Quality Improvement (QI) Mini-Collaborative Learning Session II March 2, 2010 9:00 AM – 4:30 PM...

Quality Improvement (QI)Mini-CollaborativeLearning Session II

March 2, 20109:00 AM – 4:30 PM

The Chateau Hotel & Conference CenterBloomington, IL

MOVING FORWARD IN THE ILLINOIS MLC-3 COLLABORATIVE

MARLENE MASONMCPP HEALTHCARE CONSULTING, INC.

MARCH 2, 2010

Collaborative Complexity(Where Are We Now?)

3

Learning Objectives

MCPP Healthcare Consulting, Inc.

In today’s Learning Session, the participants will develop a better understanding of:Successes in Collaborative Methods and

InterventionsBuilding Change/Improvement PackagesSelected Quality Planning and Improvement

ToolsBuilding StoryboardsBuilding QI into the Agency and Links to

Accreditation

4

SYSTEMS ARE PERFECTLY DESIGNED TO PRODUCE THE

RESULTS THEY ACHIEVE


Collaborative Model for Achieving Breakthrough Improvement

5

IHI’s* Breakthrough Series


Also known as the Collaborative Learning Method – to easily learn from each other and experts

It is a structured method for learning and action to engage organizations in real system-wide improvements

Short-term (6-18 mo.) teams seek improvement in a specific target area

*Institute for Healthcare Improvement www.ihi.org

http://www.ihi.org/

6

The Advantage of a Learning Collaborative for Improvement


Learning collaborative: a group of multi-disciplinary teams from multiple organizations which come together over the course of a year in structured meetings and phone contacts to accomplish specific learning objectives.

National experience demonstrates significant boost in pace and level of achievement of outcomes by sharing lessons learned.

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Select Topic

Experts & Planning

Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

E-mail Visits Web-site Phone Assessments

Senior Leader Reports

Learning Congress and

Publications

A D

P

S

Breakthrough Method (IHI)


8

IHI Key Elements


Topic SelectionFaculty RecruitmentEnrollment of Participants and TeamsLearning SessionsAction PeriodsModel for ImprovementSummative Congress and PublicationsMeasurement and Evaluation

9

MLC-3 Collaborative Targets


In Illinois, participation in the MLC-3 Learning Collaborative is focused on improvement in two target areas for MLC-3: Community Health Improvement Plans Chronic Disease Prevention-Obesity/Physical

Activity (reduce preventable risk factors that predispose to chronic disease)

10

MLC-3 Collaborative Approach


All sites receive training in: Quality Improvement Methods & Tools Data Analysis Tools Rapid Cycle Improvement Method

Site-based teams develop implementation plan for improvement

Series of web-based phone sessions with coaching from consultant

11

Well Done Key Elements


Enrollment of Organizations and Teams LHD (used open solicitation with proposals) and

faculty recruitment (internal and external consultants in method/tools and in content areas)

Use of Improvement Model (RCI & PDSA) Emphasized when and how to use tools Immediate application and feedback on use

Action Periods (frequency/productivity of group calls & webinars, 1-1 consults)

12

Conclusions-Successes


Consistent success and we have learned a lot about “promoting the application of QI methods and tools” (MLC-3 goal #1)

Increased Use of QI Tools: (Muskie Interim Evaluation) Fishbone – 11 (36%) to 39 (75%) Root Cause Analysis – 12 (39%) to 30 (59%) PDSA cycle – 22 (65%) to 47 (84%)

IPHI - Additional tools learned: Force Field Analysis Meeting Effectiveness tool Partner Tool Community Balanced Scorecard (CBSC)

13

Mixed Success/Opportunities to Improve


Advance Planning including: Extent of evidence to support interventions Clarity of Expectations

States’ 1st Learning Session (extent of pre-work and “change packages”)

Measurement – tracking and reporting of measures for improvement (IHI requires run charts)

14

Complexity of MLC-3 Levels of Collaborative


National Level –Target Areas with multi-state TAG

Collaboratives

State Level

Individual TAG

Individual TAG

Individual TAG

State Level

Individual TAG

Individual TAG

Individual TAG

State Level

Individual TAG

Individual TAG

Individual TAG

State Level

Individual TAG

Individual TAG

Individual TAG

State Level

Individual TAG

Individual TAG

Individual TAG

State Level

Individual TAG

Individual TAG

Individual TAG

15

Take Time to Assess Status


Stop for a moment and evaluate how your collaborative is meeting Breakthrough Model’s Key Elements

Identify 1 or 2 specific improvements for next 12 months

Get help where needed

16

Harnessing the Power


Areas that have “Mixed Success” are where TAGs can help each other Developing “Improvement Packages” Measurement – review current measures and

revise, as needed; report progress Applying new tools or methods to Planning or

improvement work Sustainability – Actively engage senior leaders in

providing necessary resources, celebrating and communicating the success, plan for standardizing improved practice and for spreading improvements/success

17

Improvements to BTS by IHI


Enhance collaborative prework – participants do more before the 1st Learning Session

Prioritize the “Change Package” according to interventions that were most effective in producing results.

Senior leaders more engaged in removing barriers

Teach teams better communication skills, especially with senior leaders

18

Adopting Success in Other States


Formal academic knowledge is bolstered by the practical voices of peers who can say “I had the same problem; let me tell you how I solved it.”

IHI Breakthrough Series White Paper- 2003

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TAG Teams Identify Success


Discuss most successful collaborative method and/or tool and most successful intervention in each team represented at table, then

Report Out – how can we help each other

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QUALITY PLANNING AND IMPROVEMENT METHODS,

MEASUREMENT STRATEGIES, AND HOLDING THE GAINS


QP/QI and Holding the Gains

21

QP compared with QI


How does quality planning differ from project-by-project quality improvement? Juran uses example of an alligator infested

swamp and the difference between removing alligators individually (QI) or draining the swamp to remove all the alligators at once (QP).*

Another description is the difference between improving an existing work activity, action or intervention and the method used to design a new program or activity.

*Joseph Juran, Juran on Planning For Quality

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QP Roadmap*


In broad terms, QP consists of developing services and processes required to meet stakeholders’ needs. Identify stakeholders and their needs Develop an activity or program to address the needs

(establish stakeholder related measures) Optimize the program or service activities to meet health

department needs Develop a work process to conduct the services and

interventions Optimize the work process, prove that it delivers the results

needed Implement the program or service in the health department

*Joseph Juran, Juran on Planning For Quality

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Application in PH


PH already has expertise in parts of the quality planning process MAPP, Sector Mapping, Partner Tool, Program Development,

many othersStrengthen QP step of optimizing program to meet HD

and stakeholder needs Force Field Analysis, Meeting Effectiveness, Interrelationship

Digraph, many othersStrengthen step of optimizing the work processes to

achieve desired results Common QI tools-work flows, fishbone diagrams, PDSA cycles

Implement only after program and work processes have been optimized to deliver results

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Holding the Gains


Logic Model can link inputs of resources, capacity and staff to process outputs and outcomes/indicators

Regular measurement established to monitor process outcomes and related health indicators

Regular reporting of outcome results (including program evaluation)

Agency infrastructure for taking action on monitoring results (e.g. QI program and QI teams)

Remeasurement and new improvement action

25

PH Program Logic Model


Inputs Outputs Short Term Outcomes

Intermediate Outcomes

Long Term Outcomes

Resources Activities

Staff

Money Improved knowledge, beliefs, attitudes

% of Spanish clients responding Yes to Usefulness of Brochure

Improved Behaviors

Program Development

Program Planning

Materials Development, Distribution

Informed, Targeted Program

Appropriate, Targeted Materials

# of materials in non-English

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Measurement Tips


Make measurement more effective:* Use SMART to develop measures; Specific,

Measurable, Attributable, Relevant and Time bound (Marni’s addition)

Plot data over time – “Tracking a few key measures over time is the single most powerful tool a team can use”*

Seek usefulness, not perfection – measurement is not the goal, improvement is the goal

Use sampling – a total of 30 is usually enough Integrate measurement into daily routine Use qualitative and quantitative data*IHI website: Improvement Methods/Measures

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Establishing Outcome Measures


Data Description and Collection Form

1st remeasurement dates:

Baseline measurement dates:

How often will the data be analyzed and reported?

What tool will be used to collect these data?

Who will collect this information:

Target or Goal:

Source of data:

Denominator:

Numerator:

Outcome Measure #1:

1st remeasurement dates:

Baseline measurement dates:

How often will the data be analyzed and reported?

What tool will be used to collect these data?

Who will collect this information:

Target or Goal:

Source of data:

Denominator:

Numerator:

Outcome Measure #1:

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Measurement Strategy


Establish quantifiable measures that address: Outcome (how is the system performing and what

is the result) Process (Are the parts/steps in the system

performing as planned) Balancing (changes designed in one part causing

problems in another part of the system)Establish measurement strategy, such as

trending data, using control charts, regular reporting, making conclusions and taking action on results

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Example of Run Chart (trend line)


Clinic 1

Clinic 2 Clinic 3 Clinic 40%

10%20%30%40%50%60%70%80%90%

100%

Series 3Series 2Series 1

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Key Follow-Up Strategy


The most important monitoring action you can take is the development of program-level reports that are made available to every staff person in the organization on a regular basis

Supervisor and program manager reports that work with the same data elements

These reports should be used on a regular basis to understand whether the program activities are performing as expected (cost, utilization, outcomes, etc.)

31

Follow-Up Monitoring


Every month key statistics should be kept to monitor how things are going, and to identify course corrections along the way

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Final Thoughts


“Two approaches to improvement to avoid: systems without passion and passion without systems.”

Tom Peters, Thriving on Chaos

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What questions do you have?


34

STAGES OF TEAM DEVELOPMENT, FACILITATION SKILLS, RADAR CHARTS AND AN EXAMPLE OF

APPLICATION FOR ACCREDITATION READINESS


More Planning and Improvement Tools

35

Why Use Teams for QI?


QI efforts need buy-in from all stakeholdersCreative ideas are neededDivision of labor is neededProcess often crosses functionsSolution generally affects many

36

Four Stages - Team Development


FormingStormingNormingPerforming

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Forming Stage of Development


StereotypesLeader dependentPoliteIndividuals not well

knownExpertise of

individuals not known

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Storming Stage of Development


Conflicts among group members

UncomfortableReliance on leaders

and facilitatorMembers learning

more about each other

39

Norming Stage of Development


Candid, open communication

Members interacting directly

Less reliance on leaders and facilitator

Feels comfortable

40

Performing Stage of Development


Accomplishing tasksWorking together

wellEveryone

participatingUse each other’s

expertiseCan be maintained

for 45 minutes only

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Use Teamwork


Teams should develop a clear charge and support resources

Teams should adopt working agreements (cell phone etiquette to decision procedures)

Teams should assign roles of facilitators and recorders

Team process has predictable stages that are useful to keep in mind: Forming, Storming, Norming, Performing

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Facilitator Role and Focus*


Is a neutral servant of the groupFocuses group on common problem and/or

processProtects group members and ensuring that

everyone participatesRemains neutral and builds trust– does not

contribute own ideas or evaluate others ideasEncourages participation by all members of

the groupDoyle and Straus, How to Make Meetings Work, Jove Books

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Facilitator Role and Focus*


Helps find win/win solutionsSuggests alternative methods or procedures

(process related)If you feel you must comment on the content

(not process) then be explicit: “I’m removing my facilitator hat to make this comment.”

Can and should make comments and decisions about the process

Coordinates pre-post meeting logisticsDoyle and Straus, How to Make Meetings Work, Jove Books

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Facilitator Tips


Always use an agenda with clearly stated agenda items and goals for each item (e.g. action, discussion, information only)

Always be respectful (remember- 94% of individual’s behavior is rational from their frame of reference)

If needing to achieve modified consensus, consider using “Fist of Five” with everyone at 3 or more as consensus Open hand – “I completely agree” Four fingers up – “I agree with some reservations” Three fingers up – “I don’t agree, but will support the decision” Two fingers up – “I need more discussion” Closed Fist – “I don’t agree and will fight the decision”

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Radar Chart – Visualize Performance Gaps


Why Use it? To visually show in one graphic the size of gaps among a number of areas or items

What Does it Do? Makes differences in strengths and weaknesses

visible Clearly displays the important categories of

performance Captures the different perceptions of all the team

members about performance

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Creating a Radar Chart


Assemble the right team/ratersSelect and define the rating categories, 5-10

categories is average, brainstorm or take from Affinity Diagram

Construct the chart, draw a large wheel on a flipchart with same number spokes as categories

Rate all performance categories, individual or team consensus

Connect ratings and interpret and use the results

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Radar Chart Example


1/5/2002

1/6/2002

1/7/20021/8/2002

1/9/2002

0

20

40

Series 1Series 2

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Creating Useful Storyboards

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Story Board Components


Plan: Description how you got started - How was the problem

identified? What is the context of the problem/why is this problem significant?

How did you assemble the team? Articulation of the aim statement - What is the intent of

the project? What is the intended end result? Examine the current approach Description of the proposed intervention or solution

to address the situation/problem. What actions or intervention should be tested to address the situation/problem?

What is the theory for improvement?

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Story Board Components


Do: Describe how you tested the intervention or action for

improvement

Study: Description of the analysis/evaluation of the

intervention/actions taken to address the situation / problem What are the results of the testing? What measurements were taken to identify if there has been an improvement?

Act: Description of the subsequent action that took place to

standardize the improvement What happened in response to the analysis of the intervention or solution that was tested? What will be done to sustain or standardize the solution? What are the next steps?

Overarching lessons learned What did you learn from the process? What worked? What did not work? What would you do differently next time?

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Sample Template


52

What is a Story Board?


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Tips for Developing QI Story Boards


Be as succinct as possible. Include only critical information.

Design for ease of comprehension and readability. Make the purpose of the project readily apparent. Avoid jargon when possible. Display the data used throughout the process. Outline conclusions based upon data. Make them visually appealing…tell a story! Present plans for sustaining the improvement or

further investigation.

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Change versus Improvement


W. Edwards Deming stated “Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.” We must become masters of improvement We must learn how to improve rapidly We must learn to discern the difference between

improvement and illusions of progress

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Building QI into Your Agency Culture

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Performance Management


Source: Turning Point Performance Management Collaborative, 2003.

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Performance Standards 1st Quadrant


Establish Performance Standards NACCHO – Operational Definition and Standards National Public Health Performance Standards

(CDC) Public Health Accreditation Board Standards

Local, State and Tribal Health Departments

Establish and Define Outcomes and Indicators Process and Intermediate Outcomes Health Status Indicators

58

Performance Measurement2nd Quadrant


Monitoring of Performance • Results of review of

performance (Accreditation/Self-Assessment) against local and state Standards

• Program evaluation results

Monitoring of Indicators and Outcomes• Process and intermediate

outcomes• Health status indicators

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Quality Improvement Process 3rd Quadrant


Use data to identify opportunities for improvement and to make decisions

Quality Improvement Methods: Improvement Collaboratives Adapting or Adopting Model Practices Establishing QI Councils, Plans, and Teams Logic Models, RCI, Business Process Analysis QI Tools; Data Analysis and Root Cause

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Application of P-D-S-A


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Adopt or Adapt Model Practices


Use data to identify need for improvementIdentify exemplary practices in:

Other local and state health departments, CDC and other national organizations,

www.naccho.org/topics/modelpractices Other industries

Describe your process (Logic Model or Flow Chart)

Study the exemplary practice processAdopt or adapt as appropriate

http://www.naccho.org/topics/modelpractices

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Reporting Progress4th Quadrant


Reporting of Performance (Local and State Standards and Program Evaluation)

Reporting of Indicators and Outcomes Health Indicators Program Evaluation Data

Requires regular tracking, analysis and review to tell you if you are achieving your agency goals

Provides the basis for deciding on QI efforts and the baseline information for measuring the impact of quality improvement activities

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Templates and Example of QI Infrastructure and agency QI

Initiative

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Demonstrate Leadership Commitment


Build a QI culture Connect the organization’s strategic plan to

performance improvementClearly stated and enacted constancy of purpose

—a deep understanding of the vision and mission

Know and use quality principlesEncourage all staff to use quality improvement

in daily workEnsure adequate QI infrastructure for quality

assessment and improvement activities

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Demonstrate Leadership Commitment


Regular review of key outcome and indicator data

Decisions made on data rather than hunches or opinions

Continued identification of improvement opportunities

Publicize successes Clear communication agency-wide regarding

the commitment to quality and the change processes necessary to implement improvement

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QI Infrastructure


Governance (formal/informal) Oversight and accountability

Program structure Who will do what when, with what processes

for recommending or decidingStaff

Support for ongoing monitoring and analysis, for training and facilitating improvement activities

Data system Collect data and report in a user friendly way

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QI Infrastructure – Tacoma Pierce County


Must have director and other senior management LEADING the initiative

Establish a steering committee or leadership group to direct and oversee agency efforts (e.g. QI Council)

Leadership and key staff on QI CouncilQI Plan and regular evaluation of QI effortsAssessment staff is an excellent resourceStart small; get people excited about a single

projectCelebration of successes is important

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QI Plan and Evaluation


Annual QI plan Lists major activities Includes calendar Identifies persons

responsible & time lines Annual evaluation of QI

plan Evaluates QI Council

meetings Analyzes performance

measure data Examines completion

rate of QI plan activities

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Quality Improvement Plan


Goals and objectivesMonitoring activities associated with

important aspects of programs/servicesPlanned QI efforts (in process, new) and

timelines Evaluation of current QI efforts Annual evaluation of QI work plan and

program description, with proposed revisions

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Quarterly Reporting Form


Plan Item Name/No.Indicator(s)Baseline Data (if applicable)Quarterly DataData SourceMethods NotesData Explanation/Other Comments

71MCPP Healthcare Consulting, Inc.

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QI Calendar (TPCHD example)


III. 2009 Quality Improvement Council Calendar

Staff Responsible Completion Date QI Council Review Date

Additional Review Dates

A. Rapid Cycle Improvement Projects

Purchasing Marcy Kulland Sep 21 Sep 22 (final report) TBD (BOH)

Solid waste code enforcement complaint resolution

John ShermanNov 23

Sep 22 (interim report)Nov 24 (final report)

TBD (BOH)

B. TPCHD Performance Measures

See Section II B Jul 31Oct 31

Jan 31, 2010

Aug 25Nov 24

Feb 23, 2010Mar 3, 2010 (BOH)

C. QI Projects at Request of Director

TBD TBD TBD TBD

D. Program Evaluation Reports

Menu labeling Rick Porso May 25 May 26

MCH home visiting David Vance Oct 26 Oct 27

E. Review of Health Indicators

Three priority indicators (Review of performance measures in Table 2)

Nigel Turner (Chlamydia)

David Vance (LBW)Rick Porso (Adult

Obesity)

Jul 31*Oct 31

Jan 31, 2010

Aug 25Nov 24

Feb 23, 2010Mar 3, 2010 (BOH)

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Performance Measures – TPCHD example


Twelve department-level measures Modeled after Healthy People 2010 Leading Health

Indicators . . . plus two more Approx. 10-20 performance measures per

business unit Percent of solid waste complaints responded to

within 20 days Reduce the rate of positivity at Infertility

Prevention Project (IPP) sites Percentage of Positive Steps clients who engage in

services for 30. days or more who have a 10% reduction on three youth violence risk factors

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TPCHD Performance Measures


Measure Indicator ResponsibilityImprove immunization rates

Increase the percentage of kindergarten enrollees that are up to date on their immunizations upon school entry from 86% to 92% by 2014.

Nigel Turner

Reduce tobacco use Decrease the percentage of adult smokers to 16% by 2014. Rick PorsoReduce overweight & obese populations

Reduce the rate of increase for adult obesity to 0% by 2014. Rick Porso

Increase healthy physical activity

Increase the percent of youth who are physically active for at least 60 minutes per day from 16.8% to 18.5% by 2014.

Rick Porso

Reduce substance abuse

Increase the number of adults receiving opiate treatment service by 23% by 2014, to 800 patients.

David Vance

Increase responsible sexual behavior

Increase the percentage of sexual partners treated for sexually transmitted diseases by 10% by 2014.

Nigel Turner

Increase access to care Increase the number of children enrolled annually in health insurance programs by 42% by 2014.

David Vance

Decrease injury and violence

Reduce youth violence risk factors among 75% of youth who participate in TPCHD youth violence prevention services for at least 30 days.

David Vance

Improve mental health Decrease adult mental health problems in 20% of families provided TPCHD evidenced-based program services by 2014.

David Vance

Improve environmental quality

Increase the percent of water systems that meet drinking water standards from 80% to 90% by 2014.

Steve Marek

Effectively respond to public health emergencies

Respond within one hour in 100% of situations where TPCHD receives a notice of need for public health response to an incident within Pierce County.

Joby Winans

Decrease rates of key communicable diseases

Increase the percent of ten key communicable diseases for which the trend in incidence rate is flat or decreasing from 38% to 50% by 2014.

Nigel Turner

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QI Activities - TPCHD


Critical to make data/reporting meaningful to staff.

Performance measures: More is not better Resource level declines after the first data

reporting period Staff need lots of practice/training to develop

good performance measures RCI/QI projects:

Quality planning is more appropriate than QI for some projects with long-term outcomes

76 MCPP Healthcare Consulting, Inc.

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TPCHD Results of QI Initiative


Most performance measures at department- and business unit-level achieved their stated target

Improvements sustained for RCI/QI projects

Health indicator projects met 100% of annual performance measures

Funding & staffing for QI has increased

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Linking QI to Accreditation

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Building QI into Standards & Measures


Domain 9: Evaluate and continuously improve processes,

programs, and interventions.Standard 9.1 B:

Evaluate and continuously improve processes, programs, and interventions provided by public health or other practitioners or agencies.

Standard 9.2 B: Implement QI of PH processes, programs and

interventions

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Plan-Do-Study-Act: PHAB Standard 9.1


Plan

Act

Do

Study

9.1.3 B: Establish goals, objectives and performance measures for processes, programs and interventions.

9.1.4 B & 9.1.5 B: Monitor performance measures and evaluate effectiveness

9.1.5 B: Identify needs for improvements are based on evaluation data and results

Specific program activities that contribute to achieving goals and performance measures.

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Agency QI Plan: PHAB Standard 9.2


Plan

Act

Do

Study

9.2.1 B Establish a quality improvement plan based on organizational policies and direction.

9.2.4 L/S Annual review of the quality plan includes: performance measures are tracked, reported and used to assess the impact of improvement actions and meaningful improvement is demonstrated in at least one objective….

9.2.4 L/S Revision of the plan with new objectives based upon the review.

9.2.2 B Implement QI efforts

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Some QI References - Handout


Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook, 2008, www.accreditation.localhealth.net

Public Health Memory Jogger, GOAL/QPC, 2007, www.goalqpc.com

Breakthrough Method and Rapid Cycle Improvement www.ihi.org

Bialek R, Duffy DL, Moran JW. The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ Quality Press; 2009

Guidebook for Performance Measurement, Turning Point Performance Management National Excellence Collaborative, 2004, http://www.phf.org/pmc_guidebook.pdf

Mason M, Schmidt R, Gizzi C, Ramsey S. Taking Improvement Action Based on Performance Results: Washington State’s Experience. Journal of Public Health Management and Practice. Jan/Feb 2010; 16(1): 24-31

http://www.accreditation.localhealth.net/

http://www.goalqpc.com/

http://www.ihi.org/

http://www.phf.org/pmc_guidebook.pdf

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THANK YOU!What questions do you have?

Contact Marni Mason at [email protected]

or 206-613-3339


mailto:[email protected]

Need TA? Have Questions? or Need to Submit Work Products?

• Laurie [email protected]

• Kathy [email protected]

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Quality Improvement (QI) Mini-Collaborative Learning Session II March 2, 2010 9:00 AM – 4:30 PM...

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