The ABCs of QI: What Changes Can We Make that Will Result

in Improvement?

Flora Maiki, MHA, Improvement AdvisorAmanda Kim, Senior Project Manager

July 7, 2020

Webinar Instructions

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Webinar Instructions

Conflict of Interest

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All presenters have signed a conflict of interest form and have declared that there is no conflict of interest and nothing to disclose for this presentation.

Learning Objectives

Describe at least two change

sources

1Learn the

purpose and components of a Driver Diagram

2Understand the

benefits and use of Process Mapping

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Review Session II - Data for QI

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• How does the current system perform?Understand

• What interventions might improve the performance of the current system?Predict

• Did our interventions result in improvement?Evaluate

• Are our improvements sustained over time?Monitor

• What do stakeholders need to know?Engage

Review Session II - Data for QI

• Understanding the context of data helps with interpreting the data

• All data exhibit variation, either common cause or special cause

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• Random• “Natural” or expected variation• Inherent to the system

Common Cause

• Non-random• Attributable to a cause• Not inherent to the system

Special Cause

Review Session II - Data for QI

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Rule DefinitionAstronomical point

• One value that is clearly different from the rest Example: When the Medical Provider is on vacation

Shift • An indication of movement, where 6 consecutive points have ‘shifted’ to the other side of the median

• If 1 point is on the median, skip it and keep counting

Trend • 5 or more points in a row, each one consecutively higher or lower in value than the previous data point

• If 2 or more consecutive points have the same value, skip all but one of the matching points when counting

Review Session II - Set of Measures

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Outcome• Relates directly to aim• Answers question – did we

achieve our aim?

Process• Measures whether a change

has been accomplished• Helps us understand why we

did or did not achieve our aim

Balance • “Unintended” impact• Can be + or - impact

Review Session II - Data Collection Plan

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• Who is responsible for getting the data (measurement)?

• Sample size– Will data be collected on the entire eligible population?

Or will you sample?• Sources

– EHR or registry report– Chart review

• Frequency– How often will the data be collected?

Sources for Change:

Driver Diagram and Process Mapping

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Focus for This Section

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

From Associates in Process Improvement.

Change Ideas

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Making Changes

• What if I wanted to become a better cook?• What are some ideas that I might use?

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Sources for Changes

• Published research• Experts• Peers• Benchmark• Patients: “Voice of the Customer/Patient”

– Focus groups; Surveys• The 5 Whys

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Driver Diagram

• Purpose– Translates a high-level improvement goal into

sub-projects– Helps organize change concepts and ideas– Tests theories about cause and effect– Serves as a communication tool

Source: Health Quality Ontario, Driver Diagram Instruction

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Driver Diagrams

Aim Statement

Outcome

Primary Drivers(Problems with the System)

Secondary Drivers(Areas for Improvement/Change Ideas)

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• Focus Area: Asthma Management

Brainstorming for Driver Diagram

No diagnosis of asthma in

EMR

Incorrect classification

in EMR

No evidence of asthma in progress

note

Provider is not using the nationally

recognized standards

Inhaled controller

medicine was not prescribed

for patient

No follow-up or case

management provided for

patient

Patient did not pick up prescribed controller

medicationPatient does not know how to properly use

controller medication

Patient does not keep

scheduled appointments

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• Focus Area: Asthma Management

Brainstorming for Driver Diagram

No diagnosis of asthma in

EMR

Incorrect classification

in EMR

No evidence of asthma in

progress note

Provider is not using the nationally

recognized standards

Inhaled controller

medicine was not prescribed

for patient

No follow-up or case

management provided for

patient

Patient did not pick up prescribed controller

medicationPatient does not know how to properly use

controller medication

Patient does not keep

scheduled appointments

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Driver Diagrams

We will improve asthma

management by increasing the ratio of inhaled

controller medications to inhaled rescue

medications from 59% to 75% by December 31,

2020

OutcomeDocumentation

Consistent Treatment Standards

Patient Engagement

Primary Drivers(Problems with the System)

Secondary Drivers(Areas for Improvement/Change Ideas)

Inhaler medication consistently prescribedStandards consistently

followed

F/up and case management provided

Understands how to properly use inhaler

Picks up inhaler

Keeps appointments

Proper classification in EMR

Diagnosis of asthma in problem list

Asthma documented in progress notes

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Let’s See How It Works . . .

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Exercise

• 10 minutes: Start a driver diagram for this scenario– Identify drivers and at least one change idea for each

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Driver Diagrams

Outcome

Primary Drivers(Problems with the System)

Secondary Drivers(Areas for Improvement/Change Ideas)

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Developing Driver Diagrams - Recap

• Team brainstorming tool • Organizes change concepts and ideas• Include those who know the work• If primary drivers are less defined, work

backwards– Collect change ideas– Cluster common ideas together to identify primary

driver

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Questions

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Breathe

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Process Mapping

What is Process Mapping?

• A visual aid for picturing our work processes• It shows each step of a process sequentially • A visual diagram of a sequence of events that

results in a particular outcome• Process mapping serves as a source for

identifying challenges/opportunities, as well as a tool for drafting new or updated processes

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Inputs Tasks Outputs

Benefits of Process Flow Mapping

• Understand the context in which the change will be made

• Serves as a tool for logical thinking about the process

• Defines & standardizes the steps and sequences• Identify changes that could be made:

– Gaps in systems– Wasted efforts (redundancy, extra steps, use of

resources)• Builds consensus

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Process Mapping Symbols

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• Start and End: Oval used to show inputs (materials, information or action) that starts a process and outputs (the results) at the end of a process

• Activity: Rectangle represents one task/ activity/step in the process

• Decision: Diamond represents a decision point in the process

• Break: A circle identifies a break in the process

• Identify holes/differences in the process “Pin yourself to the problem”

• Identify wasted effort • Keep in mind the aim of the process• Brainstorm solutions

– Develop PDSA cycles

Analyzing a Process Map

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Immunization Process

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Patient checks in and is roomed.

Nurse gathers initial information from

patient

Provider conducts well child exam,

communicates Izs needed

IZs administered and patient leaves

Provider office conducts reminder

calls

Patient stops by desk prior to

leaving

IZs entered in EHR

Patient is due for well-child appt

Patient’s IZs are checked in EHR and

CAIR

Appt. scheduled?

Patient is scheduled for next well-child

visit

Yes

Yes

No

No

No plan exists

No plan exists

Standard Process Map

Immunization Process

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Patient checks in and is roomed.

Nurse gathers initial information from

patient

Provider conducts well child exam,

communicates Izs needed

IZs administered and patient leaves

Provider office conducts reminder

calls

Patient stops by desk prior to

leaving

No plan currently exists IZ review and

tracking

IZs entered in EHR

Patient is due for well-child appt

Patient’s IZs are checked in EHR and

CAIR

Appt. scheduled?

Patient is scheduled for next well-child

visit

No plan in place for IZs if patient comes in outside of well-check

Relying on patient stop on

way out to schedule next

appt

No formal plan in place to address IZ refusals/concerns

Unable to reach

member/outdated

contact info.

Opportunity to educate on IZs

Minimum required

interval is not always met

Not all IZ dates are not being

transmitted to CAIR from EHR

Yes

Yes

No

No

Analysis of Process Map

Key Questions for Analyzing Process Steps

Purpose What? What is done? Eliminate

Why? What is the purpose?Is the purpose accomplished?Why is it necessary?What if it were eliminated?What would make it unnecessary?

CombineRearrange

Place Where? Where is it performed?What alternate locations are viable?Can the departments be reorganized?

Sequence When? What other sequences would work?Can it be combined with another event?What are the implications of other sequences?

Person Who? Who performs the task?Who else could perform it?

Means How? What other methods are available?What other process technologies exist?Can smaller scale processes be used?

Simplify

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Process Mapping Exercise

• Group Activity - Process Map

– Scenario: Shopping for my family each week. I write a shopping list just before going to the store

• Challenge: While shopping, some items are forgotten and I have to go back to the store

• Goal: Get all items in one trip and have a happy family and happy parent/caregiver

• Your role: Help me map out a basic weekly shopping routine (as-is) and identify some areas for improvement

• Create the as-is process map

• Identify areas for improvement

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Exercise

Start the shopping Process Map example

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Process Mapping Recap

• Helps us understand the current state, the positions and people involved, and the desired output

• Helps us understand how work currently happens

• It identifies process through the “eyes of your patients/customers”

• Identifies existing “work-around” and waste• Great team builder and builds consensus

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Process Mapping Recap - Guidelines

Create a high-level as-is process map, from the patient/ customer perspective

– Use post-its to create process map (tip: Use different colors, 1 for process steps and 1 for areas for improvement)

1. Identify a scribe and facilitator 2. Define the starting point3. Brainstorm high-level process steps together

(1 process step per post-it) 4. Define the ending point5. Briefly discuss & document challenges or

inefficiencies that could occur within each stepAlways include people who are impacted by the work

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Additional Sources for Change

• Benchmarking• Utilizing real experiences and input from

patients/family members: “Voice of the Customer/Patient”– Focus groups, surveys, and storytelling

• The 5 Whys

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Questions

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ABCs of QI - Upcoming Session

• Testing and Implementing Changes via the Plan-Do-Study-Act Cycle Webinar

• Date: Tuesday, July 14Time: Noon - 1 p.m. Registration:https://partnershiphp.webex.com/partnershiphp/onstage/g.php?MTID=e357b36d652e9f0c3b26f38c6b435141d

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Evaluations

Please complete your evaluation.Your feedback is important to us!

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• Approved for 1.25 AAFP Elective credits.**CME is for physicians and physician assistants and other healthcare professionals whose continuing educational requirements can be met with AAFP CME.

• Provider approved by the California Board of Registered Nursing, Provider #CEP16728 for 1.25 hours.

Continuing Education Credits

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• A Quick Guide to Starting Your Quality Improvement Projectshttp://www.partnershiphp.org/Providers/Quality/Pages/PIAcademyLandingPage.aspx

• QI Monthly Newsletters: http://www.partnershiphp.org/Providers/Quality/Pages/PCPQIPMonthlyNewsletter.aspx

Resources

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Thank You!

Improvement Advisors: • Farashta Zainal (fzainal@partnershiphp.org)• Flora Maiki (fmaiki@partnershiphp.org)• Joy Dionisio (jcdionisio@partnershiphp.org)

QI/Performance Team: • ImprovementAcademy@partnershiphp.org

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Sample - 5 Whys

• ..\..\..\..\Practice Facilitation\Quick Guide to QI Projects\Documents for User Guide\6. 5 Whys Determining the Root Cause.docxPractice

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• Evening/Sat. appts. • Parent/Caregiver work schedules • Expand appts with PCP

Community Health Clinic site will increase the percentage of assigned PHC members that have completed 6 or more Well Child Visits in the First 15 Months of Life (W15) from 47.47% to 58.54% by December 31st, 2020

Patient/Caregiver Education/Communic

ation

Provider/Staff site Education

Access

• Well child visits alerts system• Billing system alignment- new born with

well child visits• Coding Well Child Visits appointments

Community Health Clinic – Well Child Visits the First 15 months of Life

Aim StatementPrimary Drivers

(People, Systems, Processes Secondary Drivers

• Education on importance of Well Child Visits

• M/Cal Benefit communication• Parents unaware to schedule –

communicate early

Informatics/Data

• Training on documentation/coding-2 day/2 week Well Child visit.

• Train MAs on scheduling template beyond 6 weeks.

• Train staff and Providers on W15

• Research existing or create parent/caregiver education on importance of Well Child Visits.

• Create and offer parent/caregiver incentive tied into education and completed visit (s).

• Education and training on work existing and new flow processes

• Training on clinical components of W15 well child visits

• Newborn PCP identified before birth

• Expand well-child visit clinics to weekend and late aft. /evening.

• Provide monthly Well-Child only Clinics- assign/rotate Providers.

Build template to enable scheduling beyond the 6 week restriction.Build template to identify applicable patientsVerify/create template to bill 2-day and 2-week well-child visit.

Change Ideas

• C:\Users\fmaiki\Desktop\Driver Diagram example ABC's.pptx

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Example Driver Diagram

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20XX.

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Telephone Encounter from Resident MD on

baby’s birth

CTA creates patient record in

eCW enters 2 Day Visit codes as weight check

than changes this to “Well Check”

CTA contacts and schedules with

parent/caregiver weight-check with RN/Provider and

2 week visit; Schedules 2, 4, 6, 9, 12, 15 mo. well child visit .

Patient Arrives for visit?

Parent/caregiver attends 2 week

Health Check visit

MA responsible for group calls

parent/caregiver to reschedule

**MA creates “action” in eCW to

schedule 2, 4, 6, 9, 12, 15 mo well- child

visit.

Provider conducts well child visit, MA provides print-oiut

of future visit

(1) MA contacts parent/caregiver by

phone at 30 days to schedule visit

MA opens schedule page to look for the 2 4, 6, 9, 12, and/ or 15 mo well child

visit with PCP

MA calls N=3 attempts and sends letter

(2) Parent/caregiver accepts time slot?

MA schedules visit, confirmation

of address or best number to

call Parent/caregiver

requests to call back, or time/day not acceptable, MA

unable to schedule next visit ; creates

Action in eCW

Well-Child (W15) Scheduling Work Flow

Legend:PCP= Primary Care ProviderMA-=Medical AssistantCTA-= Care Team AssistanteCW= Electronic medical record practice management softwareCDPH= Child Health & Disability ProgramHighlight areas- Indicate opportunities for interventionCriteria for Scheduling:

• 2 day weight check – day after discharge or < before 10 days • CTAs try to reassign PCP for baby at 2 day visit once chart

created• Schedules up to 6 weeks out• CTAs try to keep family with the same PCP• No more than 3 CDPHs in a clinical shift/full day per Provider• No CDPHs 1st or last slot on schedule

No

Baby is assigned (on parent/caregiver

preference) to Lombardi and PCP

No

CTA sends note to Roseland to create visit. OB

remains the baby’s PCP – if

prefered

MA creates a “action” in eCW to call parent/caregiver–> 6weeks this remains until

contact is made- Calls N=3

attempts and sends letter

(4) Ensure template has correct billing

code and is the appropriate

template =2 day, 2 week, and 2

month visit Parent/

caregiver contacts Call

Center- schedules

visitParent/

caregiver contacts Call

Center – schedules

visit

YesMA scrubs schedules every day,

adds “due for CHDP” for

patients that have visits

that day and the next 2

days. Bundle immunization & well child visits when

possible

Follow-up- call follow

communication scheduling visit

Protocol as appropriate

Conclude visit Yes

Yes

Provider conducts and

records five components of the Well Child

Visit during exam. MA creates

action to schedule next

well-child visit.** (See step with

** above)No

(3) Parent/caregiver

attends the appointment?

No No

Yes

• C:\Users\fmaiki\Desktop\Well Child Work Flow v5 ABC's Example.vsdx

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