iii. bts topic selection: meet your colleagues
TRANSCRIPT
III. BTS Topic Selection: Meet Your Colleagues
PG
Pg. 3
Topic Selection: Objectives
By the end of this session you should be able to:
List the reasons that topic selection is a critical factor in success
Describe the steps in BTS topic selection
Critically analyze whether or not a specific topic should be addressed in BTS-style Collaborative
Identify other BTS College members working on topics like the one you have chosen
The IHI Breakthrough Series
An improvement method that relies on
spread and adaptation of existing
knowledge to multiple settings to
accomplish a common aim.
IHI Breakthrough Series (6 to 18 Months Time Frame)
Select
Topic
(Develop
Mission)
Planning
Group
Develop
Framework
& Changes
Participants (10-100 Teams)
Prework
LS 1
P
S
A D
P
S
A D
LS 3 LS 2
Supports
Email Phone Conferences
Extranet Visits Assessments
Sponsors Monthly Team Reports
Dissemination
Publications,
Congress, etc. A D
P
S Expert
Meeting
AP1 AP2 AP3*
LS – Learning Session
AP – Action Period
*AP3 –continue
reporting data as
needed to
document success
Holding
the Gains
IHI Breakthrough Series (6 to 18 Months Time Frame)
Select
Topic
(Develop
Mission)
Planning
Group
Develop
Framework
& Changes
Participants (10-100 Teams)
Prework
LS 1
P
S
A D
P
S
A D
LS 3 LS 2
Supports
Email Phone Conferences
Extranet Visits Assessments
Sponsors Monthly Team Reports
Dissemination
Publications,
Congress, etc. A D
P
S Expert
Meeting
AP1 AP2 AP3*
LS – Learning Session
AP – Action Period
*AP3 –continue
reporting data as
needed to
document success
Holding
the Gains
Collaborative Topic Could Be in Any of the
“Three Categories of Improvement”* I . Eliminating quality problems that arise because we fail to meet the
expectations of customers (Chapter 10, pp. 218-223)
II . Reducing costs significantly while maintaining or improving quality
(Chapter 10, pp. 224-230)
III . Expanding customer expectations by providing products and services
that customers perceive as unusually high in value
(Chapter 10, pp. 230-235)
*Source: Langley, G, Nolan, K., Nolan, T, Norman C, Provost, L The Improvement
Guide: A Practical Approach to Enhancing Organizational Performance. San
Francisco: Jossey-Bass, 2009
ADEs, SSI, Periop Care, Chronic care, Improve child literacy
Cardiac surgery, supply chain, reducing c-sections
Advanced access,
Topic Selection for IHI BTS
What do we look for?
1. Gap between science and practice
2. And…examples of better performance exist
3. And…a good “business case” exists for the topic
On Extranet: Berwick DM. Eleven worthy aims for clinical
leadership of health system reform. JAMA 1994; 272: 797-802.
Identifying the Gap
1. The gap between science and practice Current practice deviates from best available scientific knowledge
Evidence describes the gap (ideally 3 - 4 articles)
Methods to identify gaps between your organization and best practice
– Environmental scan - literature
– What is on the clinicians’ minds?
– What is on Organization’s leaders minds? – Strategic plans of health care systems
– CMS scope of work
– Regulator Goals
See: Examples of Gaps on extranet
Example of the Gap from Service
Collaborative
Dimension Low Performing
Hospitals
High Performing
Hospitals
Respect 15% 4.5%
Comfort 22% 13%
Emotional
Support 21% 11%
Involving Family/
Friends 20% 9%
Picker Survey: Percent of Patients Reporting Problems (Lower is Better)
Source: Gerteis, Edgman-Levitan, Daley, Delbanco; Through the Patient’ s
Eyes. San Francisco:Jossey-Bass 1993 pp 229-230
Example of Chronic Care Gap
Disease Parameter Typical Best
Diabetes HbA1c 30% < 8 70% < 8
Asthma Symptom free
days <50% >80%
CHF Hospital
readmits >10%/mo <3%/mo
Depression Follow-up <50% >80%
CVD LDL< 100mg/dl <50% >70%
Source ICIC
Example : Adult Cardiac Surgery Gap
Median Best
Post-op LOS 5-6 days 3 days
Interval from 3-4 days < one day
Cath to CABG
Post-op vent time 12-18 hours < 4 hours
OR time / case for 4-5 hours 2.5-3 hours
3-vessel CABG
Example of Access Gap
Patients wait more than three weeks for a routine
appointment. Same day access is achievable in primary
care; 5 days for specialty care
Patients are consistently dissatisfied with waits in clinics
and medical offices. Delighting patients with punctuality
is achievable
Public Health
Issuing Food Service Permits 41 days………14 days
Percent Teens Smoking 17% … 5.77% (Utah)
6.63 (CA)
6.88 (HI)
6.92 (DC)
Well Child Visits by Age 26% ……….. > 72%
Infant Mortality (US African 15.7%. ..7.7% (San
American) Diego) Overall 4.5%
13
2. And…there Is an
Example of Best Performance
Someone is doing it somewhere
– In health care (or your industry/profession) in similar
settings
– In health (or your industry/profession) care in
different settings
– Outside of health care (or your industry/profession)
We believe it can be done in other settings or
situations
Degree of belief that the
changes will result in
improvement
High
Getting Ideas
Idealized Design or other methods
Testing:
Prototype (in simulated environment) or Pilot (in work setting)
Spread
Adapt to new locations or populations
Successful changes
Unsuccessful proposed changes
Low
Moder- ate
When Are We Ready To Run a BTS Collaborative?
Start a Collaborative when degree of belief is moderate to high
Adapted from IG Pg 145
Implement: Make the change a permanent part of the system in location where testing
Phase 0:Generate new ideas
Observation
Synthesis
Screen
Phase 1:Planning
Collaborative
Teams
Phase 5:
Adapt &
spread
Phase 3:
Prototype testing
Phase 4:
Pilot
testing
Phase 2:
Concept
design
Milestone 1 Milestone 2
Generate new ideas Test new ideas Spread new ideas
Idealized Design Process with Deliverables
Deep Dive Team Innovation Team
Deliverables:
•Charter
•Design Targets
•Ideas/Concepts
•Captured learning & Prediction
Deliverables:
•Results of test
•Change Package
•Prediction
•Captured learning & Prediction
Deliverables:
•Results of implementation & spread
•Captured learning & Prediction
3. And….a Good “Business Case”
Exists for the Topic
– Positive financial impact (lower costs, revenue growth,
etc) for participating organizations
AND – Improved outcomes
OR
– Strong appeal to both clinicians or other subject matter
experts and administration
Is There a Business Case?
(From Improving Chronic Illness Care – MacColl Institute)
Questions to Ask
• Will the new intervention
work?
• What will it cost?
• Will it increase fee-for-service
revenues?
• Will it reduce expenses (in my
lifetime)?
• Will it increase clientele by
attracting new patients or
retaining old ones?
• Will it impact case-mix?
Answers for Chronic Illness
Improvement
Effective interventions in most
common chronic illnesses
Usually $200-500/pt/yr
If it adds assessments or encounters
not routine in usual care
Yes for CHF and diabetes, maybe
for asthma and for frail elderly, close
for depression
Patient satisfaction rises so
retention should improve, unclear
impacts on new enrollment
May increase severity
Business Case Example: “Good for Patients”
Reduction in Risk Factors for People with Diabetes
UKPDS 10 Year Study of Chronic Disease Management Findings:
A 1.0% reduction in HbA1c results in: – 17% reduction in mortality
– 18% reduction in MI
– 15% reduction in stroke
– 35% reduction in cardiovascular endpoints
– 18% reduction in cataract extraction
Describe this business case----
9.6
8.0
7.5
8
8.5
9
9.5
10
Ap
r-9
9
May-9
9
Ju
n-9
9
Ju
l-9
9
Au
g-9
9
Se
p-9
9
Oct-
99
No
v-9
9
De
c-9
9
Jan
-00
Fe
b-0
0
Mar-
00
Ap
r-0
0
May-0
0
Ju
n-0
0
Ju
l-0
0
Au
g-0
0
Se
p-0
0
Oct-
00
No
v-0
0
De
c-0
0
Jan
-01
Fe
b-0
1
Mar-
01
Ap
r-0
1
May-0
1
Ju
n-0
1
Ju
l-0
1
Ave
rag
e
Month
Average HbA1c (Southeast Cluster)
Reduction in HgbA1c in Bureau of
Primary Healthcare Southeast Cluster
– Diabetes I Collaborative
BMJ, 321, 405-412
Service Collaborative: Is Topic Ripe for
Improvement?
There is a gap--some health care providers can show much improved service in specific areas
Best practice-- in hospitality and other industries far exceeds health care service. Almost any community has local experts
Business case--Improved service increases satisfaction, compliance, and increases market share
Example: Is Chronic Illness Ripe Topic
for Improvement?
There is a gap--some health care providers can show much improved short term outcomes-blood sugar control, symptom free days, etc Is there evidence of gap being closed--Best practice in multiple office practices across the country-community health centers, group practices most often. Most regions have local experts Business Case?-- Improved chronic illness care improves patient outcomes, confidence and satisfaction; and reduces unnecessary acute care utilization. May increase volume and revenues through P4P and other contracts
Exercise: Is Your Topic Ripe for
Improvement?
Using the topic you have chosen (on your storyboard) list specific ways in which the topic meets the selection criteria
o What is the gap?
o Where are good examples of best practice?
o What is the “business case” for this topic?
Complete the Assessment of Collaborative Topic Worksheet using the 1-5 Scale.
Review your spread exercise We will report to the group in 10 minutes using your
storyboards to share the results of this exercise and
your spread plans
H Pg 3
23
Assessment of Collaborative Topic: Is Topic Ripe for a BTS Style Collaborative?
Topic:___________________________________ Reviewer’s Name: ________________________ Assessment Scale 1: Not at all 2: To a small extent 3: Somewhat 4: To a large extent 5: To a very great extent
Identifying the Gap
Score Element Comments
Does current practice deviate from best available scientific knowledge?
Are they able to provide data to quantify the gap?
Does this Topic Matter to People? (Business Case)
Does this topic matter to patients/clients? Is there a strong emotional “pull” for teams to join the Collaborative?
Does this topic matter to clinicians?
Does leadership care about this topic? Is this topic linked to the organization’s strategic plan? Is there a strong business case for this topic? (financial,
clinical, or reputation based)
Is there Evidence that Gap can be Closed?
Have others closed the gap? Do we have a list of changes that we can use in our
collaborative to get good results?
Comments:
Exercise: Building A Long-Term Spread
Strategy (from Prework)
Do you expect to spread the work of your Collaborative teams to the rest of your organization? What is the timetable for this?
What (or who) are the appropriate "units" for adopting changes from your change package? Who will make the decision to begin using the new ideas in their practice? Some examples of potential “units” include physicians, surgeons, emergency departments, hospitals, nursing units in a hospital, clinics, laboratories, or pharmacists.
How many total units do you intend to spread to? This could be all eligible units or some defined subset of them.
How many units will you select to attend your initial Collaborative? What percentage of the total units is this? How will you select these initial units?
You and Your Collaborative –
in ___ minutes!
Introduce yourself and your team
Describe your collaborative
Topic, number of organizations, location
Report on your assessment of “how ripe” the topic is:
─ The Gap
─ Who/where is the best practice
─ The business case for participants
─ Insights from your Assessment Scoring Worksheet
Your plans for Spread
Listeners role: Ask questions, provide feedback, consult
Let’s Revisit Ovretveit
Which challenges are you most concerned about? 1. Choosing the right topic
2. Ensuring participants define their objectives and assess their capacity to benefit from the collaborative
3. Defining roles and making clear what is expected
4. Ensuring team building and preparation by teams for the collaborative
5. Enabling mutual learning rather than carrying out teaching
6. Motivating and empowering teams
7. Ensuring teams have measurable and achievable targets
8. Equipping teams to deal with data and change challenges
9. Learning and planning for sustaining improvements
10. Planning and learning for spread
What is your plan for addressing them?
26