Improving Adolescent and Young
Adult Clinical Practice
The Quality Improvement Process
Rachel Wallace-Brodeur, MS, MEd
Project Director and QI Coach, National Improvement Partnership Network
May 10, 2017
Session Objectives
• Review fundamentals of quality
improvement (QI)
• How to use the Patient Satisfaction Survey
to improve quality of care
2
QI Principles
•
•
•
Incremental change
Data-driven
Environment for shared learning
•
Systems and Processes
•
Sustainability
• Team Work and Communication
• Individual and population health outcomes
Changing Systems
• Every system is perfectly designed to
achieve exactly the results it gets.
• If you want to improve, you must
change your system!
QI: The Model for Improvement
AIM
MEASUREMENT
CHANGE
From The Improvement Guide
Langley, Nolan, Nolan, Norman and Provost
QI Project Steps
•
•
•
•
•
•
Assemble your Change Team
Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for
Improvement
Convening a Change Team
•
•
Cross-functional
•
An effective improvement team is
Team members have a stake in the
outcome
•
Flexible: willing to change and respond to
the ongoing/unexpected
•
Creative: solution-oriented
Aim Statements
• What do you want to ACCOMPLISH
• Picture the END RESULT
Aims Should be SMART
SMART Aim Statement
By December 2018 the percentage of
adolescents and young adults
receiving well visits in Minnesota
increases by 2%.
Key Driver Diagram
Structured logic charts with ≥ 3 levels:
• Project Aim: SMART
• Key drivers: (elements, factors,
influences) with direct contributions to
the aim
• Primary
• Secondary
• Strategies: HOW to address the drivers
to achieve the aim
QI Project Steps
•
•
•
•
•
•
Assemble your Change Team
Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for
Improvement
Why Measure?
•
How do we know which changes
resulted in improvement?
•
Which changes are most
important to achieve our desired
result?
•
How do we know when we
accomplish our aim?
•
You can’t improve what you don’t
measure.
Data for Improvement
Collected to:
• Observe process performance
• Obtain ideas
• Test changes
• Determine sustainability
Data is (typically) already available and
easy to obtain.
Measurement
Measuring for improvement
• Short cycles
• “Just enough” data
• Learning vs. Judgment/Accountability
• Failure is good!
• Quick turnaround
• Run charts – view data over time
AYA Health Measures
• H.E.D.I.S.
• CHIPRA Core Measure Set
• State- and Health System-Specific
•
measures (often adapted from above)
NIPN Adolescent and Young Adult Health
Measures (http://nipn.org/)
Two Levels of Measurement
Project Level
1-3 core measures Takes time to
develop data collection plan
PDSA Level
Discrete measures used to inform
individual PDSA cycles
Quick to collect and feedback
Often involve manual data collection
Adapted from Associates in Process Improvement
QI Project Steps
•
•
•
•
•
Assemble your Change Team
•
Implement strategies using Model for
Improvement
Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target
populations
Process Mapping
•
•
•
•
Part of the “PLAN” step in PDSA
Use to describe current process
Use to improve process
Design an entirely new process
Flowcharts- from simple
… to more complex
Mapping the Process
•
•
•
•
•
•
Define the process to be diagrammed
Decide upon the boundaries of your process:
•
•
Where/when does it start/end?
What level of detail to include in the diagram?
Get the right people there!
Brainstorm the identified activities:
•
•
Write each on a sticky note
Arrange activities in proper sequence
Draw arrows to show the flow of the process.
Review flowchart with all involved for accuracy
Root Cause Analysis: Why??
The 5 Whys
5 Whys
Why don’t adolescents and
young adults do well visits?
QI Project Steps
•
•
•
•
•
•
Assemble your Change Team
Develop aim statement
Develop road map to achieve outcomes
Determine measurement strategy
Identify strategies to test & target populations
Implement strategies using Model for
Improvement
27
The Model for Improvement
AIM (GOAL)
MEASUREMENT
CHANGE IDEAS
From The Improvement Guide
Langley, Nolan, Nolan, Norman and Provost
How Improvement Happens:
The PDSA Cycle
Supporting Practices
PDSA Log
Measurement
Use the PDSA Cycle for
•
•
•
Testing or adapting a change idea
Implementing a change
Spreading the changes to the rest
of your system
Piloting vs. Implementation
People
Support
Needed
Time
Tolerance for
Failure
Pilot Phase
Implementation Phase
Few
Many
Resistance low
Stronger resistance
Low
High
Changes not permanent
To make change part of routine
operations
Shorter
Longer
High
Learn from mistakes
Low
Need high degree of
confidence change will be an
improvement
Adapted from the Institute for Healthcare Improvement (IHI).
Repeated Use of the PDSA
Cycle
Changes That
Result in
Improvement
A P
S D
Hunches
Theories
Ideas
A P
S D
Session Objectives
• Review fundamentals of quality
improvement (QI)
• How to use the Patient Satisfaction
Survey to improve quality of care
33
Case Study: Let’s Take a Closer Look
IMPACT IN VERMONT
34
Project Impact: The Practices
Geographical Target:
•
•
Interested practice looking for help after a youth suicide
Targeted recruitment to other sites in same geographical region
Interventions:
•
•
•
Initial site visit by faculty
•
•
•
Small monetary stipend to make desired changes
•
Use AYA Satisfaction Survey to collect data!
Gap in Care reports (Medicaid and BCBS VT)
Environmental assessment by Youth Health Advisory Council
(YHAC) members
Coaching calls, technical assistance, webinars
Tools and resources through website
http://www.med.uvm.edu/vchip/yhii
Project Impact: Youth
Established a NEW Youth Health Advisory
Council
•
Used stakeholders and community partners to
recruit widely
•
Looked for AYA who were comfortable sharing
ideas, concerns, and their experiences
•
•
Struggled with communication, meeting times
Struggled with diversity (HS students, College
students, CYSHCN)
Environmental Assessment
Environmental
Assessment Tool
Adolescent and Youth
Friendly Resource Guide
AYA Satisfaction Survey:
PDSA Cycles
• Pediatric Practice “A”
• Cycle 1: Started with one provider; gave
•
tablet to all AYAs in age range for any visit –
GREAT SUCCESS
Cycle 2: Expanded to all providers
• Pediatric Practice “B”
• Cycle 1: Created flyer to passively promote
•
survey in waiting room – not many returned
Cycle 2: Continue doing the same
AYA Satisfaction Survey:
PDSA Cycles
•
Family Medicine Practice “C”
•
•
•
Cycle 1: Created paper versions of survey and
mailed to all AYAs in age range for Well Visit
with all providers – return rate=5/50
Cycle 2: Give paper version of survey to all
AYAs for Well Visit before leaving the office
Family Medicine Practice “D”
•
•
Cycle 1: Didn’t do anything (staff transitions)
Cycle 2: Re-engaged: Considering purchasing
tablets
Survey Return
Practice A
Survey
Method
Patient
Satisfaction
Survey’s
returned
Tablets
Provider
promoted
116
Practice B
Practice C
Flyer in
Paper
waiting area
version (first
to passively
mailed, then
promote
in office)
survey
1
53
(5 from
mailing)
Baseline & 1 Month: Practice A
Future PDSA Cycles
Improve Private Time with Provider
• Examine data more closely to define
problem:
• differences by age group or
• visit type?
• What do you want to change?
• Ensure private time for all AYAs >14
regardless of visit type
Baseline & 1 Month: Practice A
Future PDSA Cycles
• Know how to contact clinic/provider
• Give card with clinic info to all AYAs
• Waiting area is welcoming
• Use stipend to make some changes
• Know what services are confidential
• Info on practice website re: confidential
services
Lessons Learned
•
Offer supportive, flexible quality improvement
strategies that fit each individual clinic’s needs
•
Celebrate and share any and all successes with
all engaged clinics
•
Encourage data collection to quantify and track
progress
•
Discover and use creative ways to engage youth
Questions?