Performance Improvement Performance Improvement --An Overview --An Overview Auxford Burks, MD Albert Einstein College of Medicine Department of Pediatrics/ Jacobi Medical Center
Jan 13, 2016
Performance ImprovementPerformance Improvement--An Overview--An Overview
Auxford Burks, MD
Albert Einstein College of Medicine
Department of Pediatrics/ Jacobi Medical Center
Thanks to:
Daniel Hyman, MD, MMM
Chief Medical Officer, Ambulatory Care Network
New York Presbyterian Hospital
Who provided all of this material
Fundamental Questions for Improvement
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?
Model for Improvement
Aim: What are we trying to accomplish?Measures: How will we know that the
change is an improvement?Ideas: What changes can we make that
will result in an improvement?
Model for Improvement
Aim: What are we trying to accomplish?
What are we trying to accomplish?
Aim: A written statement of the accomplishments expected from each pilot team’s improvement effort
Different forms are useful:– A general description of aim– Specific patient population– Some guidance for carrying out the work
The Team’s Aim Should Be:
• Strategic
• Relevant
• Exciting
• Important
• A stretch, not business as usual
• Achievable, not impossible
• Understandable
Sample Goals/Measures• 95% of patients with asthma will have symptom frequency
documented in their record (day and night) – process measure
• 95% of patients will have asthma severity specifically identified at all visits where asthma is addressed – process measure
• 90% of patients with persistent asthma will be treated with an appropriate antiinflammatory medication, at an appropriate dose – process measure
• 95% of patients with asthma will have a documented assessment of tobacco use or exposure and counseling to reduce risk if applicable – process measure
• There will be an X% reduction in ED/hospitalization rate over Y period of time – outcome measure
• Visit volume in clinic will be unchanged – balancing measure
AIM: Why the Change is Desired
• A known performance deficiency in an important process
• A gap between current performance and desired performance
Why an Aim Statement?
• Answers and clarifies “What are we trying to accomplish?
• Creates a shared language and shared methods
• Facilitates organizational conversations and understanding
• Supports accountability for team leaders
Developing the Aim Statement
• Write a clear and concise statement stating the “who, what, when, and where “
– Who will undertake the work, and who will be affected by it
– What does the team intend to do
– When will the aim be accomplished
– Where - define pilot site and spread site(s)
SMAART Aims
• Specific: Understandable, unambiguous
• Measurable: Numeric goals
• Actionable: Who, what, where, when
• Achievable (but a stretch)
• Relevant to stakeholders and organization– Strategic, Compelling, Important
• Timely: with a specific timeframe
Sample AimsWe will improve the care of patients with asthma by adhering to evidenced based guidelines for diagnosis, assessment and treatment, thereby reducing morbidity/mortality
By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 days or more in the 2-week period preceding a planned care visit.
Example of Elaborated Aim Statement
• Aim: By the end of 2005, we will increase the average number of symptom-free days for children in our practice with persistent asthma to 10 or more in the 2-week period preceding a visit. To effect change, we will be guided by using the six components of the Care Model for Child Health. Intermediate aims are that:– 95% of children with persistent asthma will have severity classified at
every visit. – 95% of children with persistent asthma will be treated with
appropriate maintenance anti-inflammatory medication.– 90% of children will receive a written asthma management plan on
which we will document family/self- management goals.
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
From: Associates in Process Improvement
Aim
Measures
Ideas
Act Plan
Study Do
A PDSA Cycle
Will encounter forms facilitate severity classification? Dr. X will try form with severity class Qs with 3 patients on Thurs
Dr. X tried with two patients. Couldn’t find a form for third patient.
Dr. X found the form helpful for prompting; thought items on form should be in a different order. Need better process for getting form to provider.
Revise form. Try new form with 3 patients tomorrow; MA will put form on chart.
PDSA Objective: Test the use of encounter form to facilitate visit
Why Test?
• Increase your belief that the change will result in improvement
• Opportunity for learning from “failures” without impacting performance
• Document how much improvement can be expected from the change
• Learn how to adapt the change to conditions in the local environment
• Evaluate costs and side-effects of the change
• Minimize resistance upon implementation
ConceptAn opportunity to create
a new connection
Thoughtprocess
Specificidea B
Specificidea A
Ideas: What Changes Can We Make That Will Lead to Improvement?
Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.
ConceptAn opportunity to create
a new connection
Thoughtprocess
Specificidea B
Specificidea A
Ideas: What Changes Can We Make That Will Lead to Improvement?
Change Concept: A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.
Promote clinical care that is consistent with scientific evidence and family preferences
Use tool to classify severity at every visit
Change Concepts vs.High Leverage Changes
Vague, strategic, creative
Specific, actionable, results
Improve care of asthma patients
Share info w/ patients & families and encourage self-management
Document asthma management plan and goals for self-management
Begin discussion of self-management goals w/ 3 patients on Monday
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
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 Improve asthma outcomes
Reduction in ED visits
Change Pkg.
PDSA example I
• A pediatrician goes to a conference one October and learns all about Improvement, PDSA cycles, and how to improve care for patients with asthma.
• He returns to his practice completely enthused and ready to do something new that will improve care.
• We’ll call our protagonist in this story, Bill Caspe
PDSA example I
• Bill decides to look at his 5 person practice’s assessment of children whose parents call for refills of asthma medications to see whether the children:– Need flu vaccines– Are having symptoms too frequently (i.e. are
not being well controlled on their current medication regimen)
• He develops a form and gives it to his nurse to use for one week when asthma meds are refilled
PDSA example I
• Is this a good PDSA cycle?– Why?– Why Not?
• What do you think happened?
PDSA example II
• The pediatric residents in a community based clinic are taught about improvement, PDSA cycles, and how to improve care for patients with asthma.
• They are provided with baseline data that shows that only 20% of children have a severity classification of their asthma in the practice’s medical records
PDSA example II
• The residents develop a sticker that prompts the questions needing to be asked to determine symptom frequency
• One resident on ambulatory block tries the sticker for 5 consecutive patients with asthma.
PDSA example II
• Is this a good PDSA cycle?– Why?– Why Not?
• What do you think happened?
PDSA Cycles
“Negative results on the fish…Let’s try rubbing two sticks together.”
PDSA Key Points:
• Make the Cycle SMALLER!!!
• Break changes down into manageable parts
• This also allows people to:– try things and give input– more easily adapt – feel included in decisions and development
Repeated Use of the PDSA Cycle for Implementation
Test of Test of patient patient surveysurvey
Routine use of patient survey
A PS D
APS
D
A PS D
D SP A
DATA
D SP A
Cycle 1: Introduce new survey form to one provider and staff
Cycle 2: Test - Use of new survey on two clinic days
Cycle 3: Try survey on other days with other providers and patients
Cycle 4: Use of survey for all patients
Cycles 5/6: Create orientation manual section on patient survey
Multiple Cycles to Test and Implement Components of the Care Model
Will a flow sheet be useful for
patients?
Use of Flow sheet V.4 by all
physicians and nurses
A PS D
APS
D
A PS D
D SP A
Learnin
g
D SP A
Cycle 1: Gather sample flow sheets, try V.1with two patients
Cycle 2: Try V.2 by two providers for a few days
Cycle 3: Two week trail of V.3, review meetings
Cycle 4: Trial of V.4 by all providers
Cycle 5: Implement use of V.4, do peer review of documentation and use
Component: Decision Support
From Chinatown, Asthma BTS, 2001
Things should be as simple
as possible but not simpler.
» Albert Einstein