, pass the ball in order

• Measurement captain needs to be timing and counting drops

• PLAN: Discuss ideas in your team and pick one. (You will have a chance to try several ideas.)

• DO: When I tell you to start, try your idea. Your measurement captain will record time and drops.

• STUDY: Check what you did against the rules and how well you did with both time and drops. Mark it on your graph.

• ACT: Make a decision about the changes. Did it work or not?

• Talk about the results in your team.

• Complete a second test—a new PDSA cycle when I tell you to start.

• Sit down when you have completed your second cycle

• After everyone is done with their second cycle, we will start together for a third one.

Purple Lake, CA

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

October Sky

How would we know we made a

difference?

If you aim at nothing, you hit it every time.

- attributed to Zig Ziglar

A few notes about measurement

Measurement family (Quantitative)

• Research

• Accountability/evaluation

• Improvement

Solberg et al The Three Faces of Performance Measurement: Improvement, Accountability and Research. Journal on Quality Improvement, Volume 23,

Number 3, March, 1997.

Comparing types of measuresImprovement Accountability Research

Aim Improve care Comparison, choice, reassurance, spur change

New knowledge

Timeline Often very brief, weeks to months

Varies Often takes years

Test observability Test observable Test observable or no test

Test may be blinded

Bias Accept consistent bias

Measure and adjust to reduce bias

Design to eliminate bias

Improvement Accountability Research

Sample size “Just enough” data--work into routine, low or no budget

Obtain all relevant available data.

“Just in case”data.Major budget expense.

Hypothesis Flexible, change as learn, part of work process

May not be a hypothesis

Fixed hypothesis

Testing strategy Sequential tests One test or no test

One large test

Confidentiality of data

Data used by improvers only

Data available to public

Protected data and restricted access

Who measures? Improvers External Highly skilled external team

Qualitative Measurement

Statistics are human beings with the tears wiped off.

- Paul Brodeur

Case1

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ay T

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)

Make Change

Before and After Test

8

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0123456789

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1 2

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(hrs

)

Before Change (measure on Week 4)

After Change(measure on week 11)

Change made between week 7 and week 8

How Will We Know a Change is an Improvement?

Case 2

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Make Change

Case 6

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Make Change

Evidence that change tested result in an improvement?

The Improvement Charter

• Document that answers the first two questions

• Describes the improvement team

• Can be used as the basis of a reporting system

Centre for CMI Improvement CharterWe aim to improve health outcomes through helping people take active roles in their health. Our initial offerings include training and support program for health care clinicians and peers and providing expertise in system redesign. In 2012 we are providing:

1. web and face-to-face training in Brief Action Planning and practice feedback to achieve competency through certification

2. face-to-face training in Stepped Care Self-management Support including cultural humility, health literacy, patient activation, behaviour change support, and advanced approaches including Motivational Interviewing, Group Medical Visits and Care Management.

3. Consultation and guidance in system redesign and evaluationBy March 31, 2012 we will have trained 150 clinicians in Brief Action Planning and have certified 50 clinicians in Brief Action Planning. We will have two evaluations in process that include patient outcomes. It is important to work on this now because there is a great interest in healthy lifestyles and to develop clinician skills in this area. Some things we need to keep in mind as we work are that this is a fledgling organization with more will than capacity.

Centre CMI data

• Process: Numbers trained, certified, accessing supports, design consultations

• Outcomes: Evaluations of trainings and patient/client outcomes when available

• Balancing: Fiscal

Centre for CMI process data

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Brief&Ac)on&Planning&(BAP)&training,&cumula)ve&

"BAP"web"training""

Goal"

"BAP"F2F"training"

"BAP"training"total"

CCMI Process Data

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BAP$Cer(fica(ons,$cumula(ve$

"BAP"cerBficates"

Goal"

NH

BCprototype

Proposals, Theories, Ideas

Changes That Result in

Improvement

A PS D

APS

D

A PS D

D SP A

Learning fr

om Data

PDSA cycles for increasing attendance at webinars

1) Send invite in newsletter

2) Send reminder

3) Poll about topics of interest

4)

CCMI process data

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!A#endance!at!Support!Ac/vi/es!

Numbers"a@ending"office"hours"

Goal"

Numbers"a@ending"webinars"

Total"accessing"support"services"PDSA #1

PDSA #2

PDSA #3

CCMI outcome data

“The Ultimate Question” www.ultimatequestion.com

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"Would'you'recommend?"'scale'of'0310'

%"higher"than"7"web"training"

Goal"

%"higher"than"7"F2F"traning"

CCMI Prototype Evaluation• Process: counts of those who

• Complete web module• Achieve certification in Brief Action

Planning• Experience Brief Action Planning• Access practice and feedback sessions

• Outcome:• Confidence of clinicians in using Brief

Action Planning• Confidence of clients/patients who have

experienced Brief Action Planning• Recommendation of the web module

Questions?

How did we do?

• What you said

• Describe prerequisites for improvement

• Describe the Model for Improvement

• Design PDSA cycles for testing a change

• Demonstrate rapid-cycle improvement

• Describe the measurement family

Thank you!