i have no relevant financial relationships with the manufacturers of any commercial products and/or...

I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an

unapproved/investigative use of a commercial product/device in their presentation.

Model for Improvement

Ruth S. Gubernick, MPH

Practicing Safety Learning Session May 30, 2009

Objectives of this Session

Participants will be able to: Identify Model for Improvement Create an Aim statement for project with

concrete goals Constitute Plan Do Study Act cycles to test

improvements, using the PS Toolkit

The First Law of Improvement

“Every system is perfectly designed to achieve exactly the

results it gets.”

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?

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?


Act Plan

Study Do

AIM

MEASURES

IDEAS

Compare the 3 questions to how we frame improvement

Aim

Measurement for learning

PDSA

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make to bring about improvement?





Act Plan

Study Do

AIM

MEASURE

IDEAS

What Are We Trying to Accomplish?

Aim: A written statement of the accomplishmentsexpected from this improvement effort

Key components:- A general description of aim – should answer,

“what are we trying to accomplish?”- Some guidance for carrying out the work and

rationale- Specific target population and time period- Measurable goals

Example (Poor)

Our practice teams will improve care for all infants and toddlers, by using the Practicing Safety Toolkit.

Sample Aim

By November 30, 2009, our practice teams will test the 3 Practicing Safetybundles (toolkit) to determine feasibility, as well as make improvements to thebundle set, so that:

100% of parents/caregivers receive assessment/screening regarding coping with crying at or by the 2-month well visit.

100% of parents/caregivers receive anticipatory guidance regarding coping with crying at or by the 2 month well visit.

100% of new mothers receive assessment/screening regarding maternal depression at or by the 2 month well visit.

100% of new mothers receive anticipatory guidance regarding maternal depression at or by the 2 month well visit.

100% parents/caregivers receive assessment/screening regarding discipline at or by the 18 month well visit

100% of parents/caregivers receive anticipatory guidance regarding discipline at or by the18 month well visit.

100% of parents/caregivers receive assessment/screening regarding toilet training at or by the 18 month well visit.

100% of parents/caregivers receive anticipatory guidance regarding toilet training at or by the 18 month well visit.

SMAART Aim

Specific: Understandable, unambiguousMeasurable: Numeric goalsActionable: Who, what, where, whenAchievable (but a stretch)Relevant to stakeholders and organizationTimely: with a specific timeframe

AIM Worksheet

The (name of your team ) intend to accomplish

By (date)

For (population)

because

Our goals include:

Special guidance that will help us stay on track:





Act Plan

Study Do

AIM

MEASURE

IDEAS

How will we know a change is an improvement?

Requires measurement

Build measurement into daily work routine Data should be easy to obtain and timely Small samples over time

Use qualitative & quantitative data Qualitative data is highly informative Qualitative data is easy to obtain

Measurement Guidelines

Balanced set of 5 to 7 measures reported each month to assure that the system is improved

Measures should reflect the aim and make it specific

Measures are used to guide improvement and test changes

Integrate measurement into daily routine Plot data measures over time and annotate

graph with changes Outcome and process measures

Measures for Practicing Safety

Target population Infants and Toddlers seen by PS clinicians in participating

practice for well care visit Numerator

# infants or toddlers with documentation that parent/caregiver received anticipatory guidance, assessment/screening, referrals/follow up regarding crying, maternal depression, bonding/attachment (at or by 2 months); discipline and toilet training (at or by 18 months).

Denominator All infants and toddlers seen in participating practice for

well care visit whose charts are reviewed.

% Receiving Assessment/Screening Re: Coping with Crying

0%

20%

40%

60%

80%

100%

Apr-09 May June July Aug Sept Oct Nov

Month

% A

chie

ved





Act Plan

Study Do

AIM

MEASURE

IDEAS

What Changes Can We Make That Will Result in Improvement?

Tests of Change need 2 components:

1. Change concepts (ideas): ready for use or

ready to adapt to your unique environment (**Use

results from pre-work assessment to inform what

you need to change)

2. PDSA test method

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)• Plan for data collection

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

PDSA: Break it Down/Simplify…

Plan - Figure out the questions you want to answer, plan a way to answer the questions, and predict results

Do - “Just do it” (i.e. do the plan)

Study - What did you learn? Did your prediction hold?

What assumptions need revision?

Act - What will you do with the knowledge you learned? Adapt? Adopt? Abandon?

What do you want to do next?

Use of the PDSA Cycles

Multiple cycles

Evidence

Best Practice

Testable Ideas

Changes that Result in

Improvement

A P

S D

APS

D

A P

S DD S

P A Data

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are Tests?

Putting a change into effect on a temporary basis and on a small scale and learning about the potential impact

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

Decrease the Time Frame for a PDSA Test Cycle

Years Quarters Months Weeks Days Hours Minutes

Drop down next “two levels” to plan Test Cycle!

What Can We Do Now!

By Next Week,By Tuesday,

By Tomorrow That won’t harm a hair on the head of a

patient?

Sequential Building of Knowledge Include a Wide Range of Conditions in the Sequence of Tests

BreakthroughResults

Theories, hunches,& best practices Learning and im

provement

A P

S D

Evidence & Data

A P

S D

A P

S D

A PS D

Test on a small scale

Test a wider group

Test new conditions

Spread

Implement

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

A PS D

A P

S D

D S

P A

Mother/Caregiver Bundle

Practice-basedSystems Index

Overall Aim: Testing PS Toolkit

A P

S D

A PS D

A P

S D

D S

P A

Toddler Bundle

Infant Bundle

Fundamental Questions for Improvement

What are we trying to accomplish?• Team Aim Statement

How will we know that a change is an improvement?

• Measures What changes can we make that will

result in an improvement?• Practicing Safety Toolkit





Act Plan

Study Do

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.

Form for planning a PDSA cyclesupports predictionand keeping one step ahead

Questions?

William Edwards Deming

“It is not necessary to change. Survival is not

mandatory.”

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.

Quality Improvement Through Planned Experimentation. 2nd edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998.

“Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990.

A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.

“Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997.

The Improvement Handbook, Model, Methods, and Tools for Improvement, Associates in Process Improvement, Austin, TX, 1997.

Note: Special thanks to Carole Lannon, MD, MPH for some slides from her Safe and Healthy Beginning Model For Improvement presentation, 8/4/07

i have no relevant financial relationships with the manufacturers of any commercial products and/or...

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