Making changes happen in your practice: Rapid cycle improvement R

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Making changes happen in your practiceRapid
cycle improvementR440Friday, October 15,
2004AAFP Scientific Assembly Gordon Moore
MDBerdi Safford MD
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• Every system is perfectly designed to get the
  results it gets

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• The targeted goals are set so high that we cant
  get there by just trying harder.
• We have to change the system design.

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• Just trying harder is the worst quality
  improvement plan of all.
• Deming

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Quality Improvement Tasks

• Find good ideas
• Test and adapt good ideas to your practice needs
  and conditions
• Sustain the improvement
• Spread successful innovations
• Create a culture of continuous improvement

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Quality Improvement Principles

• Involve all members of your office staff jointly
  in QI efforts
• Individuals (including doctors) have direct
  control over only 15 of their results
• 85 of our results are controlled by processes in
  the working environment
• Only good management can change processes
• Complex, multi-step processes create opportunity
  for error

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• To improve, you must make changes
• But
• Not all changes lead to improvement

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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?

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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?
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What Changes Can We Make That Will Result in
Improvement?

• The Domain change package contains the key
  elements of high performing system
• Use the change package to identify the changes
  you want to make to your system to achieve your
  aim

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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.
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The PDSA CycleFour Steps Plan, Do, Study, Act

• Also known as
• Shewhart Cycle
• Deming Cycle
• Learning and Improvement Cycle

Act
Plan
Study
Do
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The PDSA Cycle for Learning and Improvement
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out the cycle
• (who, what, where, when)
• Plan for data collection

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize
• what was
• learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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To Be Considered a PDSA Cycle

• The test or observation was planned (including a
  plan for collecting data).
• The plan was attempted (do the plan).
• Time was set aside to analyze the data and study
  the results.
• Action was rationally based on what was learned.

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The Model of Rapid Cycle Change

• Set the aim
• What are we trying to accomplish?
• Define the measure
• How will we know a change is an improvement?
• Test improvements
• What changes can we make that will result in an
  improvement

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Setting the Aim

• Write as a promise to your patients
• Important
• Focused
• Manageable
• Demonstrate value
• Data available or obtainable

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Defining the Measures

• A good aim statement helps define the measures
• Use both outcome and process measures.
• Measurement should not slow things down
• Seek usefulness, not perfection
• Use accessible measures (dont wait for IS)

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Establishing Measures

• Use sampling
• Use qualitative and quantitative measures
• Plot data over time
• Rapid evaluation with graphical feedback of data

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AIM 1

• Improve the care of our patients with
  cardiovascular disease

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AIM 2

• Improve our diagnosis and treatment of
  hypertension

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AIM 3

• Improve our diagnosis of patients with
  hypertension

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AIM 4

• Every patient age 18 or older will have his/her
  blood pressure measured accurately and
  appropriate action taken if it is greater than
  140/90.

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Practice Setting the Aim

• Divide into groups
• Choose hypertension or immunizations as an area
  to improve care
• Write an Aim statement

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Practice Setting the Measures

• Return to you group
• Take the aim statement that you came up with in
  the first activity and generate ideas for
  measures.

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Bon Secours First PDSA CycleOctober, 2002

• Plan
• Objective of first test What is the patient's
  perception related to HbA1cgt7?
• Prediction? Lack of knowledge (pt), 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.
  

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Bon Secours First PDSA CycleOctober, 2002

• Do
• 1 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.

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Bon Secours First PDSA CycleOctober, 2002

• 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.

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Bon Secours First PDSA CycleOctober, 2002

• Act
• 1.As noted in first test- pt's surveyed at the
  practice in a day gt50 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.
• 2. Jeff Glover developed a questionnaire for
  diabetic pt that he is giving as they are being
  scheduled to come in (those with HbA1cgt7) to
  start.
• 3. 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.
• 4. Actively investigating the registry tools and
  expanding review of diabetic charts to reschedule
  pt to be seen.

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Form for planning a PDSA cycle
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Use the PDSA Cycle for

• Testing or adapting a change idea
• Implementing a change
• Spreading the changes to the rest of your system

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Why Test?

• Increase the belief that the change will result
  in improvement
• Predict how much improvement can be expected from
  the change
• Learn how to adapt the change to conditions in
  the local environment
• Evaluate costs and side-effects of the change
• Minimize resistance upon implementation

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Learning the Sequence
What are we trying to accomplish?
We found a new technology represented by a
sequence
that can help our organization improve health
care.
We want to discover the rule (or theory) that

generated this sequence.
Each improvement team should run tests to
determine
the rule. When they are sure that they have the
rule
(based on enough tests), then implement the
technology
in their organization.
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Learning the Sequence
How will we know that a change is an
improvement?
1.
Correct predictions of results of tests
2.
A statement of the correct rule upon
implementation
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Learning the Sequence
What changes can we make that will result in
improvement?
1.
Each team can test one sequence on each cycle.
Write
down the specific sequence (example) being
tested. The
seminar leader will classify as either conforming
or
nonconforming.
2.
Run as many cycles as required until you are sure
you
know the rule. Keep track of the number of
cycles, and
whether the example test sequence was conforming
or
nonconforming to the rule.
3.
When testing cycles are complete, wait until all
teams
are done to report the implementation cycle
(state the
rule).
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PDSA Cycle for Learning the Sequence
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Sequence Technology Results
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What Did We Learn About PDSA?
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3 Principles for Testing a Change

• Test on a small scale
• Collect data over time
• Build knowledge sequentially with multiple PDSA
  cycles for each change idea. Include a wide range
  of conditions in the sequence of tests

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Test on a Small Scale

• Have others that have some knowledge about the
  change review and comment on its feasibility
• Test the change on the members of the team that
  helped develop it before introducing the change
  to others
• Incorporate redundancy in the test by making the
  change side-by-side with the existing system
• Conduct the test over a short time period
• Conduct the test in one facility or office in the
  organization, or with one customer
• Test the change on a small group of volunteers
• Develop a plan to simulate the change in some way

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Successful Cycles to Test Changes

• Plan multiple cycles for a test of a change
• Think a couple of cycles ahead
• Initially, scale down size of test ( of
  patients, clinicians, locations)
• Test with volunteers
• Do not try to get buy-in or consensus for test
  cycles
• Be innovative to make test feasible
• Collect useful data during each test
• In latter cycles, test over a wide range of
  conditions

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Decrease the Time Frame for a PDSA Test Cycle

• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes

Drop down next two levels to plan Test Cycle!
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Collect Data Over Time

• Collect useful data, not perfect data - the
  purpose of the data is learning, not evaluation
• Use a pencil and paper if the information system
  is not ready
• Use qualitative data rather than wait for
  quantitative data
• Record what went wrong during the data collection
• The Plan step includes plan to collect data for
  each PDSA Cycle
• Use sampling as part of the plan to collect the
  data

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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
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PDSA examples Improve Routine Assessment and
Care of High-risk Asthma Patients
Routine use of flow meters by high-risk patients
Cycle 5 Monitor communication and use
of flow meters with high-risk patients
DATA
Cycle 4 Test understanding of use of flow
meters by patients
Cycle 3 Train providers on teaching patients to
use flow meters
Peak flow meters for high-risk patients
Cycle 2 Test updated policy on distribution of
flow meters
Cycle 1Test communication on use of flow meters
with providers
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Multiple PDSA Cycle Ramps
Testing and adaptation
Triage
Diagnostic Testing
Fast Track Patients
Capacity / Demanding
Change Concepts
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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?
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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.