PERFORMANCE IMPROVEMENT METHODOLOGY · PERFORMANCE IMPROVEMENT METHODOLOGY Heather Mann, MSPH, CPHQ...
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PERFORMANCE IMPROVEMENT METHODOLOGY Heather Mann, MSPH, CPHQ SC PCMH Alliance November 17 th , 2017
Transcript of PERFORMANCE IMPROVEMENT METHODOLOGY · PERFORMANCE IMPROVEMENT METHODOLOGY Heather Mann, MSPH, CPHQ...
PERFORMANCE IMPROVEMENT
METHODOLOGY
Heather Mann, MSPH, CPHQ
SC PCMH Alliance
November 17th, 2017
OBJECTIVES
List and apply the fundamental concepts of the
Model for Improvement
Understand tools to organize improvement
projects
Plan and develop PDSA cycles for improvement
projects
List tips for getting started in improvement
♥ WILL
♥ IDEAS
♥ EXECUTION
►Responding to the
need to change
▪External or internal
pressure
►Alternatives to the
status quo
▪Evidence-based
►Managing change
(Implementing and
Spreading changes)
Performance Improvement
Requirements
HEALTHCARE IMPROVEMENT
METHODOLOGIES
“Trial and Error”
Studying the problem - often “paralysis
by analysis”
Model for Improvement – Framework
Developing
Testing
Implementing
MODEL FOR IMPROVEMENT
Balance – between “trial and error” and extensive
study
Balance – desire and rewards from taking action
with wisdom of careful study before taking action
THREE FUNDAMENTAL QUESTIONS
FOR IMPROVEMENT…
What are we trying to accomplish?
Articulated in an aim statement
How will we know that a change is an improvement?
Measures - Collecting small samples of data
on a continuous basis
What changes can we make that will result in an improvement?
Plan for testing changes (PDSA cycles and change package)
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Q: What are we trying to accomplish?
A: Your Aim Statement
A written statement of the accomplishments
expected from each pilot team’s
improvement effort
Contains useful information:
• A general description of the goal
• Specific population
• Numerical goals
• Plan for spread
SMART GOALS
Specific
Measureable
Attainable
Results-focused
Timely
Q: What might an AIM Statement look like?
No-Show Rate Aim Statement:
The PCMH team at XYZ practice will decrease
appointment “no-show” rate by 25% for diabetic
patients by Sept. 30, 2017.
Glycemic Management AIM Statement:
The Glycemic Management team will reduce severe
hypoglycemic events (blood glucose <50) for patients
receiving insulin therapy by 25% by September 30,
2018.
Example AIM Statements
-A particular change idea from the
change package is tested with rapid
PDSA cycles.
-The overall impact of changes
implemented is assessed through regular
monitoring of key measures.
Q: HOW DO WE KNOW THAT CHANGE IS
AN IMPROVEMENT?
A: MEASUREMENT
Q: What changes can we make that will result
in an improvement?
A: Change Package + Team Brainstorming +
Evidence-Based Best Practices
An example, for improving diabetic foot exam
rate:
Test having patient remove shoes during
rooming process as a visual que
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 whatwas learned
Do
• Carry out the plan
• Document problemsand unexpectedobservations
• Begin analysis of the data
REPEATED USE OF THE CYCLE
Hunches
Theories
Ideas
Changes
That Result
in
Improveme
nt
A P
S D
A P
S D
Very Small Scale Test
Follow-up Tests
Wide Scale Tests of Change
Implementation of Change
Spread
Project: Diabetes Improvement Cycle #: 1 Date: 10/16/2011
Objective: Pilot a diabetic group visit model within the office setting.
PLAN
Questions Predictions
1. Will patients volunteer and be willing to participate? 1. Yes, at least 7 patients will be identified for pilot group visit
2. Will our space be able to accommodate a group visit? 2. Yes, but will need to be smaller groups
3. What will the patient feedback be about the group visit? 3. At least 80% of participants will respond favorably on the evaluation.
What data will be collected during this time? (Forms to be used)
Who: TK, AR
What: Identify 7-8 diabetic patients scheduled next week and query them regarding willingness to participate in group visit. Block physician schedule for 90 minutes for group visit, prepare refreshments and gather information from patient records for the visit. Schedule first group
visit.
When: 10/20/2011
Where: ARFM
DO the Action Plan
What went wrong? What happened that was not part of the plan?
The time of day selected for the group visit made it difficult for working participants to attend so attendance was lower than expected. Some patients did not fully understand the group visit process so additional up-front communication and education is needed before next visit.
STUDY
Complete analysis of data. Summarize what was learned include results of predictions.
1. 7 patients agreed to attend the group visit but only 5 attended (71%)
2. The space was tight even with only 5 patients so group visits should probably be limited to 5 participants.
3. 100% of participants responded favorably to the group visit model and stated they looked forward to the next visit. They expressed appreciate about being included in a pilot.
ACT
What decisions were made from what was learned?
Continue with the diabetic group visit model and consider alternate meeting times. The participants indicated they would like to have basic diabetic education around medications, diet, blood sugar checks etc.
What will be the next cycle? The team will pilot having the group visit in the lobby during lunch hours when the practice is closed to allow for more space. The team will work to have a CDE (either from the hospital or pharmaceutic company) available to attend and discuss diabetes
education and answer questions from the group.
TOOLS FOR ORGANIZING IMPROVEMENT PROJECTS
TREE/DRIVER DIAGRAM
What is it?
Used to visualize the structure of a problem
Graphical view of different levels of detail
about a problem
TREE DIAGRAM
Why use it?
Facilitates dialogue and agreement among the
team
Identify and clearly display details of complex
issues
Sets project boundaries
Breaks down the project from the aim to
questions that can lead to possible
improvement cycles
TREE DIAGRAM
How do I construct?
Begin with the aim/outcome, then move to processes
and changes
Develop branches on the “tree” into different levels
of detail
Can be developed horizontally or vertically
Tree Diagram Template
tcome/Aim
Outcome/Aim
What are we trying to accomplish? How will we know a change What changes can we make that
is an improvement? will result in improvement?
(Primary Drivers) (Secondary Drivers)
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Tree Diagram Template
tcome/Aim
Outcome/Aim
What are we trying to accomplish? How will we know a change What changes can we make that
is an improvement? will result in improvement?
(Primary Drivers) (Secondary Drivers)
Reduce % of diabetic patient
with HBa1C >=9 by 25% by
June 30th, 2012
Patient
Engagement and
self-management
Medication
Regimens
Regular physician
visits
Pilot group visit model
Provide access to Certified Diabetic Educator
Offer weight loss program
Provide pill boxes
Engage PharmD in group visits
Align prescribing with insurance coverage
Reminder system
Schedule next visit before patient leaves
Reward program for visit kept
QI PROJECT MEASURES
A PROCESS IS……
A goal-directed, interrelated series of actions, events, mechanisms, or steps.
A collection of individual steps strung together to achieve a desired outcome.
A set of activities that produce services for customers.
AN OUTCOME IS…..
Result of implementation of processes
HOW WILL WE KNOW A CHANGE IS AN
IMPROVEMENT?
PROCESS MEASURES OUTCOME MEASURES
% of diabetic well visits
appointments kept
% of patients with HBa1C >9
% of patients receiving the
Influenza vaccine
# or rate patients developing
Influenza
Visit turn-around/cycle time Patient satisfaction
TRANSLATING DATA INTO INFORMATION
MEASUREMENT
“You Can’t Manage What You Don’t
Measure.”
THREE BASIC STEPS
Development of form to collect data
Collection of the data
Analysis of the data
DEVELOPING A BASELINE
A baseline serves as a reference point for
comparison
A good baseline data set:
Reflects the current processes, staffing levels, volumes
etc.
Accounts for seasonality
Considers the 3 Rs: Recent, Representative, Range
In many cases, data from the most recent 12
months is appropriate
DATA COLLECTION
Understand the scope: date range, shifts, service
lines, physicians etc.
Determine if data can be pulled from an
information system or if it must be tracked
manually
One time needs vs. on-going requirements
Understand if the data is sensitive or if it needs to
be treated with discretion
COLLECTION OF DATA
Team decisions:
Sample size
Frequency
Who will collect data
Clarify operational definitions
Direct observation or chart review
Opportunities for PDSA cycles to test data
collection tools and process
DATA ANALYSIS METHODS
Need to create method to “aggregate” individual
data collection sheets/forms
Hand tally
Excel spreadsheet
Access database
Survey tools
OPERATIONAL DEFINITIONS
Need consistent definition to ensure changes in
value are due to improvement and not
differences in data collection
Gives communicable meaning to a concept
Statement of the measurement process used
Must have 2 things:
A method of measurement or test
A set of criteria for judgement
OPERATIONAL DEFINITION EXAMPLE:
Measure: Number of Hospital Acquired Pressure
Ulcers
Operational Definition: The number of pressure
ulcers greater than stage 1 identified which were
not documented as present on admission
TIPS FOR GETTING STARTED
Let the data guide the decision
Develop a SMART goal/aim
Develop your driver/tree diagram-use this as
your guide for testing changes and developing
measures
Begin with small tests of change and spread
Small changes over time lead to large impact for
patients!
