JAMAICA QUALITY IMPROVEMENT COLLABORATIVE Clive Anderson Clinical Coordinator CHART RCU Collaborative Chairman JaQIC
JAMAICA QUALITY
IMPROVEMENT COLLABORATIVE
Clive Anderson
Clinical Coordinator CHART RCU
Collaborative Chairman JaQIC
Slide -2
Quality Improvement in
Healthcare
3rd CHART-CCAS-CMLF Joint Meeting
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Quality Improvement:
Bridging the Implementation Gap
Implementation
Gap
Where we want
to be
Current status Pro
gre
ss
Time
3rd CHART-CCAS-CMLF Joint Meeting
Slide -4
Collaborative Quality
Improvement model
• Well tested approach that
involves frontline health care
providers in developing and
implementing changes that
improve the quality of healthcare
3rd CHART-CCAS-CMLF Joint Meeting
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Improvement Collaborative (1)
An Improvement Collaborative is:
• an organized network of a large number of sites
• that work together for a limited period of time
(usually 12 - 18months)
• to rapidly achieve significant (often dramatic)
improvements in a focused topic area through
shared learning and intentional spread methods.
3rd CHART-CCAS-CMLF Joint Meeting
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Improvement Collaborative (2)
• Build will & excitement for Quality
Improvement – for improved quality of care
• Demonstrate that frontline staff can make
impactful changes
• Build a cadre of HCWs with experience in
Quality Improvement to spread the word
• Increase ability of site teams to collect,
analyze and act on their own data
3rd CHART-CCAS-CMLF Joint Meeting
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Guiding Principles for a Collaborative
• All teach, all learn!
• Learning by doing
• Learning from each other
• Using data for learning (not
judgment)
3rd CHART-CCAS-CMLF Joint Meeting
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Laboratory monitoring of HIV
• Monitor disease progression
• Guide OI prophylaxis
• Indicator of need for ART
• Assess response to therapy
• Important indicator of retention in
care
3rd CHART-CCAS-CMLF Joint Meeting
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National Adult Antiretroviral Treatment Guidelines
(Jamaica, 2011)
Baseline Follow-Up
Before ART
Initiation
After ART
Initiation or
Switch
Follow-Up
on Effective
ART
Treatment
Failure or
Clinical
Indications
CD4 x At 3 & 6
months.
Then every 6
months
x
VL 6 months 12 months x
3rd CHART-CCAS-CMLF Joint Meeting
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CHAI (2013)
37%
42%
26%
42%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SERHA SRHA NERHA WRHA
Current data shows
~42% CD4 Uptake
island wide.
3rd CHART-CCAS-CMLF Joint Meeting
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State of CD4 Testing
• 26 – 42% of patients are receiving
CD4 tests as indicated by known
standards of care.
• In other words, 6-7 of 10 patients are
leaving without the recommended
diagnostics
JAQIC
Slide -13
JAMAICA QUALITY IMPROVEMENT
COLLABORATIVE
3rd CHART-CCAS-CMLF Joint Meeting
JaQIC!
Slide -14
JAQIC! AIMS( AT EACH SITE)
• Increase CD4 tests ordered and
completed for active patients from
baseline to at least 80% by March,
2014
• Increase viral load testing from
baseline to at least 80% by March,
2014
Slide -15
JAQIC! MEASURES
• % of active* patients with CD4 count in last 6 months
• % of active* patients on ART for at least 6 months with VL count in last 12 months
• Time in days for CD4 and VL test results to come from NPHL and Cornwall Regional Laboratory
• % of dockets that have last ordered CD4 and VL results on the day of patient visit.
Slide -16
Collaborative Planning Group
• Co – Directors: Clive Anderson (Clinical Coordinator, UWI
CHART), Tina Hilton-Kong (Medical Director, ERTU CHART
Jamiaca) will serve as the co-Directors.
• Dr. Nicola Skyers – Director Treatment Care & Support, NHP
• Dr. Geoff Barrow - Medical Director, CHARES, UWI
• Content Faculty: Chris Behrens (Clinical Advisor, I-TECH)
• Improvement Advisors: Shay Bluemer Miroite, QI Advisor, I-
TECH
• Karen Zeribi, Independent QI Consultant
• Measurement Analyst: Malene Townsend, M& E Specialist
UWI-CHART
•
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Faculty members
• Members of the Collaborative Planning Group
• Director Immunology NPHL – Dr.
Michelle Hamilton,
• NHP M&E Officer - Zahra Miller,
• CHAI - Krystal Lawrence
3rd CHART-CCAS-CMLF Joint Meeting
Slide -19
William Edwards Deming
“Put everybody in the organization
to work to accomplish the
transformation. The
transformation is everybody's
work.”
3rd CHART-CCAS-CMLF Joint Meeting
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QI Methodology
• Each sites forms multidisciplinary team
• Site teams meet regularly – every 2 weeks
• All teams are joined into a collaborative learning network
• All teams are convened regularly ( every 3-4 months) at a learning session to review progress, learn from each other
• Teams use systems change strategy based on – PDSA cycles
3rd CHART-CCAS-CMLF Joint Meeting
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What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
Act Plan
Study Do
Langley, et al. p96
Goals
Measures
Ideas
3rd CHART-CCAS-CMLF Joint Meeting
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Key Points for PDSA Cycles
Do initial cycles on smallest scale possible
• Think small…a “cycle of one” usually best
• Small test does NOT equal small results!
• “Failed” cycles are good learning opportunities when small
Fail early and fail often to avoid failing spectacularly….
3rd CHART-CCAS-CMLF Joint Meeting
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Quality Improvement Teams
• Teams reviewed data and planed changes to be tested weekly.
• Carry out tests of change, and collected data
• Share data transparently in collaborative monthly reports. Submit a brief narrative report each month describing the work done, successes, and challenges.
• Participate in three Learning Sessions (3 people), monthly calls, and site visits.
3rd CHART-CCAS-CMLF Joint Meeting
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Learn with Rapid PDSA Cycles
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Very Small Scale Test:
Follow-up Tests
Wide-Scale Tests of Change
Implement Change
Source: Langley et al. The Improvement Guide.
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Institute for Healthcare Improvement, www.ihi.org
Improvement Collaborative Structure
3rd CHART-CCAS-CMLF Joint Meeting
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The Process
• Learning Session I (Oct 1-3, 2013) • Baseline site level data shared at LSI was a surprise
to all. Some teams were as high as 57%, some as low as 2%.
• Challenges in getting baseline VL data.
• Teams shared average turn around time for CD4 and VL results.
• Aim: Increase the percent of CD4/ VL tests completed according to national guidelines from baseline to 80% by March 2014.
• Ideas for improvement were generated using tools including FMEA and swim lane.
• PDSA concept introduced and plans for improvement made.
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Swimlane flow charts ARE fun!
3rd CHART-CCAS-CMLF Joint Meeting
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PDSA = Learning + Improving!
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
3rd CHART-CCAS-CMLF Joint Meeting
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Example of Repeated PDSA Cycles at
Cornwall Regional Hospital
Hunches
Theories Ideas
Changes That Result in
Improvement
A P
S D
A P
S D
Very Small Scale Test: Tried flagging dockets that need CD4
and VL tests with just 10 dockets
Follow-up Tests: Tried putting order sheet in dockets
(no change)
Folow-up Tests: Identified docs who weren’t
ordering tests and met with them
Follow –up Tests:
Re-tried inserting order
form for test into dockets of
patients who need tests
Source for Ramp Concept: Langley et al. 1996. The Improvement Guide: A Practical
Approach to Enhancing Organizational Performance.
Change Concept:
Identify in advance dockets of
patients that need an
updated Viral Load or CD4
test
Slide -32
The Process cont’d
• Action periods
• Immediately following LS1 (Friday October 4) four
sites with support from ITECH and UWI-CHART
were visited to help with start up and sharing ideas
to larger team.
• Sites tested ideas and made changes as
necessary.
• UWI-CHART and CHART Ja conducted and
supported an average 3 site visits per site
including 1 exchange site visit. 3rd CHART-CCAS-CMLF Joint Meeting
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The Process cont’d
• Learning Sessions II and III
• Ten sites came together to share progress and learn from each other ( steal shamelessly).
• All sites had seen an improvement after 2 months of implementation but the December period saw a dip in CD4 and VL uptake.
• VL baseline was shared at LSII.
• Improvement was seeing in turn around time for CD4, but lab challenges with VL processing caused continued lengthy waits for VL results.
3rd CHART-CCAS-CMLF Joint Meeting
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The Process cont’d
• Learning Sessions II and III
•Patients invited to share their
experience at LSII. .
3rd CHART-CCAS-CMLF Joint Meeting
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Examples of Changes Tested
• Phlebotomist comes on site to take
blood.
• Education/Instruction kits/cooler for
driver transporting samples.
• Drivers route examined and changed
to allow faster delivery of results 3rd CHART-CCAS-CMLF Joint Meeting
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Examples of Changes Tested
• Assign patients 3 and 6 week test
return date for CD4 and VL
respectively before actually clinic
appointment.
• Call & Schedule follow up visit for
patients missing appointments.
3rd CHART-CCAS-CMLF Joint Meeting
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Examples of Changes Tested
• Increase in the number of days for sample
collection
• Contact Investigator verifies with the lab the
following day if blood was drawn.
• Pre-pull and review dockets prior to
appointments.
• Place reminders in dockets for clinicians to
order CD4/Viral load tests where applicable.
3rd CHART-CCAS-CMLF Joint Meeting
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THE RESULTS: Combined sites: CD4
Uptake
35%
44%
56%
45%
54% 55% 58%
68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 May '14
Slide -39
3 JaQIC! Sites Achievements
57%
72% 74%
67% 70%
32%
64% 66%
59% 60%
2%
36%
44%
53% 53%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Baseline October November December January
Site X
Site Y
Site Z
JaQIC Learning Session 1: October 1, 2013
Slide -40
THE RESULTS : Combined sites: VL
Uptake
40% 36% 37%
30%
49%
38%
54%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 May '14
3rd CHART-CCAS-CMLF Joint Meeting
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8 month outcomes
• Significant improvement in important measure
achieved
• QI methodology validated in our setting
• Cadre of healthcare workers trained in QI
methods
• Sustainability assured as QI
accepted as job function of TCSOs
3rd CHART-CCAS-CMLF Joint Meeting
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Most Importantly
• HCWs convinced of importance of
generating/analyzing their own data and using
it to improve care
• Genuine sense of a multidisciplinary TEAM
generated
• Frontline staff accepted responsibility for
improving the quality of care delivered at their
site
3rd CHART-CCAS-CMLF Joint Meeting
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CONCLUSIONS
• The delivery of modern health services is
complex and dynamic
• It is feasible to study the process of health
care and find ways to improve it— to direct
change
• Our hypotheses about how to improve health
care should be tested before we accept
them— the scientific method
• • 3rd CHART-CCAS-CMLF Joint Meeting
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• Frontline health workers can do
most of this work (with support) —
they know the system - they are the
system experts
• A few simple analytical tools, like
flowcharts, can apply to most health
system issues
3rd CHART-CCAS-CMLF Joint Meeting
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QI Collaboratives - excellent tool
• More rapid progress - Each team learns from
work of the others: don’t re-invent the wheel
• Peer group provides motivation/competition for
QI work
• Facilitates spread of improvements--more
efficiently
• Pressure for better quality, quantitative
records
• Framework for rapid scale up 3rd CHART-CCAS-CMLF Joint Meeting
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3rd CHART-CCAS-CMLF Joint Meeting DANK JE