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© 2004 Institute for Healthcare Improvement
The Model for Improvement
A Method to Test, Implement, and Spread Change Ideas for Improving Care for People
Living with HIV and AIDS
© 2004 Institute for Healthcare Improvement
Objectives
List the three improvement questionsDescribe the PDSA CycleIdentify one tip to improve:
Use of aims Use of measures PDSA cycles Team practice
© 2004 Institute for Healthcare Improvement
Introduction (15 minutes)
Name Where you work What you doExpectations for the session
What are we trying toaccomplish?
How will we know that achange is an improvement?
What changes can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
© 2004 Institute for Healthcare ImprovementThe Model for Improvement was developed by Associates in Process Improvement.
© 2004 Institute for Healthcare Improvement
First Question
What are we trying to accomplish?AIM content:
Explicit statement Specific actionsStretch goals
AIM characteristics:Time specificMeasurableDefine participants
© 2004 Institute for Healthcare Improvement
Example
The clinic will improve care of HIV/AIDS
patients by making changes in the following
areas: self–management and adherence
support; decision support for clinicians;
clinical information systems; delivery system
design; community linkages; and leadership.
Focusing on education, prevention, and early
intervention, our goals include:
© 2004 Institute for Healthcare Improvement
Example
80% of patients with at least one visit every 3 months
85% of patients with documented medication education/adherence counseling
90% of applicable patients with PCP/MAC prophylaxis
© 2004 Institute for Healthcare Improvement
Pairs Discussion (10 minutes)
With a partner, discuss your experience with aim statements. What has worked? What has not worked? (3 minutes)
Next, join another pair. Briefly share the highlights of both discussions. Then develop a few tips you would give regarding the development and use of aim statements. (4 minutes)
Last, be prepared to tell the large group one of these tips. (3 minutes)
© 2004 Institute for Healthcare Improvement
Second Question
How will we know that a change is an improvement?
© 2004 Institute for Healthcare Improvement
Measurement for Learning and Process Improvement
Measurement for
Research
Purpose To bring new knowledge into daily practice
To discover new knowledge
Tests Many sequential, observable tests
One large "blind" test
Biases Stabilize the biases from test to test
Control for as many biases as possible
Data Gather "just enough" data to learn and complete another cycle
Gather as much data as possible, "just in case"
Duration "Small tests of significant changes" accelerates the rate of improvement
Can take long periods of time to obtain results
© 2004 Institute for Healthcare Improvement
A Family of Measures
Outcome measures
Process measures
Balance measures
© 2004 Institute for Healthcare Improvement
Balance Measures
Measures of the other parts of the system
© 2004 Institute for Healthcare Improvement
Measurement: Types and Time
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S DD SP A
DATA
Process
Measures
Harm
Outcome Measures
© 2004 Institute for Healthcare Improvement
Tips for Measurement #1
Plot data over time Tracking a few key measures over time is the single most powerful tool a team can use.
% Patients with a Visit in Past Three Months
© 2004 Institute for Healthcare Improvement
Tips for Measurement #2
The perfect is the enemy of the good.
© 2004 Institute for Healthcare Improvement
Tips for Measurement #4
Integrate measurement into the daily routine
© 2004 Institute for Healthcare Improvement
Third Question
What changes can we make that will result in improvement?
© 2004 Institute for Healthcare Improvement
Change Concept
While all changes
do not lead to improvement,
all improvement requires change
© 2004 Institute for Healthcare Improvement
Change Ideas
Changes to improve care for people living with HIV disease
http://www.IHI.org/IHI/ Topics/HIVAIDS/ HIVDiseaseGeneral/ Changes/
© 2004 Institute for Healthcare Improvement
Reflect Back To … (10 minutes total)
The project of which you are most proud, something you were involved with that really improved the situation for patients or for staff. It comes readily to mind because it was/is important to you.
© 2004 Institute for Healthcare Improvement
Reflect Back To …
Make a few notes in answer to these questions: What was the project? Who was involved? What changes were made that resulted in an
improvement? What did you learn?
© 2004 Institute for Healthcare Improvement
Reflect Back To …
Turn to someone at your table, preferably someone you don’t know or have not yet spoken with.
Introduce yourselves and share your stories.
© 2004 Institute for Healthcare Improvement
Debrief
What happened? Collaborative
learning Networking Good ideas ready
for change
© 2004 Institute for Healthcare Improvement
What is the PDSA Cycle?
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
© 2004 Institute for Healthcare Improvement
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S DD SP ALearning fro
m Data
Very small scale test
Follow-up tests
Wide-scale tests of change
Implementation of change
© 2004 Institute for Healthcare Improvement
Why Test?
Increase degree of beliefDocument expectations Minimize resistanceLearn and adapt Evaluate costs and side effects
© 2004 Institute for Healthcare Improvement
Start Small and Do More
Use of flowsheet will improve care
to known standards
Improved Decision Support
A PS D
APS
D
A PS D
D SP A
DATA
D SP A
Cycle 1A: Adapt Clinic X Standard’s based flow sheet and test with one of Joanne’s patients
Cycle 1B: Revise flowsheet and test with Dr. Burton’s patients next Monday
Cycle 1C: Present refined flowsheet to all 3 clinicians and document feedback
Cycle 1D: Revise and test flow- sheet with all patients for one week
Cycle 1E: Implement and monitor the standards
© 2004 Institute for Healthcare Improvement
PDSA Tip #1: Scale Down
YearsQuartersMonthsWeeksDaysHoursMinutes
“Drop 2”
© 2004 Institute for Healthcare Improvement
A P
S D
AP
SD
A P
S D
D S
P A
A P
S D
AP
S D
A P
S D
D S
P A
A P
S D
AP
S D
A P
S D
D S
P A
A P
S D
AP
SD
A P
S D
D S
P A
A P
S D
AP
SD
A P
S D
D S
P A
Community Resources
Self-Manage-ment Support
Delivery System Design
Clinical Information Systems
A P
S D
AP
SD
A P
S D
D S
P A
LeadershipDecision Support
PDSA Tip #3: Changes in Parallel
© 2004 Institute for Healthcare Improvement
MODEL FOR IMPROVEMENT
Objective for this PDSA Cycle
DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.
DATE:____CYCLE:____
PLAN:QUESTIONS:
PREDICTIONS:
PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE
PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE
PDS
A
STUDY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.
ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
PDSA Tip #4
© 2004 Institute for Healthcare Improvement
© 2004 Institute for Healthcare Improvement
PDSA Tip #5
Current Situation Resistant Indifferent Ready
Low Confidence that current change idea will lead to Improvement
Cost of failure large
Very Small Scale Test
Very Small Scale Test
Very Small Scale Test
Cost of failure small
Very Small Scale Test
Very Small Scale Test Small
Scale Test
High Confidence that current change idea will lead to Improvement
Cost of failure large
Very Small Scale Test Small
Scale TestLarge Scale Test
Cost of failure small
Small Scale Test
Large Scale Test
Implement
© 2004 Institute for Healthcare Improvement
Ideas for Change (10 minutes)
At your table, develop a small PDSA cycle based on one of the good ideas you heard from our sharing a few minutes ago.
Use the grid from Tip #5 to determine and justify the size of your cycle.
© 2004 Institute for Healthcare Improvement
Teams
“A team is a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable.”
--Jon R. Katzenbach
© 2004 Institute for Healthcare Improvement
Team Practice: Tip #2
Simplify Team ReportsGood bullets; not paragraphsSmaller, more frequent? Other ideas?
© 2004 Institute for Healthcare Improvement
Closing
The Model for ImprovementList the three improvement questionsDescribe the PDSA CycleIdentify a method (tip) to improve:
Use of aimsUse of measuresPDSA cyclesTeam practice
© 2004 Institute for Healthcare Improvement
Web Resources
http://www.IHI.org/IHI/Improvement/ ImprovementMethods provides information on improvement methods, strategies, and changes
© 2004 Institute for Healthcare Improvement
References
Deming WE. Out of the Crisis. Cambridge, Massachusetts: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1982.
Deming WE. The New Economics. Cambridge, Massachusetts: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1993.
Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco, California: Jossey-Bass; 1996.