Support for Innovation and Improvement Learning Series

1
Support for Innovation and Improvement Learning
Series

• Foundations Session 3
• Collaborative Learning
• Breakthrough Series
• Supporting Action Periods
• Learning Communities
• Presenter
• Margie Wiebe, RN
• Quality Improvement Advisor Impact BC

2
What are we trying to accomplish?

• Understand the benefits and challenges of
  collaborative learning
• Describe the traditional breakthrough series
  learning collaborative
• Learn strategies to support practice teams during
  action periods
• Define learning communities and identify
  resources to support self-directed learning

3
Why learn collaboratively?

• Traditional
• Didactic education increases knowledge, but does
  not change practice
• Trying harder will not work, working smarter
  will, and changing the care system will work
• Quality Chasm-Institute of Medicine, (2001)
• Collaborative learning is the method for success
• Share and learn from one another
• Share generously, steal shamelessly
• There are no experts all have expertise
• Celebrate success, celebrate failure
• Model for Improvement and measurement
• Learning sessions and action periods and
  supportive coaching

4
Institute for Healthcare Improvement (IHI)

• Breakthrough Series Collaboratives were founded
  in 1991
• Aim lead the improvement of health care
  throughout the world
• Focus on Quality Improvement methods
• Thousands of teams and people have now
  participated in Breakthrough Series

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Features of structured collaboratives

• Multi-professional teams commit to improve
  specific subject area
• There is knowledge behind what needs to be
  improved Change Package
• Participants learn from experts and each other
  Collaborative Learning
• Ovretveit et al (2002) Davis, C (2009)

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Features of structured collaboratives

• Participants learn how to use the method to make
  improvement - IHI Model For Improvement
• small tests of change in quick succession
• Participant teams set measurable targets and
  collect data to track performance
• Some collaboratives use a model for changing the
  system (Expanded Chronic Care Model)
• Ovretveit et al (2002) Davis, C (2009)

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Features of structured collaboratives

• Teams meet for Learning sessions at least 3 times
  in 12-18 months for ½ or full day
• To learn new methods
• Report changes and results
• Share experiences
• Consider how to spread their innovations
• Between Learning sessions there are activated
  Action Periods
• Teams test changes to make an improvement
• Collaborative organizers provide extra support
• Emails, site visits, teleconference, reports,
  etc.
• Ovretveit et al (2002) Davis, C (2009)

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Learning Sessions should build consecutively

• 1st Learning session
• Expert faculty present vision and change package
• Teams learn the Model for Improvement to
  prepare them how to do PDSAs
• 2nd Learning session
• Teams learn more from each other (challenges,
  barriers, lessons learned)
• Formal Clinical presenters
• bolster academic knowledge by peers who can say
  I had the same problem let me tell you how I
  solved it
• 3rd Learning session
• Focus on sustainability, spread, sharing, and
  plan next collaborative
• IHI Innovation Series (2003) The Breakthrough
  Series

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Action Periods

• Aim to build collaboration and support
  organizations as they try new ideas even at a
  distance
• IHI Innovation Series (2003) The Breakthrough
  Series

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Action Periods

• Activities and Objectives
• Rapid tests of change in quick succession
  documented in a number of change areas
• Conference calls, list serv discussions, site
  visits
• Consistent team meetings (once a month)
• Complete monthly reports (data, narratives)
• Mentor Improvement using measurement
• one or more process measures ( increases over
  time)
• one or more outcome measures (action period 2
  onward)
• Documented use of sustainability concepts and
  spread activities (action period 3)
• IHI Innovation Series (2003) The Breakthrough
  Series

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Step 1 To start a Breakthrough Learning Series
Collaborative

• A planning group meets one day to organize things
• Who is the planning group
• academic experts, application experts (Dr),
  improvement experts, collaborative experts,
  experienced team members

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Step 1 To start a Breakthrough Learning Series
Collaborative

• A planning group meets one day to organize things
• What happens
• Develop a charter
• Develop a change package
• Evidence of large gaps in current practice
• Developed by expert committee who have scientific
  and practical knowledge

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Step 2 Team recruitment

• Think about who should be on the team the team
  members in the patient journey
• Doctors and their staff
• Hospital Department (involve leads)
• Community and patients (add additional team
  members in Learning Session 2)

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Engaging people

• Find out what is important to them
• Encourage them their contribution is critical
• Support them in achieving their goalsshare what
  you care about

Axelrod, 2008
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Engaging physicians

• Assessment
• Find out what is important to them
• How does their office practice function frame
  of reference
• What does their practice profile demonstrate
  data accuracy?
• Doctors value collegiality find out who their
  trusted colleagues are
• Who are the early adopters and laggards
• Has anyone done this before?
• Know your community profile - influences
  physicians practices
• IHI physician engagement (2009) and personal
  experience Wiebe, M (2009)

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Engaging physicians

• Adopt an engaging style
• Involve doctors from the beginning
• Work with real leaders and early adopters
• Make physician involvement visible
• Explain what is expected, how much time,
  supports
• Is this a good business case (show them)
• Build trust, communicate candidly, be transparent
• Value physicians time do not waste their time
• Will this improve work-life balance
• Their practice is very private - confirm
  confidentiality
• IHI physician engagement (2009) and personal
  experience Wiebe, M (2009)

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Engaging physicians

• Adopt an engaging style
• Know that doctors are suspicious of interpreted
  data
• Generate light not heat with data
• Make the right thing easy to try
• Make the right thing easy to do
• Understand they do not want to spend the time
  doing the work
• Segment the engagement plan
• Use 20/80 rule, activate champions and trusted
  colleagues, identify laggards
• Show courage (show back-up to BCMA)
• IHI physician engagement (2009) and personal
  experience Wiebe (2009)

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Tools For Engaging physicians

• An Incomplete Guide to Engaging Physicians into
  Primary Care Improvement (double click an the
  picture for download) Draft version

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Step 3 Pre-Work

• Meet with teams Use engagement strategies
• Share change package
• Get commitment to participate
• Get them to started in using measurement tools
• Get them started on developing a registry
• Get them to assess baseline status
• Tell them about storyboards and sharing (tell
  them how you will help)
• Real world does this happen?

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IHI collaborative learning model
Participants (10-100 teams)
Select Topic (develop Aim)
Prework
Dissemination Holding the Gains Publications Congr
ess etc.
Identify Changes Concepts
P
P
P
A
D
D
A
A
D
Planning Group
S
S
S
LS 2
LS 1
LS 3
AP1
AP2
AP3
Supports Email Site Visits Phone
calls Conference calls Assessments Team Reports
Senior Leader reports
LS Learning Session AP Action Period
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Step 3 Learning Session 1

• Most didactic of all learning sessions
• Presentations should
• Show the gap - create passion for the work (Will)
• Clearly share the change package
• Participants need to
• Learn Improvement models
• Expanded Chronic Care Model
• Breakthrough learning series
• Improvement Model (PDSAs)
• Be part of creating the aim for buy in and team
  spirit
• Learn measurement know how to collect data and
  use it to influence tests of change
• Learn how to choose small tests of change that
  will have BIG impact
• Mix content activity time
• explain baseline then look at team baselines

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Step 3 Learning Session 1

• Move the teams to action (Execution)
• Team planning time (at least 40 minutes)
• Faculty circulates to coach teams (give teams
  simple PDSA forms)
• Ask what do you want to accomplish encourage
  teams to look at their baseline data
• Ask how will you know change is an improvement
  what will they measure
• Ask What changes can you make that will result
  in improvement - choose short tests of change 1or
  2 during action period

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Step 3 Learning Session 1

• Move the teams to action (Execution)
• Teams report out their next steps
• Coordinator writes teams PDSAs on a flip chart
• Accountability, support, and help narrow the
  tests if they seem to broad

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Step 3 Learning Session 1

• Final but important step
• Inform teams prepare to share your test of
  change next time
• Explain your follow-up plan during action period
  (site visits, email, teleconference, reports)
• Plan date for next learning session
• Learning session evaluation forms

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Coordinators PDSA Project Planning Form -
document each teams PDSA
Team Name __________________________________Page
___ of ___
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Action Period 1

• Without follow-up (accountability) nothing
  happens
• Team calls (find out who is key contact)
• Site visits (Tell them, we will always look at
  your measurements and make meaning of them
  together)
• Emails (make a distribution list)
• Teleconferences (connect teams)
• Mentor PDSAs and Measurement
• Call PDSA something else small test of change
• Help them succeed
• You probably will have to write the PDSA for them
  
• When working with large organizations-participate
  in leadership calls
• Build next learning session

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Supporting Action Periods
P
P
P
A
D
D
A
A
D
S
S
S
LS 2
LS 1
LS 3
AP1
AP2
AP3
Supports Email Site Visits Phone
calls Conference calls Assessments Team Reports
Senior Leader reports
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Effective coach support.

• Build relationships
• Demonstrate credibility
• Listen
• Ask questions (studies teams work, knows
  details)
• Reinforce and build on strengths
• Praise positive work
• Give feedback
• Offer suggestions some have found
• Connect teams to work together

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Effective coaching creating desired outcomes

• Teams will not want to let the team down (common
  goal)
• Teams are motivated when they are used as
  positive examples
• Teams need to feel supported
• Teams will produce if you keep them accountable
• Teams will continue if it is a positive
  experience, even if it was hard work

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Tools for coaching

• A Practice Coaching Manual
• http//www.improvingchroniccare.org/downloads/icic
  _practice_coaching_manual.pdf
• Agency for HealthCare Research and Quality (2009)

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Action Period PDSA testing repeat short cycles
of testing
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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Bring Monthly Recall Report in Action Period 1
Flow Sheet Observations
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Mental Health Module Measurements
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Monthly report includes

• Narrative reports
• of changes (ECCM) tested and implemented
• Clinical Information System
• Decision Support
• Delivery System Redesign
• Self-management
• Data reports
• Improvement in data (outcome process measures)

35
Mental Health data summary (the last page...)

• Mental Health Train-the-Trainer Collaborative
  Narrative/Data Report
• Practice _______ Physician ________ MOA
  ________

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Example Action Period 1 Team report

• We have completed 3 PDSA cycles
• First PDSA adding pop up alerts to our EMR to
  alert our receptionist to extend asthma patient
  visits by15 minutes
• Second PDSA have receptionist, when scheduling
  a patient, make a note under the reason for
  visit that patient has asthma
• Third PDSA person responsible for pulling
  charts to see the note the receptionist added
  and this would trigger her to go into registry to
  print the flow sheet and place it on the chart
• The above PDSA cycles have been successful.

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Learning Session 2

• Curriculum built on status of teams
• Highlight successful teams in presentations
• Invite inspiring presenters with experience
• Accelerating improvement
• Storyboard presents progress
• Enough time to mingle and build team collegiality
  
• Teams leave with action plans

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Action Period 2

• Support teams
• Team calls
• Team reports
• Site visits
• Identify gaps, barriers
• Build team spirit everyone is valued
• Help choose PDSAs that will improve measures
• Leadership calls
• Faculty monitoring progress

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Overall Aim Test in all Expanded Chronic Care
Model components to improve chronic care
Specific Test Cycles
Clinical Information System
Decision Support
Community Engagement
Delivery System design
Self-management
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Bring Run-Charts During Action Period 2
3rd next available appointment (short)
3rd next available appointment (long)
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Bring Key Measures Report in Action Period 2
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Learning Session 3

• Highlight successful teams (shed light not heat)
• Teams providing much of content for each other
• Storyboards show progress
• Team work time
• Introduction to sustaining changes and spread
• Action period planning
• Next collaborative planning

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Action Period 3

• Often longer than other action periods to
  consolidate changes
• Team supports (tackle difficult scenarios)
• Site visits
• Team calls
• Team reports
• Leadership calls
• Plan the outcome event

44
Data extremes report
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Outcome event (Congress)

• Showcase successes
• Invite others to get engaged
• Teams present change package
• Storyboards summarize participation
• Recruit teams for next Breakthrough Series
• Harvesting session or publication

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Lessons from research on quality collaboratives

• Defining Purpose
• Choosing the right subject
• Defining roles, clarity of expectations
• Team building and team preparation (involve
  senior managers)
• Organizing Running Learning Sessions
• Enable mutual learning rather than teaching
• Motivate empower teams being at a meeting does
  not mean buy in
• Ensure teams have measurable and achievable
  targets
• Equip teams to deal with data and change
  challenges
• Ovretveit et al (2008) Quality Collaboratives
  lessons from research

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Lessons from research on quality collaboratives

• Post Collaborative Transition
• Planning for sustainability (community of
  practice or learning community)
• Spread (among participants practical changes) and
  (use of quality methods) and (spread beyond a
  specific patient or disease population)
• Ovretveit et al (2008) Quality Collaboratives
  lessons from research

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Learning Communities,Self-directed learning and
11 coaching
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Learning Communities

• Membership defines a sense of community
• Common values and beliefs
• Actively learn from each other
• Loyalty to the group
• Ongoing contact (may be virtual)
• Fulfillment of individual needs
• safe place to express opinions, ask for help or
  information and get it
• Shared events and emotional connection
• share stories and experiences
• Davis, C (2009) Impact BC

50
Learning Communities

• Main differences
• Can add members as you go
• May or may not be time limited
• May not have well-developed change package
  (innovation community)
• Virtual or in-person or a combination
• Sharing paramount
• Can learn through 3rd person coaching instead of
  face to face learning
• Davis, C (2009) Impact BC

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Self-directed learning

• Books
• Journals
• Conferences
• Internet
• Podcasts
• Social networks

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Questions For Coaching Session

• What are the key components of a Breakthrough
  learning collaborative
• What is one lesson you learned from quality
  collaboratives that sticks out to you
• What would you like to try in your community with
  regard to learning collaborative and what support
  would you need

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Next Supporting Innovation Improvement Web
Conference

• Please fill out the survey
• Next call Nov 10, 2009
• Human Dimensions of Change
• Creating a Culture of Improvement
• Pre-reading
• NHS Improvement Leaders Guide ILG 3.1 Managing
  the Human Dimensions of Change
• http//www.institute.nhs.uk/index.php?optioncom_j
  oomcartItemid194main_pagedocument_product_info
  cPath65products_id305
• Please note you will need to create an account
  to access these materials

55
Coaching Session

• Interior Health Authority Margie Wiebe
• 1-877-977-0888 code 6585
• Fraser Health/Vancouver Coastal/VIHA Valerie
  Nicol
• 1-877-385-4099 code 64461
• Northern Health Authority Judy Huska
• 1-877-385-4099 code 7865959

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Tools used for team evaluation

• ACIC Assessing Chronic Illness Care
• Team self-assessment tool
• http//www.improvingchroniccare.org/index.php?
  pACIC_Surveys35
• Assessment Scale for Collaboratives (IHI tool)
• Number of changes (ECCM) tested implemented
• Improvement in the data
• http//www.ihi.org/IHI/Topics/Improvement/Improve
  mentMethods/Tools/AssessmentScaleforCollaboratives
  IHITool.htm

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Popular web learning sites

• www.ImpactBC.ca
• IHI open school (US) www.ihi.org/IHI/Programs/IHIO
  penSchool/ courses, video
• HRSA knowledge gateway (US)
• www.healthdisparities.net/hdc/html/home.aspx
• Saskatchewan Health Council
• www.hqc.sk.ca
• Quality Improvement Innovation Partnership (ON)
• www.qiip.ca

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More web learning sites

• Health Improvement Skills Center (US)
• www.improvementskills.org/
• California Healthcare Foundation (articles,
  video) www.chcf.org
• Innovations Exchange (US)
• www.innovations.ahrq.gov/index.aspx
• DOQ-IT University (US)
• www.masspro.org/DOQITU/
• NHS Institute for Innovation and Improvement
• www.institute.nhs.uk/