Associate Professor Moira Inkelas Centre for Healthier Children, Families and Communities University of California, Los Angeles #evidence4impact
A learning system for improving family and community outcomes Moira Inkelas, PhD, MPH Associate Professor UCLA Fielding School of Public Health, Department of Health Policy and Management Symposium: Evidence for Impact June 2017 1
Percent of children with cystic fibrosis who are below 5th percentile for weight and are receiving supplemental feedings Rates for 120 Centers of Excellence (ranked low to high) Overall rate for 120 Centers of Excellence 100% Guideline/goal 80% 60% Actual 40% 20% 0% Source: Schechter MS & Margolis P. 2005. Improving subspecialty healthcare: Lessons from 3 cystic fibrosis. Journal of Pediatrics.
Median Predicted Survival Age, 1994-2006 40 First reports reveal The Bell Curve significant published variability Quality Improvement starts 741 35 Lives 30 Predicted survival Predicted survival improves from 29 improves from 28 years to 37 years years to 29 years 25 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 Year Source: GT O ’ Connor/Cystic Fibrosis Foundation
To achieve an outcome for a population, we are seeking solutions that… …work at scale (do not break down when we try it for everyone) …will spread to others (all organizations implement the change, not just the most “enlightened” organization) …are sustained over time (do not degrade as attention turns to other topics)
Source: Parry, Carson-Stevens, Luff, McPherson, Goldmann. Recommendations for evaluation of health care improvement initiatives. Academic Pediatrics . 2013;13:S23-S30.
as� a� System� I ’ m� sure� glad� the� hole� is� not� in� our� end!� Every system is perfectly designed to achieve exactly the results it gets.
How is improving a system different from improving a program? • Programs can be planned, implemented and evaluated. • It is not possible to plan and specify each of the detailed actions necessary for a system to produce better results. • Optimizing one part of a system does not optimize the overall system. • Meddling with one part of a system often sets off other problems • Community systems are complex and are never permanently “fixed”. To change outcomes for a population, we need an approach that sets a heading but allows for adaptation and adjustment, using testing to learn its way forward.
Separation - avoid crowding neighbors Alignment - steer towards average heading of neighbors Cohesion - steer towards average position of neighbors
“A learning system is designed to generate and apply the best evidence for the collaborative choices of each person and provider; to drive the process of discovery as a natural outgrowth of care; and to ensure innovation, quality, safety, and value in care .” Institute of Medicine (IOM). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . September 2012.
The Model for Improvement Model for Improvement Some is not a number, What are we trying to Aim accomplish? By when? soon is not a time, Measures How will we know that a hope is not a plan. change is an improvement? What change can we make that Changes will result in improvement? Act Plan Study Do Source: Provost L. Model for improvement: Aims, measures, changes. Associates in Process Improvement.
Population Care for Child Wellness: Collaborative Key Driver Diagram Revision date: 3/16/17 Secondary Drivers Primary Drivers Changes Inviting to families Trusted relationships with families Same day access to team GLOBAL AIM Serve as trusted Services and staff preserve dignity partners for Single point of contact Effective and accountable families partnerships optimize Family agency; succeed w/ goal Proactive, capable, accessible team children’s health potential and family opportunity Elicit risks, assets, priorities Learn families’ assets, risks and needs Use family well-being measure Identify social goals, needs, SMART AIM Offer value, match services to families’ needs Future-casting to anticipate & priorities address needs, goals and priorities By October 2017, each cross-partner team (site) achieves family health and Intra & inter agency workflows Co-manage care between organizations social goals for a shared population of at least 25 Communication workflows Work as a single Evolve services and resources to be effective and families system to user-friendly Registry functionality Measures achieve goals Families reach outcome goals Pareto of care needs, & of Bundle care for accountability for a population Up-to-date risk assignment desired experiences with care Families achieve their Segment population to reduce disparity, inequity Plan new services needed: personal goal build or partner Families receive bundled care Mass customize & risk stratify Frequent and transparent data for learning Measures dashboard Person-centered process design (co-design) Learn and Personas to aid design improve to Use the Model for Improvement solve complex Use small tests of change problems Sustained resources, investment & key Common terms (care/wellness) stakeholders (ROI) Find and fix barriers Innovate with peers Network innovation groups
“Hot oil! We need hot oil!.... Forget the water balloons!”
Using plan-do-study-act (PDSA) cycles for sequential building of knowledge Include a range of conditions in the sequence of tests, before implementing the change Changes that result in improvement A P S D A P S D Implement the change A P S D Test new conditions A P More Testing S D Theories, hunches, & best Small Scale practices Source: Associates in Process Improvement
Deciding the Scale of Testing Test small at the outset, when we know less, which make it easier to see cause and effect Readiness to Make the Change Current Situation Not Ready Indifferent Ready Cost of failure is Low large Confidence that current Cost of change idea will failure is lead to small Improvement Cost of failure is High large Confidence that current Cost of change idea will failure is Implement lead to small Improvement Source: The Improvement Guide , Langley et al. 2009
“Houston, we’ve had a problem” ”We’re on number 8. You’re Carbon dioxide buildup talking about number 692.” ”We gotta find a way to make this fit into a hole for that .” Ambiguity MANAGE UNCERTAINTY, NOT TASKS Power-up protocol INTEROPERABILITY ”Don’t give me anything they don’t have up there.” Apollo 13 flight path REDUCE COMPONENTS
Mann Gulch, Montana 1947
How We Collaborate to Innovate Extreme family orientation Put families at the center of care Clarity of purpose Produce a coherent vision out of many problems Solutions that scale Create solutions that customize to work for all, spread, and sustain Bias toward action More “creating and doing”, than “meeting and planning” Embrace experimentation and use of data for learning Build to think and learn Embrace ambiguity Expect fog and take small steps to get unstuck All contribute and take ownership Bring together partners with diverse roles and viewpoints 24 Sources: StartStrong Co-Creation Session, February 25, 2014 (Business Innovation Factory), and IDEO 24
Lucas B & Nacer H. The habits of an improver . The Health Foundation. 2015.
“Measure only what matters, and mainly for learning.” The goal of measurement is to drive a change • Focus diverse partners on shared outcomes • Establish shared accountability for reaching goal targets • Shape an understanding of what matters and how to influence it • Build and maintain enthusiasm for improvement • Enable partners to think and work as a system • Support improvement with frequent, real-time information
Purpose of Accountability Improvement Research Measurement “ Are we better or “ Are we getting “ What is the truth? ” Key question worse than…? ” better? ” Penalty for being Misdirected reward, Misdirection for an Misdirection for the wrong penalty, resources initiative profession Requirements and Risk adjusted, with Real time, raw counts, Complete, accurate, characteristics denominators, consistent definitions, controlled, glacial validity utility pace, expensive Typical displays Performance relative Run charts, control Comparison of to benchmarks and charts, time between control and standards events experimental populations Social conditions Neutrality; leaders Data shared in low- Meets scientific for use of measures and managers are stakes, safe standards of the primary users environment that is discipline; utility to conducive to change participants is usually secondary Adapted from Solberg, Mosser, McDonald Jt Comm J Qual Improv. 1997 Mar;23(3):135-47.
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