Performance ImprovementPerformance Improvement--An Overview--An Overview

Auxford Burks, MD

Albert Einstein College of Medicine

Department of Pediatrics/ Jacobi Medical Center

Thanks to:

Daniel Hyman, MD, MMM

Chief Medical Officer, Ambulatory Care Network

New York Presbyterian Hospital

Who provided all of this material

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?

Model for Improvement

Aim: What are we trying to accomplish?Measures: How will we know that the

change is an improvement?Ideas: What changes can we make that

will result in an improvement?

Model for Improvement

Aim: What are we trying to accomplish?

What are we trying to accomplish?

Aim: A written statement of the accomplishments expected from each pilot team’s improvement effort

Different forms are useful:– A general description of aim– Specific patient population– Some guidance for carrying out the work

The Team’s Aim Should Be:

• Strategic

• Relevant

• Exciting

• Important

• A stretch, not business as usual

• Achievable, not impossible

• Understandable

Sample Goals/Measures• 95% of patients with asthma will have symptom frequency

documented in their record (day and night) – process measure

• 95% of patients will have asthma severity specifically identified at all visits where asthma is addressed – process measure

• 90% of patients with persistent asthma will be treated with an appropriate antiinflammatory medication, at an appropriate dose – process measure

• 95% of patients with asthma will have a documented assessment of tobacco use or exposure and counseling to reduce risk if applicable – process measure

• There will be an X% reduction in ED/hospitalization rate over Y period of time – outcome measure

• Visit volume in clinic will be unchanged – balancing measure

AIM: Why the Change is Desired

• A known performance deficiency in an important process

• A gap between current performance and desired performance

Why an Aim Statement?

• Answers and clarifies “What are we trying to accomplish?

• Creates a shared language and shared methods

• Facilitates organizational conversations and understanding

• Supports accountability for team leaders

Developing the Aim Statement

• Write a clear and concise statement stating the “who, what, when, and where “

– Who will undertake the work, and who will be affected by it

– What does the team intend to do

– When will the aim be accomplished

– Where - define pilot site and spread site(s)

SMAART Aims

• Specific: Understandable, unambiguous

• Measurable: Numeric goals

• Actionable: Who, what, where, when

• Achievable (but a stretch)

• Relevant to stakeholders and organization– Strategic, Compelling, Important

• Timely: with a specific timeframe

Sample AimsWe will improve the care of patients with asthma by adhering to evidenced based guidelines for diagnosis, assessment and treatment, thereby reducing morbidity/mortality

By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 days or more in the 2-week period preceding a planned care visit.

Example of Elaborated Aim Statement

• Aim: By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 or more in the 2-week period preceding a visit. To effect change, we will be guided by using the six components of the Care Model for Child Health. Intermediate aims are that:– 95% of children with persistent asthma will have severity classified at

every visit. – 95% of children with persistent asthma will be treated with

appropriate maintenance anti-inflammatory medication.– 90% of children will receive a written asthma management plan on

which we will document family/self- management goals.

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

From: Associates in Process Improvement

Aim

Measures

Ideas

Act Plan

Study Do

A PDSA Cycle

Will encounter forms facilitate severity classification? Dr. X will try form with severity class Qs with 3 patients on Thurs

Dr. X tried with two patients. Couldn’t find a form for third patient.

Dr. X found the form helpful for prompting; thought items on form should be in a different order. Need better process for getting form to provider.

Revise form. Try new form with 3 patients tomorrow; MA will put form on chart.

PDSA Objective: Test the use of encounter form to facilitate visit

Why Test?

• Increase your belief that the change will result in improvement

• Opportunity for learning from “failures” without impacting performance

• Document 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

ConceptAn opportunity to create

a new connection

Thoughtprocess

Specificidea B

Specificidea A

Ideas: What Changes Can We Make That Will Lead to Improvement?

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.

ConceptAn opportunity to create

a new connection

Thoughtprocess

Specificidea B

Specificidea A

Ideas: What Changes Can We Make That Will Lead to Improvement?

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.

Promote clinical care that is consistent with scientific evidence and family preferences

Use tool to classify severity at every visit

Change Concepts vs.High Leverage Changes

Vague, strategic, creative

Specific, actionable, results

Improve care of asthma patients

Share info w/ patients & families and encourage self-management

Document asthma management plan and goals for self-management

Begin discussion of self-management goals w/ 3 patients on Monday

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement Improve asthma outcomes

Reduction in ED visits

Change Pkg.

PDSA example I

• A pediatrician goes to a conference one October and learns all about Improvement, PDSA cycles, and how to improve care for patients with asthma.

• He returns to his practice completely enthused and ready to do something new that will improve care.

• We’ll call our protagonist in this story, Bill Caspe

PDSA example I

• Bill decides to look at his 5 person practice’s assessment of children whose parents call for refills of asthma medications to see whether the children:– Need flu vaccines– Are having symptoms too frequently (i.e. are

not being well controlled on their current medication regimen)

• He develops a form and gives it to his nurse to use for one week when asthma meds are refilled

PDSA example I

• Is this a good PDSA cycle?– Why?– Why Not?

• What do you think happened?

PDSA example II

• The pediatric residents in a community based clinic are taught about improvement, PDSA cycles, and how to improve care for patients with asthma.

• They are provided with baseline data that shows that only 20% of children have a severity classification of their asthma in the practice’s medical records

PDSA example II

• The residents develop a sticker that prompts the questions needing to be asked to determine symptom frequency

• One resident on ambulatory block tries the sticker for 5 consecutive patients with asthma.

PDSA example II

• Is this a good PDSA cycle?– Why?– Why Not?

• What do you think happened?

PDSA Cycles

“Negative results on the fish…Let’s try rubbing two sticks together.”

PDSA Key Points:

• Make the Cycle SMALLER!!!

• Break changes down into manageable parts

• This also allows people to:– try things and give input– more easily adapt – feel included in decisions and development

Repeated Use of the PDSA Cycle for Implementation

Test of Test of patient patient surveysurvey

Routine use of patient survey

A PS D

APS

D

A PS D

D SP A

DATA

D SP A

Cycle 1: Introduce new survey form to one provider and staff

Cycle 2: Test - Use of new survey on two clinic days

Cycle 3: Try survey on other days with other providers and patients

Cycle 4: Use of survey for all patients

Cycles 5/6: Create orientation manual section on patient survey

Multiple Cycles to Test and Implement Components of the Care Model

Will a flow sheet be useful for

patients?

Use of Flow sheet V.4 by all

physicians and nurses

A PS D

APS

D

A PS D

D SP A

Learnin

g

D SP A

Cycle 1: Gather sample flow sheets, try V.1with two patients

Cycle 2: Try V.2 by two providers for a few days

Cycle 3: Two week trail of V.3, review meetings

Cycle 4: Trial of V.4 by all providers

Cycle 5: Implement use of V.4, do peer review of documentation and use

Component: Decision Support

From Chinatown, Asthma BTS, 2001

Things should be as simple

as possible but not simpler.

» Albert Einstein