Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality Improvement ... · Collaboratives: Creating the Spark of Improvement Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality Improvement Program

Collaboratives: Creating the Spark of Improvement

Stephen L. Davidow, MBA-HCM, CPHQ, APR

Quality Improvement Program Manager

©2015 PCPI Foundation. All rights reserved.

Speaker

Stephen L. Davidow, MBA-HCM, CPHQ, APR

Director of Quality Improvement

PCPI

Chicago, IL

2


Learning objectives

• Define a QI Collaborative

• Discuss the project management considerations

• Describe three key structural components of a traditional collaborative

• Explain the purpose of a collaborative

• Discuss the importance of setting aims and measures

• Explore how a collaborative can serve as the foundation for scale and spread of improvement and innovation

Disclaimer: This presentation is a distillation of a full-day workshop.


Change

“There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things...”

-Niccolo Machiavelli, The Prince


What is a collaborative?

Collaboratives provide the structure that organizations need to close performance gaps in which interested organizations can easily learn from one another and from recognized experts in topic areas where they want to make improvements.

Typically:

– 6- to 18-month duration

– Bring together a large number of teams from similar types of provider organizations (hospitals or clinics) to seek improvement in a focused topic area.

– Range in size from 12 to 160 teams.

– Teams for in-person meetings usually include three members at Learning Sessions (three face-to-face meetings over the course of the Collaborative)

– Additional members working on improvements in the local organization

– Sometimes thought of as pilot or prototype


The purpose of a collaborative is to:

• Develop a common understanding of a problem

• Set common expectations

• Clarify aim and goals

• Serve as an innovation laboratory

• Encourage peer-to-peer sharing and learning

• Provide a safe place to test or explore ideas and tools before rolling out broadly

• Motivate and invigorate improvement initiatives

• Develop a community focused on improvement


The purpose of a collaborative is to:

• Develop a common understanding of a problem

• Set common expectations

• Clarify aim and goals

• Serve as an innovation laboratory


• Provide a safe place to test or explore ideas and tools before rolling out broadly

• Motivate and invigorate improvement initiatives

• Develop a community focused on improvement

CREATE NEW KNOWLEDGE


IHI Breakthrough Series Model

(18-Month Time Frame)

YOUR

Topic

(Develop

mission and

aim)

Planning

Group

Develop

Framework

& Changes

Participants (10-100 Teams)

Prework

LS1 LS 3LS 2

Supports

Extranet (e-community, email) Webinars

Visits (LS and Assessments) Sponsors

Monthly Team Reports

Dissemination

Meetings,

Publications,

Guides, etc.

Expert

MeetingAP1 AP2 AP3*

LS – Learning Session

AP – Action Period

*AP3 – continue

reporting data

as needed to

document

success

Hold the

Gains


General continuous QI work flow

Identify a problem

Evaluate data and look for

causes

Develop improvement

ideas

Test and implement

improvement ideas

Monitor and sustain

Adjust, revise and

repeat


General continuous QI work flow

Where do collaboratives fall in the improvement cycle? Testing improvement ideas.

Identify a problem

Evaluate data and look for

causes

Develop improvement

ideas

Test and implement

improvement ideas

Monitor and sustain

Adjust, revise and

repeat


Why should we focus on this problem?

What does national data tell you?

What does state data tell you?

What does regional data tell you?

What does your data tell you?

– Registry

– Other

What do research studies tell you?


Planning team

• Champions

• Leaders

• Those with on-the-ground experience

• Project managers

• Data collection and analysis expertise

• QI advisor

Usually serve as your faculty throughout collaborative


Creating the problem statement

Problem statements provide shared context to the perception of a problem, and then a proposed solution.

Need to establish:

1. Context | Establish a context for your audience

2. Problem | Define the problem within this context

3. Solution | Propose a solution to this problem


Determining basic collaborative structure and time lines

• Standard IHI Model

• Virtual

• Something in between

• Scope of problem

• What is known about the problem

• Existing tools and standard work

• Geographic area

• Complexity of participating organizations

• Privacy

– Stories

– Data


Selecting faculty and establishing roles and responsibilities

• Expertise

• Past experience with QI/collaboratives

• Availability

• Principal investigator vs. faculty (and how many?)

• Cross functional, multi-disciplinary as necessary

• Define commitment

– Upfront planning

– In-person meetings

– Monthly planning/faculty calls

– Coaching

– Site visits

– After-collaborative work (drafting/editing results)

• Principal investigator fee vs. honoraria


Partners and/or collaborators

• Are there organizations or individuals who have vital interest in the success of this work?

– Professional organization/societies

– Community group or social service agency

– QIN-QIOs

– Public health

– Employers and/or businesses

– Academic institutions

– Health systems

– Health plans/payors

– Other


Identifying project management requirements

• In-person vs. virtual meetings

• Severity and scope of problem – What’s the financial or safety pain level?

• Are their known solutions and examples of success?

• Available staff and volunteer faculty

• Number of participants and organizations

• Size of participating organization teams

• Size of universe (facility, local, system, regional, state, national)

• Timeframe for completion

• Specific deadlines for deliverables, e.g., grant requirements

• Need for scale and spread beyond collaborative experience


Budget considerations

• Operating costs

– Staff

• Project Manager (staff or consultant)

• Improvement advisor (staff or consultant)

• Coaching (consultant and/or faculty)

• Administrative support

– Faculty - Honoraria

– Travel expenses – staff and faculty

– Meeting space; AV/tech support; and food and beverage

– Webinar platform, phone, postage, overnight delivery

– Data collection system

– Data analysis, reports and presentation


Recruiting

• Identify target participants and plan communication schedule to meet launch schedule

• State purpose of collaborative clearly

• Articulate “WIFM”

• Communicate parameters about who should participate and qualifies

– Previous clinical and QI experience

– Requirement re: QI methodology (specific vs. flexible)

– Types of organizations and units

– Team composition

– Demonstrable C-level/clinical leader support and champions

– Recruit and for participants complete any required pre-work, as well as arrange schedules to participate in meetings & webinars


Recruiting (cont.)

• Set expectations on participation

– In-person meetings (All three required)

– Action period webinars (representation)

– Report outs (Progress)

– Data submission (monthly, weekly)

• Deadlines for story boards

• Options for unavoidable absence for high-performers

• Provide enough time to:

– Allow proper application review and follow up (staff and/or faculty)


Application

• Include:

– Description/purpose of collaborative and why collaborative is being created; end goal

– Background information

– Experience in clinical or operational area

– Descriptive data

– Key contact

– Team composition including senior leadership/C-suite support attestation

– Approval to share data within collaborative and in aggregate

– Grounds for participation/dismissal

– Potential to highlight individual success stories as part of scale and spread (with permission)

– Clearly stated submission deadline


Preventing Attrition

• Recruit participants knowing there will be attrition

– Expect as much as 50%; average 20-30%

– May depend on format and requirements

• Time away for clinical staff (lost revenue)

• Operating expenses (travel expenses)

• What can you do to reduce attrition?

– Assess participant readiness – what do they need in place to participate

• Determine previous experience

• Signs of culture of QI

• C-suite and other engagement/support

• Require CEO and other senior management sign-off

• Provide faculty and improvement advisor support

• Opportunity and mechanism for peer interaction during action periods

– Extranet or online community


Curriculum plan outline

• Date

• Focus/purpose

• Faculty/presenters

• Activity-talk topic (May include the following depending on learning session or action period:)

– Lecture Q&A

– Storyboard rounds

– Share tools

– Discussion (peer-to-peer learning)

– Working activity/New work plans

– Implications

– Plans for scale and spread (Potential participant roles)

– Celebrate success (last in-person session)

• Learning objectives

• Assignments (for the sites)

• Resources (from the collaborative and sites)


Developing collaborative environment

Initial in-person meeting:

– Mostly orientation to problem and expert faculty lectures

– Review story boards with faculty, QI advisor and peers

– Design first tests of change

Over time:

• In-person and virtual time together must allow for a balance of lecture and team sharing

• Walk-a-rounds

• Report outs and coaching calls

• Site visits

• Near real-time via Extranet (listserv or via PCPI online community – Coming SOON!)

Important: Send participants home with assignments; set expectation for progress reports


Different types of QI measures

Establishing measures for quality improvement efforts

• Outcome measures

– Impact on the values of the patients and health system; and others such as payers, employees and the community

• Process measures

– Is the process and the steps involved working as planned?

• Balance measures (Different than structure measures, which usually have to do with counts and capability)

– Are the improvements being implemented causing problems elsewhere in the system?


Creating change

• What does the research/literature tell you?

– Your past experience or past attempts at improvement elsewhere – lessons?

• Recognized individual or organizational leaders – Is anyone doing well?

– Resource, partner or faculty?

• Brainstorm change ideas

• Affinitize and prioritize those change ideas

– Group and refine

– Use PICK method or group consensus, perhaps

• Create change package

– Use driver diagram

• Decide how prescriptive collaborative will be about participants use’ of the change package


Setting Aims

• “What are we trying to accomplish?”

– Time specific and measureable (SMART- Specific, Measurable, Attainable, Relevant, Time-bound)

– Specific population of patients affected or specific system involved

– Tied to IOM’s six “Overarching Aims for Improvement” - defined in Crossing the Quality Chasm: A New Health System for the 21st Century.

• Safe

• Effective

• Patient-centered

• Timely

• Efficient

• Equitable

When creating aims, clearly state:

• Who is doing the work

• For whom

• Where

• Expected rate of improvement

• By when


Aim statement examples

• Emergency Department team will reduce patients’ wait time for initial physician visit to 20 minutes or less within 6 months.

• Primary care physician and specialist physician dyad will reduce time to schedule, complete and close referrals for cardiac patients by 50% within 6 months.

• ABC hospital will achieve 95% hand hygiene compliance in all inpatient units with new protocol within 12 months.

• Deeply Caring Hospital will reduce the average number of rapid response team visits to patients admitted to hospital floors from the ED from 3.5 to 1 per month within 90 days using the new hand off standard work procedures and EHR-based communication tool.


Why a driver diagram?

• Clearly articulate aim statement

• Determine primary drivers of change to achieve aim

• Identify secondary drivers that support primary drivers

• List change ideas or action items that correlate to drivers

• Prioritize and synthesize change ideas most likely to make progress toward or achieve aim


Who typically creates the driver diagram?

Individually or a group of a combination of the following:

• Task force

• Collaborative faculty

• External experts

• Aided by staff

• Improvement advisor (trusted individual)

Aim:

Measures:

Primary drivers Secondary drivers

Outcome measures:1.

2.

Process Measures:1.

2.

Key Driver Diagram Template

Project name: ____________________________________________________Leader name: ______________________________________________Team members: _____________________________________________Champions/sponsor: __________________________________________PCPI ©2016. All rights reserved.


Improved health and healthcare


Antibiotic Stewardship


Increase Use of Oral Health Care


The value and nature of pre-work

• Understand the current state internally and externally

• Provide a baseline for comparison against national standard, benchmark or what’s expected

• How do you know where to go if you don’t know where you’ve been?

• Level setting – get participants on the same page

• Likely participants have differing performance records and experiences

• Operating from same understanding of problem

• Marshall human and other resources to make improvement – Get ready, get set, go

• Identify team members, sponsors and champions


Setting up data collection tools and reports

• How many measures do you have?

• Can you use an existing system, e.g., clinical registry?

• Paper, Microsoft Excel or online

• Prospective vs. retrospective chart review

• EHR extraction

• Site specific vs. aggregate for comparison


Getting participants to tell their story

For in-person or phone report outs during action periods, use story boards:

• Site Introduction:

– Site name

– Number of team members participating

– What surprised you most from review of current state data?

• Site specifics

– Description

– Location

– Size (bed size/number of visits or discharges)

– Type of unit, clinic or facility participating

– Number of beds, etc.


Getting participants to tell their story (cont.)

• Collaborative Team Members

– Name, credentials, and role

• What surprised us!

– List 1-3 items that surprised you about your data, management of condition or situation based on your data review? (positive and/or negative)

• What we do well?

– List 1-3 things based on data review you do well

• What we need to improve?

– List 1-3 improvement items based on your data review

• What we want to fix first?

– Identify one item your group would like to fix first and foremost


Improvement is about testing

• Test the changes under a wide range of conditions (robust design)

• Foolproof the new process/procedure

• Use technology where appropriate


Definitions

• Testing: Learning what works in your system

– Change is not permanent

– Failure very useful here, even expected

– Fewer people affected than during implementation

• Implementing: Making change a routine day-to-day operation of the system on your pilot unit

– Don’t expect failure here

– More people affected than during testing

– Increased resistance compared to testing

– Generally requires more time than testing


Scaling and spreading improvement

• Are your lessons applicable to a wide cross-section of clinical settings and by a broad array of professionals?

• What did you learn that surprised you?

• Who can help you scale and spread your prototype?

• Are you ready to:

– Publish?

– Prepare a tool kit with standard work?

– Post results on your website?

– Present at a conference(s) – poster session or full presentation?

– Tweak your change package and re-test?

– Did you identify potential new partners?


Spreading a change to other

locations

Developing a change

Implementing a change

Testing a change

Theory and

prediction

Test under a

variety of

conditions

Make part of

routine operations

The sequence for improvement and spread


Summary of key development steps

1. Determine nature and extent of problem

2. Identify project management requirements

3. Select expert panel, faculty and establish roles and responsibilities

4. Seek potential partners and collaborators – as necessary

5. Determine collaborative structure and time lines

6. Create aim statements, driver diagrams and change packages

7. Develop curricula, timeline and the environment for engagement

8. Recruit participants – set expectations

9. Examine the value and nature of pre-work

10. Develop and implement action plans

11. Create measures, data collection tools and mechanism to share stories

12. Sustain and spread improvement

13. Keep going!


Take-a-ways

Collaboratives:

• Are a lot of work!

• Require planning

• Help develop a common understanding of a problem

• Force participants to clarify aim and goals

• Focus on data to drive change


• Provide a safe place to explore before rolling out

• Motivate and invigorate those conducting the improvement initiatives

• Provide/create a community focused on improvement

• Set the stage for scale and spread

• Worthwhile and satisfying


Thank you!Stephen L. Davidow, MBA-HCM, CPHQ, APR

312-224-6065 office

[email protected]

Documents

Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality Improvement ... · Collaboratives: Creating the Spark of Improvement Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality Improvement Program