quality improvement methods for fit for residents

07/31/09

Quality Improvement Methods for Fit For Residents

Debra Lotstein, MD, MPHJuly 31, 2009

Presenter

Presentation Notes

60 mins

07/31/09

Continuous Quality Improvement:A Very Brief Review

• Developed from manufacturing industry– Toyota Production System, Lean manufacturing, Six

Sigma, etc.• Recently applied to Health Care

– Institute for Health Care Improvement, Pursuing Perfection, etc.

• Fundamental principles1. System oriented 2. Emphasis on Teamwork/cooperation3. Directed towards processes 4. Data-driven 5. Customer Focus 6. Pro-active

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1. What is a system?

A system is a network of interdependent components that work together to try to accomplish the aim of the system “

W Edwards Deming

The New Economics. P. 50

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the economics of trust (trust factor is new title) by O Whitney.

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I’m sure glad the hole is not in our

end!

People unclear on

the concept of a system!

2. Focus on Teamwork

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Sum it up in a metaphor

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3. What is a Process?

• A series of steps, interactions of people and resources that get to an outcome– E.g. baking a cake; child receiving vaccines

• Studying the process can help to:– Identify inefficiencies– Design ways to assure desired results

• “Poka Yoke” (Mistakes Avoid)– Standardize to avoid “bad” variability

• Stay flexible to keep “good” variability

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Presentation Notes

For instance, Toyota has an average of 12 mistake-proofing devices at each workstation and a goal of implementing each mistake-proofing device for under $150. Automatic transmissions: the inability to remove a car key from the ignition switch of an automobile if the automatic transmission is not first put in the "Park" position, so that the driver cannot leave the car in an unsafe parking condition where the wheels are not locked against movement. (This is an example of trapped key interlocking). 3.5" floppy disks: the top-right corner is shaped in a certain way so that the disk cannot be inserted upside-down. UK 13 amp electric plugs: it is impossible to wrongly insert the plug into the socket, due to its arrangement of three rectangular pins. Microwave ovens: a door switch automatically disconnects the activation button when the door of the oven is opened. As a result, it is impossible to cook anything in a microwave oven unless the door (which contains a Faraday cage to block microwaves) is fully closed. If it were possible to activate an oven with the door open, this would allow dangerous leakage of high intensity microwave radiation, which would be very harmful to any living creatures in the immediate area.

07/31/09Source: The Data Guide: Learning from Data to Improve Healthcare. Developed from Solberg, Leif I., Mosser, Gordon and McDonald, Susan. “The Three Faces of Performance Measurement: Improvement, Accountability and Research.” Journal on Quality Improvement. March 1997, Vol.23, No. 3.

4. Data Driven • Without data, improvement efforts are driven by

“common knowledge,” opinions, keeping the status quo

• May be qualitative• Data for improvement is different from data for

research• Aim is to improve care (not new knowledge, accountability)• Focus on collecting just enough data• Common to use time series• Unlike research, hypothesis flexible, frequent tests of change

Presenter

Presentation Notes

Data for improvement, accountability and research are different We already spoke about research and improvement. We also collect data in healthcare for accountability. We have a different aim and use different methods here as you can see. Improvement:�improve care Just enough data/small sequential samples Accept consistent bias Hypothesis flexible- change as learning takes place Testing: sequential small tests of change Data available only to those involved in improvement Accountability: �Aim is for comparison, spur for change No testing- evaluating current perfomance Adjust for bias No hypothesis/no tests Data publically available For research:�aim is to generate new knowledge Design to eliminate bias Sample size enough to show difference Fixed hypothesis, one large test Confidential data

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Principles of QI, Continued

5. Customer Focus– Who is the customer?

6. Pro-active– Not quality assurance– M + M vs. Root cause analysis– Begin with your aims: FFR goals

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Exercise: Chart Review Data Analysis

• Assess baseline of process and outcome measures with each of 3 chart review groups

• Over the year you won’t have to do this-we will send back measures to you

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Charts of patients less than or equal to 6 months:

1) Outcome: % Exclusively BF at 6 months= #10a checked / total # charts

2) Process: % BF infants counseled to BF without formula through 6 months

= # 11 is yes / # 10a +10b

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Question:�for 2- if already supplementing (i.e. 10b) should still say BF exclusive right? Also, if it’s a 6 month visit, you would not counsel for this; so only if 5 months or younger? �Or just use question 12: % BF infants counseled to BF until 12 months of age?

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Charts of Well child visits 2-19 years old

1) Outcome: % of overweight patients= #12b is between 85-94% / # 6 is yes AND 12 is yes

2) Outcome: % of obese patients= #12b is >=95% / # 6 is yes AND 12 is yes

3) Process: % with BMI Plotted= #12 is yes / # 6 is yes

4) Process: % with physical activity assessed at WCC=# 24 or 25 or 26 is yes / # 6 is yes

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Overweight/Obese Patient Charts

1) Outcome: % with BMI stable over 3 months

= # of charts with current BMI minus BMI 2-4 months ago is between -1to 1 / total # charts with 2 BMIs 2-4 months apart

2) Process: % with self-management goal set= #31 c is checked / # total charts

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Chart Review Data Analysis• What was surprising about the results?

• What do the results tell you about where to focus improvement efforts?

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For Fit for Residents: Use QI Methods to Reach Clinic Change Objectives

• Using rapid cycle QI methods:– Can help adapt tools to your setting– Increases buy-in from faculty and residents– Increases chances of long-term implementation

• Doing QI with residents can be challenging– Using Model for Improvement helps keep effort on track– Identify faculty champion to keep continuity – Identify time for QI work

• Pre-clinic meetings• Noon conferences• Elective rotations

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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

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To increase the chance: You will reach your goals That changes made will result in sustained improvement in performance Your group will stay together Developed by Associates in Process Improvement Based on the work of Deming Popularized in health care by the Institute for Health Care Improvement (IHI) Based on trial and learning

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Act Plan

Study Do

Aim

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Sometimes we will refer to this as the 3 questions… The first question in the MFI:�What are we trying to accomplish? The answer to this is our aim

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The Aim Statement• Answers the question: What are we trying to

accomplish?• Lists specific goals of the effort• Should specify:

time specific, measurable, specify population• Examples:

– To increase the percent of infants exclusively BF at 6 months to 80%

– To improve the percent of children aged 2-19 at well child visits who have their diet and activity level assessed.

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Act Plan

Study Do

Measures

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Presentation Notes

The second question How will we know that a change is an improvement- is answered by the measures we collect from the processes we’re working on. We will talk about measurement in much more detail tomorrow. Information from measurement, or data, guides the actions we take.

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Is A Change an Improvement?

“All improvement is change, but not all change is an improvement”

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How will you know?

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Measures • Answers the question: How will we

know that change is an improvement?• Need to measure over time

– Baseline– After various changes are made

• Chose 3-5 measures – More is too burdensome– Chose a variety of types of measures:

process, outcome and balancing

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Presentation Notes

Processes: number of children get BMI measured Outcome: Change in BMI over time Balancing measures:

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Different Types Measures

1. % of patients with BMI >95%

2. % of patients with BMI plotted

3. time per visit per overweight/obese patient

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Processes: number of children get BMI measured Outcome: Change in BMI over time Balancing measures:

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Act Plan

Study Do

Ideas for change

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The 3rd question, what change can we make that will result in improvement? is answered by the ideas that we just discussed.

07/31/09

Ideas for Change

• Answers the question: What changes can we make that will result in improvement?

• Sources of ideas:– From research (e.g. EBM)– From theory e.g. the Chronic Care Model– Brainstorming and creative thinking

• Examples– Create a computerized registry of all

overweight/obese patients seen in clinic

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Act Plan

Study Do

Use PDSA Cycles to Test and Implement Changes

Plan the details of the test and predicting the outcome of the test

Do: Conduct the test and collect data

Study: Compare predictions to the test results

Act: Take action based on the new knowledge

Presenter

Presentation Notes

This is sometimes called the shewhart cycle, or plan do check act, but in any case The Plan do study act, or PDSA cycle is used to test and implement the change we make to see if they lead to improvement. We first Plan the details of the test and predicting what we think will happen We then conduct the test and collect data Study: compare our predictions to the results of the test Finally, we close the circle by taking action based on our new knowledge Again, we will have more time hearing about and practicing using the cycles tomorrow.

07/31/09

Why Test? • Allow opportunity for “failures” without

impacting performance• Document how much improvement can be

expected from a change• Learn how to adapt a change to conditions

in the local environment• Evaluate costs and side-effects of the

change• Minimize resistance once go to wide-scale

implementation

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Presentation Notes

Example –NEED example-- Does it work when the office is busy? Not about consensus. Biggest new idea to learn here in our model for improvement. Testing. A lot of cultures do not promote testing. We stay in test cycles until we succeed. We avoid big failures. Convince yourself the idea will work. How much bang will we get? Adapt your changes. Side effects—a different data collection strategy needed. Biggest application for testing—learn to ask that this idea works or doesn’t work for a few hours. Once they run the test and it is a good idea, they want to keep at it. Make sure you know why we’re running tests.

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Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A PS D

A PS D

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

Presenter

Presentation Notes

Example��1st PDSA: identify ADA guidelines and Test one chart to see if can identify care reaching guideline 3. Identify % pts currently receiving guideline care using chart review of last 10 diabetic patients 4. Reach consensus among provider over guidelines 5. Draw up a template note- test out on one patient 6. Test out template with a few doctors, a few patients 7. Remeasure performance on those charts to see if better 8. Implement new form

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Fit For Resident Clinic Changes• Provide easily accessible BMI calculation tools• Patient data tracking and prompting tools

– E.g. Lifestyle log• Clinical decision support tools (for labs, referrals, etc)• Develop and use patient counseling tools

– Supporting Motivational interviewing (goal setting, scales)– Exercise prescription– Food props/posters

• Community resource materials for nutrition and physical activity– E.g. brochure

• Develop group visits or educational sessions – E.g. KP Kids

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Develop a plan for carrying outQI activities

1) Identify how you will create QI teams• When, where, who?

2) Identify high priority aims for improvement • Use baseline chart review, discussions with faculty

and residents3) Identify measures that tell you how you are

doing • We will send data back from chart reviews

4) Identify 2-3 changes you’d like to start testing• Pick the easiest one to start with• Work on only 1-2 at a time

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Lifestyle Log Evaluation

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Evaluation of the Lifestyle Log and Reach out and Jump Intervention

• Utilized a time-series design with systematic chart reviews to collect information at six months prior to intervention (the point of first-intervention), and at one month, six months and 12 months post-intervention.

• Intervention was defined as the date when the lifestyle log was placed in the chart and utilized or a jump rope was first given.

• Sample:– 136 children– 2-15.9 year olds– 48.5% female– 97.1 % Latino

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BMI Percentile Means for Different Age Groups at Each Point in Time

90

91

92

93

94

95

96

97

T 1 T 2 T 3 T4 T 5

2-5.99 Years6-9.99 Years10-16 Years

Presenter

Presentation Notes

Significant results for age group 1. A paired samples t test was calculated to compare the mean BMI percentiles of children ages 2 – 5.99 years at time points two and four. The mean percentiles at time point two was 95.90 (sd = 4.41) and the mean of the percentile at time point four was 93.10 (sd = 8.60). A significant decrease from time point two to four was found (t(36) = 2.777, p < .017). A significant decrease was also found for this age group between time points two and five (mean 91.30, sd = 12.32) (t(36) = 2.930, p < .017). T4=.009 T5=.006 Significant results for age group 3. A paired samples t test was calculated to compare the mean BMI percentile of children ages 10 - 16 years at time points two and five. The mean percentile at time point two was 95.74 (sd = 2.77) and the mean of the percentile at time point four was 94.36 (sd = 4.56). A significant decrease from time point two to five was found (t(36) = 3.329, p < .017). All other comparisons were not significant. T5=.002

07/31/09

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Average Cups ofJuice/day

Average Cups ofSoda/day

Baseline1 year later

Lifestyle Log Intervention Promotes Behavioral Change

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0

0.5

1

1.5

2

2.5

Average # of Hrs ofTV/weekday

Average # of Hrs ofTV/weekend day

Baseline1 year later

Lifestyle Log Intervention Promotes Behavioral Change

07/31/09

91.592

92.593

93.594

94.595

95.596

Intervention 1 mo 6 mo

Mean BMI Percentile+ JRMean BMI Percentil -JR

Reach Out and Jump: It Helps!!!!

quality improvement methods for fit for residents

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