Transcript Orientation to IHI’s Breakthrough Series

Implementing an IHI Model Collaborative on
Tobacco Use Screening in a state and local
health department setting in South Carolina
What we did and what we learned
Doug Taylor and Joe Kyle
Office of Performance Management
South Carolina Department of Health and
Environmental Control
Pam Gillam
Center for Healthcare Policy and Research
University of South Carolina
Presentation Overview

Overview SC DHEC and Health Services

Agency Strategic Plan and Priorities

Development of Tobacco Cessation Policy

IHI Collaborative Model

Implementing statewide tobacco cessation policy
SC DHEC Structure
 7-
Member Board appointed by Governor
w/consent of Senate
 Commissioner selected by the Board
 Agency is not part of the Governor’s
Cabinet
 Four Deputy Areas
 Centralized system/Vertically Integrated
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State HD/Central Office
8 Regions
No local BOHs
SC DHEC’s 8 Public Health Regions
Health Services
 Largest Deputy Area in DHEC
 2.662 FTE’s statewide in 8 Public Health Regions with
local health departments in all 46 counties and over 90
service delivery sites
 Major areas of responsibilities include CDC/HRSA
programs
 Diverse team of health and environmental professionals
to include:

Nurses, administrators, physicians, epidemiologists, nutritionists,
pharmacists, administrative support, laboratory specialists,
health educators, and social workers
General Role of Central Office and Role of
Regions

Central Office (State) Level
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State level Health Improvement
Obtaining Resources
Development of Policies, Regulations, etc
Program Guidance & Oversight
Subject Matter Expertise – Consultations (public & private
sector)
State, Federal and National relationships, partnerships
Region (Local) Level

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Community level Health Improvement
Direct Service Delivery
Implementation of Policies
Region and local relationships, partnerships
Agency Priorities
 SC
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DHEC’s Strategic Plan 2005-2010
5 Broad Goals
24 Strategic Goals
88 Objectives
Each Deputy Area monitors their Objectives
through performance measures
Since 2007 all Deputy Areas began presenting
performance related data to DHEC’s Executive
Management Team
DHEC Strategic Plan
Goal
2: Improve the quality and years of healthy life for all
Strategic Goal
2-A: Promote healthy behaviors
Tobacco Related Objectives
2-A-1:
Develop effective state and local partnerships to promote
healthy behaviors including good nutrition, physical activity and
tobacco use cessation.
2-A-3:
Implement interventions to prevent tobacco use, promote
cessation and reduce exposure to secondhand smoke.
2-A-4:
Collaborate with public and private partners to develop and
implement statewide prevention plans targeting diabetes,
cardiovascular health, cancer, injury, tobacco, obesity or
associated risk factors.
Priority Performance Measure

DHEC Health Services will adopt policy to
implement the Public Health Service Guideline
(2As+R) for tobacco use and dependence with
all of its clinical clients.
Tobacco Cessation
Policy Development Timeline
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HS Management Retreat prioritized Tobacco (and Tobacco Use
Screening) as a public health issue (Jan 07)
Original draft policy developed in 2007
The updated Clinical Practice Guidelines were released from the
Federal Government in May 2008
Tobacco Prevention and Control staff updated draft policy and
submitted to DHEC’s Manual Oversight Committee for review and
approval (summer 2008)
Policy deployment then delayed until Tobacco Collaborative results
were in, since results would affect policy content and deployment
strategies
After Collaborative, policy approved in November 2009 with an
official implementation date of July 1, 2010 (1st time this way)
State level team organized to support implementation of policy
SCDHEC’s Use of
the IHI’s Breakthrough
Collaborative for Tobacco
Cessation
Pamela S. Gillam, MPA
Center for Health Services & Policy Research
Arnold School of Public Health
University of South Carolina
Presentation Objectives

To recognize the key components/phases of the
IHI Breakthrough Series as a quality
improvement methodology
 Understand how SCDHEC adapted the IHI
Breakthrough Series model to work in its
environment
What is the IHI Breakthrough
Series?
IHI’s Breakthrough Series (BTS) is an
improvement method that relies on spread
and adaptation of existing knowledge to
multiple settings to accomplish a common
aim.
IHI Breakthrough Series
(6 to 18 months time frame)
Select
Topic
Participants (10-100 teams)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
Dissemination
P
A
D
A
S
P
D
A
S
LS 1
LS 2
AP1
AP2
D
S
LS 3
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
Visits
Phone Conferences
Assessments
Monthly Team Reports
Publications,
Congress. etc.
AP3*
Holding
the Gains
*AP3 –continue
reporting data as
needed to
document success
IHI Goals for a BTS
 Achieve
results
 Accelerate improvement– get results
faster!
 Define, document, and disseminate good
ideas
 Build clinical and public health leaders of
change
The IHI Breakthrough Series is NOT:
 Research
for new clinical knowledge
 Single-setting (single team) focus
 Small changes to existing systems
 A benchmarking project
 A consulting engagement
IHI BTS- 5 Phases
 Phase
1- Topic Section- General
 Phase 2- Topic Selection- Development
and Expert Meeting
 Phase 3- Prework
 Phase 4- Learning Sessions and Action
Periods
 Phase 5- Holding the Gains and Spread
IHI Breakthrough Series
Phase 1: Topic Selection
DHEC Tobacco Collaborative
November 2008 - June 2009
Select
Topic
Participants (7 teams)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
Dissemination
P
A
D
A
S
P
D
A
S
LS 1
LS 2
AP1
AP2
D
S
LS 3
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
TA Visits
Publications,
Congress. etc.
Monthly Phone Calls
Monthly Team
Reports
Holding
the Gains/
Spread
Topic Selection for TCC
1.
2.
3.
There is a gap between science
(evidence) and practice; 2A+R identified
as EBP;DHEC not doing it.
Examples of better performance exists;
Other states using it.
A good “Business Case” exists for the
topic; Seen as priority in 2 Regions
participating in MLC3.
Adaptation of Phase 1: Topic
Selection
Traditional IHI BTS Model Phase
1
• Group of Individuals and/or an
Entity at leadership level in a
specific field initiate BTS
Collaborative
• Define the topic
•Open up a call for teams to
participate in BTS collaborative
•Teams typically pay to participate
Adaptation of BTS Model Phase
1
for SCDHEC Collaboratives
• SCDHEC initiated discussion at
both state and local levels to
define topic
•State office asked 2 regions if
they would be interested in
participating MLC3 grant
•State office asked 2 participating
regions to choose topics from
Target areas provided by MLC3
•Regions chose topic; State
leadership “blessed” topic choices
•Regions received a portion of
grant $$ for participating
IHI Breakthrough Series
Phase 2:
Topic Development
And
Expert Meeting
DHEC Tobacco Collaborative
November 2008 - June 2009
Select
Topic
Participants (7 teams)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
Dissemination
P
A
D
A
S
P
D
A
S
LS 1
LS 2
AP1
AP2
D
S
LS 3
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
TA Visits
Publications,
Congress. etc.
Monthly Phone Calls
Monthly Team
Reports
Holding
the Gains/
Spread
In this step, Experts are Identified
Experts are knowledgeable in the
subject matter/QI
 Some experts are chosen to be
Collaborative Faculty

For TCC, faculty were staff from Division
of Tobacco Control and Prevention/Office
of Performance Mgmt/USC/Regional
Leadership
Experts Develop the Following:
 Collaborative
Charter, that includes—
 Change Package- 12 Changes in TCC
Change Package
 Measurement Strategy- Primary Measures
used- # of smokers, # who accept referral,
amount of time to implement intervention
Adaptation of Phase 2: Topic
Development and Expert Meeting
Traditional IHI BTS Model
Phase 2
• 12-15 Experts meet to refine
topic
•Experts, w BTS staff facilitation,
develop Change Package
Adaptation of BTS Model
Phase 2
for SCDHEC Collaboratives
• With regional teams help, experts
identified within agency on topic
• Change package developed
based on internal expert
knowledge and literature review
•Feedback received from regional
team leadership on collaborative
charter and change package
IHI Breakthrough Series
Phase 3: Prework
DHEC Tobacco Collaborative
November 2008 - June 2009
Select
Topic
Participants (7 teams)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
Dissemination
P
A
D
A
S
P
D
A
S
LS 1
LS 2
AP1
AP2
D
S
LS 3
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
TA Visits
Publications,
Congress. etc.
Monthly Phone Calls
Monthly Team
Reports
Holding
the Gains/
Spread
Prework




For Planning Group
Develop materials- TCC
change package,
Prework materials
Present to Region
leadership on TCC
Assist regions in
developing teams
Plan LS1
For Collaborative Teams
 Develop TCC teams
 Discuss aims and focus
work
 Engage the senior leader
 Initiate measurement and
other information
gathering
 Begin development of
storyboard
TCC Teams
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Region 4
Lake City Family
Planning
Darlington WIC
Sumter WIC
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Region 8
Beaufort Family Planning
Hampton Family Planning
Jasper WIC
Colleton WIC
Adaptation of Phase 3: Prework
Traditional IHI BTS
Model Phase 3
• Planning Group is made up of
BTS staff and experts
•Teams do not participate in
planning group activities
Adaptation of BTS Model
Phase 3
for SCDHEC Collaboratives
• Planning Group is made up of
state office staff responsible for
MLC3 grant, internal experts,
AND regional team leadership
IHI Breakthrough Series
Phase 4: Learning Sessions and
Action Periods
DHEC Tobacco Collaborative
November 2008 - June 2009
Select
Topic
Participants (7 teams)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
Dissemination
P
A
D
A
S
P
D
A
S
LS 1
LS 2
AP1
AP2
D
S
LS 3
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
TA Visits
Publications,
Congress. etc.
Monthly Phone Calls
Monthly Team
Reports
Holding
the Gains/
Spread
Learning Session Objectives
Learning Session 1
Get Ideas
Get Methods
Get Started
Learning Session 2
Get More Ideas
Get Better at
Methods
Get a “Stride”
Learning Session 3
Celebrate Successes
Get ready to Sustain
and Spread
Test all
changes on
small scale
Action Period 1
Test &
implement
all changes
Action Period 2
Learning Session Objectives
1.
2.
3.
4.
Learn and “get” the Change Package
Learn method for accelerating
improvement (PDSA)
Get connected to colleagues
Make solid plans for taking action quickly
TCC LS1 Agenda
DAY 1
 Introduction to IHI BTS
process
 Review of Collaborative’s
mission and goals
 Intro of 2As + R
 Intro of Change Package
 Training in 2As + R
 Intro to QI
 Team Meeting time
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DAY 2
Orientation to The Model
for Improvement/PDSA
Measurement and
Reporting
Team Meeting time
Next Steps (Action Period
1)
Model for Improvement
What are we trying to
accomplish?
How will we know that a change is an
improvement?
AIM
What change can we make that will result in
improvement?
From: Associates in Process
Improvement
Act
Plan
Study
Do
MEASURE
CHANGES
Sumter County HD
AIM 1:
By the end of the collaborative, 100% of
Prenatal/Post-Partum WIC clients and Sumter
Co. HD will receive the 2As + R.
AIM 2:
25% of Tobacco Users will accept referral to
Quitline.
Sumter County HD
MEASURES:
Length of Client Visit– 1:1 time with NES
Average length of time to implement 2As + R
with clients
Client Tobacco Use Rate
% of WIC PN, PP, BF clients who receive 2As +
R with fidelity
% of tobacco users accepting referral to the
Quitline
Sumter County HD
CHANGES: (taken from change package)

IB. Include tobacco use as a vital sign.
 IC. Ask patients if they use tobacco and
document tobacco-use status on a regular basis.
 ID./IVB. Designate staff/clinicians to implement
the 2 A’s and R.
Sumter County HD
CHANGES: (taken from change package)

IIA. Implement a tobacco-user identification
system.
 IIC./IIIB. Track the degree to which clinicians are
identifying, documenting and treating patients
who use tobacco and provide feedback to
staff/clinicians about their performance.
 IVA. Have tobacco cessation materials and other
information in every exam room or room in
which clients are seen.
Hampton County HD
PDSA Cycle
PLAN PHASE (of PDSA)
WHO: Support Staff will be provided the necessary posters
and cards for the Quitline
WHAT: Material placement and distribution of a set number
of materials which will be counted at the beginning and
the difference tabulated at the end of the PDSA cycle for
the number of cards and the tear off on the posters
WHEN: Starting on December 15, 2008 and continuing
through December 19, 2008
WHERE: In Health Departments clinic waiting room(s) and
exam rooms
Action Period Objectives
 Support
teams in their improvement work
 Build collaboration and shared learning
 Assess collaboration and progress
This is the time of maximal learning
AND WHERE THE REAL ACTION IS!
Adaptation of Phase 4: Learning
Sessions and Action Periods
Traditional IHI BTS
Model Phase 4
Adaptation of BTS Model
Phase 4
for SCDHEC Collaboratives
• Learning Continuum– At
beginning, teams learn from
experts; by end, experts learn from
teams
•Technical assistance typically via
emails, intranet, listserv, monthly
conference calls, and monthly
reports
• Learning Continuum– At
beginning, teams learn from
experts; by end, experts learn from
teams
•Technical assistance provided by
emails, listserv, monthly
conference calls, monthly reports,
AND TA visits
IHI Breakthrough Series
5th Phase:
Holding the Gains
and
SPREAD
DHEC Tobacco Collaborative
November 2008 - June 2009
Select
Topic
Participants (7 teams)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
P
Dissemination
P
A
D
A
S
P
D
A
S
LS 1
LS 2
AP1
AP2
D
S
LS 3
Supports
LS – Learning Session
AP – Action Period
Email (listserv)
TA Visits
Publications,
Congress. etc.
Monthly Phone Calls
Monthly Team
Reports
Holding
the Gains/
Spread
Holding the Gains and Spread
Holding the Gains-- Continued tracking of
improvements
Spread-- Adapting change to areas or
populations other than your pilot
populations
Part of the BTS Design!
For TCC,
Thinking about Spread Important
2
As + R was going to become a DHEC
policy
 Promising practices for implementing 2As
+ R in WIC and Family Planning
 Talked about Spread in LS1 and LS2
Beaufort County HD
2A+R Spread Training Plan
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WFD Coordinator presents @ site meetings
Ice Breaker
Policy
Power Point Presentation
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
Current Tobacco Cessation Programs
Smoking Prevalence & Disease Connection
Impact of Quitting & Success of Cessation Programs
2A’s+R Protocol
Role Plays
Beaufort County HD Spread
DSME
NBHV
Home Health
WIC/FP/STD
CRS
TB
IHI BTS- 5 Phases
 Phase
1- Topic Section- General
 Phase 2- Topic Selection- Development
and Expert Meeting
 Phase 3- Prework
 Phase 4- Learning Sessions and Action
Periods
 Phase 5- Holding the Gains and Spread
Deploying and Implementing the
Tobacco Use Screening Policy
post Collaborative, throughout
the SC system
State level planning
By
the Fall of 2009 data from the Tobacco Collaborative,
describing impact in FP/STD and WIC clinics and promising
ideas on how best to implement
DVD of 3rd learning session of major findings and
recommendations
Final Report with detailed data, findings and
recommendations (late summer 2009)
CO workgroup convened, all areas affected by policy
(September-Nov 2009)
FP/STD, HH, NBHV, WIC, and TB with TA from Tobacco
Division and Office of PM
Reviewed policy, findings from Collaborative
Made program specific recommendations on strategies
to prepare for July 2010 full implementation
State level planning
•For WIC and FP/STD (programs in the Collaborative):
•Reviewed results, made additional recommendations to
improve upon results (i.e. WIC drop down menu to
document intervention rather than write in under Alerts
tab)
•For HH, TB and NBHV (programs not in the Collaborative):
•Began to design test of changes to figure out best way to
implement within their program areas
•Challenge:
•Develop implementation strategies for all affected
programs
•Get staff trained in implementation
•Develop evaluation plan to monitor policy once
implemented on July 1, 2010
Region and State level planning
•Regions were required to develop testing, training
and deployment plans (see plan template handout)
•To take advantage of unprecedented planning
time allowed prior to full policy implementation
(Nov 09-June 10)
•Plans submitted by mid March 2010
•CO, Tobacco Division developed and implemented
a TOT
•Targeting Region lead Tobacco staff, covered
policy, protocol, and program specific steps and
requirements
•TOT materials sent out to regions for all staff
training
Region and State level planning
•Monitoring (see handout)
•Each program responsible for ensuring policy is
followed within their area, through site visits and
program reports
•Performance measure developed to monitor
program implementation
•Quitline data reported on to include:
•Fax referral volume
•Referrals not reached by Quitline
•# of referrals enrolled/registered with
Quitline
Region and State level planning
•Evaluation (see handout)
•7 and 30 day quit rates of clients receiving
Quitline services
•Prevalence of tobacco use among DHEC clients
compared to baseline
•7 and 30 day quit rates for non referred SC
Quitline clients
•Client satisfaction
Use of IHI model in other areas
•No, for simple, mundane, small (organizationally)
level work
•Yes, if evidence known and how to implement
needs to be figured out, for a large system
deployment
•SC: Implementation of FastTrack for STD
customers
•Pilot (to confirm evidence), IHI
Collaborativelike 8 teams (one per Region),
statewide deployment
•Yes, if evidence not known
•Pilot first (to generate the evidence)