Transcript template oheads - Safety Net Institute

California Chronic Care Learning
Communities Initiative Collaborative
Learning Session I
Where Are We Going and
How Will We Know We Are There?
Model for Improvement
Part 1: Aims & Measures
Angela Hovis, Improvement Advisor
Session Objectives
Participants will be able to:
Describe the Model for Improvement and its
utility in accelerating improvement
initiatives
Define a team’s aim and measures
Understand the utility of annotated run
charts
First: A Word About The Pilot Site and Spread
Leadership
-Topic is a key strategic initiative
-Goals and incentives aligned
-Executive sponsor assigned
-Day-to-day managers identified
Measurement and Feedback
Set-up
Better Ideas
-Develop the case
-Describe the ideas
-Target population
-Successful sites
-Key groups who make the
adoption decision
-Initial strategy to reach all
sites
Social System
Successful
Sites
-Key messengers
-Communities
-Transition issues
-Technical support
Knowledge Management
© 2004 Institute for Healthcare Improvement
Breakthrough Series Collaborative
Select
Topic
Participants (teams/pilot sites)
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
Congress,
P
A
P
D
A
S
LS 1
P
D
A
S
D
S
LS 2
Guides,
Publications
LS 3
Supports
Email
Visits
Phone
Assessments
Monthly Team Reports
© 2004 Institute for Healthcare Improvement
etc.
The First Law of Improvement
“Every system is perfectly designed to
achieve exactly the results it gets.”
© 2004 Institute for Healthcare Improvement
Care Model
Health System
Community
Health Care Organization
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
©McColl Institute
Delivery
System
Design
Decision
Support
Productive
Interactions
Improved Outcomes
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Key Elements of
Breakthrough Improvement
Will to do what it takes to change to a
new system
Ideas on which to base the design of the
new system
Execution of the ideas
© 2004 Institute for Healthcare Improvement
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?
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?
©Associates in Process
Improvement
Act
Plan
Study
Do
1. What Are We Trying to Accomplish?
Developing the Team Aim Statement
Write a clear and concise statement of who, what,
when, and where
• What does the team intend to do - use charter as a guide
• Who - patient population for collaborative
• Where - define pilot site and spread site(s)
Align aim with strategic goals of the organization
Make the target for improvement unambiguous –
use numerical goals consistent with goals in the
charter
© 2004 Institute for Healthcare Improvement
The Team’s Aim Should Be:
Strategic
Relevant
Compelling
Important
A Stretch
Achievable
Unambiguous
Understandable to Everyone!
© 2004 Institute for Healthcare Improvement
Example of an Aim statement
ABC Hospital System will use the chronic care
model to redesign care for patients with
diabetes to help and empower them to reach
their maximum health potential. We will begin
our improvement work at the West Clinic with
Dr. Grant’s and Dr. Moyen’s patients.
Example of an Aim statement (cont.)
by September 30, 2005, our goals for this pilot population are:
 Average HbA1c ≤7.0
 At least 60% of patients with diabetes will have HbA1c <7.0
 90% of patients with diabetes will have 2 HbA1c tests in the
last 12 months




70% of patients will have LDL-c<100
50% of patients will have documented BP below 130/80
60% of appropriate patients on statins
50% of patients will have a current, documented selfmanagement goal
 90% of patients with diabetes will have a current foot exam
Example of an Aim statement-Complete
ABC Physicians Group will use the chronic care model to redesign care for
patients with diabetes to help and empower them to reach their maximum health
potential. We will begin our improvement work with Dr. Grant’s and Dr. Moyen’s
patients and by September 30, 2005, our goals for this pilot population are:
 90% of patients with diabetes will have 2 HbA1c tests in the last 12 months
 70% of patients with diabetes will have HbA1c <7.0
 90% of patients will have at least one LDL test in the past 12 months
 70% of patients will have LDL-c<100
 50% of patients will have documented BP below 130/80
 50% of patients will have a current, documented self-management goal
 25% of patients who smoke will have ceased smoking
 90% of patients with diabetes will have a current foot exam
After successful implementation at the pilot practices, changes will be spread to
other chronic conditions, other physicians in our clinic, and other clinics in our
system.
Fundamental Questions
for Improvement
• What are we trying to accomplish?
Model for Improvement
Team Aim Statement
• How will we know a change is
an improvement?
Measures
• What changes can we make that will
result in improvement?
Change Package
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
2. How Do We Know That a Change
is an Improvement?
This collaborative is about changing your
organization’s approach to improving the
care of patients
It is not about measurement.
© 2004 Institute for Healthcare Improvement
“You can’t fatten a cow by
weighing it.”
-- Proverb
However….
© 2004 Institute for Healthcare Improvement
Measurement Guidelines
Need a family of measures reported each month to
assure that the system is improved.
These measures should clarify your aim statement &
make it tangible
These measures are used to guide improvement
Integrate measurement into daily routine
Plot data for the measures over time and annotate
graph with changes
© 2004 Institute for Healthcare Improvement
Some Measurement Assumptions
The purpose of measurement in the collaborative is for
learning not judgment.
All measures have limitations, but the limitations do not
negate their value.
Measures are one voice of the system. Hearing the voice of
the system gives us information on how to act within the
system.
Measures (especially as a family) tell a story; goals give a
reference point.
© 2004 Institute for Healthcare Improvement
Well Defined Measures
REQUIRED M EASURES
Measure
Definition
1. AVERAGE HBA1C
Average HbA1c value for
diabetic patients in the
registry
2. Percent of patients with
controlled HbA1c
% of patients with HbA1c  7:
3. Patients w ith 2 HbA1c’s
in last year (at least 3
months apart)
% of patients with 2 HbA1c’s:
4.PATIENTS WITH LDL
< 100
The number of patients in the registry
with HbA1c  7 divided by number of
all patients who have an HbA1c.
Multiply by 100 to get percentage.
The number of diabetic patients in the
registry who have had two HbA1c’s (at
least 91 days apart) in the last 12
months, divided by the total number of
diabetic patients in the registry.
Multiply by 100 to get percentage
% of patients with LDL < 100:
The number of diabetic patients in the
registry who have had a fasting LDL
less than 100 in the last 12 months,
divided by the number of patients with
a fasting LDL in the past 12 months.
Multiply by 100 to get percentage.
Data Gathering Plan
Goal
Notes/Comments
On the last workday of each month,
search the registry for all patients with a
diagnosis of D M who have had an
HbA1c in the past 12 months. Add all
of these patients’ most recent HbA1c
values together and divide by the
number of such persons.
Š 7.0
On the last workday of each month,
count the patients in the registry whose
most current HbA1c value is  7. At
the same time count the number of
patients who have an HbA1c value.
•60%
On the last workday of each month,
search the registry for all patients with a
diagnosis of D M who have had two
HbA1c’s within the last 12 months (at
least 91 days apart). At the same time,
count the number of patients in the
registry
•90%
If many patients in the registry do not have at
least one HbA1c, then this measure may not give
a useful estimate of population average. Thus, we
require teams to report the number of patients for
whom an HbA1c within the past 12 months has
been documented. The goal  7 for average
HbA1c derives from current ADA guidelines for
individual patients,
Reference 8
THERE ARE NOT GOOD BENCHMARK
DATA FOR THIS GOAL. TEAMS IN PAST
COLLABORATIVES TYPICALLY SEE
BASELINE PERCENTAGES BETWEEN 2040%. SUBSEQUENTLY MANY
COLLABORATIVE LEADERSHIP TEAMS
SEE 60% A S A GOOD STRETCH GOAL
REFERENCE 8
On the last workday of each month,
search the registry for all patients with a
diagnosis of D M with a fasting LDL <
100 in the last 12 months. At the same
time, count the number of patients with
a diagnosis of DM who have had a
fasting LDL in the last 12 months.
•70%
Cut-off of 100 aligns with ADA guidelines since
2000 Reference 7,8 and National Cholesterol
Education Program (NCEP) Adult Treatment
Panel III guidelines from 2001
Reference 9.
How did you pick your optional measures?
How are you getting the data for
your measures?
Share ideas for how to collect data
Visual Display of Data:
Annotated Run Chart
Eliminates ink that does not add
information
Shows the data
Makes good use of space
Integrates words with the data
© 2004 Institute for Healthcare Improvement
Annotated Run Chart
Change 1
tested
Change 2
tested
Observed
Data
Value
(e.g.,
Infection
Rate)
Time Order (e.g., Month)
Plot small samples frequently over time
© 2004 Institute for Healthcare Improvement
Effectiveness Annotated Time Series
(Run Chart) - Iowa Health Systems
35
Family of Measures- Example
A 1c Test
Self-Management Goals
100.0%
Pe rc e nt
Pe rc e nt
80.0%
60.0%
40.0%
20.0%
0.0%
Oc t 04
N ov 04
D ec 04
J an 05
Feb 05
Mar 05
Apr 05
May 05
J un 05
J ul 05
Aug 05
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Sep 05
Oc t 04
N ov 04 D ec 04
J an 05
Feb 05
Month
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
N ov 04
D ec 04
J an 05
Feb 05
Mar 05
Apr 05
May 05
J un 05
J ul 05
Aug 05
Sep 05
May 05
J un 05
J ul 05
Aug 05
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Oc t 04
Sep 05
N ov 04 D ec 04 J an 05
Feb 05
Mar 05
Apr 05
May 05 J un 05
J ul 05
Aug 05
Sep 05
Month
Month
BP Control
A1c Control
40.0%
80.0%
30.0%
60.0%
Per cen t
Per cen t
Apr 05
Foot Exam
Pe rc e nt
Pe rc e nt
Smoking C essation
Oc t 04
Mar 05
Month
20.0%
10.0%
40.0%
20.0%
0.0%
0.0%
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Month
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
Month
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Reasons for Plotting Data Over Time
• In improvement efforts, changes are not
fixed but are adapted over time.
• Time series graphs annotated with
changes and other events provide evidence
of sustained improvement - will guide you as
to when you should implement and whether
or not you are holding your gains.
• Will help generate support for your efforts.
• Will help sell spread to other parts of your
organization
• Summary Statistics hide information
(patterns, outliers).
© 2004 Institute for Healthcare Improvement
Importance of Time Order Graph
Unit 1 Cycle Time
90
Cycle Time (min)
80
70
60
50
40
30
20
Changes made
10
D
ec
N
ov
ct
O
S
ep
t
A
ug
Ju
ly
ne
Ju
M
ay
A
pr
M
ar
Fe
b
Ja
n
0
Run Chart - a graphical record of a measure plotted over time
Pre-Post Example: Cycle Time
80
Cycle Time (minutes)
70
70
60
50
40
35
30
20
35
10
0
Avg. Before Change
Avg. After Change
© 2004 Institute for Healthcare Improvement
Unit 2 - same pre and post averages
Unit 2 Cycle Time
90
70
60
50
40
30
20
Changes made
10
D
ec
N
ov
ct
O
Se
pt
Au
g
ly
Ju
Ju
ne
M
ay
Ap
r
M
ar
Fe
b
n
0
Ja
Cycle Time (min)
80
© 2004 Institute for Healthcare Improvement
Unit 1 Cy cle Time
90
70
60
50
40
30
20
Change
10
ec
D
ov
N
ct
O
S
ep
t
Ju
A
u
g
ly
e
n
Ju
M
ay
A
pr
M
ar
Fe
b
0
Ja
n
Cycle Time Results
for Units 1, 2, and 3
Cycle Time (min)
80
Unit 2 Cy cle Time
90
Cycle Time (min)
80
80
60
60
50
40
30
20
Change
10
N
ov
D
ec
N
o
v
D
ec
ct
O
t
g
S
ep
A
u
Ju
ly
e
Ju
n
M
ay
r
A
p
M
ar
n
Ja
40
Fe
b
0
50
35
Unit 3 Cy cle Time
30
100
Change
90
40
30
20
10
ct
O
t
S
ep
g
A
u
ly
Ju
e
n
y
M
a
r
A
p
M
a
r
0
b
Avg. After Change
50
Fe
Avg. Before Change
60
n
0
70
Ja
10
80
Ju
20
Cycle Time (min)
Cycle Time (minutes)
70
70
70
Team Meeting 1 Agenda
1. Review Your Aim Statement and Optional Measures:
In light of what you have learned this today, you may
wish to change your aim statement. Remember to:
State your intent.
Define your patient population, pilot site, target for
spread, other specifics.
List numerical goals for aims as outlined in the
charter and any additional optional aims.
2. Review your Team
3. ACIC and Identify Ideas for Change
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.
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