An Introduction to Quality Improvement
for MINTiesConnie Davis, MN, ARNP
[email protected] for Comprehensive Motivational Interventions
www.centreCMI.caSeptember 13, 2012
Fort Wayne, IN
Who is in the room?
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
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Del
ay T
ime
(hrs
)
Make Change
Before and After Test
8
3
0123456789
10
1 2
Dela
y Ti
me
(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
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Del
ay T
ime
(hrs
)
Case 3
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Del
ay T
ime
(hrs
)
Case 5
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Del
ay T
ime
(hrs
)
Make Change
Case 4
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Del
ay T
ime
(hrs
)
Make Change
Make Change
Case 6
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Del
ay T
ime
(hrs
)
Make Change
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
0"
20"
40"
60"
80"
100"
120"
140"
160"
Mar+12"
Apr+12"
May+12"
Jun+12"
Jul+1
2"
Aug+12"
Sep+12"
Oct+12"
Nov+12"
Dec+12"
Jan+13"
Feb+13"
Mar+13"
Brief&Ac)on&Planning&(BAP)&training,&cumula)ve&
"BAP"web"training""
Goal"
"BAP"F2F"training"
"BAP"training"total"
CCMI Process Data
0"
10"
20"
30"
40"
50"
60"
Mar,12"
Apr,12"
May,12"
Jun,12"
Jul,1
2"
Aug,12"
Sep,12"
Oct,12"
Nov,12"
Dec,12"
Jan,13"
Feb,13"
Mar,13"
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
0"
5"
10"
15"
20"
25"
Mar)12"
Apr)12"
May)12"
Jun)12"
Jul)1
2"
Aug)12"
Sep)12"
Oct)12"
Nov)12"
Dec)12"
Jan)13"
Feb)13"
Mar)13"
!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
0"
20"
40"
60"
80"
100"
Mar+12"
Apr+12"
May+12"
Jun+12"
Jul+1
2"
Aug+12"
Sep+12"
Oct+12"
Nov+12"
Dec+12"
Jan+13"
Feb+13"
Mar+13"
"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?