III. (abcd) BTS Topic Selection PG Pg. 3
Topic Selection: Objectives By the end of this session you should be able to: List the reasons that topic selection is a critical factor in success Describe the steps in BTS topic selection Critically analyze whether or not a specific topic should be addressed in BTS-style Collaborative Identify other BTS College members working on topics like the one you have chosen
The IHI Breakthrough Series An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim.
IHI Breakthrough Series (6 to 18 Months Time Frame) Select Topic (Develop Mission) Expert Meeting Develop Framework & Changes Planning Group Participants (10-100 Teams) Prework LS 1 A P S D A P S D LS 2 LS 3 AP1 AP2 AP3* A P S D Dissemination Publications, Congress, etc. Holding the Gains LS Learning Session AP Action Period Supports Email Phone Conferences Extranet Visits Assessments Sponsors Monthly Team Reports *AP3 continue reporting data as needed to document success
Fiascos from the Field! A. The topic no one cares about Topic may/may not be strategically important to the organization Organizations may even be told to send a team B. The topic is of vital interest to organizations. Teams want to join your collaborative because of the important of the topic. However, no one in the past has been able to close the gap to get good results. You don t know how to do so either. Discuss assigned scenario with your team. What impact could this situation have on your ability to run a successful Collaborative?
IHI Breakthrough Series (6 to 18 Months Time Frame) Select Topic (Develop Mission) Expert Meeting Develop Framework & Changes Planning Group Participants (10-100 Teams) Prework LS 1 A P S D A P S D LS 2 LS 3 AP1 AP2 AP3* A P S D Dissemination Publications, Congress, etc. Holding the Gains LS Learning Session AP Action Period Supports Email Phone Conferences Extranet Visits Assessments Sponsors Monthly Team Reports *AP3 continue reporting data as needed to document success
Collaborative Topic Could Be in Any of the Three Categories of Improvement * I. Eliminating quality problems that arise because we fail to meet the expectations of customers (Chapter 10, pp. 218-223) II. ADEs, SSI, Periop Care, Chronic care, Improve child literacy Reducing costs significantly while maintaining or improving quality (Chapter 10, pp. 224-230) Cardiac surgery, supply chain, reducing c-sections III. Expanding customer expectations by providing products and services that customers perceive as unusually high in value (Chapter 10, pp. 230-235) Advanced access, *Source: Langley, G, Nolan, K., Nolan, T, Norman C, Provost, L The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass, 2009
Topic Selection for IHI BTS What do we look for? 1. Gap between science and practice 2. And examples of better performance exist 3. And a good business case exists for the topic On Extranet: Berwick DM. Eleven worthy aims for clinical leadership of health system reform. JAMA 1994; 272: 797-802.
Identifying the Gap 1. The gap between science and practice Current practice deviates from best available scientific knowledge Evidence describes the gap (ideally 3-4 articles) Methods to identify gaps between your organization and best practice Environmental scan - literature What is on the clinicians minds? What is on Organization s leaders minds? Strategic plans of health care systems CMS scope of work Regulator Goals See: Examples of Gaps on extranet
Dimension Example of the Gap from Service Collaborative Picker Survey: Percent of Patients Reporting Problems (Lower is Better) Low Performing Hospitals High Performing Hospitals Respect 15% 4.5% Comfort 22% 13% Emotional Support Involving Family/ Friends 21% 11% 20% 9% Source: Gerteis, Edgman-Levitan, Daley, Delbanco; Through the Patient s Eyes. San Francisco:Jossey-Bass 1993 pp 229-230
Example of Chronic Care Gap Disease Parameter Typical Best Diabetes HbA1c 30% < 8 70% < 8 Asthma CHF Symptom free days Hospital readmits <50% >80% >10%/mo <3%/mo Depression Follow-up <50% >80% CVD LDL< 100mg/dl <50% >70% Source ICIC
Example : Adult Cardiac Surgery Gap Median Best Post-op LOS 5-6 days 3 days Interval from 3-4 days < one day Cath to CABG Post-op vent time 12-18 hours < 4 hours OR time / case for 4-5 hours 2.5-3 hours 3-vessel CABG
Example of Access Gap Patients wait more than three weeks for a routine appointment. Same day access is achievable in primary care; 5 days for specialty care Patients are consistently dissatisfied with waits in clinics and medical offices. Delighting patients with punctuality is achievable
Public Health 14 Issuing Food Service Permits 41 days 14 days Percent Teens Smoking 17% 5.77% (Utah) 6.63 (CA) 6.88 (HI) 6.92 (DC) Well Child Visits by Age 26%.. > 72% Infant Mortality (US African 15.7%...7.7% (San American) Diego) Overall 4.5%
2. And there Is an Example of Best Performance Someone is doing it somewhere In health care (or your industry/profession) in similar settings In health (or your industry/profession) care in different settings Outside of health care (or your industry/profession) We believe it can be done in other settings or situations
When Are We Ready To Run a BTS Collaborative? Degree of belief that the changes will result in improvement High Moderate Successful changes Start a Collaborative when degree of belief is moderate to high Low Getting Ideas Unsuccessful proposed changes Testing: Implement: Spread Idealized Design or other methods Adapted from IG Pg 145 Prototype (in simulated environment) or Pilot (in work setting) Make the change a permanent part of the system in location where testing Adapt to new locations or populations
Idealized Design Process with Deliverables Deep Dive Team Phase 0:Generate new ideas Innovation Team Phase 1:Planning Collaborative Teams Screen Synthesis Observation Deliverables: Charter Design Targets Ideas/Concepts Captured learning & Prediction Phase 4: Pilot testing Phase 3: Prototype testing Phase 2: Concept design Deliverables: Results of test Change Package Prediction Captured learning & Prediction Milestone 1 Milestone 2 Phase 5: Adapt & spread Deliverables: Results of implementation & spread Captured learning & Prediction Generate new ideas Test new ideas Spread new ideas
3. And.a Good Business Case Exists for the Topic Positive financial impact (lower costs, revenue growth, etc) for participating organizations AND Improved outcomes OR Strong appeal to both clinicians or other subject matter experts and administration
Is There a Business Case? (From Improving Chronic Illness Care MacColl Institute) Questions to Ask Will the new intervention work? What will it cost? Will it increase fee-for-service revenues? Will it reduce expenses (in my lifetime)? Will it increase clientele by attracting new patients or retaining old ones? Will it impact case-mix? Answers for Chronic Illness Improvement Effective interventions in most common chronic illnesses Usually $200-500/pt/yr If it adds assessments or encounters not routine in usual care Yes for CHF and diabetes, maybe for asthma and for frail elderly, close for depression Patient satisfaction rises so retention should improve, unclear impacts on new enrollment May increase severity
Business Case Example: Good for Patients Reduction in Risk Factors for People with Diabetes 10 9.5 9.6 Average HbA1c (Southeast Cluster) UKPDS 10 Year Study of Chronic Disease Management Findings: Average 9 8.5 8 7.5 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 May-00 Jun-00 Jul-00 Aug-00 Sep-00 Oct-00 Nov-00 Dec-00 Jan-01 Feb-01 Mar-01 Apr-01 May-01 Jun-01 Jul-01 Month Reduction in HgbA1c in Bureau of Primary Healthcare Southeast Cluster Diabetes I Collaborative 8.0 A 1.0% reduction in HbA1c results in: 17% reduction in mortality 18% reduction in MI 15% reduction in stroke 35% reduction in cardiovascular endpoints 18% reduction in cataract extraction Describe this business case---- BMJ, 321, 405-412
Service Collaborative: Is Topic Ripe for Improvement? There is a gap--some health care providers can show much improved service in specific areas Best practice-- in hospitality and other industries far exceeds health care service. Almost any community has local experts Business case--improved service increases satisfaction, compliance, and increases market share
Example: Is Chronic Illness Ripe Topic for Improvement? There is a gap--some health care providers can show much improved short term outcomes-blood sugar control, symptom free days, etc Is there evidence of gap being closed--best practice in multiple office practices across the country-community health centers, group practices most often. Most regions have local experts Business Case?-- Improved chronic illness care improves patient outcomes, confidence and satisfaction; and reduces unnecessary acute care utilization. May increase volume and revenues through P4P and other contracts
Exercise: Is Your Topic Ripe for Improvement? H Pg 3 Using the topic you have chosen (on your storyboard) list specific ways in which the topic meets the selection criteria o What is the gap? o Where are good examples of best practice? o What is the business case for this topic? Complete the Assessment of Collaborative Topic Worksheet using the 1-5 Scale. Review your spread exercise We will report to the group in 10 minutes using your storyboards to share the results of this exercise and your spread plans
Assessment of Collaborative Topic: Is Topic Ripe for a BTS Style Collaborative? Topic: Reviewer s Name: 24 Assessment Scale 1: Not at all 2: To a small extent 3: Somewhat 4: To a large extent 5: To a very great extent Identifying the Gap Score Element Does current practice deviate from best available scientific knowledge? Are they able to provide data to quantify the gap? Comments Does this Topic Matter to People? (Business Case) Does this topic matter to patients/clients? Is there a strong emotional pull for teams to join the Collaborative? Does this topic matter to clinicians? Does leadership care about this topic? Is this topic linked to the organization s strategic plan? Is there a strong business case for this topic? (financial, clinical, or reputation based) Is there Evidence that Gap can be Closed? Have others closed the gap? Do we have a list of changes that we can use in our collaborative to get good results? Comments:
Exercise: Building A Long-Term Spread Strategy (from Prework) Do you expect to spread the work of your Collaborative teams to the rest of your organization? What is the timetable for this? What (or who) are the appropriate "units" for adopting changes from your change package? Who will make the decision to begin using the new ideas in their practice? Some examples of potential units include physicians, surgeons, emergency departments, hospitals, nursing units in a hospital, clinics, laboratories, or pharmacists. How many total units do you intend to spread to? This could be all eligible units or some defined subset of them. How many units will you select to attend your initial Collaborative? What percentage of the total units is this? How will you select these initial units?
You and Your Collaborative in minutes! Introduce yourself and your team Describe your collaborative Topic, number of organizations, location Report on your assessment of how ripe the topic is: The Gap Who/where is the best practice The business case for participants Insights from your Assessment Scoring Worksheet Your plans for Spread Listeners role: Ask questions, provide feedback, consult
Let s Revisit Ovretveit Which challenges are you most concerned about? 1. Choosing the right topic 2. Ensuring participants define their objectives and assess their capacity to benefit from the collaborative 3. Defining roles and making clear what is expected 4. Ensuring team building and preparation by teams for the collaborative 5. Enabling mutual learning rather than carrying out teaching 6. Motivating and empowering teams 7. Ensuring teams have measurable and achievable targets 8. Equipping teams to deal with data and change challenges 9. Learning and planning for sustaining improvements 10. Planning and learning for spread What is your plan for addressing them? 27
To the Workbook 28 PG Pg. 3 Please go to the Planning Guide section of the Workbook and complete the Worksheet for Topic Selection.