Transcript Document

California Chronic Care Learning
Communities Initiative Collaborative
Learning Session I
How Do We Get There Quickly?
Model for Improvement - Part 2:
Testing Changes with PDSA Cycles
Angela Hovis, Improvement Advisor
Session Objectives
Participants will be able to:
• Describe the Model for Improvement and its
utility in accelerating improvement initiatives
• Use the change package
• Describe the importance of testing changes for
learning and improvement
• Test Changes with PDSAs
© 2004 Institute for Healthcare Improvement
Testing Changes
“Not all changes are improvements,
but all improvements are a result
of changes!”
© 2004 Institute for Healthcare Improvement
Side Bar:
Test vs Implement vs Spread
• Test
• Trial and Learn - try and adapt ideas
• Implement
• make a change part of the day to day
operation of the system in the pilot
• Spread
• make a change part of the day to day
operation of the system outside of the pilot
Fundamental Questions
for Improvement
• What are we trying to accomplish?
• Team Aim Statement
• How will we know that a change is an
improvement?
• Measures
• What changes can we make that
will result in an improvement?
• Changes
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Stud
y
Do
© 2004 Institute for Healthcare Improvement
3. What Changes Can We Make
That Will Result in Improvement?
• The “change package” contains good
concepts and ideas (based on best
practices and research) for changes
that can help us accomplish our goals.
• Use the change package to identify the
changes you want to make to your
system to achieve your aim.
Using the The Care Model for Self-Management Support
Health System
Community
Health
Resources and
Care
Policies
Organization
Clinical
SelfDelivery
Management
Decision Information
System
Support
Support Systems
Design
Informed,
Activated
Patients and
Caregivers
Productive
Interactions
Prepared,
Proactive,
Practice Team
Improved Outcomes for Patients with Diabetes/CAD
Change Concept: A general notion or
approach to change that has been found to be
useful in developing specific ideas for changes
that lead to improvement.
Concept
An opportunity to create
a new connection
Specific
idea A
Thought
process
Specific
idea B
Change Concepts vs.
Specific Changes
Vague, Strategic,
Arrange: Provide follow up to patients
after they have set goal (agree)
Conceptual
Contact patients one week after they
have set goal
Find out how patients are doing with
their goal - reassess confidence level
and see if they have questions or
concerns
Specific Ideas, Actionable
At time of office visit, solicit patient’s
preference for follow up and
have MA either call or e-mail patient
within 3 weeks office visit
Using the Change Package
Self-management Component of Care Model
Concept
2. Use eff ective selfmanagement support
strategies that include
goal setting, action
planning and problemsolving and follow-up.
Key Change
d. AGREE on collaboratively set goals
based on patient’s confidence in their ability
to change the behavior
Example of Idea to Try
a. Assess patient confidence to achieve their action plan using a 1-10 scale.
(Also described in Lorig et al.)
htt p://www.h ealthdisparit ies.net/resources.html (scroll down) look
for Provider Support for Patient Self-Management
b. Use CARE vital signs from howsyourhealth.org to set goals
c. Use techniques from motivational interviewing (express empathy, develop
discrepancy, avoid argumentation, roll with resistance, support selfeffi cacy)
e. ASSIST patients with problem-solving by 1. Use problem-solving method described by Lorig et al individually and in
identifying personal barriers, strategies, and
groups to teach patients problem solving skills.
social/environmental support
2. Hold a group diabetes/CAD visit and incorporate goal-setting, actionplanning and problem-solving into the agenda. (see Health Care
Organization)
3. Screen for depression with PHQ-9
htt p://www.d epressionprimarycare.org/clinicians/toolkits/materials/forms/phq9/
 Other depression management resources:
MacArthur Foundation Toolkit
htt p://www.d epression-primarycare.org/clinicians/toolkits/
f. ARRANGE a specifi c follow-up plan.
1. Schedule telephone follow-up and make it part of someone’s job description.
2. Engage volunteers to assist with fo llow-up.
3. Use email to communicate with patients about goals, action plans and
follow-up. Relay Health?
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
© 2004 Institute for Healthcare Improvement
What is the PDSA Cycle?
Act
Plan
• Objective
• What changes
• Questions and
are to be made?
predictions (why)
• Plan to carry out
• Next cycle?
the cycle (who,
what, where, when)
Study
Do
• Complete the
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize what • Begin analysis
was learned
of the data
© 2004 Institute for Healthcare Improvement
The PDSA Cycle
Why
Test?
Act
Plan
Study
Do
© 2004 Institute for Healthcare Improvement
Three Doors and Goat:
Experiencing PDSA
Presented by Angela Hovis
Office Practices Summit
March 27, 2004
Created by: Roberto Colacioppo ([email protected])
IMECC / UNICAMP (www.ime.unicamp.br)
Campinas – São Paulo – Brazil
The Three Doors Game
Learning how to run PDSA and use forms
Pick a door, please.
1
2
3
Without opening your door, I will show you a
goat, ok?
1
2
3
Do you want to switch?
1
2
3
Wow! You got the car!
1
2
3
Do you want to switch?
1
2
3
Sorry, You got the goat!
1
2
3
Flowchart

The host of the show shows the three doors

Contestant chooses a door

Host opens a door with a goat from the two
doors not chosen

Host asks if the contestant wants to switch doors

Contestant decides yes or no

Host opens the other two doors
Background info
• This story is true, and comes
from the American T.V. game
show “Let's Make a Deal”,
presented by Monty Hall in the
70’s.
• This situation was discussed in
the popular "Ask Marylin"
question-and-answer column of
the Parade magazine in the 90’s.
• Her answer was: "Yes, you
should switch."
• To date, Ms. vos Savant has
received over 10,000 letters,
mostly disagreeable.
Monty Hall
Marilyn vos Savant
Is Ms. vos Savant correct?
• What does your intuition tell you about this
problem?
• Does the contestant have a 50-50 chance of
winning with either choice?
• Or is it better to switch from the original
choice?
• To learn about this question, we will work
on a PDSA cycle.
The PDSA Cycle
Act
• What changes
are to be made?
• Next cycle?
Study
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Do
• Complete the
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize what • Begin analysis
was learned
of the data
MODEL FOR IMPROVEMENT
Cycle:
Date: _____
Objec tives fo r this PDSA Cycle:
QUESTIONS:
Let's use
a basic
PDSA form
PREDICITONS:
PLAN:
PLAN FOR CHANGE OR TEST (INCLUDING ANY COLLECTION OF DATA): WHO, WHAT,
WHEN, WHERE
DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND FEEDBACK. DESCRIBE
WHAT HAPP ENED INCLUDE REPORTING OF ANY UNEXP ECTED EVENTS. BEGIN
ANALYSIS.
STU DY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.
ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR NEXT CYCLE.
© Associates in Process Improvement 2002
All Rights Reserved
Fill in the objective, questions and
predictions
•Project: Monty
Hall Problem
•Objective: Finding
•Cycle #:
1
•Date:
03/27
a solution to the Monty Hall Problem
PLAN
•Questions
Does the contestant have the
same chance of winning with
either staying or changing the
original choice?
•Predictions
Yes, it doesn't matter
No, staying with original is better
No, switching is better
•What data will be collected during this time? (Forms to be used)
Make a plan to collect data
•Project:
Monty Hall Problem
•Objective:
•Cycle #:
1
•Date:
03/27
Find a solution to the Monty Hall Problem
PLAN
•Questions
Does the contestant have the
same chance of winning with
either staying or changing the
original choice?
•Predictions
Yes, it doesn't matter
No, staying with original is better
No, switching is better
•What data will be collected during this time? (Forms to be used)
• Work in pairs (host and contestant)
• Each pair will simulate both situation 10 times with playing cards
• Data will be collected in the form attached
• A Run Chart (attached) will be filled with results from all pairs
• Observations focused on the difference between the two situation will be
collected
Using playing cards to collect data
Switching: 10
times
Staying: 10
times
EXAMPLE
original
choice
Here we have a
goat
(red card)
Make a plan to collect data
•Project:
Monty Hall Problem
•Objective:
•Cycle #:
1
•Date:
03/27
Find a solution to the Monty Hall Problem
PLAN
•Questions
Does the contestant have the
same chance of winning with
either staying or changing the
original choice?
•Predictions
Yes, it doesn't matter. Chances are equal.
No, staying with original is better
No, switching is better
•What data will be collected during this time? (Forms to be used)
• Work in pairs (host and contestant)
• Each pair will simulate both situation 10 times each with playing cards
• Data will be collected in the form attached
• A Chart (attached) will be filled with results from all pairs
• Observations focused on the difference between the two situation will be
collected
Worksheet
Data Collection for 3 doors and Goat
Decision Run
1
2
3
Stay
4
with
5
Original
6
Door
7
8
9
10
Totals
Result
Car
Goat
Decision Run
Switch
Doors
1
2
3
4
5
6
7
8
9
10
Totals
Result
Car
Goat
Make a plan to collect data
•Project:
Monty Hall Problem
•Objective:
•Cycle #:
1
•Date:
03/27
Find a solution to the Monty Hall Problem
•PLAN
•Questions
Does the contestant have the
same chance of winning with
either staying or changing the
original choice?
•Predictions
Yes, it doesn't matter. Chances are equal.
No, staying with original is better
No, switching is better
•What data will be collected during this time? (Forms to be used)
• Work in pairs (host and contestant)
• Each pair will simulate both situation 10 times each with playing cards
• Data will be collected in the form attached
• A Chart (attached) will be filled with results from all pairs
• Observations focused on the difference between the two situation will
•be collected
Chart for Data
#of times out of 10 = car
3 doors and goat
Staying
Switching
10
9
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19
cycle or trial
Make a plan to collect data
•Project:
Monty Hall Problem
•Objective:
•Cycle #:
1
•Date:
03/27
Find a solution to the Monty Hall Problem
PLAN
•Questions
Does the contestant have the
same chance of winning with
either staying or changing the
original choice?
•Predictions
 Yes, it doesn't matter. Chances are equal
No, staying with original is better
No, switching is better
•What data will be collected during this time? (Forms to be used)
• Work in pairs (host and contestant)
• Each pair will simulate both situations 10 times each with playing cards
• Data will be collected in the form attached
• A Chart (attached) will be filled with results from all pairs
• Observations focused on the difference between the two situation will
•be collected
Let's carry out the plan
DO
•
What went wrong? What happened that was not part of the plan? Begin
analysis.
• Write your observations made during simulation: What
happened? What are the differences between staying with
and changing the original choice?
STUDY
•
Complete analysis of data. Summarize what was learned include results
of predictions.
•
1.
•
2.
Let's study!
STUDY
•
•
Complete analysis of data. Summarize what was learned include results of
predictions.
•
1.
•
2.
•
3.
•
4.
What does the variation the data graph indicate?
What hints can we extract from the observations to explain such
behavior of the data?
Can we conclude and formulate a theory about the Monty Hall
Problem?
Summarize what was learned. Compare to predictions .
Decisions...
ACT
•
What decisions were made from what was learned?
•
What will the next cycle be?
What did we learn from this
exercise?
Why Test Changes?
•
•
•
•
•
To increase the belief that the change will
result in improvements in your setting
To avoid surprises or challenge
assumptions
To learn how to adapt the change to
conditions in your setting
To evaluate the costs and “side-effects”
of changes
To minimize resistance when spreading the
change throughout the organization
© 2004 Institute for Healthcare Improvement
Some comments and feedbacks: PDSA…
… helps to focus and to organize our job (objective, questions and
predictions). (P)
… helps to plan which data will answer our questions (it stimulates
using data). (P)
… stimulates to plan the analysis of the data before obtain it (avoid
waste). (P)
… stimulates to document observations (D)
… stimulates insights and creativity. (D)
… stimulates to test paradigms by comparing predictions and actual
data. (S)
… helps to learn what is necessary to go ahead. (S)
… stimulates to apply the specific knowledge obtained. (A)
… is an efficient way to document our improvement project. (form)
Some misuses of PDSA by beginners
• Tendency to make objective statements too broad
• Confusion between objective and questions
• Tendency to formulate many irrelevant questions
to the PDSA objective
• Tendency to put Plan issues (e.g. What data do
we need? Who will collect data?) mixed with
PDSA questions
• Tendency not to anticipate in the Plan step how
they will analyze data to be collected
• Tendency not to record useful observations in
“Do”
• In Study, they draw conclusions that don't answer
PDSA questions (they forget the original focus)
• Tendency to do too much in one THE PDSA,
instead of cycles
• Tendency to use PDSA for collecting data on a
measure rather than to test an idea for change
Promoting Adoptive Behavior:
Moving to Action
“Persuasion is not enough…… After
adopters understand the new ways, they
must be provided with the necessary
guidance and ample opportunity to
perfect the modeled activities under
circumstances where they need not fear
making mistakes.”
Albert Bandura
© 2004 Institute for Healthcare Improvement
Bon Secours First PDSA Cycle
(Office Practices - October, 2002)
• Plan
• Objective of first test: To know how to motivate patients to
healthier behavior with respect to HbA1c education
• Question: What is the patient's perception related to
HbA1c>7?
• Prediction: Lack of knowledge (pt) and not motivated to lose
weight, test blood, etc.
• (who, what, where, when, how) Pt identified in teams first data
collection (pre-IMPACT meeting) contacted to come in for visit
on 10/14 to identify barriers.
• Measure(s) to assess the success of this test - How's your
health?" tool and patient interview.
© 2004 Institute for Healthcare Improvement
Bon Secours First PDSA Cycle
• Do
• One patient was interviewed and used the
How's Your Health tool. The pt is well educated
and had insight that when the MD calls him
when his HbA1c is going up-he adheres to diet
and exercise. He also identified that travel is a
problem with compliance. They mapped a
trend related to his blood. He also identified
from the tool some areas that had not really
focused on such as foot care.
© 2004 Institute for Healthcare Improvement
Bon Secours First PDSA Cycle
• Study
• See above-we disproved our theory-pt is
knowledgeable but we need to customize
teaching relative to travel and staying on the
path. Pt more motivated when someone is
calling him back or contacting him and he is
motivated to be contacted by email so this will
be part of his plan.
© 2004 Institute for Healthcare Improvement
Bon Secours First PDSA Cycle
• Act
• As noted in first test- pts surveyed at the practice in a day
>50% do want to be contacted and wish to contact office by
email. Computer being set up in office space to go ahead
and arrange to answer email by staff and gather email
addresses.
• Jeff Glover developed a questionnaire for diabetic pt that he
is giving as they are being scheduled to come in (those with
HbA1c>7) to start.
• Letter drafted to introduce the survey tool and we will look
to add some incentive for returning the survey such as
return envelope included or perhaps movie tickets? Will
reformat tool to 1 page and we will email to Marie after
reformat.
• Actively investigating the registry tools and expanding
review of diabetic charts to reschedule pts to be seen.
© 2004 Institute for Healthcare Improvement
Tips for Testing Changes





Identify changes that will assist the team
to reach goals
Harvest good ideas and adapt them to your
setting
Solicit team members ideas
Start with changes that are easy to
implement
Link multiple testing cycles to accelerate
learning
© 2004 Institute for Healthcare Improvement
Tips for Testing Changes






Test large innovative changes on a small
scale (e.g. one MD, one patient)
Collect useful data during each test
Learning from “failed” tests
Test over a wide range of conditions
Develop plans to simulate the change
Make changes side-by-side with the
existing system
© 2004 Institute for Healthcare Improvement
Move Quickly
to Testing Changes
•
•
•
•
•
•
Year
Quarter
Month
Week
Day
Hour
“What tests can we
complete by next
Wednesday?”
© 2004 Institute for Healthcare Improvement
Repeated Use of the PDSA Cycle
A P
S D
Changes That
Result in
Improvement
Implementation
of Change
A P
S D
Follow-up
Hunches
Tests
Theories
Ideas Very Small
Scale Test
Wide-Scale
Tests of Change
Build knowledge
sequentially with
multiple PDSA cycles
for each change idea.
Routine use of
flow meters by
high-risk patients
Cycle 5: Monitor
A P
communication and use of
S D
flow meters with high-risk
patients
Cycle 4: Train providers on teaching
patients to use flow meters
A P
S D
Peak flow
meters for
high-risk
patients
Cycle 3: Revise and test with 3 providers and their
patients for one week
Cycle 2: Revise and test with 2 provider and 6 patients
Cycle 1:Test communication on use of flow meters with 1 patient
Example of Testing
Multiple Changes
Cycles for
Implementing
Group Visit
Recruitment
Size and
Location
Program
Content
The Right Team
1st PDSA
By next
Wednesday,
November 3
Table Exercise
Plan for Action Period 1
and First PDSA
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
© 2004 Institute for Healthcare Improvement
References
• The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance. G. Langley, K. Nolan, T. Nolan, C.
Norman, L. Provost. Jossey-Bass Publishers., San Francisco,
1996.
• Quality Improvement Through Planned Experimentation. 2nd
edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998.
• “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T.
W. Nolan and L. P. Provost, May, 1990.
• A Primer on Leading the Improvement of Systems,” Don M.
Berwick, BMJ, 312: pp 619-622, 1996.
• “Accelerating the Pace of Improvement - An Interview with
Thomas Nolan,” Journal of Quality Improvement, Volume 23,
No. 4, The Joint Commission, April, 1997.
© 2004 Institute for Healthcare Improvement