Foundations – Practice Transformation March 11, 2016
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Foundations – Practice Transformation
March 11, 2016
To provide an overview of change management and practice transformation
To review Model for Improvement, PDSA process, and process mapping
To demonstrate PDSAs and process mapping including examples
Better Care for Individuals
Better Health for the Population
Lower Cost through Improvement
Improved Provider Satisfaction
Source: The IHI Triple Aim framework was developed in 2007 by the Institute for Healthcare Improvement in Cambridge, Massachusetts (www.ihi.org)
Focus on individuals and families
Redesign of primary care services and structures
Population health management
Cost control platform
System integration and execution
Provider Preventative
Med
Intervention
New Acute
Complaint
Test Results
Chronic
Disease
Monitoring
Medication
Refill
Hospital Behavioral
Health Provider
Referral to Specialist
Public Health
Ambulatory Center
Adapted from: Southcentral Foundation & Institute of Healthcare Improvement (2010)
Adapted from: Southcentral Foundation & Institute of Healthcare Improvement (2010)
Case
Manager Pharmacist Provider RN/MA
PT/OT/
Dietician
Behavioral
Health
Specialist
Healt
hcare
T
eam
Patient
Preventative Med
Intervention
New Acute Complaint
Test Results
Chronic Disease
Monitoring
Medication Refill
Link Healthcare Delivery with Population Health
Quality Improvement needs to be the way we do things, not an added task or responsibility.
It is a priority, not an intrusion on “real jobs”
“We have to get comfortable with discomfort because we will experience it frequently when we seek to change the status quo.”
Source: Studer, Q. (2003) Hardwiring Excellence. Firestarter Publishing, Gulf Breeze, FL.
Recognize Embedded Tensions and Paradoxes
◦ Revitalization vs. Normalization
◦ Globalization vs. Simplification
◦ Innovation vs. Regulation
◦ Digitization vs. Humanization
Hold Everyone Accountable
Provide Resources
Emphasize Continuous Learning
Source: 4 Things Successful Change Leaders Do Well Douglas A. Ready January 28, 2016, Harvard Business Review
“Burning platforms can work. But they can also create a panic that stops new action.”
In large-scale change, if fear is not converted to positive energy it can become a liability.
Fear may make people focus on self-preservation instead of organizational transformation.
Source: Kotter, J.(2002). The Heart of Change. Harvard Business Review Press, Boston, MA.
Too much change at once can be overwhelming
Utilize a stepwise approach to change
Celebrate small wins
Focus on a few small changes at a time
Avoid change fatigue
John Kotter’s 8 Steps for Successful Large Scale Change
Source: Kotter, J.(2002). The Heart of Change. Harvard Business Review Press, Boston, MA.
Increase Urgency People see the need
Empower Action More people feel able to act on the vision
Build the Guiding Team
Team to guide and work together
Create Short-term wins
Momentum builds acceptance
Get the vision right
Identify right vision & strategy
Don’t let up People make wave after wave of change
Communicate for buy-in
Help people see Make change stick
New behaviors continue despite turnover
Source: Heath, Chip & Dan, (2007). Made to Stick. Random House Publishing, NY.
Six Principles of Sticky Ideas
1. Simplicity
2. Unexpectedness
3. Concreteness
4. Credibility
5. Emotions
6. Stories
14
https://www.youtube.com/watch?v=gmoDpj1jtyA
It’s not about adding another initiative or another priority
To review and improve processes by standardizing, streamlining and making workflow more efficient
Change processes to allow us to focus on the work we are passionate about.
Make Clinician satisfaction and Well Being quality indicators
When physicians perceived themselves as providing high-quality care or their practices as facilitating their delivery of such care, they reported better professional satisfaction.
The Rand Medical Outcomes Study demonstrated a significant positive correlation between physician satisfaction and patient adherence to physician care recommendations among patients with major chronic conditions
Source: Friedberg, M, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR439.html.
OIG – Noncompliance with medications results in 125,000 deaths each year from cardiovascular disease alone.
In studies of patient behavior, half of patients don’t take prescriptions as directed.
“Satisfied patients are more likely to comply with treatment”
Source: Beeson, S., (2006). Practicing Excellence. The Studer Group, LLC.
Non-compliance is one of the most important problems in healthcare today.
“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” –William A. Foster
“What defines “excellence”? Excellence is when employees feel valued, physicians feel their patients are getting great care, and patients feel the service and quality they receive are extraordinary.” –Quint Studer
Source: McAslan, M.(2015). Advancing Excellence in Healthcare Quality. Greenbranch Publishing, LLC.
Source: Studer, Q. (2003) Hardwiring Excellence. Firestarter Publishing, Gulf Breeze, FL.
Proactive approach to prevention, screening, treatment and follow-up
4 Foundational Elements: ◦ Engaged Leadership
◦ Data-driven Improvement
◦ Empanelment
◦ Team-based Care
Vision and inspire followers
Focus on shared values
Engagement - Visible “change sponsor”
Model the way
Provide resources
Remove barriers
Communicate changes
Reactive Proactive
Clinic-centric patient centric
Physician team-based
Memory data-driven
One patient at a time Population focus
Clinician Expert Clinical and Patient Expertise
“Patients who come in” Accountability and Care Coordination for all of your patients
Empanelment Access Continuity of Care Team-based Care Registry Care Management for High Risk Patients Patient Engagement and Self Management
Support Care Coordination Transitions of Care Across the Medical
Neighborhood Patient Experience and Feedback
We can’t just work harder
Effective change requires an understanding not only of how one part of a system functions, but of how all the system parts are linked together and coordinated.
Dr. Donald Berwick, co-founded the Institute for Healthcare Improvement (IHI) in 1991, has been quoted as saying, “Every system is perfectly designed to achieve exactly the results that it achieves.”
New roles and responsibilities
Quality and safety is everyone’s job
Practice at top of license
Performance driven teamwork with a patient-centered focus
Ideas come from everyone
Work smarter, not harder
Who are the key stakeholders?
Who are the formal and informal leaders?
Project champion – sponsor, support, keep on track, eliminate barriers
Identify team members – variety of roles ◦ Provider Champion
◦ Process Owners/Subject Matter Experts
◦ Team Members
“The Modern business meeting might be compared to a funeral: A gathering of people
Wearing uncomfortable clothes
And would rather be somewhere else.
A major difference is that most funerals have a definite purpose” – Dave Barry
Source: CHA Science of Process Improvement; PDSA Project Planning Presentation, (2015).
For research findings to become established healthcare practice takes an average of 17.6 years. (Bemmel JH, 2000)
What are we trying to achieve? ◦ Know exactly what you are trying to do – have clear
aims and objectives
How will we know that change is an improvement? ◦ Measuring processes and outcomes
What changes can we make that will result in an improvement? ◦ What have others done? What hunches do we have? ◦ What can we learn as we go along?
A method to test a change
and asses its impact.
Breaks down change into manageable, bite-sized, time-limited chunks
Minimizes risks and expenditures of time and money.
Plan
Do Study
Act
Recruit the team
Describe current process
Describe the problem
Draft an Aim statement
Identify causes and alternatives
Set the scope of the project Along the way you may identify 6 other
opportunities for improvement – it is important to understand the scope of the work
Stay on task
Understand how the involved processes currently work, and why they are structured as they are.
Do you need more data?
Listen and gather ideas about how to get better results.
Be creative. List more than one potential solution.
Lasting solutions usually come from changing the work process, not from awareness or training.
Non-Statistical Tools ◦ Process Flow Chart
◦ Cause/Effect Diagram
◦ Brainstorm
◦ Inter-relationship Diagram
◦ Prioritization Matrices
‣Many of these tools also come in handy during the “Study” phase of the cycle.
Plan
“Lean”
Meeting skills
Information/Knowledge
People skills
Communication
QI methodologies
Your QIA is a great
resource for these!!
State aim
Describe goal
Describe change
Source: IHI – The model for improvement is adapted from Deming’s work and developed by Associates in Process Improvement
What are we trying to accomplish?
Why is it important?
Who is the specific target population?
When will this be completed?
How will this be carried out?
What is/are our measurable goal?
Goals are
Specific
Measurable
Achievable
Realistic
Time-phased
‣ Offer all patients same-day access to their primary care physician within 9 months
‣ Reduce waiting time to see a physician to less than 15 minutes within 9 months.
‣ By February 2017, 25% of licensed child care providers in Mesa County will be trained in the "I am Moving, I am Learning" curriculum.
Baseline Measures What data shows a need for change? How much change is realistic?
Outcome Measures How does the change impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?
Process Measures Are the parts/steps in the system performing as planned? Are we on track in our efforts to improve the system?
Balancing Measures (looking at a system from different directions/dimensions) Are changes designed to improve one part of the system causing new problems in other parts of the system?
Design measures around aims.
Outcome measures allow the observation and assessment of the results of care and/or services provided.
STRUCTURE
Staff, Equipment, Facilities, Supplies, Financing
PROCESS
Technical, Interpersonal,
Activities, Timeliness
OUTCOME
Results of Care/Service
“We are not measuring just to measure. We are measuring to align specific leadership and employee behaviors… that cascade throughout the organization to drive results.” – Quint Studer
Source: Studer, Q. (2003) Hardwiring Excellence. Firestarter Publishing, Gulf Breeze, FL.
Processes deliver the outputs they are designed to deliver!
Staff may learn how to compensate for poorly designed processes in order to achieve better outcomes, but gains achieved by this means are rarely sustainable over time and tend to result in staff burnout.
If you want real change, you have to work on the process.
Process: A sequence of steps or actions carried out in order to provide a particular service and/or to deliver a specified outcome.
Need to go out and observe the process in action.
Many times we think we know what the process should be, but there are short-cuts, work-arounds, or variation depending who is performing the task.
Describe a Process as It Works Today
Create a Second Ideal Process
Identify gaps, brainstorm, and create new workflows to close gaps
Complete PDSA cycles to test your new changes
Once you achieve the end ideal end results, create a written work flow that can be used for training new staff
What measures of process performance might you collect data for before you decide where to make changes?
Given your understanding of current processes, what changes might you recommend piloting?
Daily Huddle
Revised Daily Huddle
. . .
7:45 Start
. Discuss dress code
. Discuss vacation schedule
Discuss new
patients
Discuss
anticipated
needs
8:07 Finish
7:45 Start
Discuss new
patients
Discuss anticipated
needs
Discuss staff
assignment
Discuss available
appts
7:58 Finish
Begin by making sure that people understand why a change is needed, and how to implement the solution to be piloted.
Monitor the progress of the pilot project.
Make sure the data you’ll need to evaluate success is collected.
Effective communication is especially important during change.
Plan
Do Study
Act
Introduce Health
Behavior Assessment
Tool
Routine use Health Behavior Assessment Tool
A P
S D
A P
S D
Cycle 1: Test with 1 MA/1 patient/family
Cycle 2: One MA test one afternoon. Revise workflow and prompts.
Cycle 3: Test with another MA. Make revisions.
Cycle 4: Refine process until smooth. Record for training.
Cycle 5: Monitor implementation – continued use by MAs
Aim: Use the Health Behavior Assessment Tool on 75% of our pediatric population ( 0– 18) with a BMI in the >80% with in the next 6 months
At the PDSA Level
How long did it take to use?
Is this the right time to use this tool in the flow of the visit?
Did we remember this new work task?
What if someone can’t read?
Et al….
Ongoing Monthly Measures
% BMI percentile assessment
% nutritional counseling % physical activity
counseling % healthy weight plan % of children seen at least
twice over the last year that are >=85 percentile
Analyze results and compare the results with your goal.
What worked? Do you need to carry out another PDSA? Do you need to involve more people?
What didn’t work and why?
Do you need to change the plan?
Plan
Do Study
Act
What do staff/patients say about how well the solution worked?
In hindsight, what are the pro’s and con’s of your solution?
Do you believe this change can be sustained?
Plan
Do Study
Act
Adapt, Abandon or Adopt based on the analysis of the collected input and information.
Plan
Do Study
Act
If the change you piloted was successful: ◦ Celebrate your success!
◦ Take whatever steps are necessary to formalize the change.
If the change you piloted didn’t work out as intended: ◦ Share the results. ◦ Use the lessons learned to develop a new
plan. ◦ Begin another PDSA cycle
Plan
Do Study
Act
Testing and refining ideas
Implementing new procedures & systems - sustaining change
Bright idea!
‣ Decide if change will work in actual environment
‣ Decide on combination of changes for desired effect
‣ Evaluate cost, social impact, side effects
‣ Evaluate how much improvement we can expect
‣ Increase degree of belief
‣ Are processes working as intended?
‣ Are staff completing assigned tasks?
‣ Is documentation evident?
‣ Are patient materials kept up to date?
‣ Does the team receive timely feedback and support for a job well done?
‣ “Never underestimate the difference that simple changes can make in the eyes of the physicians, the employees, and the patients.” Studer (2003)
Source: Studer, Q. (2003) Hardwiring Excellence. Firestarter Publishing, Gulf Breeze, FL.
https://www.youtube.com/watch?v=jsp-19o_5vU
Source: Beeson, S., (2006). Practicing Excellence. The Studer Group, LLC.
Copyright © 2014 TrueSimple, LLC Williams, DM. Mr. Potato Head Plan, Do, Study, Act (PDSA) Exercise. Austin, TX: TrueSimple, LLC. 2014. (Available on www.truesimple.com
Hold the Gains
1. Supportive Management Structure
2. Structures to “Foolproof” Change 3. Robust, Transparent Feedback Systems 4. Shared Sense of the Systems to Be Improved
5. Culture of Improvement and a Deeply Engaged Staff
6. Formal Capacity-Building Programs/Communication
Source: IHI 5 Million Lives Campaign.
Lay the Foundation for Spread
Develop a Plan for Spread
Refine the Spread Plan
Source: IHI 5 Million Lives Campaign.
Change is hard Transformation is a team sport Vision and day to day leadership is critical Use the 3 questions from the Model for
Improvement 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement? Use a strengths-based approach – build on what
you are already doing Tackle your challenges in context
Our role is to support you in this process
To provide Coaching and Encouragement
To provide resources and examples
To support community based learning opportunities
To maximize the use of the EHR to improve work flow and reporting.
Why is any of this important to your transformation journey?
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