Transcript No Slide Title

The Model for
Improvement
A Method
to Adapt, Implement, and Spread
Changes
Connie Davis
September 14, 2000
(prepared with assistance from Lloyd Provost, Associates in Process
Improvement and the Institute for Healthcare Improvement)
Three Fundamental
Questions 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?
The PDSA Cycle for Learning and Improvement
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
Repeated Use of the PDSA Cycle
Changes That
Result in
Improvement
A P
S D
A P
S D
Proposals,
Theories,
Ideas
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
What are we trying to accomplish?
Aim (also called Charter)
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
• Guidance for carrying out the work.
Different Populations
PILOT SITE
AP
S D
AP
S D
System of Focus
for the BTS
(defined by Aim)
A P Small-scale
S D tests of change
The Total Health
Care System
(spread sites)
How Do We Know That a
Change is an Improvement?
This collaborative is about changing your organization’s
approach to caring for patients.
It is not about measurement. But ……
• Population management and measurement are key
components of clinical care.
• Key outcome measures are required to assess progress
on your pilot team’s aim.
• Specific measures are required for learning about
concepts tested during PDSA cycles.
Measurement Guidelines
• The key measures plotted and reported each month
should clarify your team’s aim and make it tangible.
• Be careful about over-doing process measures.
• Make use of your patient population data base
(registry) and administrative data for measurement.
• Integrate measurement into the daily routine.
• Plot data on the key measures each month during
the Collaborative.
• The question - How will we know that a change is an
improvement? usually requires more than one
measure. A balanced set of five to seven measures
helps assure that the system is improved.
For Each of the Key Measures
• Define each of the measures for your pilot
population (numerator and denominator).
• Begin reporting your measures immediately.
• Use the current administrative and registry data
as the means to obtain your measures each
month whenever possible.
• Develop run charts to display your measures
each month throughout the Collaborative.
Minimum Standard for Monthly Reporting
Annotated Time Series
Percent of Patients with Documented Collaborative Goals
Goal=90%
90
80
70
60
50
40
Cycle 3: 8 patients self measuring blood glucose
Cycle 2: Test of Group Visit
30
20
10
Cycle 1: Dr. Smith
/ 3 patients
Sep-00
Aug-00
Jul-00
Jun-00
May-00
Apr-00
Mar-00
Feb-00
Jan-00
Dec-99
Nov-99
Oct-99
Sep-99
Aug-99
Jul-99
Jun-99
May-99
Apr-99
0
Mar-99
Percent of Patients in Registry
100
Percent of Diabetics in Registry
Improvement in Glycemic Control Percent
of (Patients with HbA1c >9.5 in Clinic A)
80
70
70
60
50
40
35
30
20
10
0
Before Change
After Change
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Change
Implemented
Jan
90
80
70
60
50
40
30
20
10
0
date
% of Diabetics in Registry
Improvement in Glycemic Control
(% of Population with HbA1C >9.5
in Clinic A)
100
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Change
Implemented
Jan
100
90
80
70
60
50
40
30
20
10
0
date
% of Diabetics in Registry
Improvement in Glycemic Control
(% of Population with HbA1C >9.5
in Clinic B)
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
Change
Implemented
date
% of Diabetics in Registry
100
90
80
70
60
50
40
30
20
10
0
Improvement in Glycemic Control
(% of Population with HbA1C >9.5
in Clinic C)
Family of Measures for Diabetes
What changes can we make that
will result in an improvement?
Chronic Care Model
Community
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Health System
Organization of Health Care
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Change Concepts from the Chronic Care Model
•
Community
- Resources to support patient care are identified and made easily accessible.
•
Health System
- Organization goals for chronic illnesses are part of annual business plan.
- The system actively impacts the entire patient population with education and services.
•
Self-management Support
- Patients assisted in setting personal goals and given aids to assist in changing
behavior.
- Mechanisms for patient peer support and behavior change programs.
•
•
•
Decision Support
- Evidenced-based guidelines and protocols are integrated into the practice systems.
- The system integrates the clinical expertise from generalists and specialists.
Delivery System Design
- The practice anticipates problems and provides services to maintain quality of life.
- Systems are designed for regular communication and follow-up.
Clinical Information System
Change Concepts vs. High Leverage Changes
Vague, strategic,
creative
Improve care of chronic population
Provide effective behavioral change
interventions.
Documented patient receipt of selfmanagement support
Specific, actionable, Begin documenting collaborative
results
goals during next week’s visits
References
• The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. JosseyBass Publishers., San Francisco, 1996.
• “Eleven Worthy Aims for Clinical Leadership of Health System Reform,” Don
M. Berwick, JAMA, September 14, 1994, Vol. 272, #10, p. 797-802.
• “The Foundation of Improvement.” Langley, G. J., Nolan, K. M., Nolan, T. W.,
1994. Quality Progress, ASQC, June,1994, pp. 81-86.
• “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ,
312: pp 619-622, 1996.
Washington State Diabetes
Collaborative #2
• Joint effort of Dept. of Health, PRO-West
and ICIC
• Health plans and provider teams from
around the state work together for 12
months
• Begins Feb. 2001, sign up by December
• Contact LaDon Kessler, PRO-West,
364-9700