Practice Experience: Applying Process Improvement Models Choose a Quality Improvement Model from Chapter 5 in the Spath (2018) textbook and apply this model to your practice problem. practice proble

Practice Experience: Applying Process Improvement Models Choose a Quality Improvement Model from Chapter 5 in the Spath (2018) textbook and apply this model to your practice problem. practice proble
Rapid Cycle Quality Improvement (RCQI) A Resource Guide to Accelerate Improvement Efforts for Health Resources and Services Administration (HRSA) Grantees Health Workforce Technical Assistance Center School of Public Health University at Albany, State University of New York 1 Rapid Cycle Quality Improvement Resource Guide Updated: June 2016 School of Public Health, University at Albany State University of New York 1 University Place, Suite 220 Rensselaer, NY 12144-3445 Phone: (518) 402-0250 Web: www.chwsny.org Email: [email?rotected] 2 Table of Contents Quality Improvement Overview …………………………………………………………………………………………………………………. 3 Three Fundamental Questions ……………………………………………………………………………………………………… 3 RCQI vs Research ……………………………………………………………………………………………………………………………………………. . 4 RCQI and Grant Programs Administered by HRSA ?s Bureau of Health Workforce ……………………… 4 The Model for Improvement ………………………………………………………………………………………………………………………… 5 What Are W e Trying to Accomplish? ………………………………………………………………………………………………………… 5 Aim Statements as They Apply t o the FOA ………………………………………………………………………………………………. 6 Examples of Aim Statements …………………………………………………………………………………………………………. 6 1. Advanced Nursing Education ………………………………………………………………………………….. 6 2. Primary Care Training and Enhancement …………………………………………………………… 7 3. Predoctoral Training in General Pediatric and Public Health Dentistry ……. 7 How Will W e Know If a Change Is an Improvement? …………………………………………………………………………… 7 Various Levels of Measurement …………………………………………………………………………………………………… 8 Dynamic vs Static Data ……………………………………………………………………………………………………………………. 9 Applying Improvement Measurement to the FOA ………………………………………………………………….. 10 Examples of Measures ……………………………………………………………………………………………………………………………………. 10 Example 1: Advanced Nursing Education …………………………………………………………………………………. 10 Example 2: Primary Care Training and Enhancement ………………………………………………………….. 11 Example 3: Predoctoral Training in General Pediatric and Public Health Dentistry ……. 12 What Changes Can W e Make That Will Result in Improvement? ……………………………………………………… 12 Tests of Change: PDSA Cycles ……………………………………………………………………………………………………….. 13 Applying PDSA Cycles to the FOA ………………………………………………………………………………………………… 14 Examples of Changes ………………………………………………………………………………………………………………………………………. 14 Example 1: Advanced Nursing Education …………………………………………………………………………………. 14 Example 2: Primary Care Training and Enhancement ………………………………………………………….. 16 Example 3: Predoctoral Training in General Pediatric and Public Health Dentistry ……. 17 Conclusio ns ……………………………………………………………………………………………………………………………………………………….. 18 3 Q UALITY IMPROVEMENT OVERVIEW The Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services characterizes quality improvement (QI) as systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. 1 QI is a continuous process that employs rapid cycles of change over time . QI models create: 1. The structure , which represents the attributes of settings in which care is delivered 2. The process by which to determine whether good medical practices are followed 3. The outcome , or impact of care on health status Several models create a specific framework for how QI skills and techniques can be applied to improve care and outcomes. This document will focus on the use of rapid-cycle quality improvement (RCQI), defined as a ?quality improvement method that identifies, implements, and measures changes made to improve a process or a system. ? 2 RCQI is based on the Model for Improvement developed by Thomas Nolan, PhD, and colleagues at Associates in Process Improvement. The Model for Improvement is a simple but powerful tool proven to accelerate improvement efforts and has been used successfully by hundreds of health care organizations as well as by educators, by community-based organizations, and in many other organizational settings to improve various processes and outcomes. 3 The model consists of 2 parts: addressing 3 fundamental questions and engaging in tests of change. Three Fundamental Questions ? What are we trying to accomplish? Develop a specific, time-limited, and measurable aim statement. ? How will we know that a change is an improvement? Identify process and outcome measures to be collect ed over time in order to track improvement and progress toward the aim statement. ? What change can we make that will result in improvement? Formulate ideas for changes to help accomplish the aim. 1 Health Resources and Services Administration. http://www.hrsa.gov/quality/toolbox/methodology/ qualityimprovement . Accessed June 9, 2016. 2 Robert Wood Johnson Foundation. http://www.rwjf.org/en/library/research/2013/04/quality-equality-glossary.html . Accessed June 9, 2016. 3 See the Institute for Healthcare Improvement website ( http://w ww.ihi.org ) for stories on improved outcomes using the Model for Improvement. 4 The Model for Improvement uses a structured process whereby organizations focus on specific elements of care in need of improvement and conduct small tests of change while measuring the impact of those changes on key process and outcome measures. RCQI VS RESEARCH Research is defined in 45 CFR 46.102(d) and 45 CFR 164.501 as a ?systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge .? 4 In contrast to research, RCQI has 2 potential focuses: (1) translating existing knowledge into clinical practice to improve health care quality and (2) discovering new innovations to improve health care quality that have not yet been researched. RCQI takes a systems approach to support organizations and uses the theory of prediction to test ideas and identify those that lead to the greatest improvements within these systems. This philosophy centers on the process of discovery through experience, allowing organizations to alter or ?tweak? their hypothes es and then test again. RCQI encourages the application of several tests over time to identify the most successful ideas ?those that have the greatest impact on overall program outcomes. RCQI AND G RANT PROGRAMS ADMINISTERED BY HRSA?S BUREAU OF HEALTH W ORKFORCE HRSA continues to encourage grantees to utilize RCQI principles and tools to accomplish the overarching goals associated with specific funding opportunities. Awardees are expected to incorporate RCQI into their work plan and evaluation efforts so that improved outcomes for patients, providers, and communities can be realized. This resource guide has been developed to support organizations that have received HRSA funding for programs such as: ? Advanced Nursing Education Program (funding opportunity number HRSA- 15-046) ? Predoctoral Training in General, Pediatric, and Public Health Dentistry and Dental Hygiene (HRSA- 15-050) ? P ostdoctoral Training in General, Pediatric, and Public Health Dentistry (HRSA- 15-051) ? G eriatrics Workforce Enhancement Program (HRSA- 15-057) ? P rimary Care Training and Enhancement Awards (HRSA- 15-054) 4 Department of Health and Human Services. Code of Federal Regulations, 45 CFR 46. http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html . Accessed June 9, 2016. 5 T HE MODEL F OR IMPROVEMENT As noted above and as illustrated by the figure on page 3, the Model for Improvement comprises a set of 3 fundamental questions that drive all improvement efforts in addition to the Plan-Do-Study- Act (PDSA) cycle, also known as the Deming or Shewhart cycle. 5 While the ter m ?PDSA cycle ? may be familiar to many, it is often misunderstood and misused. Although the 3 questions in the Model for Improvement may be answered in any order, all 3 must be addressed when embarking on improvement activities. Each of the 3 questions specified by the Model for Improvement will be reviewed in more detail below. ? View an informational video on the Model for Improvement from the Institute for Healthcare Improvement (IHI) W HAT A RE WE T RYING TO ACCOMPLISH ? RCQI is a robust methodology that ensures organizations can accomplish measurable and meaningful results in a timely fashion . However, before an organization can achieve improvement, it must create a measurable description of its organization?s desired improvement. Doing so requires a critical ev aluation of current systems and processes to identify where the greatest opportunity for improvement exists. Organizations also must make many decisions around what can feasibly be accomplished within a specific time frame. The first question in the Model for Improvement asks What are we trying to accomplish? Th e answer to this question is often referred to as an aim statement. The purpose of an aim statement is to provide QI teams with clear, well-defined goals. It provides a sense of direction and allows your QI team to identify the steps that should be taken to meet the end goal. Organizations are more likely to successfully improve quality when they establish effective aim statements. 6 A strong aim statement should include answers to the following questions: 1. What do you hope to accomplish with this improvement project? 2. Who is the target population for this improvement project? 3. When is the deadline for completing this improvement project? 5 Langley GJ et al . The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009. 6 Health Resources and Services Administration. http://www.hrsa.gov/quality/toolbox/methodology/ readinessassessment/part5.html . Accessed June 9, 2016. Aim Statement A concise written statement that describes what a team expects to accomplish with an improvement effort. A good aim statement is: ? Unambiguous ? Time specific ? Population specific ? Measurable Setting numerical goals clarifies the aim, helps create tension for change, directs measure – ment activities, identifies resources that will be needed, and focuses initial changes . 6 4. How much improvement do you plan to accomplish by your deadline, in specific and measurable terms? An aim statement could be viewed as the ? destination? for your improvement work. You may take several different paths to this destination, but the aim statement will keep the improvement team focused on what, specifically, it wishes to accomplish. An aim statement can be applied to anything one wishes to improve. More information on developing project aim statements can be found on the HRSA website . A IM STATEMENTS AS T HEY APPLY TO THE FOA Many of HRSA?s Funding Opportunity Announcements ( FOAs) ask applicants to create a logic model ?that is , a 1-page diagram that represents the conceptual framework of the proposed work. A logic model has several components, but an aim statement will address the goals and outcomes described in the model. As goals are often written as general statements of improvement, the use of aim statement methodology to clarify these goals will allow you to clearly articulate what you seek to accomplish by the end of the FOA. Similarly, the work plan needed for the ?Response to Program Purpose? section of an FOA asks for ? objectives and sub-objectives [for the project goals] that are specific, measurable, achievable, realistic, and time-framed. ? These are the essential elements of an aim statement. Examples of Aim Statements 1. Advanced Nursing Education In response to the FOA on advanced nursing education, you would likely create several objectives and sub-objectives for your work plan . While your work within this FOA would include many different elements, one objective in your work plan might focus specifically on ensuring that all preceptors meet certain competency requirements . For this objective, you might craft an aim statement similar to the following: By June 2017, XYZ University will ensure that 100% of clinical preceptors are prepared to facilitate a positive clinical experience for students . All preceptors will undergo an annual clinical competency evaluation and will score at least 90% competency in 4 domains: 1. Student evaluation 2. Goal setting 3. Teaching strategies 4. Demonstration of organized knowledge By establishing this aim, you are stating specifically what it is that you hope to accomplish for this objective. Although you are not setting forth exactly how you are to accomplish this, you are giving yourself a measurable end. 7 2. Primary Care Training and Enhancement In response to an FOA on primary care training and enhancement, you would likely create several objectives and sub-objectives for your work plan. While your work within this FOA would include many different elements, one objective in your work plan might focus specifically on improving provider effectiveness in working with disadvantaged patients. For this objective, you might craft an aim statement similar to the following: By June 2020, XYZ University plans to partner with local federally qualified health center s (FQHCs) to develop a Family Medicine Residency Program that increases the number of primary care physicians committed to serving low-income populations in underserved communities such that: 1. Residents complete at least 128 hours of clinical time at the FQHC caring for disadvantaged populations 2. At least 10 residents complete their residency training by 2020 3. At least 50% of residents who complete training continue to work with disadvantaged populations upon entering practice By establishing this aim, you are stating specifically what it is that you hope to accomplish for this objective. Although you are not setting forth exactly how you are to accomplish this, you are giving yourself a measurable end. 3. Predoctoral Training in General Pediatric and Public Health Dentistry In response to an FOA on predoctoral training in pediatric and public health dentistry, you would likely create several objectives and sub-objectives for your work plan. While your work within this FOA would include many different elements, one objective in your work plan might focus specifically on improving dental/medical integration within local service delivery systems. For this objective, you might craft an aim statement similar to the following: By June 2018, XYZ University will partner with at least 3 local FQHCs to improve the integration of oral health and primary care services such that: 1. All medical and dental staff receive specialized training to enhance competenci es across disciplines and improve the co- management of patients? medical and oral health needs 2. At least 50% of patients with high-risk dental needs receive care coordination support to address both their dental and medical needs By establishing this aim, you are stating specifically what it is that you hope to accomplish for this objective. Although you are not setting forth exactly how you are to accomplish this, you are giving yourself a measurable end. H OW WILL WE K NOW T HAT A CHANGE IS AN IMPROVEMENT ? All QI endeavors begin with the identification of a need and the acknowledgment of a gap between the current performance of a system and the performance you strive to achieve. While QI is not all 8 about data collection and assessment, without those procedures, we are unable to determine whether we have accomplished the change we seek. In RC QI work, measurement allows an organization to determine if a change or a new project is actually leading to improvement . This is based on the realization that not all ch ange leads to improvement of a system. As discussed previously, the first step to beginning an RCQI project is to propose a specific and measurable aim. This identifies where an organization hopes their work will take them . To assess whether you are accomplishing your aim, you should establish a small set of measures to track over time. These are often referred to collectively as a ?family of measures.? These measures fall into 2 main categories: process measures and outcome measures . IHI has created a video that describ es these types of measures. While determining what process and outcome measures you may wish to track, a few points should be borne in mind: 1. The measures you select should help you to measure progress towards your aim. 2. The measures should be closely related to the system you are working to improve such that they are sensitive enough to indicate change to the system. 3. Avoid tracking too many process measures and losing sight of your outcome. 4. Identify measures that can be collected more frequently than quarterly or annually. 5. Ensure that the collection of these data is feasible and practical. Various Levels of Measurement Organizations are accustom ed to collecting and reporting data. These data may be used internally to make program decisions, reported to governing and accrediting bodies or to current or future funders, or used in a rigorous evaluation. It is important to understand that the types of data collected and reported for each of these purposes are vastly different. According to Solberg and colleagues, 7 3 major categories of measurement exist: 1. Measurement for research. The primary focus is seeking out new knowledge. These studies are often of long duration, expensive, and elaborate. 2. Measurement for accountability. The measures used for accountability often matter to external parties and focus on specific outcomes or results. While these data assess outcomes, they typically aggregate an outcome across a population and provide little insight into how process might be changed in order to improve the outcome. 3. Measurement of improvement. Measurement of improvement is exactly that ?measures that help us determine whether improvements can be realized in care and outcomes for 7 Solberg LI et al. Jt Comm J Qual Improv. 1997;23(3):135-147. Family of Measures Process m easures: Measures that drive the outcome and help a team to assess if parts/steps within a system are performing as expected Outcome m easures: Used to assess t he intended impact on and/or improvement o f the population of interest 9 patients . Improvement measurement is useful to (a) identify where a system might need focused improvement efforts, (b ) collect measurement data over time to determine when improvement has been accomplished, and (c ) assess the system?s ability to sustain improved outcomes. The following information from Solberg et al describes some of the specific differences between measurement for improvement, accountability, and research. Aspect Improvement Accountability Research Aim Improvement of care (efficiency and effectiveness) Comparison, choice, reassurance, motivation for change New knowledge (efficacy) Test observability Test observable No test ; evaluate current performance Test blinded or controlled Bias Accept consistent bias Measure and adjust to reduce bias Design to eliminate bias Data ?Just enough? data, small sequential samples Obtain 100% of available, relevant data ?Just in case? data Testing s trategy Sequential tests No tests One large test Determining if a c hange is an i mprovement Run charts or Shewhart control charts (statistical process control) No – change focus ( eg, comput ation of percent change or rank order of results) Hypothesis, statistical tests ( t test, F test, chi – square test ), P values Confidentiality of the d ata Data used only by those involved with improvement Data available for public consumption and review Research subjects ? identities protected Dynamic vs Static Data RCQI focus es on the use of dynamic data, which are time-series data assessed over a period of time . This type of data is preferred over static data, which are data aggregated to represent less frequent time intervals (see graphs below) . For this reason, data collection should be done in real time to track the impact of ideas over time . Run charts ?graphs of data over time ?are one of the most important tools in QI. For more information on run charts, please refer to the on-demand IHI course en titled Using Run and Control Charts to Understand Variation . 10 RC Q I data are always for learning, not judgment. The end goal is to improve outcomes for patients and/or health care providers. While the data collected through PDSA methods and other RC QI efforts indicate whether changes are being realized, they should not be used to judge or analyze an organization. Rather, organizations should use these data to make informed decisions about whether their changes are leading to improvement. Applying Improvement Measurement to the FOA As we have discussed, HRSA FOAs ask applicants to submit a work plan that includes objectives and sub-objectives with specific and measurable goals. To do this, applicants should identify core outcome measures by crafting aim statements for these objectives and sub-objectives. Applicants also are asked to identify core activities associated with each of these objectives and sub-objectives. In the process, applicants have the opportunity to identify a core set of process measures that could be used to track progress in meeting the outcomes of each objective. As also noted earlier, HRSA FOAs often ask applicants to construct a logic model, or a pictorial representation of the proposed activities, and explain how these activities will drive the intended outcomes. The ?outputs? section of th e logic model serves as another location in which to identify process measures. Similarly, the ?outcomes? section is an ideal place to identify some core outcome measures for an objective. E XAMPLES OF MEASURES Example 1: Advanced Nursing Education In the example aim statement described earlier, we established an aim focused on assessing the clinical competency of all preceptors so that students have a positive clinical experience . This is the long-term goal, established with specific and measurable criteria. As an applicant working to accomplish this aim, it will be critical to set up a few relevant measures to be track ed over time in order to assess whether progress is being made . In establishing these measures, you will need to consider both process and outcome measures . The process measures help to ensure that you are making the changes needed to meet the objective, while the outcome measures will verify whether improvement has been realized in the population . For this example, there are 2 populations for whom you are working to improve outcomes: clinical preceptors and students . Below is a list of measures that you might track while working on this objective within your work plan. Dynamic Data Static Data Measure Time or Sequence Measure Median Time 1 Time 2 Measure 11 Potential Process Measures Potential Outcome Measures Total number of p receptors Total number of preceptors scoring at least 90% competency in each domain Total number of preceptors completing annual competency evaluation Total number of preceptors scoring at least 90% competency in all 4 domains Total number of preceptors receiving education to improve clinical competency Percentage of preceptors reporting that they feel prepared to supervise clinical students Percentage of students meeting clinical objectives It should be remember ed that the measures required for RCQI are different from those required for other types of projects, such as clinical research or program evaluation. RCQI measures should be specific for and sensitive to the system you are working to improve. The measures might incorporate validated tools, but this is not a requirement. What is more important when collecting data for RCQI is that the measures do 2 things: (1) inform your decisions regarding whether the proposed change is an improvement and (2) evaluate the system supporting the change to ensure that the necessary processes exist to sustain the work. Identifying sustainable improvement can be done by tracking data over a period of several months to verify that improved outcomes are not only accomplished but maintained. Example 2: Primary Care Training and Enhancement In the example aim statement described earlier, we established an aim focused on increasing the number of primary care providers committed to serving low-income populations in underserved communities. This is the long-term goal, established with specific and measurable criteria. As an applicant working to accomplish this aim, it will be critical to set up a few relevant measures to be track ed over time in order to assess whether progress is being made. In establishing these measures, you will need to consid er both process and outcome measures. The process measures help to ensure that you are making the changes needed to meet the objective, while the outcome measures will verify whether improvement has been realized in the population. For this example, the work is focused primarily on improving process and outcomes for residents. Below is a list of measures that you might track while working on this objective within your work plan. Potential Process Measures Potential Outcome Measures Total number o f resident s working with disadvantaged populations Percentage of residents completing at least 128 hours of clinical time working with disadvantaged populations Total number of hours worked with disadvantaged populations per resident Percentage of r esidents indicat ing that they intend to continue to work with disadvantaged populations upon completing training Number of m atriculated students per year Percentage of r esidents scoring at least 80% on a specific tool that measures comfort working with disadvantaged populations 12 It should be remembered that the measures required for RCQI are different from those required for other types of projects, such as clinical research or program evaluation. RCQI measures should be specific for and sensitive to the system you are working to improve. The measures might incorporate validated tools, but this is not a requirement. What is more important when collecting data for RCQI is that the measures do 2 things: (1) inform your decisions regarding whether the proposed change is an improvement and (2) evaluate the system supporting the change to ensure that the necessary processes exist to sustain the work . Example 3: Predoctoral Training in General Pediatric and Public Health Dentistry In the example aim statement described earlier, we established an aim focused on improving dental/medical integration within the local service delivery system. This is the long-term goal, established with specific and measurable criteria. As an applicant working to accomplish this aim, it will be critical to set up a few relevant measures to be track ed over time in order to assess whether progress is being made. In establishing these measures, you will need to consider both process and outcome measures. The process measures help to ensure that you are making the changes needed to meet the objective, while the outcome measures will verify whether improvement has been realized in the population. For this example, there are 2 populations for whom you are working to improve the outcome: (1) medical and dental staff and (2) patients. Below is a list of measures that you might track while working on this objective within your work plan. Potential Process Measures Potential Outcome Measures Number of s taff trained Percentage of staff scor ing at least 80% in cross – competency assessment Number of interdisciplinary team meetings held for co – management Percentage of patients with a dental/medical co – management care coordinator Number of p atients with a care coordinator Percentage of patients receiving routine preventive oral health services It should be remembered that the measures required for RCQI are different from those required for other types of projects, such as clinical research or program evaluation. RCQI measures should be specific for and sensitive to the system you are working to improve. The measures might incorporate validated tools, but this is not a requirement. What is more important when collecting data for RCQI is that the measures do 2 things: (1) inform your decisions regarding whether the proposed change is an improvement and (2) evaluate the system supporting the change to ensure that the necessary processes exist to sustain the work. W HAT CHANGES CAN WE MAKE THAT W ILL RESULT I N IMPROVEMENT ? Once your organization has established a specific aim statement and a family of measures to be track ed while you work to accomplish your aim, it is time to identify ideas through which your organization may accomplish this aim ?often the easiest part of any improvement project. Such ideas are referred to as change ideas. A change idea is any idea you might try out to change or improve a specific system. Change ideas may be simple or complex and can be derived from a 13 n umber of sources, including the professional literature, professional associations, conferences, and colleague experiences. Change ideas are the heart of all improvement work. Organizations interested in doing RCQI must identify a series of ideas to try while working to accomplish the overall aim. The beauty of RCQI is that it involves a process of prediction-based testing to allow organizations to gain confidence that an idea is leading to improvement. Thus, organizations have the ability to try several ideas and see which works best. This level of adaptability and agility mak es RCQI unique. RCQI always begins with a change idea, but the manner in which that change idea is introduced to the system is what makes this model different from many others. RCQI encourages organizations to in itially try an idea on a very small scale for the purpose of testing it out in the current system. By starting very small, organizations are

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