Associate Professor Moira Inkelas Centre for Healthier Children, - - PowerPoint PPT Presentation

#evidence4impact

Associate Professor Moira Inkelas

Centre for Healthier Children, Families and Communities University of California, Los Angeles

Moira Inkelas, PhD, MPH

Associate Professor UCLA Fielding School of Public Health, Department of Health Policy and Management

A learning system for improving family and community outcomes

1

Symposium: Evidence for Impact June 2017

3

Percent of children with cystic fibrosis who are below 5th percentile for weight and are receiving supplemental feedings

Source: Schechter MS & Margolis P. 2005. Improving subspecialty healthcare: Lessons from cystic fibrosis. Journal of Pediatrics.

100% 80% 60% 40% 20% 0%

Rates for 120 Centers of Excellence (ranked low to high) Guideline/goal Actual Overall rate for 120 Centers of Excellence

Median Predicted Survival Age, 1994-2006

25 30 35 40 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 Year

Predicted survival improves from 29 years to 37 years

First reports reveal significant variability Quality Improvement starts

Predicted survival improves from 28 years to 29 years

741 Lives

Source: GT O’Connor/Cystic Fibrosis Foundation

The Bell Curve published

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

• ur

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
• verall 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.

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

Model for Improvement

Act Plan Study Do

The Model for Improvement

Aim Measures Changes

Source: Provost L. Model for improvement: Aims, measures, changes. Associates in Process Improvement.

Some is not a number, soon is not a time, hope is not a plan.

Serve as trusted partners for families Identify social goals, needs, priorities Primary Drivers Work as a single system to achieve goals for a population Population Care for Child Wellness: Collaborative Key Driver Diagram

Measures

Families reach outcome goals Up-to-date risk assignment Families achieve their personal goal Families receive bundled care

By October 2017, each cross-partner team (site) achieves family health and social goals for a shared population of at least 25 families

Learn and improve to solve complex problems Secondary Drivers Changes GLOBAL AIM

Effective and accountable partnerships optimize children’s health potential and family opportunity

SMART AIM Revision date: 3/16/17

Elicit risks, assets, priorities Inviting to families Intra & inter agency workflows Registry functionality Use family well-being measure Family agency; succeed w/ goal Trusted relationships with families Offer value, match services to families’ needs and priorities Evolve services and resources to be effective and user-friendly Frequent and transparent data for learning Proactive, capable, accessible team Services and staff preserve dignity Learn families’ assets, risks and needs Co-manage care between organizations Segment population to reduce disparity, inequity Bundle care for accountability Person-centered process design (co-design) Use the Model for Improvement Sustained resources, investment & key stakeholders (ROI) Mass customize & risk stratify Communication workflows Measures dashboard Find and fix barriers Same day access to team Future-casting to anticipate & address needs, goals Plan new services needed: build or partner Pareto of care needs, & of desired experiences with care Innovate with peers Network innovation groups Common terms (care/wellness) Personas to aid design Single point of contact Use small tests of change

“Hot oil! We need hot oil!.... Forget the water balloons!”

Changes that result in improvement Theories, hunches, & best practices

A P S D A P S D A P S D A P S D

Small Scale More Testing Test new conditions Implement the change

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

Source: Associates in Process Improvement

Current Situation Not Ready Indifferent Ready Low Confidence

that current change idea will lead to Improvement Cost of failure is

large

Cost of failure is

small High Confidence

that current change idea will lead to Improvement Cost of failure is

large

Cost of failure is

small

Implement

Deciding the Scale of Testing

Readiness to Make the Change

Source: The Improvement Guide, Langley et al. 2009

Test small at the outset, when we know less, which make it easier to see cause and effect

“Houston, we’ve had a problem”

Carbon dioxide buildup Power-up protocol INTEROPERABILITY ”We’re on number 8. You’re talking about number 692.” ”We gotta find a way to make this fit into a hole for that.” REDUCE COMPONENTS ”Don’t give me anything they don’t have up there.” MANAGE UNCERTAINTY, NOT TASKS

Apollo 13 flight path

Ambiguity

Mann Gulch, Montana

1947

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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

Sources: StartStrong Co-Creation Session, February 25, 2014 (Business Innovation Factory), and IDEO

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Lucas B & Nacer H. The habits of an improver. The Health Foundation. 2015.

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

“Measure only what matters, and mainly for learning.”

Purpose of Measurement Accountability Improvement Research Key question “Are we better or worse than…?” “Are we getting better?” “What is the truth?” Penalty for being wrong Misdirected reward, penalty, resources Misdirection for an initiative Misdirection for the profession Requirements and characteristics Risk adjusted, with denominators, validity Real time, raw counts, consistent definitions, utility Complete, accurate, controlled, glacial pace, expensive Typical displays Performance relative to benchmarks and standards Run charts, control charts, time between events Comparison of control and experimental populations Social conditions for use of measures Neutrality; leaders and managers are the primary users Data shared in low- stakes, safe environment that is conducive to change Meets scientific standards of discipline; utility to participants is usually secondary

Adapted from Solberg, Mosser, McDonald Jt Comm J Qual Improv. 1997 Mar;23(3):135-47.

!

29%

• Child care

• 33

• 40
• 23

• 20

• 14
• 16
• 16

• 106
• 96
• 97
• 86
• 158
• 99
• 63

0%! 100%!

0%! 20%! 40%! 60%! 80%! 100%!

0%! 20%! 40%! 60%! 80%! 100%!

0%! 20%! 40%! 60%! 80%! 100%!

0%! 20%! 40%! 60%! 80%! 100%!

0%! 20%! 40%! 60%! 80%! 100%!

At least 1 neighbor with whom you could discuss a personal problem Can get medical care when needed Flexible when life doesn’t go as planned

0%! 20%! 40%! 60%! 80%! 100%!

Not$ depressed$ Safe% places% for% children% to% play% Caregivers)see) child)regularly) Food$ has$ not$ run$

• ut$

E D SI .

In doctor offices In child care In the community overall In family support programs Goal In community hubs 16%! 12%! 13%! 15%! 12%! 20%! 9%! 20%! 16%! 20%! 20%! 19%! 65%! 72%! 68%! 65%! 70%! Vulnerable At risk On track

Developmental progress at school entry Conditions of families Home routines and health behaviors Measures of real-time improvement in services and supports Family and community conditions Reading proficiency, third grade Potential and actual reach to children in the community

0% 20% 40% 60% 80% 100%

Health Child care Total Family Support

0% 20% 40% 60% 80% 100%

H

Goal target

Family support

Opportunities for learning within sectors

“The provider/staff shared with me local resources for social support”

Opportunities for learning across sectors

Measurement for Learning

l Family Family Family Family

Family support Partner A Family support Partner B Family support Partner C Family support Partner D

1 2 3 4 5 6

CBSC CNI Expo Fam Source StJ DCFS Fam Source CB StJohns CSSD DPSS WIC Echo 211 Rightway Esperanza FEP Crystal Stairs CFRC Pub Counsel 1736 BestStart PACE PanAm LAC CEO StThomas Camino LIFT Pathways Mag Elem HopeSt Leopoli Lanterman Hoover NAC Welcome Baby USC_FM Redshield Allpeople SAJE Normandie Toberman Angelica Jumpstart KYCC Kidwatch CII DMH Grand as Parents LA Perinatal Mental Health MP Family Ctr Redeemer YPI

Familiarity with services/supports

• ffered

by partners

Know quite a bit

Know li le

2013 2014

1 2 3 4 5 6

StJohns FEP KYCC SAJE Camino Rightway Kidwatch DPSS LAC CEO NAC Redshield Hoover PanAm PACE Welcome Baby Lanterman Fam Source StJ 211 Jumpstart Angelica Pub Counsel 1736 CII Grand as Parents MP Family Ctr YPI

Ease

• f

linkage

2013 2014

It’s very easy It’s not easy

1 2 3 4 5 6

StJohns KYCC CSSD Esperanza FEP SAJE StThomas LIFT Camino Rightway Kidwatch WIC Redshield CBSC USC_FM Echo 211 NAC Normandie Welcome Baby CNI PanAm DPSS Hoover PACE Lanterman HopeSt LAC CEO Crystal Stairs DCFS Pathways Jumpstart Allpeople Mag Elem Fam Source StJ CFRC Expo Fam Source CB Leopoli Angelica Pub Counsel Toberman 1736 BestStart CII DMH Grand as Parents LA Perinatal Mental Health MP Family Ctr Redeemer YPI

Frequency

• f

linkage

Rou nely Never

2013 2014

Know quite a bit Know little It’s very easy It’s not easy Routinely Never

Measuring Experiences in a Process

60% 50% 80% 40%

1%

Provider asks if parent has any concerns Parent shares their concern Provider probes and evaluates concern based

• n history and

home context Provider & parent plan together how to address the concern

What proportion of parents with a concern about their child leave a visit with an written idea about how they can address the concern?

Provider reviews information about the child before the visit Provider refers to case manager to develop plan

100% 50%

Provider checks if parent understands the plan

25%

Plan is written down for the parent and documented in the record

__%

“Once this organization implements a change, the change tends to stick.”

53%

“Most people in this organization are willing to change how they do things in response to feedback from others.”

55%

“When people in this organization experience a problem, they make a serious effort to figure out what’s really going on.”

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Average of 12 data points before and after a change

10 20 30 40 50 60 70 80 Avg Before Change Avg After Change Cycle Time (min.)

10 20 30 40 50 60 70 80 90 100

date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Change Made

Cycle Time (min.)

10 20 30 40 50 60 70 80 90 100

date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Change Made

Cycle Time (min.)

10 20 30 40 50 60 70 80 90 100

date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Change Made

Cycle Time (min.)

What is our confidence that the change led to an improvement?

Displaying Measures for Learning

Source: The Improvement Guide, Langley et al. 2009

% of clients reporting being asked about depression % who discussed local resources for social support

0% 20% 40% 60% 80% 100%

12345678910 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

0% 20% 40% 60% 80% 100%

123456789 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

“If we are not the best, we can certainly be the best at getting better, and then we will be the best.”

Summary

• A learning system enables people to:

– Build and maintain enthusiasm for changes; – Think and work as a system; – Plan collective actions around shared outcomes; – Learn how to design and implement small tests of change, to be more successful with improvements; – Use co-design, testing and prototyping to learn how to scale, spread and sustain what works