Spreading Quality in CDM

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Spreading Quality in CDM

• Mike Hindmarsh
• MacColl Institute
• Seattle, Washington
• USA

Adapted from Institute for Healthcare
Improvement and Associates for Process
Improvement
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A Recipe for Improving Outcomes
System change strategy

• Learning Model

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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Model for Improvement

• Three Questions
• 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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The PDSA Cycle for Learning and Improvement
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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Multiple PDSA Cycles
--Sequential building of knowledge --Include a
wide range of conditions in the sequence of tests
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Removing Razors First PDSA Miami Valley

• Objective  Replace the practice of pre-op
  shaving with the use of clippers
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• Questions Can we get cooperation from surgeon
  and O.R. staff?  Are there any barriers?  What
  are staff/physician perceptions about hair on
  incision site?
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• Predictions  There will be a learning curve. 
  There will be mixed acceptance and resistance.
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• PLAN  On October 27, 2003, one surgeon will be
  asked by a team member who is a clinical nurse
  manager in surgical service to use clippers on
  one surgery patient instead of having that
  patient shaved.  Collection of data will be via
  direct observation by that team member.

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Removing Razors First PDSA Miami Valley (Cont.)

• DO Dr. Moncrief was asked to use clippers on his
  patient instead of shaving by Linda Hawley.  At
  first he said no, but after being told that it
  was a Class 1A recommendation, he agreed to try
  it.  Not only did he comply, but he used clippers
  on two of his cases and instructed staff to never
  place another blade on his case cart.
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• STUDY There was full cooperation in this first
  test of change after some initial resistance. 
  One barrier noted for spreading change was a lack
  of supplies.  In this test, there were no
  negative perceptions related to using clippers
  noted.
• ACT Additional clippers are being ordered and
  are expected to arrive in about a week.  Six
  other clinical nurse managers were in serviced in
  anticipation of conducting another PDSA that
  includes six other surgeons after the clippers
  arrive.  A learning board is also being
  constructed.

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Multiple Cycles to Implement Each Component of
the ICIC Chronic Care Model
Component Decision Support
Use of Flow sheet V.4 by all physicians and
nurses
Chinatown, Asthma BTS, 2001
Learning
Cycle 5 Implement use of V.4, do peer review of
documentation and use
Cycle 4 Trial of V.4 by all providers
Cycle 3 Two week trial of V.3, review meetings
Cycle 2 Try V.2 by two providers for a few days
Will a flow sheet be useful for asthma patients?
Cycle 1 Gather sample flow sheets. Try V.1 with
two patients
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Decrease the Time Frame for a PDSA Test Cycle

• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes

Drop down next two levels to plan Test Cycle!
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Chronic Conditions Breakthrough Series
Participants Engage
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Collect Data Over Time When Conditions Are
Expected To Change
Baseline
Begin implementation on pilot unit
Testing
Successful Testing
Evidence of improvement during implementation
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Successes of Teams in Collaboratives The
Benefit of Organized Chronic Care

• 1.5 - 2 times as many patients with major
  depression will be recovered at six months
• Inner city kids with moderate to severe asthma
  have 13 fewer days per year with symptoms
• Readmission rates of patients hospitalized with
  CHF will be cut nearly in half
• Significant reductions in HbA1cs for patients
  with diabetes

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Adoption is a DOING thing!
COMMUNICATED
BETTER IDEAS
In a certain way
Happens over time
Thru a social system
(C) 2001, Sarah W. Fraser
Adapted from Rogers, 1995
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A Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives
aligned -Executive sponsor assigned -Day-to-day
managers identified
Social System -Key messengers -Communities
-Technical support -Transition issues
Set-up -Target population
-Adopter audiences -Successful sites
-Key partners -Initial spread
strategy
Better Ideas -Develop the case -Describe the
ideas

Communication Strategies (awareness technical)
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Closing the Gap!
Rate of Awareness
Rate of Adoption
1
2
3
early adopters
early-late majority
laggards
Adapted from Rogers, Van de Ven, Gladwell, Bass
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Getting Ready

• Topic is a key strategic initiative
• Leadership is on board and tasked with specific
  work
• Successful site(s) identified
• Describe the ideas
• Develop the case

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How Do We Spread? Whats Your Plan?

• Many possible ways
• Natural diffusion
• Chronic Care Collaboratives
• Extension agents
• Campaign model
• Hybrid models

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Things to Consider in Developing a Plan for
Spread

• Nature of the Intervention(s)
• Organizational Structure
• Social System
• Ability to reach target sites all at once
• Constraints

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Communication Plan

• Building Awareness
• Moving people from decision to action
• Supporting and mentoring early adopters

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The WAY in which we communicate is important
SHARE INFORMATION
SHAPE BEHAVIOUR
General Publications flyers newsletters videos art
icles posters
Personal Touch letters cards postcards
Face-to-face one-to-one mentoring seconding shadow
ing
Public Events Road shows Fairs Conferences Exhibit
ions Mass mtgs
Interactive Activities telephone email visits semi
nars learning sets modeling
Adapted from Ashkenas, 1995
(C) 2001, Sarah W. Fraser
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Overall Lessons

• Set the agenda (build will)
• Utilize or build an infrastructure to support
  spread
• Clearly define what is being spread
• Connect people to peers, experts and resources
• Set targets and timeframe and make progress
  visible

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The Social Network

• Identify thought leaders
• Understand cultural beliefs as facilitators or
  barriers
• Keep the message consistent with the real world
• Make the change as easy as possible
• Incent successful change
• Broadcast successes
• Acknowledge that this is hard work!!

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