This is Jeff Anderson, I'm a cardiologist at Cincinnati Children's Hospital and I'm also one of the co-leads of the quality work group for ACPC. And this presentation this morning is for the Quality Network and it's a basic presentation on quality improvement to hopefully help you take the projects that you're working on and affect some change at your institutions. The objectives for today will be to talk about the model for improvement and how that model can be used to focus your work. We're going to talk a little bit about what's called the profound theory of knowledge. We'll talk about development and purpose of a key driver diagram, the concept of the IHI breakthrough collaborative series, and then the importance of an improvement team in your work. I wanted to start with the model for improvement. There are several different theories and methods that can be used for carrying out quality improvement work. The model that we focus on in this collaborative and that has been used in multiple other collaboratives is called the model for improvement. The model for improvement is a framework for trying to keep focused on the work that you're doing and making sure that the work that you're doing is resulting in outcomes. I have included here a number of resources that you may be interested in using in your work and they go from simple to complex as you go from left to right. The improvement guide is where the model for improvement really arose. This is a book that isn't written specifically for healthcare but includes many of the principles of quality improvement under the model for improvement. In the middle is a book called the Healthcare Data Guide. This book really walks through how you can learn from data in healthcare to lead improvement projects. Then finally, for those of you interested in more advanced improvement theory and research methodology using planned experimentation, this book, Quality Improvement Through Planned Experimentation, is quite a good book. For those of you interested in creating or improving your quality improvement library, these are really great resources. The model for improvement really foundationally starts with these three questions. These are the questions that you should be asking as you begin an improvement project. Number one, what is it that you're trying to accomplish? What does great look like on the end of this project? Number two, how will we know that a change is an improvement? What measures do you need to be following so that you can know you've made an improvement? Then third, what change can you make that will result in improvement? This question will be asked over and over again because likely one change isn't going to be the only thing that needs to happen to make improvement in your system. The PDSA cycle is an integral part of the model for improvement as well. Many of you have heard or probably even used this methodology in your improvement projects. Once you've asked the question, what change can we make that will result in improvement, the PDSA cycle is the piece of the program that executes that change. You plan for implementing a change into the system. You implement it in the due part of the cycle. You study what happened with that change, and then you act. Acting can be either to repeat the cycle, can be to abandon that change because it didn't work or alter it in some way so that it can be tested again. One important thought when coming up with PDSA cycles is that this can be done and is meant to be done on a fairly small scale. It can be done in one clinic on one day. It can be done even with one patient at a time. The key is that you, in the process of implementing a change, that you also study and understand what that change did to the system and then decide what to do with that information. This is these two slides, the questions that we ask and then the execution through the PDSA cycles are what really the model for improvement is all about. Why do we use the model for improvement? This model is simple. It facilitates the work that we're doing. It provides a framework for the application of statistical tools and methods. It encourages us to plan based on a theory. It emphasizes, encourages the iterative learning process and it provides a way to empower people in the organization to take action. Rather than just going out and making changes, it really gives you a tool and a framework for implementing changes and then understanding what's happening with your system when you implement those changes. As the last slide noted, the model for improvement provides a way for us to learn in an iterative way. We often use cycles of PDSAs where we use multiple implementations of changes that will result in improvement. On the far left of this slide, our changes are often driven by hunches or theories. Ideally all of the things that we implement are driven by data, but in pediatric cardiology especially we are often using our best knowledge available and not perfect medical knowledge in the changes that we're making. If we're using hunches or theories or ideas or expert opinion, we often start with very small tests. This is where I was talking about implementing something in one clinic or in one patient even. If that is effective, that can be followed up by two clinics or several patients. As you do more and more testing, your degree of belief that your hunch or your theory or your change is related to your outcome becomes greater and then you can move to more wide scale tests in your whole outpatient clinic setting or in multiple clinics. Then once your degree of belief that your change is making a difference is very high, then you may spread this to the entire system and create a way to sustain your changes. This is, we talk about PDSA ramps or iterative PDSA cycles and this is what we're talking about when we use that language. Paired with the model for improvement as a framework for the work that you're doing, I thought it was also important to discuss just for a moment the concept of the profound theory of knowledge. One of the pioneers of quality improvement work that we reference is Deming who was in industry and manufacturing in the early 1900s. He really developed some of the theories that we use now for improvement in healthcare, although he wasn't in healthcare specifically. He talks about this concept of a profound theory of knowledge. This is, I think, important because as you go about making changes to your system, it's important to understand the system as a whole and how you can affect different areas of the system to make your change happen. Let me explain this figure here. This is supposed to be a magnifying glass that is looking at a system and the handle there is the values that are inherent to your system. Whatever your children's hospital values are or your heart division or institute's values are ultimately color how you look at the system that you're operating in. Then within the system, there are several important elements that will affect how easy it is to enact change or how your system operates in general. For one, if you start at the 9 o'clock position, you have to have a theory of the system that you're trying to affect. You have to have an understanding of the clinical knowledge of the patient population, for example. If you go to 12 o'clock, you have to have an appreciation of the system itself. This might be understanding how patients flow through the system or how patients come in or out of the system. How the system operates, does one provider follow a single patient through their lifetime? Do multiple providers see the patient over time? This is understanding not the clinical knowledge, but how your system works. At the bottom, understanding variation is key to making changes. This would be looking at individual providers and how they take care of patients in different ways. Then finally on the right, something that we often don't think about in making changes to a system, and that's the psychology of change. What are the psychologic undertones that are keeping people from or helping people decide to make changes that you might implement? This may be the political setup of the system, this may be people holding on to their longstanding beliefs, because I've always practiced this way, I'm not going to change, all elements of psychology that need to be considered when we're trying to make changes to a system. So I included this in the presentation because I think quality improvement work can be hard and frustrating at times, and it's important if things aren't working well to step back and ask yourself, do I understand all of these important pieces of the profound theory of knowledge? Another tool within the model for improvement that will be important for your work is the key driver diagram. And the purpose of the key driver diagram is to organize your theory of improvement for a project. It will help you focus the selection of changes to test by identifying the drivers that will ultimately result in improvement. It connects your aim or outcome of the project, these key drivers, and then the specific interventions to create a learning structure. And it's a one-page document that can be used to communicate the work that you're doing to other people. So that's the purpose of the key driver diagram. This comes from the Improvement Guide, and it's just another slide that really describes the key driver diagram purposes and the setup. So if you look at the figure on the right, it explicitly says what the outcomes are for this project, in this case, to improve access and reduce waiting times. What are the drivers? These are specific things that this project thinks will improve access and reduce waiting times. So matching supply to demand, redesigning the care processes. And then the change concepts or interventions are the specific things that you would implement that might ultimately affect the outcomes. So just to walk through the anatomy of the key driver diagram. So your SMART aim is included as a sort of centerpiece for the key driver diagram. And most of you have worked with SMART goals or SMART aims before. These should be specific, measurable, attainable, realistic, and time-bound. And below the SMART aim is really the global aim. So you may be increasing the number of patients referred to a neurodevelopmental clinic, and that's something you can measure. But the global aim would to be improve neurodevelopmental outcomes in our population. The drivers are things you believe ultimately will affect your outcome. And then the interventions are potential actions that you may want to test to achieve those key drivers. At one point, one of the outpatient measures or quality metrics is the improving influenza immunization rates at institutions. And so we created a key driver diagram to give an example of things that you would put into a key driver diagram. So in this case, the SMART aim is to increase the percentage of healthcare personnel caring for pediatric cardiology patients at Blank Institution who receive the annual influenza vaccine from whatever the baseline rate is to 90% by a certain date. So you can see some aspects of a SMART aim in this sentence. It's very specific about what is being planned. It is measurable because we can determine what the rates of immunization are. It's attainable, at least for most institutions. It's reasonable and rational. And then it's time-bound because you have a goal date. This SMART aim also has the population defined here, which I think is always nice. And then the global aim is to reduce risk of infection in patients with congenital heart disease. The drivers you'll notice aren't specific things that you would actually implement, but they are important broad areas that may affect the outcome. So documentation is important. Availability of the vaccine is important. Education about the importance of the vaccine. These are all things that we would hope would improve immunization rates. And then specific interventions, assigning an influenza champion, someone who's leading the project, ordering the influenza vaccine by a specific date. So these are specific things that you can intervene on that would then ultimately affect the outcome. So that's the anatomy and example of a key driver diagram. And you would want to create a key driver diagram for the project that you're working on. In the case of the quality network projects, there may be key driver diagrams like this one that are disseminated for specific projects, but you may even need to take that key driver diagram and alter it slightly, at least on the intervention side, to meet the needs of your specific institution. For the last couple of topics, I wanted to cover metric development. So this development of metrics was carried out by the quality work group teams to develop these outpatient metrics for quality networks, for the quality network. But if you're creating a metric for a project that you're doing at your institution, a separate quality improvement project, you'll want to make sure you specifically define the numerator and the denominator, and then the period of assessment of that metric. This goes back to the M part of the smart name, which is something that's measurable. And it's an important part of the communication of your project, because people will ask, well, how are we being measured on this? So developing your metrics with these things in mind are important. And finally, I just wanted to talk about this concept of the IHI Breakthrough Series. So the Institute of Healthcare Improvement developed this concept and published it a decade ago or so. And this is the method that we're using in the quality network to disseminate information, to work together in a collaborative fashion, and to ultimately make improvements, we hope. And this is a generic version of what this IHI Breakthrough Series looks like. And it can be altered slightly, depending on the work group. But on the left side, this is where topics are selected by a planning group or expert group of clinicians in our case. The knowledge is codified, and this is where metrics would be developed and interventions might be determined, key driver diagrams would be created. And then participants are recruited, work on collecting baseline data, and then come together for a learning session. So LS stands for learning session. And we held our first learning session this fall for the quality network. Going away from the first learning session, teams would go back and do PDSA cycles in between learning sessions. Support structures are set up where teams communicate by email or by webinars or phone calls until they come back again for the next learning session. Data is shared at those learning sessions. People can see where they are compared to their peers. And high performers may share what is working for them so that information can be taken back and help everyone improve. The IHI Breakthrough Series was meant to end after several learning sessions. A report created and published and a national congress held or disseminated the information in some manner. So this is how multiple learning networks have carried out their work and how we'll work through these projects in the quality network in this collaborative. And within both the model for improvement and the concept of the IHI Breakthrough Series, team building is emphasized significantly. So when you're developing your team to do quality improvement work, there are some important aspects of this. First, it is more helpful for teams to be multidisciplinary. Can imagine even in the projects that are within this quality network, which may seem simple, like making sure Tetralogy patients are tested for 22q11 or making sure counseling happens for patients with higher BMIs. Having not just physicians on your team, but nurses and scheduling staff and patients and parents can help you understand that theory of profound knowledge and what the system is and what the psychology of the system is. It's critical really to have frontline staff as part of that, whether that is nurses or medical assistants or others. The what of improvement team building is really holding regular meetings, consensus building on developing key driver diagrams, developing and executing PDSA cycles, and then having the opportunity to review, digest, and act on the data that comes out of the project. So that's all I have for a introductory session on quality improvement. If this was live, we would certainly have opportunities to ask questions or clarify some of the things that I've said. Because this is recorded, I wanted to make sure everyone had my contact information. I am always happy to answer questions about specific projects, either within or outside of the quality network. And so please don't hesitate contacting me if you have questions or I can be helpful in any way. Thank you very much.

quality improvement

model for improvement

PDSA cycles

healthcare projects

Institute for Healthcare Improvement

multidisciplinary teams