Transcript Document

Moving From Causal Analysis to
Testing and Measuring
Interventions
Jane Caruso, NQC Consultant
Kevin Garrett, Sr. Manager, NQC
January 23, 2014
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Learning Outcomes
Participants will be able to increase their knowledge in the
following areas:
• Using data to determine your AIM
• Using causal analysis results to inform your
intervention
• Planning PDSA Cycles
• Additional resources
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Agenda
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Overview
QI Principles and Framework
PDSA Cycles
Grantee Examples
Q&A
Quality Improvement
Fundamental Concept of Improvement:
“Every system is perfectly designed to achieve exactly
the results it achieves”
Principles of Improvement:
• Understanding work in terms of processes and systems
• Developing solutions by teams of providers and patients
• Focusing on patient needs
• Testing and measuring effects of changes
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So The Question Of The Day Is:
HOW DO WE CAUSE AN EFFECT?
How do we know that if we do something, make a
change…..
it will cause the desired effect or have the desired
outcome?
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Getting Started…
Moving out of
Wonderland!
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WHEN do you do your PDSA?
QI Project Steps
Step 1: Collect & clean data – ask it the right questions
Step 2: Bring the right mix of people & skills to the table
Step 3: Investigate the process/problem – look for a cause
Step 4: Develop a Team work plan
Step 5. Plan and Test Changes – PDSA Cycles
Step 6: Evaluate Results with Key Stakeholders
Step 7: Systematize Change
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Step 1: Data
• Run data often for cleanliness and comprehensiveness.
Don’t base strategy development of poor data.
• Ask your data the right questions so that you get the right
answers! Have you filtered your query properly? Did leave out the women with
certain hysterectomies from your pap query? Did you omit the folks with positive history
from your TB query?
• Present your data to your Team in a way that is useful and
easy to understand.
• Use your data to help you both determine your aim, and
design the strategies that will cause the effect you seek.
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Step 2: Team Composition
• Seek different skill sets: medical, clinical, data, quality,
statistics, technical writers, social service and CM,
administrators, consumers……and whomever might be
relevant from the community for a QM Committee
• A QM Committee would be broad-based (above) and all
inclusive….a QI Project Team might be a subset of the
QM Team and include fewer members with a more
targeted focus. Interaction between these two
memberships is critical
• Listen to everyone and encourage a respectful interchange
of experience and ideas. Encourage thoughts and ideas
outside of the norm.
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What is the difference?
Tests
Putting a change into
effect on a temporary
basis and learning about
its potential impact
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Tasks
Steps that need to be
accomplished prior to a
test or implementation
Step 3: Investigate The Cause
We look at “Cause” in 2 ways:
• What is “causing” the problem?
• What will “cause” a solution?
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Step 3: Investigate The Cause Of The Problem
What

is Root Cause?
“Root Cause is the fundamental breakdown or failure of a process
which, when resolved, prevents a recurrence of the problem.”
Or, in other words
It’s a brainstorming process with a systematic approach to get to the true root
cause….through the relentless use of “WHY?”
When Root Cause is addressed, and you fix it, the problem goes away and doesn’t
come back.
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Step 3: Investigate The Cause
If we don’t know the cause of the problem, we cannot effectively
design a strategy to produce the effect we are looking for.
How do we find the cause?
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Fishbone (aka: Ishikawa) analysis
The 5 Whys
Focus Groups
SWOT analysis
Deep data dives
Flow charts
Pareto Charts
Step 4: Develop Your Team Work Plan
Format your work plan so it is written or in chart format, and it is easy
to read and follow. It should identify what gets done, when, and by
whom.
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Assign tasks
Set goals
Decide on a beginning and an end
Timeline
Measure
Report back and share
Allow for tweaks and set backs
Lancaster General Hospital. Comprehensive Care Center. PA
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Step 5: PDSA Time!
So now, we are ready to
“cause” the fix!
Now that we have our
data, our Team, our
problem causes, our
work plan, we can
start to implement
CHANGE that will
CAUSE the desired
EFFECT.
Never stop your Team
from trying something
innovative, creative, or
different!
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How can we accelerate change
and improvements in HIV
programs?
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Change Method
The Model for Improvement
(MFI)
is a method to help accelerate change… and increase
the odds that the changes we make are an
improvement.
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Model for Improvement
• Improvement is about learning
• trial and error (scientific method)
• improvements require change, however not all changes
are an improvement
• Measure your progress
• only data can tell you whether improvements are made
• integrate measurement into the daily routine
• Improvements thru continuous cycles of
changes
• Plan-Do-Study-Act approach
• changes are initiated on a small scale to test them before
implementation
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Model for Improvement
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The PDSA Cycle
for Learning and Improvement
Act Plan
Objective
Adapt? Questions and
Adopt ? predictions (why)
Abandon? Plan to carry out the cycle
Next cycle? (who, what, where, when)
Next cycle?
Study Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
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Carry out the plan
(on a small scale)
Document problems
and unexpected
observations
Begin analysis
PDSA (Test) Cycles Have Been Going on for
Years
“Negative results on the fish…
Let’s try rubbing two sticks together.”
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Why Test ?
• Increase your confidence that the change will result
in improvement in your organization
• Learn to adapt the change to conditions in the local
environment
• Minimize resistance when you move to
implementation
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The Cycles Build on Each Other…
Changes That
Result in
Improvement
A P
S D
Implementation
of change
Wide-scale tests
of change
A P
Hunches
Theories
Ideas
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S D
Follow-up tests
Very small scale test
PDSA
Changes in Parallel
Information
Systems
S D
A P
ADAP
Eligibility
Process
A P
S D
A P
A P
S D
S D
A P
S D
A P
S D
A P
S D
S D
A P
CM adjust
intake process
A P
A P
S D
A P
S D
A P
S D
A P
A P
S D
S D
A P
A P
S D
S D
A P
A P
S D
S D
AIM/Goal:
Increase
patient
access
to care.
S D
Testing ……………….Implementation………….Spread
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How Do Tests Lead to Improvements?
• You learn something from each test
• That knowledge gets incorporated into the next test
• Over time, as you build knowledge and expertise,
you design a change that will more likely result in
improvement in your environment
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Grantee Examples
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From Lucy Graham – St. Mary's
Family Medicine, Grand Junction, CO
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Why read an ice cream label?
• 3 minutes to administer
• Easy to document
• Validated tool in English and
Spanish
• Assesses
• Prose literacy
• Numeracy (Quantitative)
• Document literacy
From: National Quality Center Technical Assistance Call, October 18, 2012: Why read an ice cream label? Lucy Graham, RN, MPH, St. Mary’s Family
Medicine, Grand Junction, Colorado.
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The Newest Vital Sign (Pfizer, Inc)
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Ice Cream Label Assessment Questions
1.
2.
3.
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If you eat the entire container, how many calories will you eat?
Answer: 1,000 is the only correct answer
If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice
cream could you have?
Answer: Any of the following is correct: 1 cup (or any amount up to 1
cup), half the container. Note: If patient answers “two servings,” ask
“How much ice cream would that be if you were to measure it into a bowl?”
Your doctor advises you to reduce the amount of saturated fat in your diet. You
usually have 42 g of saturated fat each day, which includes one serving of ice
cream. If you stop eating ice cream, how many grams of saturated fat would you
be consuming each day?
Answer: 33 is the only correct answer
Ice Cream Label Assessment Questions
4.
If you usually eat 2,500 calories in a day, what percentage of your daily
value of calories will you be eating if you eat one serving?
Answer: 10% is the only correct answer
READ TO SUBJECT: Pretend that you are allergic to the following substances:
penicillin, peanuts, latex gloves, and bee stings.
5.
6.
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Is it safe for you to eat this ice cream?
Answer: No
(Ask only if the patient responds “no” to question 5): Why not?
Answer: Because it has peanut oil.
Interpretation
• Number of correct answers: Tally up ‘Yes’ answers
• Score of 0-1 suggests high likelihood (50% or
more) of limited literacy.
• Score of 2-3 indicates the possibility of limited
literacy.
• Score of 4-6 almost always indicates adequate
literacy.
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Where Did My Fish Go?
Problem:
• Environmental studies in New York found that certain
fish in certain areas of New York State should not be
consumed in large quantities
• Fisherman are granted limited licenses to catch these fish
• Potential for commercial fisherman to over fish
• Where to get data to “measure” consumption
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Where Did My Fish Go?
Potential Solutions?
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Where Did My Fish Go?
• Engage commercial fisherman to report data; use
statistical analysis to judge consumption
• Potentially involve major retail outlets
• Public awareness campaign in regions most affected
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Where Did My Fish Go?
• Potential PDSA Cycles
• Try to limit the number of commercial fisherman that are
licensed; adjust as the data starts showing a change
• Develop a public awareness campaign and then look to one area
that the data revealed to be high consumers and conduct a
survey; expand the survey as it shows results.
What else?
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Patient Education Tool
Kawanis Collins, Magnolia Medical Center
Identified a new sub population at risk
• 43 clients on ADAP – September, 2012
• ADAP State Guidelines for qualification changed from
CD4<350 to CD4<500 – added 19 patients
• Adherence Teach Back Tool was used to educate 10
clients who were newly eligible to be on medication
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Take Your HIV Medicine
On Time and Every Day
Educator name:
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The CD4 T cells in your body are your friends
CD4-T
They are like a factory, making things that protect you from infection.
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But HIV is a clever virus.
HIV
CD4-T
It hijacks your good CD4 T cells, and turns them into an HIV factory.
Then you get a lot of HIV (a big Viral Load).
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Study: Progress Log
Adherence Teach Back Tool
Week
Total Clients
Start Meds
Refused Meds
(9/10-9/14)
2
1
1
(9/17-9/21)
0
0
0
(9/24-9/28)
0
0
0
(10/1-10/5)
2
1
1
(10/8-10/12)
1
1
0
(10/15-10/19)
1
1
0
(10/22-10/26)
1
1
0
(10/29-11/1)
0
0
0
(11/5-11/9)
1
1
0
(11/12-11/16)
3
3
0
Total
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Questions?
Comments?
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Contact Information
Jane Caruso, MS, NQC Consultant, NQC/HIVQUAL,
[email protected]
Kevin Garrett
National Quality Center
212-417-4730
NationalQualityCenter.org
[email protected]
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