Quality Improvement Fundamentals. Fundamentals in Quality Improvement Cedars Sinai Community Clinic Initiative Kate Colwell MD.

Transcription

1 Quality Improvement Fundamentals Fundamentals in Quality Improvement Cedars Sinai Community Clinic Initiative 2016 Kate Colwell MD A project of Community Partners 2/17/2016 Objectives Increase your knowledge as a team about: Models for improvement How to use the Model for Improvement to improve performance in your clinic. We will mention other tools you can learn to use. 1

2 3 10/7/2015 How do we get results? Clear unambiguous AIM Measurement system to know we are making progress Effective ideas about how to achieve our Aim Realistic progress. Trying things in small steps 2

3 Institute of Medicine: Safe Effective Patientcentered Timely Efficient What is Quality Care? Equitable * Our patients might say I trust I m getting good care They understand me I get care when I need it The receptionist smiled at me and called me by name I know what I need to do to be healthy 3

4 First Law Of Improvement Every system is perfectly designed to achieve exactly the results it gets. Donald Berwick, MD Berwick, DM. A primer on leading the improvement of systems. Br Med J 1996; 312: Timeline to Improvement ContinuousQI EvidenceBasedMedicine Guidelines Pathways Just Culture Culture of Quality 2000 QUADRUPLE Meaningful Use Patient Centered Medical Home W h o l e P e r s o n C a r e 4

5 Choose your Models ALL Improvement Models Cyclical Processes Test the changes on small scale first Ongoing measurement Analyze/study data Apply lessons learned from one test to the next Use of Measurement Need for Senior Leadership Support 5

6 The Model for Improvement Aim What are we trying to accomplish? Measure Change How will we know if a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do How do I figure out what s first? Start with a Problem Identify problems by reviewing existing data and then identifying the cause(s) through brainstorming, flow charts, cause and effect diagrams, etc. Consider which Change Ideas make the most sense Choose the best method for this problem. 6

7 How do I figure out what s first? Start with a Problem Identify problems by reviewing existing data then identifying the cause(s) through brainstorming flow charts cause and effect diagrams, etc. Start with Data A1C Averages by Clinician A1C Values Series Providers 7

8 NO NO NO NO NO NO NO NO 15 10/7/ /7/2015 8

9 The Model for Improvement Aim What are we trying to accomplish? Measure Change How will we know if a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do AIM Happy Clinic aims to have the healthiest diabetic patients in LA County. By Dec 31, % of our diabetic patients (DM I and II) will have most recent A1C value of < /7/2015 9

10 The Model for Improvement Aim What are we trying to accomplish? Measure Change How will we know if a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do Run Chart ANNOTATED For IMPROVEMENT Diabetes Patients with HbA1c >9 50% 45% 40% 35% 30% 25% 20% 15% 10% Diabetes Patient Education Program Begins Jul 11 Sep 11 Nov 11 Jan 12 Mar 12 May 12 Jul 12 Patients 18 with DM with HbA1c >9 Goal Only 37 Patients away from Goal 20 10/7/

11 The Model for Improvement Aim What are we trying to accomplish? Measure Change How will we know if a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do What do I do next? Start with a Problem Identify problems by reviewing existing data and then identifying the cause(s) through brainstorming, flow charts, cause and effect diagrams, etc. Consider which Change Concepts and Ideas make the most sense Choose the best method for this problem. 11

12 Ideas for Change PROBLEM CHANGE CONCEPTS CHANGE IDEAS IDEAS TO TEST PDSA CHANGE PACKAGES TOOLKITS 24 10/7/

13 The Model for Improvement Aim What are we trying to accomplish? Measure Change How will we know if a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do Why Test? Possible Objectives of Testing Increase your belief that the change will result in improvement Opportunity for learning from failures without impacting performance Document how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side effects of the change Minimize resistance upon implementation Adapted from: Associates in Process Improvement (API) 13

14 Small Tests of Change IMPROVE HEALTH IN CA Improve healthcare in my clinic Improve access to care Eliminate Waste Decrease no show rate Reminder calls PDSA: Marta Gutierrez will call 3 patients on Mon morning to see if morning reminder calls will reach the patients. Where do Ideas come from? Start with Analytic tools Flow mapping Fishbone Comparative data Then find answers Staff experience Conferences Online resources IHQC resources Articles 14

15 Fishbone for Colon Cancer Screen OTHER COST Insurance probs Lab probs Access Problems No panel management PATIENT UNAWARE Doesn t understand Poor technique Fears INADEQUATE TIME Unaware of care gap Unaware of CRC Gdline Inadequate Screening CRC LACK of Pt education Uncomfortable with topic CLINIC P&P CLINICIAN Changes to Test (Change Packages & Brainstorming) Patient unaware they need screening In reach Look up last results every clinic visit Provider orders test and educates patient MA sets up test and educates patient Outreach Monthly list by provider Front office staff call patients to come in for visit MA calls patient and provides CRC education In reach& Outreach Start campaign to coincide with flu shots. 15

16 The Model for Improvement Aim What are we trying to accomplish? Measure Change How will we know if a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do PDSA PLAN Choose an idea Start small Who will test what when? How will data be gathered? DO Try it out and gather data STUDY Look at the data ACT Decide if this should be repeated on a larger scale or different way or if something else should be tried /7/

17 How to test? Start with a tiny test Try it on more patients each time Or more staff people Or for a longer period of time Start with one idea Try it in a different language Try the opposite idea Try two competing ideas at the same time Try to do it faster or cheaper First idea to test PROBLEM: Can we capture patients who need CRC screening while they are here for flu shot Question: How much time will it take to look up screening needs while patients here for flu shot. PLAN: Front Desk checks patient in and looks up last CRC test STUDY: Front keeps tally sheet and estimates how many minutes to look up each result 17

18 First PDSA DO: MONDAY MORNING ONE front desk person tries to look up results as each patient checks in for flu shot for one half day. STUDY: Front desk feels VERY stressed and confused and does not like this process ACTION: They decide that Lead MA will run a list the night before of everyone coming in for flu shot, note who is over 50 and look up CRC testing.!!!first TEST DONE!!!! Second PDSA DO: LATE MONDAY AFTERNOON LEAD MA prints list for flu shots the next day and looks up CRC results STUDY: This took 15 minutes ACTION: MA decides that if Front Desk prints the list earlier in the day, she will be able to look for CRC results during spare moments of the day. SECOND PDSA COMPLETE : 2 in 1 day! 18

19 Third PDSA Continue a series of tests of PDSA #2: Tues & Weds continue creating a list, altering who does what when. PDSA Series #3 Is it effective to notify patients? DO: Weds the staff doing flu shots start to notify patients they are due for CRC screening. STUDY: Tally sheets show that 9 of 12 patients refused screening ACTION: Design a script for talking to patients about need for screening. Plan the next PDSAs PLAN: Monday morning huddle for 10 minutes. Decide patients need written and verbal education about CRC screening. Clinician agrees to review written material and choose what they should use. RN thinks there is a poster about CRC screening to post in the waiting area. MA says she is very uncomfortable with the script 19

20 Simultaneous 4 th /5 th /6 th PDSAs #4 DO Clinician chooses written material and front desk hands it out. STUDY MA asks patient if they understood the material. #5 DO RN hangs poster in waiting room STUDY MA asks patient if they saw it/understood it #6 DO RN finds bilingual education piece about the importance of CRC screening and practices script with ONE MA STUDY MA finds the script acceptable and says she will test it the next day. 6 PDSAs series in 2 weeks!!! 20

21 Tasks Vs Tests of Change (PDSAs) Task Behavior or step that has to happen for an action to take place Examples: Staff education & reminders Process Mapping Staff/Patient surveys Team meetings, action plans Tasks vs. Tests Test (PDSA) Team tries something new on a Small Scale Quick; cyclical; Tested under different conditions before implemented LOOK AT THE DATA Examples Testing new form to see if it changes staff behavior Testing a change in a process and asking if it is working better Testing new patient outreach methods (reminder calls, mailers, etc) Testing a morning huddle with care teams to review/prepare for their day 21

22 Task or Test? Collecting our baseline no show rate Task Test Task Task or Test? Starting reminder calls the evening before an appointment for patients of 4 clinic providers Test 22

23 Task or Test? Task Follow up phone calls to patients to figure out why they missed their appointments Test Task or Test? Process flow mapping appointments for pediatric patients that are not up to date with their vaccines Task Test 23

24 Task or Test? Task For pediatric patients, print vaccine histories the day before appointments instead of during appointment Test Keys to Successful Cycles of Small Tests of Change Scale down: do small tests (# of patients, sites) Get outside input re: feasibility of your plan Test change on team members, interested volunteers Conduct test in 1 site, or with 1 5 patients, a short time Be innovative to make test feasible Collect useful data during each test Test over a wide range of conditions Plan for multiple cycles & think a couple cycles ahead Adapted from the Institute for Healthcare Improvement Breakthrough Series College. 24

25 Your Improvement Journey Identify your Needs /why you need to improve Learn Quality Improvement Model (s) Develop an Aim Develop a Logic Model &Project Plan Learn needed Tools Develop a Measurement System Find Better Ideas Test Changes Measure Test changes, measure, sustain, spread 50 10/7/

26 I am ALWAYS available for questions: Recommended Reading (listening) WIHI: itunes or California Healthlines The Best Practice Charles Kenney Whack a Mole David Marx Undressing the Elephant Sarah W. Fraser The Improvement Guide Gerald Langley et al. 26

27 What do you think Quality Health Care would look like? * Why is Improvement Important? Everyone wants to be healthy 27

28 55 10/7/2015 The 2001 Institute of Medicine Quality Report The current care systems cannot do the job. Trying harder will not work. Changing care systems will. 28

29 Don t we already have Quality Health Care? American Health care gets it right 54.9% McGlynn EA, Asch SM, Adams UJ. Et al, The Quality of Health Care Delivered to Adults in the United States NEJM 2003; 348(26) (June 26) Escalating Pace of Improvement 29

30 QI Cheat Sheet Identify your Needs Learn Quality Improvement Model (s) Develop an Aim Develop a Logic Model & Project Plan Learn needed Tools Develop a Measurement System Find Better Ideas Test Changes Measure Test changes, measure, sustain, spread Test changes, measure, sustain, spread How Do YOU identify Improvement Opportunities in YOUR clinic???? 30

31 Identify your QI needs Self Assessment Tools incl: ACIC: Assessment of Chronic Illness Care Required reporting HEDIS scores UDS reporting Meaningful Use Attestations Patient Centered Medical Home gaps Patient complaints Staff complaints Surveys How else? Identify the Problem(s) Mini team meeting: How did you come to define your BCCQ project? Would it have been helpful to use these tools? Data Brainstorm Cause & effect diagram Flow mapping * 31

32 Fishbone for Hypertension OTHER PATIENT Can t afford Rx Insurance probs Doesn t understand End state Ds. Pharmacy doesn t get Rx Side effects or fears Access Problems Inadequate time Doesn t notice BP Poor technique taking BP Unaware pt not taking Rx Inadequate Blood Pressure control Lack of Pt education Unaware of HTN Gdline CLINIC Policies& Procedures CLINICIAN NO Pt comes to clinic Rx (transmitted ) to pharmacy NO YES YES NO BP Accurately Checked Pt gets Rx NO Pt comes to clinic YES NO Clinician notices BP & writes Rx YES YES YES Pt takes Rx YES Clinician notices BP & writes Rx NO NO YES 32

33 Think Big: Start Small 33