III. (abcd) BTS Topic Selection

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Topic Selection: Objectives

By the end of this session you should be able to:List the reasons that topic selection is a critical factor in successDescribe the steps in BTS topic selectionCritically analyze whether or not a specific topic should be addressed in BTS-style CollaborativeIdentify other BTS College members working on topics like the one you have chosen

The IHI Breakthrough Series

An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim.

IHI Breakthrough Series(6 to 18 Months Time Frame)

Select Topic

(Develop Mission)

Planning Group

Develop Framework & Changes

Participants (10-100 Teams)

Prework

LS 1

P

S

A DP

S

A D

LS 3LS 2

SupportsEmail Phone Conferences

Extranet Visits Assessments

Sponsors Monthly Team Reports

DisseminationPublications,

Congress, etc.A DP

SExpert Meeting

AP1 AP2 AP3*

LS – Learning Session

AP – Action Period

*AP3 –continue reporting data as needed to document success

Holding the Gains

Fiascos from the Field!A. The topic no one cares about

─ Topic may/may not be strategically important to the organization

─ Organizations may even be told to send a team

B. The topic is of vital interest to organizations. Teams want to join your collaborative because of the important of the topic. However, no one in the past has been able to close the gap –to get good results. You don’t know how to do so either.

Discuss assigned scenario with your team. What impact could this situation have on your ability to run a successful Collaborative?

IHI Breakthrough Series(6 to 18 Months Time Frame)

Select Topic

(Develop Mission)

Planning Group

Develop Framework & Changes

Participants (10-100 Teams)

Prework

LS 1

P

S

A DP

S

A D

LS 3LS 2

SupportsEmail Phone Conferences

Extranet Visits Assessments

Sponsors Monthly Team Reports

DisseminationPublications,

Congress, etc.A DP

SExpert Meeting

AP1 AP2 AP3*

LS – Learning Session

AP – Action Period

*AP3 –continue reporting data as needed to document success

Holding the Gains

Collaborative Topic Could Be in Any of the “Three Categories of Improvement”*

I . Eliminating quality problems that arise because we fail to meet the

expectations of customers (Chapter 10, pp. 218-223)

II . Reducing costs significantly while maintaining or improving quality

(Chapter 10, pp. 224-230)

III . Expanding customer expectations by providing products and services

that customers perceive as unusually high in value

(Chapter 10, pp. 230-235)

*Source: Langley, G, Nolan, K., Nolan, T, Norman C, Provost, L The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass, 2009

ADEs, SSI, Periop Care, Chronic care, Improve child literacy

Cardiac surgery, supply chain, reducing c-sections

Advanced access,

Topic Selection for IHI BTS

What do we look for?1. Gap between science and practice

2. And…examples of better performance exist

3. And…a good “business case” exists for the topic

On Extranet: Berwick DM. Eleven worthy aims for clinical leadership of health system reform. JAMA 1994; 272: 797-802.

Identifying the Gap1. The gap between science and practice

Current practice deviates from best available scientific knowledgeEvidence describes the gap (ideally 3 - 4 articles)Methods to identify gaps between your organization and best practice– Environmental scan - literature– What is on the clinicians’ minds?– What is on Organization’s leaders minds?

– Strategic plans of health care systems– CMS scope of work– Regulator Goals

See: Examples of Gaps on extranet

Example of the Gap from Service Collaborative

Dimension Low Performing Hospitals

High Performing Hospitals

Respect 15% 4.5%Comfort 22% 13%

Emotional Support

21% 11%

Involving Family/ Friends

20% 9%

Picker Survey: Percent of Patients Reporting Problems (Lower is Better)

Source: Gerteis, Edgman-Levitan, Daley, Delbanco; Through the Patient’ s Eyes. San Francisco:Jossey-Bass 1993 pp 229-230

Example of Chronic Care Gap

Disease Parameter Typical Best

Diabetes HbA1c 30% < 8 70% < 8

Asthma Symptom free days

<50% >80%

CHF Hospital readmits

>10%/mo <3%/mo

Depression Follow-up <50% >80%

CVD LDL< 100mg/dl <50% >70%

Source ICIC

Example : Adult Cardiac Surgery Gap

Median Best

Post-op LOS 5-6 days 3 days

Interval from 3-4 days < one dayCath to CABG

Post-op vent time 12-18 hours < 4 hours

OR time / case for 4-5 hours 2.5-3 hours3-vessel CABG

Example of Access Gap

Patients wait more than three weeks for a routine appointment. Same day access is achievable in primary care; 5 days for specialty care Patients are consistently dissatisfied with waits in clinics and medical offices. Delighting patients with punctuality is achievable

Public HealthIssuing Food Service Permits 41 days………14 daysPercent Teens Smoking 17% … 5.77% (Utah)

6.63 (CA)6.88 (HI)6.92 (DC)

Well Child Visits by Age 26% ……….. > 72%Infant Mortality (US African 15.7%. ..7.7% (San American) Diego) Overall 4.5%

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2. And…there Is an Example of Best Performance

Someone is doing it somewhere– In health care (or your industry/profession) in similar

settings– In health (or your industry/profession) care in

different settings– Outside of health care (or your industry/profession)

We believe it can be done in other settings or situations

Degree of belief that the 

changes will result in 

improvement

High

Getting Ideas

Idealized Design or other methods

Testing:

Prototype (in simulated environment) or Pilot (in work setting) 

Spread 

Adapt to new locations or populations

Successful changes

Unsuccessful proposed changes

Low

Moder‐ate

When Are We Ready To Run a BTS Collaborative?

Start a Collaborative when degree of belief is moderate to high

Adapted from IG Pg 145

Implement:

Make thechange a permanent part of the system in location where testing 

Phase 0:Generate new ideas

Observation

Synthesis

Screen

Phase 1:Planning

Collaborative Teams

Phase 5: Adapt & spread

Phase 3:Prototype testing

Phase 4:Pilottesting

Phase 2: Concept design

Milestone 1 Milestone 2

Generate new ideas Test new ideas Spread new ideas

Idealized Design Process with Deliverables

Deep Dive Team Innovation Team

Deliverables:•Charter•Design Targets•Ideas/Concepts•Captured learning & Prediction

Deliverables:•Results of test•Change Package•Prediction•Captured learning & Prediction

Deliverables:•Results of implementation & spread •Captured learning & Prediction

3. And….a Good “Business Case” Exists for the Topic – Positive financial impact (lower costs, revenue growth,

etc) for participating organizations

AND– Improved outcomes

OR– Strong appeal to both clinicians or other subject matter

experts and administration

Is There a Business Case? (From Improving Chronic Illness Care – MacColl Institute)

Questions to Ask• Will the new intervention

work?

• What will it cost?

• Will it increase fee-for-service revenues?

• Will it reduce expenses (in my lifetime)?

• Will it increase clientele by attracting new patients or retaining old ones?

• Will it impact case-mix?

Answers for Chronic Illness ImprovementEffective interventions in most

common chronic illnesses

Usually $200-500/pt/yr

If it adds assessments or encounters not routine in usual care

Yes for CHF and diabetes, maybefor asthma and for frail elderly, close

for depression Patient satisfaction rises so

retention should improve, unclearimpacts on new enrollment

May increase severity

Business Case Example: “Good for Patients” Reduction in Risk Factors for People with Diabetes

UKPDS 10 Year Study of Chronic Disease Management Findings:

A 1.0% reduction in HbA1c results in:– 17% reduction in mortality– 18% reduction in MI– 15% reduction in stroke– 35% reduction in

cardiovascular endpoints– 18% reduction in cataract

extractionDescribe this business case----

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Average HbA1c (Southeast Cluster)

Reduction in HgbA1c in Bureau of Primary Healthcare Southeast Cluster – Diabetes I Collaborative

BMJ, 321, 405-412

Service Collaborative: Is Topic Ripe for Improvement?

There is a gap--some health care providers can show much improved service in specific areas

Best practice-- in hospitality and other industries far exceeds health care service. Almost any community has local experts

Business case--Improved service increases satisfaction, compliance, and increases market share

Example: Is Chronic Illness Ripe Topic for Improvement?

There is a gap--some health care providers can show much improved short term outcomes-blood sugar control, symptom free days, etc

Is there evidence of gap being closed--Best practice in multiple office practices across the country-community health centers, group practices most often. Most regions have local experts

Business Case?-- Improved chronic illness care improves patient outcomes, confidence and satisfaction; and reduces unnecessary acute care utilization. May increase volume and revenues through P4P and other contracts

Exercise: Is Your Topic Ripe for Improvement?

Using the topic you have chosen (on your storyboard) list specific ways in which the topic meets the selection criteria

o What is the gap?o Where are good examples of best practice?o What is the “business case” for this topic?

Complete the Assessment of Collaborative Topic Worksheet using the 1-5 Scale.Review your spread exerciseWe will report to the group in 10 minutes using your storyboards to share the results of this exercise and

your spread plans

HPg 3

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Assessment of Collaborative Topic: Is Topic Ripe for a BTS Style Collaborative? 

Topic:___________________________________ Reviewer’s Name: ________________________ Assessment Scale 1: Not at all 2: To a small extent 3: Somewhat 4: To a large extent 5: To a very great extent

Identifying the Gap 

Score  Element  Comments  Does current practice deviate from best available scientific 

knowledge?  

  Are they able to provide data to quantify the gap?

 

Does this Topic Matter to People? (Business Case) 

  Does this topic matter to patients/clients? Is there a strong emotional “pull” for teams to join the Collaborative?

 

  Does this topic matter to clinicians?    Does leadership care about this topic?

  Is this topic linked to the organization’s strategic plan?

  Is there a strong business case for this topic? (financial, clinical, or reputation based)

 

 

Is there Evidence that Gap can be Closed? 

  Have others closed the gap?

  Do we have a list of changes that we can use in our collaborative to get good results?

 

Comments:  

Exercise: Building A Long-Term Spread Strategy (from Prework)

Do you expect to spread the work of your Collaborative teams to the rest of your organization? What is the timetable for this?

What (or who) are the appropriate "units" for adopting changes from your change package? Who will make the decision to begin using the new ideas in their practice? Some examples of potential “units” include physicians, surgeons, emergency departments, hospitals, nursing units in a hospital, clinics, laboratories, or pharmacists.

How many total units do you intend to spread to? This could be all eligible units or some defined subset of them.

How many units will you select to attend your initial Collaborative? What percentage of the total units is this? How will you select these initial units?

You and Your Collaborative –in ___ minutes!Introduce yourself and your teamDescribe your collaborativeTopic, number of organizations, location

Report on your assessment of “how ripe” the topic is:─ The Gap─ Who/where is the best practice─ The business case for participants─ Insights from your Assessment Scoring Worksheet

Your plans for Spread

Listeners role: Ask questions, provide feedback, consult

Let’s Revisit OvretveitWhich challenges are you most concerned about?1. Choosing the right topic 2. Ensuring participants define their objectives and assess their capacity to

benefit from the collaborative3. Defining roles and making clear what is expected4. Ensuring team building and preparation by teams for the collaborative5. Enabling mutual learning rather than carrying out teaching6. Motivating and empowering teams7. Ensuring teams have measurable and achievable targets8. Equipping teams to deal with data and change challenges9. Learning and planning for sustaining improvements10. Planning and learning for spread

What is your plan for addressing them?

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To the Workbook…Please go to the Planning Guide section of the Workbook and complete the Worksheet for Topic Selection.

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