6/7/19 An Introduction to Quality Improvement ‘- JAMIE WOOLDRIDGE, MD CHIEF, PEDIATRIC PULMONARY 1 Objectives 1. Describe the components included in the Model for Improvement ‘- 2. Describe how to apply the Plan, Do, Study, Act (PDSA) cycle to test, implement, and spread change 2 Quality Improvement vs. Quality Assurance • Systems focused •Relies on Inspection • Uses proactive approach •Uses retrospective approach • Fallibility Recognized •Perfection Myth ‘- • Teamwork •Solo practitioner o t w e o r u • Errors seen as •Errors punished H s a y e t M l i a opportunities for learning u Q “How can we provide “Do we provide better services?” good services?” Ward. D (2014) QA vs QI NNPHI Roundtable discussion 3 1
6/7/19 Central Law of Improvement “Every system is perfectly designed to get the results it gets.” ‘- Paul Batalden, MD 4 Approaches The Typical Approach: Design Design Approved Design Design ‘- CONFERENCE ROOMS REAL WORLD Implement 5 Approaches Applied Science Approach: Approved Design Approved ‘- CONFERENCE ROOMS REAL WORLD Test & Test & Test & Modify Modify Modify Implement 6 2
6/7/19 The Model for Improvement What are we trying to accomplish? “This model is not magic, but it is probably How will we know a change is an the most useful single framework I have improvement? encountered in twenty years of my own work ‘- on quality improvement.” What changes can we make that will result in improvement? Dr Donald M. Berwick Former Administrator of the Centres for Medicare & Medicaid Services | Professor of Paediatrics and Health Care Policy at Act Plan the Harvard Medical School Study Do 7 The Improvement Guide, API, 2009 What are we trying to ‘- accomplish? 8 SMART Goal ‘- How can you Is it actually Is it When do What measure and attainable in something you want to exactly is it track the the given that you achieve this you want to progress of time frame? really want to goal by? achieve? the goal? do? Will it directly 9 benefit you? 3
6/7/19 Aim Statement Review • June 2018 through July 2019, teams participating in the NYS AQIC will utilize the “National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma” ‘- (2007) to improve the diagnosis, management and outcomes for children with asthma. Teams will: • Reduce the average number of hospitalizations for asthma patients in the previous 6 months by 20% • Improve the percent of asthma patients classified as “well controlled” by 40% 10 Aim Statement Review • By June 2020, our aim is to increase the percentage of our patients with persistent asthma with appropriately assessed level of current asthma control from 20% to 80% and to improve the percentage of patients with ‘- currently up to date and documented asthma action plans from 40% to 80%. 11 How will we know a change is an improvement? ‘- 12 4
6/7/19 Model for Improvement A Model for Learning and Change What are we trying to accomplish? How will we know a change is an improvement? ‘- What changes can we make that will result in improvement? Act Plan Study Do The Improvement Guide, API, 2009 13 How Do We Know That a Change is an Improvement? • Quality Improvement is about changing and improving care provided to patients ‘- • It is not about measurement. • However …… 14 Measurement Assumptions •LEARNING not judgement •LIMITATIONS do not negate value ‘- •FREQUENCY matters •VOICE of the systems •STORY of your work 15 5
6/7/19 Aspect Improvement Accountability Research Aim Improve care Compare, reassure, spur New knowledge change Methods Yes N/A. Evaluate current Test blind or controlled Performance Measurement in 3 Worlds performance Test Observable Bias Accept stable bias Adjust data to reduce bias Design to eliminate Sample Size Just enough data, small N/A. Report 100% Just in case data sequential samples ‘- Hypothesis Flexible Yes. Revised as learn and test No hypothesis Fixed hypothesis How to determine Run or Shewhart charts No focus on change Hypothesis, Statistical tests: F- improvement test, t-test, chi square, p value Testing Strategy Small sequential tests No tests 1 large test Data confidential Data used only by those involved No subjects. Data is for public Subjects protected in improvement 16 Measures •Outcome •Process ‘- •Balancing 17 A Closer Look PROCESS MEASURES OUTCOME MEASURES • Data collection may be time • Are patient focused limited • Reflect how care is experienced ‘- • Are within your control differently by a family • Are linked to your ideas • Sometimes take time to � move (changes) the marker � • Are a means to the ends – not • Are in your aim! the ends 18 6
6/7/19 Using your Data •Once you have collected data it is important to show it off! ‘- •How you graph your data has a major impact on what you can do with it. 19 Run Charts Run charts are graphs of data over time and are one of the single most important tools in performance improvement. ‘- 20 Observe a System Identify Improvement 65% 100 % 90% 60% 80% 55% 70% 50% 60% 45% 50% 40% 40% J- 18 F- 18 M - 18 - 18 M - 18 J- 18 J- 18 - 18 - 18 1 8 1 8 1 8 J- 19 F- 19 M - 19 - 19 M - 19 J- 19 J- 19 - 19 - 19 1 9 1 9 J- 18 F- 18 M - 18 - 18 M - 18 J- 18 J- 18 - 18 - 18 1 8 1 8 1 8 J- 19 F- 19 M - 19 - 19 M - 19 J- 19 J- 19 - 19 - 19 1 9 1 9 A A S O - N - D - A A S O - N - A A S O - N - D - A A S O - N - M easu r e 1 M edi an M easu r e 1 M edi an ‘- Sustained Improvement Identify Lost Gains 100 % 100 % 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% M - 18 M - 18 1 8 1 8 1 8 M - 19 M - 19 1 9 1 9 M - 18 M - 18 1 8 1 8 1 8 M - 19 M - 19 1 9 1 9 J- 18 F- 18 - 18 J- 18 J- 18 - 18 - 18 J- 19 F- 19 - 19 J- 19 J- 19 - 19 - 19 J- 18 F- 18 - 18 J- 18 J- 18 - 18 - 18 J- 19 F- 19 - 19 J- 19 J- 19 - 19 - 19 O - N - D - O - N - O - N - D - O - N - A A S A A S A A S A A S 21 M easu r e 1 M edi an M easu r e 1 M edi an 7
6/7/19 Key Elements of Data Collection •Research and Quality Improvement data are different •If you aren’t using it don � t collect it ‘- •Look at your data often – use it to make decisions •Give data back to those who give it to you 22 ‘- “You can’t fatten a cow by weighing it � Palestinian Proverb 23 What changes can we ‘- make? 24 8
6/7/19 Model for Improvement A Model for Learning and Change What are we trying to accomplish? How will we know a change is an improvement? ‘- What changes can we make that will result in improvement? Act Plan Study Do The Improvement Guide, API, 2009 25 ‘- PDSA CYCLES 26 But there is more than one way to… Bake a cake Make a bed ‘- Drive to work 27 9
6/7/19 PLAN ACT Prediction If ____ Then____ Select an action based on the results of the test: Plan to carry out the test • Adopt (who, what, when?) • Adapt Plan for data collection Act Plan ‘- • Abandon Study Do DO STUDY Carry out the plan Compare to prediction Document observations – What did you learn successes/unexpected What was unexpected issues What about the data Begin analysis of data 28 Planning for change: PDSA cycles •SMALL (VERY SMALL) tests of change •1 provider, 1 nurse, 1 patient, 1 intervention ‘- •Over and over (and over) again – same scenarios, different scenarios •Reflect on each one – adapt / adopt, real time change 29 Use of the PDSA Cycle Changes That Result A P in Improvement Learning from Data S D D S ‘- P A A P S D PDSA’s will grow A P each time S D Proposals, Theories, Ideas 30 10
6/7/19 Common Hang Ups •Starting too big •Decision by committee ‘- •Implementing too quickly •Decisions without data •Spreading too quickly •Tasking not testing •Talking not doing 31 Resources • IHI - http://www.ihi.org/education/IHIOpenSchool/resources/_layouts/ihi/pages/videos/ViewAll.aspx?tc=14 896aaa-7504-4ba1-88f6- 647b6a096de9&tcOp=Or&ttl=Improvement+Capability&TargetWebPath=/education/ihiopenschool/re sources&sort=ModifiedDate%7CDescending&xchildtags=1 ‘- • NICHQ - http://www.nichq.org/QI_101/story_html5.html?lms=1 • Books: 32 Thank You! ‘- 33 11
6/7/19 Questions ‘- 34 12
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