Diane Jacobsen MPH, CPHQ

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Using the Model for ImprovementAccelerati
ng and Spreading Improvement

• Diane Jacobsen MPH, CPHQ
• Maine Regional Diabetes Collaborative
• LS2 March 20-21, 2003

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System of Care for Chronic Illness
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
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Cycles for Testing

• Increase the belief that the change will result
  in improvement.
• Document how much improvement can be expected
  from the change.
• Learn how to adapt the change to conditions in
  the local environment.
• Evaluate costs and side-effects of the change.
• Minimize resistance upon implementation.

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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
A
P
S
D
Hunches Theories Ideas
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Cycles for Testing Changes

• Aim Increase Patient self-management
• Cycle 1 Educate staff and prepare information
• Cycle 2 Distribute information to patients
• Cycle 3 Obtain referrals to educators and
  classes
• Cycle 4 Clinical educator is affiliated with
  clinic staff
• Cycle 5 Educator in empowerment methods
• Cycle 6 Educator meets with all patients in
  registry once per year

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Aim Improve management of the population with
diabetes lipid levels
Lipid testing and control an integral part of
system
DATA
Cycle 5 Implement protocol with all staff
Cycle 4 Set target level for lipid levels
Cycle 3
Collaborative planning on control levels
Develop approaches to improve lipid levels
Establish protocol for routine lipid measurement
Cycle 2
Cycle 1 Develop a system to track lipid levels
for pts with diabetes
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Cycles for Implementation

• The change is permanent need to develop support
  processes to maintain change.
• High expectation to see improvement (no
  failures).
• Increased scope will lead to increased
  resistance.
• Generally takes more time than tests.

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The PDSA Cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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Do Study

• Reasons for failed tests
• 1. Change not executed well
• 2. Support processes inadequate
• 3. Hypothesis/hunch wrong
• Change executed but did not result in local
  improvement
• Local improvement did not impact diabetes care
• Collect data during the Do Phase of the Cycle to
  help differentiate these situations.

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Successful Cycles to Test Changes

• Plan multiple cycles for a test of change
• Think a couple of cycles ahead
• Scale down size of test ( patients, clinics)
• Test with volunteers
• Do not try to get buy-in, consensus, etc.
• Be innovative to make test feasible
• Collect useful data during each test
• Test over a wide range of conditions

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Overall Aim Improve Glycemic Control
Specific Test Cycles
Routine HbA1c testing protocol
Diabetes Registry
Visit planning prompt
Team approach to care
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Testing on a Small Scale

• Have others that have some knowledge about the
  change review and comment on its feasibility
• Test the change on the members of the team that
  helped develop it before introducing the change
  to others
• Incorporate redundancy in the test by making the
  change side-by-side with the existing system
• Conduct the test in one facility or office in the
  organization, or with one patient
• Conduct the test over a short time period
• Test the change on a small group of volunteers

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Implementing Change Sequentially

• The path of least resistance- best use of the
  people willing to change
• Impact- biggest improvements early in
  implementation
• Learning- the most learning as the change is
  implemented
• Resources- best scheduling and use of available
  resources
• Interdependence- will the change work without
  all its components?

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Holding the Gains

• Make reversal as difficult as possible
• Establish a standard practice
• Use measurement and audits
• Pay attention to maintenance processes,
  especially orientation and training

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Ease of Back-Sliding

• Old system New System
• How much effort?
• Operations
• How much effort?
• Team

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Attributes of the Change(determine the ease of
spread)

• Relative advantage(evidence from testing)
• Compatibility with current values
• Simplicity of the change and transition
• Testability of the change
• Ability to observe the change and its impact

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A System for Spread

• Roles and responsibilities
• Target population
• Promotion and communication
• Schedule for spread
• Team approach for re-invention
• Review and guidance
• Investment in support services

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Roles and Responsibilities

• Choose a senior leader who is responsible for
  managing the spread
• Enlist some partners executives, managers,
  committees, practices, professions
• Set up a team for each area of spread
• Use the original team as technical advisors

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Target for Implementation and Spread
PILOT SITE System of Focus for the Collaborative
(defined
by Aim)
Small-scale tests of change
The Total Health Care System (spread sites)
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Promotion and Communication

• Brief the Board and executive committees
• Target other influential people
• Explain why the change is needed
• Let people know who is on the team
• Assume the role of ambassador for change
• Use the attributes of a successful change as an
  outline for your communication
• Continue the communication as changes are
  developed and tested
• Publicize the results of the tests
• Use various communication vehicles

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Team Approach/Review and Guidance

• Provide specifics on measurement
• Insist on the one-page reports each month
• Do a brief check-in weekly
• Do a one hour review with each team monthly
• Ask the organizational leader for specific items
  or help that the teams need
• Use the collaborative for help and advice