Transcript Systems Change: From a “Good Idea” to a Practice Culture

Systems Change Using Quality
Improvement:
From a “Good Idea” to a Practice
Culture
Artwork by Caroline S. © 2010 American Academy of Pediatrics (AAP)
Children's Art Contest. Support for the 2010 AAP Children's Art Contest was
from the Flight Attendant Medical Research Institute.
Objectives
• To understand the importance of creating a system
to address tobacco use and secondhand smoke
exposure in clinical practice
• To understand how to implement quality
improvement changes in your clinical system using
the Plan-Do-Study-Act Cycle
What is Quality Medical Care?
•
The Institute of Medicine (IOM) defines healthcare
quality as care that is:
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Safe
Effective
Patient Centered
Efficient
Timely
Equitable
Barriers to Change
• The system is designed
• For patients with acute issues
• To provide preventive care and acute illness
management
• To support a single service encounter
• Lack of time
• Reimbursement issues
What Can We Do?
• We have the tools and the knowledge
• Evidence-based treatments exist
• Unique opportunities to use treatments exist
• How do we incorporate this into the day-to-day
operations of our practices?
• Implementation strategies exist
Think of Your Practice as a “System”
• Include all the parts that make the practice run
• Staff, clinical and administrative
• Records, paper and electronic
• Rooms, hallways, waiting rooms
• Resources in the community and beyond
Analyze System Flow
Patient
checks in
and goes to
registration
or waiting
room
Patient returns to
waiting room after
registration or to
triage
Registration
Labs drawn
Follow-up
appointments
scheduled
LAB
Check In
Triage
Waiting Room
Check Out
Exam
Vitals signs Diagnoses and
taken
lab results
entered in chart
Rx
Prescription
written and/or
filled
Be Thoughtful In Your Implementation
• Understand the current system
• Research the areas most in need of change in your
practice
• Start with the end in mind…how do you want your
system to function?
Decision Support* is CRUCIAL
• You need support from the top AND the bottom
• Who’s in charge of Implementation? Supplies?
Tracking outcomes?
• New tasks shouldn’t be added to anyone’s (already
too long) list – make time and space for them
*AKA “buy in”
Team Involvement Is CRITICAL
• Involve your staff early!
• First meet with key staff, then invite participation by
staff at all levels
• Be sure to include:
• Front desk
• Nursing and clinical staff
• Administration
Get Input
• Brainstorm about implementation and barriers
• Invite ideas on logistics of asking and advising
• Develop implementation plans, using Plan-Do-StudyAct cycles
The PDSA Cycle
The PDSA Cycle:
Plan, Do, Study, Act
• Prepare a plan for
implementing one small
step.
• Keep it very small!!
• Be very specific
• Include staff
• Prepare materials
• Set a time for the test
(like today!)
Plans Have Components
• How will success be measured?
• What are we doing?
• Who will be the subject(s)?
• How will we start? Finish?
• Where will it be done?
• When will it be done?
The PDSA Cycle:
Plan, Do, Study, Act
• Do it!
• Test it on ONE “sample”
• One family, visit, nurse,
or doc
• Observe flow of program
in the office
• Note places for
improvement
The PDSA Cycle:
Plan, Do, Study, Act
• Study it!
• How did it go?
• How was clinic flow
affected?
• Were all materials
available and easy to
access?
• What adjustments
need to be made?
The PDSA Cycle:
Plan, Do, Study, Act
• Do another cycle
• Slightly improved or
completely new
• Several cycles are
typical
• Step back and take a
look at the “big”
picture
The PDSA Cycle:
Plan, Do, Study, Act (Part 2)
• Implement in the entire
practice.
• Inform staff
• Prepare materials
• Make needed changes
to the office system
• Prepare a routine
review cycle
Monitor and Feedback
• Are procedures working as intended?
• Are staff completing assigned tasks?
• Is documentation evident?
• Are patient materials kept up to date?
• Does the team receive timely feedback and support
for a job well done?
Model for Improvement
What are we trying
to accomplish?
How will we know
that a change is an
improvement?
What changes can we
make that will result in
an improvement?
Your Aim
The Measures
The Cycle for
Learning and
Improvement
Now What?
• Mobilize your team!
• Start with an Aim statement…what do you want
to accomplish?
• Then develop small but measurable activities
• Create a PDSA (Plan, Do, Study, Act) cycle
Need more information?
American Academy of Pediatrics
Julius B. Richmond Center of Excellence
www.aap.org/richmondcenter
American Lung Association
www.lung.org/cessationta
Audience-Specific Resources
State-Specific Resources
Cessation Information
Coding & Payment Information
Tobacco Control E-mail Lists
Clinical Practice Change Resources