# Presentation: 512406

## Model for Improvement

- National Combined Councils Meeting
- February 3, 2008

## Model for Improvement

- What are we trying to

- accomplish?

- How will we know that a

- change is an improvement?

- What change can we make that

- will result in improvement?

## Fundamental Questions for Improvement

- What are we trying to accomplish?
- How will we know that a change is an improvement?
- What change can we make that will result in improvement ?

## The PDSA Cycle for Learning and Improvement

**The PDSA Cycle for Learning and Improvement**

**Act**

-  What changes
-    are to be made?
-  Next cycle?

**Plan**

-  Objective
-  Questions and
-    predictions (why)
-  Plan to carry out
-    the cycle (who,
-    what, where, when)

**Study**

-  Complete the
-    analysis of the data
- Compare data to
-         predictions
- Summarize what
-    was learned

**Do**

-  Carry out the plan
-  Document problems
-    and unexpected
-    observations
-  Begin analysis
-    of the data

## Why Test?

## Why Test?

- Increase the belief that the change will result in improvement
- Predict 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

## Repeated Use of the Cycle

**Hunches Theories Ideas**

**Changes That Result in Improvement**

**DATA**

## Testing on a Small Scale

## Testing on a Small Scale

- Have others that have some knowledgeable about the change review and comment on its feasibility.
- Test the change on the members of the team that helped developed it before introducing the change to others.
- Incorporate redundancy in the test by making the change side-by-side with the existing system.
- Conduct the test in one facility or office in the organization, or with one patient.
- Conduct the test over a short time period.
- Test the change on a small group of volunteers.
- Develop a plan to simulate the change in some way.

## Do           Study	

**Do           Study****	**

**Reasons for failed tests****	****	****	**
- 1. Change not executed well
- 2. Support processes inadequate
- 3. Hypothesis/hunch wrong:
- 		  - Change executed but did not result in local improvement
- 		  - Local improvement did not impact access or efficiency
- Collect **data** during the Do Phase of the Cycle to help differentiate the these situations.

## Questions for Users of the PDSA Cycle

- Is the planning based on theory? Stated?
- Are the predictions made prior to data collection?
- Are multiple cycles run?
- Is there documentation of what was learned?
- Does the learning provide a basis for action?

**Notes:**
Use these questions to help evaluate the strength of a test or series of tests.  If a team can answer yes to all of these questions, then they have used the PDSA cycle as a tool for learning...one that will accelerate improvement in the organization.  Teams can use these questions as a check list in evaluating how well they are utilizing the PDSA for learning.

## Accelerating Learning and Improvement

***What Cycle can we complete by next Tuesday?***
- Willing to compromise on scope, size, rigor, and sophistication, but the Cycle must be completed by Tuesday.

## Aim: Improve primary care appointment availability     	     through reducing and standardizing appoint types

**Reduction of appointment types will increase appointment availability**

**Improved access**

**DATA**

- Cycle 1:Define a small number of appointment types

- Cycle 2:Compare requests to the types for one week

- Cycle 3:Test the types with 1-3 physicians

- Cycle 4: Standardize appointment types

- Cycle 5: Staff education in
-                new standards

## Overall Aim: Increase Access

***Specific Test Cycles***

**Standardpanel size**

** ****Scheduling**
**protocols **

**  ****Appointment**
**  ****types**

**Team approach**
**to care**

**Overall Aim: Increase Access**

## Three Different Purposes for Measurement

| Aspect | Improvement | Accountability | Research |
| --- | --- | --- | --- |
| Aim: | Improvement of care | Comparison, choice, reassurance | New knowledge |
| Methods:
 | Test observable | No test, evaluate current performance | Test blinded or controlled |
| Bias: | Accept consistent bias | Measure and adjust to reduce bias | Design to eliminate bias |
| Sample Size: | “Just enough” data, small sequential samples | Obtain 100% of available,  relevant data | “Just in case” data |
| Flexibility of
Hypothesis: | Hypothesis flexible, changes as learning takes place | No hypothesis | Fixed hypothesis |
| Testing Strategy: | Sequential tests | No tests | One large test |
| Determining if  a Change is an
Improvement: | Run charts or Shewhart control charts | No change focus | Hypothesis, statistical  tests (t-test, F-test, chi square, p-values) |
| Confidentiality of
the Data: | Data used only by those involved with improvement | Data available for public consumption and review | Research subjects’ identities protected |
| Frequency of Use: | Daily, weekly, monthly | Quarterly, annually | At end of project |

## Measurement for Improvement

- Develop a measurement system to guide improvement work and assess results
- Summary measures to monitor status of system (vital signs, not estimates of parameters, plot over time, balanced)
- More focused measures to determine how well changes are being adapted
- Integrate data collection into daily work

**Notes:**
Develop a measurement system to guide improvement work and assess results
Summary measures to monitor status of system
	vital signs, not estimates of parameters
	plot over time
	balanced set
More focused measures to determine how well changes are being adapted
	data collected for a short period

Integrate data collection into daily work
Include in a current activity
Make IS input and output easy
Define roles and responsibilities
Set aside time to review

## Minimum Standard for Monthly Reporting in the Collaborative:Annotated Time Series

## Family of Measures for Chronic Care BTS

**Family of Measures for Chronic Care BTS**

## Track your PDSA cycles and Key measure(s).  Annotate your graph to reflect whether a change led to an improvement

**Track your PDSA cycles and Key measure(s).  Annotate your graph to reflect whether a change led to an improvement**

**NE Team:  Actual team PDSA cycles and graph**

## Monitor and evaluate patient outcomes - Consider measuring the following:

- Clinical outcomes, such as A1c, blood pressure, lipid levels, and weight.
- Physical activity levels.
- Patient satisfaction.
- Health care service utilization.
- Quality of life.
- Costs.
- Hospital admissions.

- From the Indian Health Diabetes Best Practices: Diabetes Systems of Care (Page 6)

## IPC Measures (Fall 2007)

| Measurement Domain | Areas of Focus/Coverage |
| --- | --- |
| Clinical Prevention | Keeping current on intake screenings |
|  | Keeping current on cancer related screenings |
|  | Keeping current on Immunizations |
| Management and Prevention of Chronic Conditions | Control of Blood Pressure (Cardiovascular Disease) |
|  | Control of Lipids (Cardiovascular Disease) |
|  | Diabetes Care |
|  | Obesity |
|  | Asthma |
| Costs | Dollars spent outside primary care |
| Patient Experience | Experience and Efficiency |
|  | Activation |
|  | Satisfaction |
|  | Building relationships for care |
|  | Access |

## Slide 22

| Measurement
Domain | Areas of Focus/Coverage | Core Measure | Goal |
| --- | --- | --- | --- |
| Clinical
Prevention | Keeping current on intake screenings | Intake Screening Bundle  | 70% |
|  | Keeping current on cancer related screenings | Cancer Screening Bundle | 70% |
|  | Keeping current on Immunizations | Childhood Immunizations  | 90% |
| Management and
Prevention
of Chronic
Conditions | Control of Blood Pressure (Cardiovascular Disease) | BP in Control Bundle | 70% |
|  | Control of Lipids (Cardiovascular Disease) | LDL in Control Bundle | 70% |
|  | Diabetes Care | Diabetes Comprehensive Care | 70% |
|  | Obesity | Nutrition Education for at risk populations | 60% |
|  | Obesity | Exercise Education for at risk populations | 60% |
|  | Asthma | New measure coming in 2008  |  |
| Costs | Dollars spent outside primary care | Number of Hospitalizations | 20% less |
|  | Dollars spent outside primary care | Number of ER and Urgent Care Visits | 40% less |
|  | Dollars spent outside primary care | Total Costs of Outside Services | 20% less |
| Patient
Experience | Waiting and Efficiency | Average Office Visit Cycle Time | 45 minutes |
|  | Activation | Percent of Patients with Self Management Goal Set  | 70% |
|  | Activation | Patient Confidence | 90% |
|  | Satisfaction | Patient Recommending Health Facility | 95% |
|  | Building relationships for care | Continuity of Care | 80% |
|  | Access | Third Next Available Appointment | Same week |

## Intake Screening Bundle

| Specific Measures inside the Intake Screening Bundle |  |  |
| --- | --- | --- |
| Measure | Numerator | Denominator |
| Alcohol Misuse Screening | Female patients screened for alcohol use, who have alcohol-related diagnoses, or who have received alcohol-related education or counseling during the Report Period, including refusals in the past year | Female Active Clinical patients ages 15 to 44 (child-bearing age). |
| Depression Screening | Patients screened for depression or diagnosed with mood disorder at any time during the Report Period, including documented refusals in past year. | Active Clinical patients ages 18 and older |
| Domestic/IPV Screening | Patients screened for or diagnosed with intimate partner (domestic) violence during the Report Period, including documented refusals in past year. | Female Active Clinical patients ages 15-40. |
| Tobacco Use and Assessment | Patients screened for tobacco use during the Report Period | Active Clinical patients ages 5 and older |
| BMI Assessed (Obesity Assessed) | All patients for whom BMI can be calculated, including refusals in the past year. | Active Clinical patients ages 2 through 74 |
| BP Assessed | Patients with BP values documented within the last year | All Active Clinical patients ages 20 and over, broken down by gender  |

## Cancer Screening Bundle

| Specific Measures inside the Cancer Screening Bundle |  |  |
| --- | --- | --- |
| Measure | Numerator | Denominator |
| Breast Cancer Screening | Patients with documented mammogram in past two years or refusal in past year | Female Active Clinical patients ages 52 through 64, without a documented bilateral mastectomy or two separate unilateral mastectomies. |
| Cervical Cancer Screening | Patients with documented pap smear in past three years or refusal in past year | Female Active Clinical patients ages 21 through 64 without a documented history of hysterectomy. |
| Colorectal Cancer Screening | Patients who have had ANY CRC colorectal screening, defined as any of the following:  A) Fecal Occult Blood test (FOBT) during the Report Period; B) flexible sigmoidoscopy or double contrast barium enema in the past five years; C) colonoscopy in the past 10 years, or D) a documented refusal in the past year | Active Clinical patients ages 51-80 without a documented history of colorectal cancer or total colectomy |

## BP and LDL in Control

| Outcome Measure Bundles |  |  |
| --- | --- | --- |
| Bundled Measure | Numerator | Denominator |
| Blood Pressure in Control | Patients 20 years old or older: 
a) DM with BP < 130/80 
b) IHD with BP < 130/80
c) Or no diagnosis of DM / IHD with BP < 140/90 | Patients in panel 20 years old and older |
| LDL in Control | Patients in the panel > 18 years old with CVD and/or DM with last LDL < 100 within the last year | Patients in the panel > 18 years old with CVD and/or DM |

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