UPDATES ON THE NHPCC
QUALITY IMPROVEMENT
COLLABORATIVE (QIC)
Karen Droze, MS
Regional Coordinator
Southeast Region Hemophilia Network
Hemophilia State Comprehensive Care Meeting
March 4, 2016
Objectives for Today
1. Understand the concept of Quality Improvement
2. Distinguish between QA, Research and QI
3. Describe the current models of QI
4. Define Clinical Microsystems
5. Provide overview of the NHPCC QI Collaborative
6. Review Coaching Model
7. Recap sites and coaches selected
8. Understand your role
9. Learn about future directions
Quality Improvement Defined
• What is QI?
Quality Improvement is a formal approach to the analysis
of performance and systematic efforts to improve it. There
are numerous models used.
Some common models:
• FADE
• PDSA
• Six Sigma (DMAIC)
• Microsystems
• Others
QA versus QI
• Quality Assurance – reactive, retrospective, policing,
and in many ways punitive. Assigns fault or blame. Older
term.
• Quality Improvement – both prospective and
retrospective reviews. It is aimed at improvement.
Attempts to avoid attributing blame, and to create systems
to prevent errors from happening.
QI versus Research
• QI:
• Intent is to improve current practice. For internal use only.
• By definition, the data is confidential.
• Action is within existing standards of care.
• Institutional Review Board (IRB) approval is not necessary.
• Research:
• Intended to create generalized knowledge.
• Desire to publish or present.
• Testing new methods.
• Needs IRB approval!
Benefits of Quality Improvement
• QI activities can be very helpful in improving how things
work. Trying to find where the “defect” in the system is,
and figuring out new ways to do things can be challenging
and fun. It’s a great opportunity to “think outside the box.”
• An effective QI program can really help make your life
better and Improve Care!
Measurement: Process and Outcome
Indicators
• Three types of measures used in quality work:
• Structure: Physical equipment and facilities
• Process: How the system works
• Outcome: The final products, results
A Healthcare Example
• GOAL: Reduce infant mortality
• Structure: Availability of physicians and/or midwives
providing obstetrical care
• Process: 1) Percent of mothers receiving prenatal care
prior to 12 weeks gestation 2) Percent of mothers taking
prenatal vitamins and 3) Percent of smoking mothers
counseled to quit
• Outcome: 1) Neonatal mortality rate and 2) Pre-maturity
rate
FADE Model FOCUS: Define and verify
the process to be improved
ANALYZE: Collect and analyze
data to establish baselines,
identify root causes and point
toward possible solutions
DEVELOP: Based on the data,
develop action plans for
improvement, including
implementation, communication,
and measuring/monitoring
EXECUTE: Implement the
action plans, on a pilot basis as
indicated, and
(EVALUATE): Install an ongoing
measuring/monitoring (process
control) system to ensure success.
PDSA Model
PLAN: Plan a change
or test of how
something works
DO: Carry out the plan
STUDY: Look at the
results. What did you
find out?
ACT: Decide what
actions should be taken
to improve
Six Sigma
• DMAIC:
• Define
• Measure
• Analyze
• Improve
• Control
An improvement system
for existing processes
falling below specification
and looking for
incremental improvement
Lean Six Sigma
Lean Six Sigma projects comprise aspects of
Lean's waste elimination and the Six Sigma
focus on reducing defects, based on critical to
quality (CTQ) characteristics
Clinical Microsystems Global
Aim
1
2
3
Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Flowchart
Cause & Effect
The Dartmouth Microsystem Improvement Ramp
* 5P Assessment/Effective Meeting Skills
10 Key Success Characteristics
• Leadership
• Organizational Support
• Staff Focus
• Education and Training
• Interdependence
• Patient Focus
• Community and Market Focus
• Performance Results
• Process Improvement
• Information and Information Technology
5 Ps
Very High Risk
Chronic
Very High Risk
Healthy
Healthy
Healthy
Chronic
Functional
& Risks
Biological
Costs
Expectations Chronic
Very High Risk
Healthy
P A C PP E
P A C PP E
P A E
Functional
& Risks
Biological
Costs
Satisfaction
People with
healthcare
needs
People with
healthcare
needs met
Measuring Team Performance & Patient Outcomes and Costs
Measure Current Target Measure Current Target
Panel Size Adj.
Direct Pt. Care Hours:
MD/Assoc.
% Panel Seeing Own
PCP:
Total PMPM Adj.
PMPM-Team
External Referral Adj.
PMPM-Team
Patient Satisfaction
Access Satisfaction
Staff Satisfaction
STAFF MEMBERS:
Skill Mix: MDs __ RNs __ NP/PAs ____ MA ____ LPN _____ SECs ___
Microsystem Approach 6/17/98
Revised: 03/04
c Eugene C. Nelson, DSc, MPH
Paul B. Batalden, MD
Dartmouth-Hitchcock Clinic, June 1998
Prevention
P
Acute
A
Chronic
C
Educate
E
Palliative
PP
Microsystem Name
Purpose/AIMPatients
Processes
Performance PatternsProfessionals
Palliative
Purpose
Patients
Processes
Professionals
Performance patterns
Common themes
• These models are all means to get at the same thing:
Improvement. They are forms of ongoing effort to make
performance better
• In industry, quality efforts focus on topics like product
failures or work-related injuries
• In administration, one can think of increasing efficiency or
reducing re-work
• In medical practice, the focus is on reducing medical
errors and needless morbidity and mortality, streamlining
processes and improving outcomes
NHPCC and Dartmouth Institute
Faculty and program support for coaching and
learning about microsystems
Margie Lisa Randy Maria Ashleigh
(eCTC Program
Coordinator)
National Quality Improvement
• HRSA requires that the NHPCC conduct Quality
Improvement Projects with the 8 Regions
• Regions will be required to conduct Quality
Improvement Projects in next grant cycle (starting
June 1, 2017)
• Agreement that the regions will collaborate on Nat’l QI
projects
• Focus on two topics for quality improvement projects
• Timeframe is two years
• HRSA requires we address at least one HP2020
measure
NHPCC Quality Improvement Collaborative
(QIC)
• National consultant Marjory Godfrey, PhD to work with
NHPCC, and regions to rollout 10 pilot sites
• Each region will have least one pilot HTC site
• ATHN Data Summit provided an introduction to Quality
Improvement concepts
• ATHN Data Summit had an Adolescent Transition
breakout that focused on the quality improvement
process for transition
Aim of NHPCC QI Collaborative (QIC)
To leverage ATHN Clinical Manager technology and ATHN
dataset to inform improvement activities that result in
improved care and outcomes for patients and providers
Develop the improvement capabilities of interprofessional
improvement teams specific to transition from pediatric to
adult care at Hemophilia Treatment Centers (HTCs) in the
USA
Selection of National QI Topic
• HRSA Program Priority
• HP2020 Measure
• Gap in care in Patient Needs Assessment
• Build upon work already done through the NHPCC Work Groups
• Regions and HTCs need buy in that it is an area of importance
• Needs to be doable in two years
Adolescent transition was chosen as first topic for national QI.
Goal of Transition in Hemophilia Care
The NHPCC in conjunction with the U.S.
network of
Hemophilia Treatment Centers (HTCs)
recommend adoption of a systematic approach
to support
youth, families, and young adults
in their transition from
pediatric to adult health care
The Discipline of Coaching
”…Building relationships among people who are
continuously learning about the changing environments in
which they live and work, intervening in and moving to set
aside ineffective and counter-productive habits, and
building new skills, practices, habits, and platforms for
collaborating in this ever changing world.”
Chauncey Bell, Foreward from
Coaching: Evoking Excellence in Others, by James Flaherty, 2010
Qualifications of Coaches
• Employed by HTC or consumer
• Their HTC collects HP2020 measures and quality
metrics
• Must be committed to participate in all aspects of
project in pilot project
• Willingness to assist in training future coaches and
work with future QI projects
Coaches ⁻The National Hemophilia Program is committed to training up to 8
coaches from different regions to assist with the rollout of the
national Quality Improvement (QI) pilot project as required under
the new 2 year grant with MCHB
– The coaches will participate in a one year structured learning
process consisting of in-person and e-meetings, independent
learning, and interactions with experienced coaches to learn about
QI and its implementation.
– Selected coaches will guide another HTC (cannot be their
own HTC) with the QI project
– The process of coaching a QI project involves interacting,
guiding and problem solving with the HTC as they implement their
QI project
– The coaches must be committed to assisting with national and
regional QI project in subsequent years
Commitment
• Complete written assignments
• Interaction with Pilot Site
Attend monthly pilot project team meetings via conference calls
Travel to pilot HTC site for one visit
Consult with experienced coach as needed
Assist pilot HTC in collecting and reporting measures as needed
• In Person Meetings
Pilot and coach meeting
E-coach Face to Face Meeting
Face to Face meeting at the ATHN Data Summit 2016
Qualifications of QI Pilot Site
• HTC team committed to Transition QI Project
• Specific areas of transition to be selected
• Subject matter experts in adolescent transition
• HTC specific requirements
• Monthly team meetings
• Work with QI coach
• Collect and submit QI data
• In person two day meeting
• Collaborative Learning
QI Sites
Yale
Hem Ctr of Western PA
Emory
Nationwide
Children’s
Cincinnati
Children’s
Hemophilia Outreach Ctr
Gulf States
Colorado (Denver)
Ctr for Inherited Blood Disorders
Rady Children’s
NHPCC QIC Phases
Baseline Assessments
Quality Improvement Assessment (QIA)
Your Coach will review with you to plan coaching and a teaching plan to advance your learning
Improvement Teams
Individual QIA assessments
Set up regular improvement meetings using effective meeting skills
Action Phase
Coaching Site Visit between now and March 1st
The 5Ps
Dartmouth microsystem improvement curriculum
Adobe Connects
F2F meetings
Reflection
October 2016
Final Session October 6-7, 2016
ATHN Data Summit, Chicago, IL
Opportunity for all HTCs to Participate
• Webinar on Transition to guide staff though the
Got Transition website
• HTCs complete transition readiness assessment
annually
• HTC complete at least one core element
• HTC collect HP2020 measure administered by survey
Summary
• Key points to remember:
• Improving Healthcare quality is our responsibility
• Measurement and improvement are possible
• Identify the root cause before making changes
• Be creative in developing solutions
• Do what you can to get ready for
the enhanced rollout
Resources
Ann Forsberg Director, NHPCC [email protected]
Marjory Godfrey, Co-Director & Founder, The Dartmouth
Institute Microsystem Academy [email protected]
Institute for Healthcare Improvement www.ihi.org
GotTransition www.gottransition.org