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The M odel 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) Slide 2 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? Slide 3 The PDSA Cycle for Learning and Improvement Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data Slide 4 Repeated Use of the PDSA Cycle Proposals, Theories, Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A Learning from Data Slide 5 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? Model for Improvement ActPlan StudyDo Slide 6 What are we trying to accomplish? Aim (also called Charter) A written statement of the accomplishments expected from each pilot teams improvement effort Contains useful information: A general description of the goal Specific population Numerical goals Guidance for carrying out the work. Slide 7 AP SD AP SD The Total Health Care System (spread sites) Small-scale tests of change PILOT SITE System of Focus for the BTS (defined by Aim) AP SD Different Populations Slide 8 This collaborative is about changing your organizations 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 teams aim. Specific measures are required for learning about concepts tested during PDSA cycles. How Do We Know That a Change is an Improvement? Slide 9 Measurement Guidelines The key measures plotted and reported each month should clarify your teams 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. Slide 10 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. Slide 11 Minimum Standard for Monthly Reporting Annotated Time Series Slide 12 Improvement in Glycemic Control Percent of (Patients with HbA1c >9.5 in Clinic A) Slide 13 Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic A) Slide 14 Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic B) Slide 15 Improvement in Glycemic Control (% of Population with HbA1C >9.5 in Clinic C) Slide 16 Family of Measures for Diabetes Slide 17 Chronic Care Model What changes can we make that will result in an improvement? Slide 18 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 - A registry of patients with a chronic condition is maintained and utilized. Slide 19 Change Concepts vs. High Leverage Changes Vague, strategic, Improve care of chronic population creative Provide effective behavioral change interventions. Documented patient receipt of self- management support Specific, actionable, Begin documenting collaborative r esults goals during next weeks visits Slide 20 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. 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. Slide 21 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