My Practice is Perfect So Why Are Some Of My Patients Unhappy and Unhealthy

Developing a Provider Culture of Dynamic Quality Improvement

My Practice is Perfect So Why Are Some Of My Patients Unhappy and

Unhealthy

Quality Health Care

“Problems in health care quality are serious and extensive; they occur in all delivery

systems and financing mechanisms. Americans bear a great burden of harm

because of these problems, a burden that is measured in lost lives, reduced functioning, and wasted resources. Collectively, these

problems call for urgent action.”Institute of Medicine, Committee on Quality of Health Care in America.

Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001

Quality Health Care

“The Institute of Medicine outlines 6 aims for improving our nation’s health care system by stating that all health care

should be

safe,

effective,

patient-centered,

efficient,

equitable, and

timely. “Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National

Academy Press; 2001

Quality Health Care

The quality of health care is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with

current professional knowledge.

Donald Berwick

How Do We Define Health Care

Three Domains of Health Care

1. Structural

2. Processes3. Outcomes


Three Domains of Health Care

1. Structural – tools available for care

2. Processes – activities we do

3. Outcomes - results

IndicatorsIndicators are the metrics we use to

measure the element of the three domains.

As medical professionals, we are used to working with these. Vital

signs are a outcome metric we use all the time.


Types of Quality Problems

1. Overuse – risk of potential harm exceeds the possible benefit

2. Underuse – opportunity for likely favorable outcome missed

3. Misuse - appropriate service causes a preventable complication and full potential benefit not acheived

Six Health Care Improvement Dimensions

1. Safe - Avoiding injuries to patients from the care

2. Effective - Providing services based on scientific knowledge

3. Patient-centered - respectful of and responsive to individual

4. Timely - reducing delays

5. Efficient - avoiding waste

6. Equitable – patient doesn’t impact the quality of service offered

Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st

Century. Washington, DC: National Academy Press; 2001.

I Wish My Practice Was This Simple

A Better Model of My Practice

Direct Effects of Practice Variables on Patient Outcome

Age

Gender

Family

Health Status

Care Coordination

Communication

A Better Model of My Practice

Numerous Direct and Indirect Effects of Practice Variables on Patient Outcome

Age

Family

Health Status

Care Coordination

Communication

R=Residual Error

RF

RA

RHS

RC

RCC

RP

Blalock HM, Causal Models in the Social Sciences, Aldine Publishing Co., 1999.

Building Blocks of Quality Improvement

Focus on PROCESS

Both internal and external CUSTOMER driven

Use objective DATA to make

decisions

Building a Team for Quality Improvement

• Multidisciplinary TeamMD NursingLab ITBilling Office StaffMedical RecordsManagement

• Clear involvement of leadershipVariable sponsorship

Efficient communication• Meet regularly• Foster “No Bad Suggestion”

culture

Quality Improvement Model

The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].



What Are We Trying To Accomplish?

AIMUse quality indicators to make a list of

problems faced by your practice or opportunities for change.

Prioritize the problems or opportunities for change

Make goal improvement unambiguous and achievable

Be clear on boundaries

What Change Can We Make That Will Result in Improvement?

Change ConceptsEliminate wasteImprove work flowOptimize inventory – VaccinesChange the work environmentImprove provider/customer experienceImprove time efficienciesDecrease variation in the processMistake proofingImprove product or service

Langley G et al. The Improvement Guide. Josey-Bass Publishers, San Francisco, 1996; xxi,

p295.


AIMUse quality indicators to make a list of

problems faced by your practice or opportunities for change.

Prioritize the problems or opportunities for change

Make goal improvement unambiguous and achievable

Be clear on boundaries


AIM

FOCUS on

what is important to your organization

not what is sexy

STEAL shamelessly


AIMAvoid AIM drift

Be ready to refocus – always learn from current data set

Pilot, try a panel of strategy and spread


AIMHOW GOOD?

BY WHEN?


AIMHOW GOOD?

BY WHEN?

Highland Pediatrics will decrease mean registration to physician time by 20% in 18 months.


AIMHOW GOOD?

BY WHEN?

Highland Pediatrics will offer 3 possible well care visits times

within 48 hours of parental request within the next 6 months.


AIMHOW GOOD?

BY WHEN?

Highland Patients will decrease ER or hospital admissions in known Asthma patients by 15% in 12

months.


AIMHOW GOOD?

BY WHEN?

Highland Pediatrics babies will have completed maternal

Edinburgh screens on the chart for the one and four months visits for 90% of patients in 12 months.



How will we know a change is an improvement?

Know that progression is vital

BUT can be painful


ChallengesAdds work

Threatening – I plead the 5th

Difficultly with accuracy and consistency

Using the data to take action

Manual vs Automated

Management’s reality conflicts with data

Measured elements chosen inappropriately

Lack of training in data collection and analysis


OpportunityHealthier and more effective decision

making processProgress (or lack of) can be followedBuild a defined platform for improvement and areas of opportunity

Build confidence in understanding of operationsEveryone is talking a similar language

Easier to see trends – move to proactive instead of reactive

Focus on important items

Data sells ideas and limits the power of dramatic anecdote


RulesQI is for learning how well what you do correlates with what you want to do

QI is not to build a case to punish someone

“All measures have limits, but limitations do not negate value.”

Use a “balanced set of measures”

Focus on a VITAL FEW forget the common many

Data plotted over time


StepsAIM Statement

Concept

Measures

Operational Definition

Data Collection

Analysis

Test Change


Operational DefinitionClear and not ambiguous

Measurement methods

Measurement equipment

Identifies criteria

Specific measures

Ends with numerator/

denominator


Run ChartMeasure over time

Common and Special Causes

Dr Coffman - Edinburgh Screening

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Q2/11 Q3/11 Q4/11 Q1/12 Q2/12 Q3/12 Q4/12 Q1/13

one month

four month

Balance




“All improvement will result in change. All change will not result in improvement”

“Every system is perfectly designed to get the precise results that it gets”


Do a detailed analysis of your area of concern

Review the current Evidence-Based Medicine

Review Benchmarks (ie, learning from superior performers in the area chosen for improvement)

Advice from experts or others who have attempted improvement in similar topics

Brainstorming, critical thinking, and hunches about the current system of care

Don’t reinvent the wheel


Change ConceptsEliminate wasteImprove work flowOptimize inventory – VaccinesChange the work environmentImprove provider/customer experienceImprove time efficienciesDecrease variation in the processMistake proofingImprove product or service

Langley G et al. The Improvement Guide. Josey-Bass Publishers, San Francisco, 1996; xxi,

p295.



How To Use a PDSA Cycle

PlanDescribe the change to be tested.What do you predict will happen?When will you conduct the test?Who will be involved?Who needs to know about the test?How will you conduct the test?

DoConduct the test.Document what happened.

StudyDiscuss the results of the test.How do your results compare with

your predictions?What did you learn?

ActBased on the results of the test

adopt, adapt, or abort the change.

Overview on Testing Change

Must have a THEORY and a PREDICTION

Test on small scale and collect data over time

Build on your understanding with multiple PDSA cycles for each change idea

Look at change over a wide range on circumstances as you sequence through your PDSA cycles


Change Concept

Testing Change Concept

Applying Change Concept

Universalization

Theory and Prediction

Test over a spectrum of conditions

Become routine operation


AIM: Improve infant care of depressed mothers by better screening mothers at one and four month visits

Cycle 1: MD gives mom Edinburgh Screening Tool to complete during exam to 3 moms

Cycle 2: MD gives screen to all moms for a month

Cycle 3: RN introduces screen during rooming, MD grades

Cycle 4: All staff oriented to use of Edinburgh Screen Tool

Having moms fill out Edinburgh Screening Tool will help identify mothers at risk for severe post partum depression

Data

15% have EST

90% have EST


Change Concept

Testing Change Concept

Applying Change Concept

Universalization

Theory and Prediction

Test over a spectrum of conditions

Become routine operation

PDSA Cycle

Why did you succeed?

Why did you fail?

What further changes do you now need to make in order to succeed?

Were there unintended consequences or harm created by your change attempts?

Concept Triangle

Change Concept-I want to minimize my vaccine inventory

Concept Triangle

Idea-

Only order to replace what we have used that month


Concept Triangle

Idea-


Idea Concept-

Not overstock by over ordering


Concept Triangle

Idea-


Idea Concept-


Another way to do that idea concept-

Track our use from last year and purchase potential deficient compared to current stock


Concept Triangle

Idea-


Idea Concept-


Another way to do that idea concept-

Track our use from last year and purchase potential deficient compared to current stock


Summary

My Mind SetThink like your customer for the problem at hand

Focus on processes – How you do what you do

Use DATA

My Map and CompassMy AIM – What am I trying to accomplish

How do I know a change is an improvement?

What change can I make that will result in improvement?

My TransportationStart SMALL and end with ALL

Build your understanding of your processes through sequential testing

Test, Implement, Spread

ReferencesBerwick DM. Developing and testing changes in delivery of care. Ann Intern Med1998;128(8):651-656.

Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280(11): 1000-1005.

Clemmer TP, Spuhler VJ, Berwick DM, Nolan TW. Cooperation: the foundation of improvement.Ann Intern Med. 1998;128(12):1004-1009.

Council on Medical Service. Quality of care. JAMA.1986;256(8):1032-1034.

Donabedian A. The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI: Health Administration Press, 1980. Explorations in Quality Assessment and Monitoring; vol 1.

Horbar JD. The Vermont Oxford Network: evidence-based quality improvement for neonatology.Pediatrics. 1999;103(1)(suppl E):350-359.

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

Langley GJ, Nolan KM, Nolan TW, Normal CL, Provost LP. The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996. E):203-214.

Lloyd R. An Introduction to the Model for Improvement. The Institute for Healthcare Improvement . 2007-06-29

Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15):1515-1523.

Perla RJ, Provost LP, Murray SK. Sampling considerations in health care improvement. Quality Management in Health Care. 2013 Jan/Mar;22(1):36-47.

Plsek PE. Quality improvement methods in clinical medicine. Pediatrics. 1999;103(1)(suppl

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My Practice is Perfect So Why Are Some Of My Patients Unhappy and Unhealthy