Session # F1 Practical PDSAs1. Introductions 2. Brief background – quality framework 3. Identify a...
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Practical PDSAs How to use a quality framework to improve your integrated care initiative Nadiya Sunderji, MD MPH FRCPC Priya Vasa, MD MSc CCFP Ann Stewart MD CCFP St. Michael’s Hospital and University of Toronto, Canada Session # F1 CFHA 20 th Annual Conference October 18-20, 2018 • Rochester, New York
Transcript of Session # F1 Practical PDSAs1. Introductions 2. Brief background – quality framework 3. Identify a...
Practical PDSAsHow to use a quality framework to improve your integrated care initiative
Nadiya Sunderji, MD MPH FRCPCPriya Vasa, MD MSc CCFPAnn Stewart MD CCFP
St. Michael’s Hospital and University of Toronto, Canada
Session # F1
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
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Practical PDSAs: How to use a quality framework to improve your integrated care initiative Integrated mental health care models have demonstrated effectiveness but are variably implemented in primary care settings, leading to a "quality chasm" between the research evidence and real-world performance. We developed a quality framework to evaluate and drive improvements in integrated care. We’re now implementing quality measures and improvement projects based upon the framework in several primary care settings. In this workshop, we will guide workshop participants in applying the quality framework to their own clinical settings by: identifying priorities areas for improvement; developing plans for measurement and evaluation, and; creating a template for one Plan-Do-Study-Act (PDSA) cycle. We will orient participants to the IHI Model for Improvement. We will provide illustrative examples of different types of PDSA cycles for learning about the ‘problem’, developing a change idea, or implementing/testing a change idea. We share our practical experiences and lessons learned. Objectives Discuss the role for quality measurement and quality improvement in integrated care, and identify relevant domains and dimensions of quality Apply a quality framework for integrated care to select a specific dimension of quality as a target for improvement in their own setting Develop a potential PDSA cycle to begin the process of integrated care measurement and improvement in their own setting Outline (60 minutes) Building upon a highly successful workshop at last year’s conference, this session will introduce or re-introduce participants to a quality framework that they can use to drive improvements in their integrated care program. Through hands-on exercises and brief didactic presentations, we will further equip participants with knowledge and skills to begin a quality improvement (QI) project. - Introductions and audience input regarding level of experience, challenges encountered, and their personal learning objectives for participating in this session (10 mins) - Mini-didactic about our quality framework (7 mins) - Self-reflection exercise to identify a ‘problem’/improvement opportunity that the participant wants to target during this workshop (5 mins to reflect) HANDOUT - Mini-didactic the IHI Model for Improvement and to share case examples of PDSA cycles used to: a) learn about a ‘problem’; b) develop a change idea; c) implement/test a change idea (example from project to improve care for people experiencing co-morbid diabetes and depression) (12-13 mins) - Small group work and coaching for participants to develop one potential PDSA cycle for their target ‘problem’/opportunity (15 mins) HANDOUT - Large group reflections, Question and Answer period (10 mins) Resources provided: - Handout to guide self-reflection on the integrated care quality ‘problem’ / opportunity in their setting - Exercise sheets for small groups e.g. template for creating your PDSA cycle - Selected references on QI
Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.
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Learning ObjectivesAt the conclusion of this session, the participant will be able to:
1. Discuss the role for quality improvement in integrated care, and identify relevant domains and dimensions of quality
2. Apply a quality framework for integrated care to select a specific dimension of quality as a target for improvement in their own setting
3. Develop a potential PDSA cycle to begin the process of integrated care measurement and improvement in their own setting
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Include the behavioral learning objectives you identified for this session
Outline1. Introductions
2. Brief background – quality framework
3. Identify a target for improvement in your setting*
4. Introduction to the IHI Model for Improvement
5. Example PDSA cycles
6. Develop a potential PDSA cycle for your improvement idea*
7. Take up, Q&A
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Introductions and audience input regarding level of experience, challenges encountered, and their personal learning objectives for participating in this session
Background•A "quality chasm" between the research evidence for integrated care and real-world implementation & outcomes.
•We developed a quality framework to evaluate and drive improvements in integrated care.
•QI approaches enable iterative tests of change to improve care delivery in a context-appropriate and sustainable way
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Integrated mental health care models have demonstrated effectiveness but are variably implemented in primary care settings, leading to The framework synthesizes empirical research and pragmatic experience to define goals for integrated care programs and the structures and processes that need to be in place for successful implementation.
What are we trying to achieve?CLIENT CARE OUTCOMESCare achieves good results for clients.
POPULATION-BASED CAREAppropriate care is delivered to the whole population of clients who are, or who should be, served by the primary care team (i.e. services are equitable).
ACCESS AND TIMELINESS OF CAREClients can easily receive care within a reasonable timeframe considering their illness severity, level of risk, and level of function.
CLIENT INCLUSION AND PARTICIPATIONCare is geared toward providing the best possible experience for clients, and achieving outcomes that are important to clients.
VALUE AND EFFICIENCYFrom a system perspective, care delivers good value considering the costs.
What conditions and activities are helping or hindering us?INFRASTRUCTURE, LEADERSHIP AND MANAGEMENTCare is provided under appropriate conditions (e.g. appropriate physical space, having skilled health care providers from different disciplines).
LEVEL OF INTEGRATION BETWEEN MENTAL HEALTH AND PRIMARY CARE SERVICES Services are well coordinated within the collaborative mental health program in primary care, and also between the primary care team and outside mental health specialists.
EVIDENCE-BASED PRACTICESPrograms and treatments are designed and implemented with consideration of the best available research and the local context.
TEAM FUNCTIONINGThe clinical team of primary care and mental health providers work well together.
QUALITY IMPROVEMENTCollaborative Care team and program are continuously working to improve quality.
COLLABORATION FOR PATIENT SAFETYCollaborative Care program is organized to provide the safest possible care.
Your turn*
Thinking about who your program serves, what it’s trying to achieve, and with what resources…
What are the strengths and most important improvement opportunities to your program?
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How might you measure the improvement goal?
Model for improvement
Institute for Healthcare Improvement (IHI)
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Case for quality improvement You can’t improve what you can't measure... etc
Three types of PDSAs• Understand the problem• Develop the intervention• Make a change
PDSA ramp
‘Real life’ PDSA ramp
Ogrinc & Shojania, BMJQS 2018
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As Tomolo et al4 have described, this type of work involves frequent ‘false starts, miss firings, plateaus, regroupings, backsliding, feedback, and overlapping scenarios within the process.’ Far from the commonly shown schematic of perfect circles rolling up the hill of change, they depict a complex tangle of a network in which the changes inexorably move to better performance
Example: Implementing measurement-based care for depression in primary care
Specific Aim: By September 2018, 80% of patients with diabetes and known depression (according to their healthcare provider or chart) at the St. Jamestown site of the SMAFHT will have at least one PHQ-9 scale done within the last 12 months.
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Use this also to illustrate SMART aim: Specific, Measurable, Timely; Achievable, Relevant SMART aims are: Specific – what will you do? who will do it? Measurable – how much change will occur and in what direction? what data will be used? Timely – when will it be achieved? Achievable – consider timeframe, environment, resources, constraints Relevant – to the organization & key stakeholders Why use SMART objectives? To provide a structured approach to developing and designing a work plan. To set the stage for measuring performance and identifying opportunities for improvement To systematically monitor progress towards a target To succinctly communicate intended impact and current progress to stakeholders To concretely describes how goals will be met How to Write SMART Objectives In order to understand how the parts of SMART objectives flow together, the order of the SMART components listed below will go out of order—SMTRA. This is because the Specific, Measurable and Time-Bound parts are clearly visible in the standard written format for objectives. The Achievable and Relevant pieces are more abstract and require reflection.
ExampleOutcome measure:% of St Jamestown patients with diabetes and known depression who have completed PHQ-9 within the past year (EHR search)
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How will we know if a change is an improvement? Family of measures: Process measures: what activities will change? how can their completion (or lack thereof) be tracked? Outcome measures: what will the desired result be? Balance measures: foreseeable unintended consequences for patients for those who have to change Generally they get more sophisticated over time e.g. if introducing a new form: is there a form in the chart is it correctly completed?
ExampleProcess measures
% of St Jamestown patients with diabetes who have a visit with any FHT healthcare provider within the past year (EHR search)
Balance measures:
Staff perceived workload (Qualitative: did the clinic run late more so than it did previously? Did the RN do fewer other activities since adding this process? Quantitative: how many patients seen each day?)
Acceptability of process to patients (qualitative focus group; quantitative survey)
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(since PHQ scale completion will likely be visit-triggered)
PDSA cycles
Second test of change
First test of change
Process mapFP, RN, clerical
Fishbone12
Interviews w team
Chart audit
EHR search
Understanding the ‘problem’ in its contextDeveloping intervention Testing intervention
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EHR search - # of patients with both conditions, and baseline measures - % who had PROM in past year, % who had visit in past year Chart audit – deeper dive on 10 randomly selected patients – evidence-based treatments offered? accepted/received? team-based? Interviews Perceived challenges in care of patients with diabetes and mental illness? More specifically, depression? Knowledge and opinions of measurement-based care? Current processes, roles, resources? Ideas and support for change? Summarized in fishbone Interviews – processes used by PCPs who already successfully use measurement-based care Focus group – develop process (first test of change) Observation – steps involved in the proposed new process (first test of change), materials needed Interviews - Perceived feasibility, acceptability and impacts (+ or -) of the change
PDSA
Cycle Prediction Do Study Act1 Depression is common among
patients with diabetes. It’s also associated with worse diabetes care processes and outcomes.
Electronic health record search of SMAFHT patients x 1 year. Descriptive statistics of depression prevalence. Histograms to compare diabetes care and outcomes for patients with versus without “known depression”.
“Prevalence” of depression 17.9% among patients with diabetes. Mean A1c and BP comparable for patients with diabetes with vs. without depression. Not more likely to be overdue for these measures. More appointments (including with DEP team) but also more no-shows.
Depression is common in diabetes; although there is no difference in diabetes processes and outcomes, there may be room to improve depression management.
2 Depression care in this population does not conform to evidence-based practices and quality standards.
EHR search plus detailed chart audit of subset of patients: a) measurement-based care (e.g. PHQ-9), b) receiving 1+ evidence-based Rx or psychotherapy, c) offered at least one such treatment, d) retention in treatment, and e) time interval to treatment adjustment.
Although 97% of patients saw a FHT clinician in the past year, only 3% had a PHQ-9 done in the past year; only 25% ever had one done.
PHQ-9 rarely used, which is inconsistent with best practice. Qualitatively explore provider perspectives on challenges in care of these patients, and specifically in use of rating scales.
3 Clinicians perceive challenges and improvement opportunities in care of these patients and in use of scales.
Interviewed 12 healthcare providers.
Barriers to using PHQ-9: time, remembering, patient acceptability, language & literacy, concern of what will do if patient is symptomatic. Ideas for using PHQ-9: wait room (paper or tablet), email, embed in standard diabetes form and have RN do at pre-visit, pharmacist via phone during med rec.
Fishbone diagram. Process map. Small tests of change. Collect informal feedback from patients to refine intervention as we begin to use rating scales.
Small data
Your turn again*•What is one next step to explore the ‘problem’ / opportunity?
•Plan & predict•Do (understand problem develop intervention test a change)
•Study (measure)•Act (interpret & plan next steps)
Reflections? Questions?
Thank you!Nadiya Sunderji ([email protected]) Priya Vasa ([email protected]) and Ann Stewart ([email protected])
Co-authors: Abbas Ghavam-Rassoul, MD MHSc CCFP FCFP, Allyson Ion, PhD(c), Gwen Jansz, MD PhD CCFP
St. Michael’s Hospital & University of Toronto
Funding: Ontario Ministry of Health and Long Term Care AFP Innovations Fund; CIHR Strategy for Patient Oriented Research; Health Canada and Mental Health Commission of Canada
Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
1. Sunderji N, Ghavam-Rassoul A, Ion A, et al. Driving improvements in the implementation of collaborative mental health care: A quality framework to guide measurement, improvement and research. Toronto, Canada: 2016. Available at https://www.researchgate.net/publication/312539646_Driving_Improvements_in_the_Implementation_of_Collaborative_Mental_Health_Care_A_Quality_Framework_to_Guide_Measurement_Improvement_and_Research
2. Sunderji N, Ion A, Ghavam-Rassoul A, Abate A. Evaluating the Implementation of Integrated Mental Health Care: A Systematic Review to Guide the Development of Quality Measures. Psychiatric Services68(9): 891-898
3. NHS Institute for Innovation and Improvement. The Good Indicators Guide: Understanding How to Use and Choose Indicators. Available at: http://www.apho.org.uk/resource/item.aspx?RID=44584(2008)
4. Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017 Jul;26(7):572-577. doi: 10.1136/bmjqs-2016-006245
5. Etchells E, Ho M, Shojania KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Saf. 2016 Mar;25(3):202-6. doi: 10.1136/bmjqs-2015-005094
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