improving your primary care practice: part 2 sue butts-dion improvement advisor institute for...

Improving Your PrimaryCare Practice: Part 2

Sue Butts-DionImprovement Advisor

Institute for Healthcare Improvement

This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.

Learning Objectives

By the end of this module you will be able to: Describe several benefits of “testing small” Describe scaling up tests of change Identify 2 tools all improvers need in their

toolkits

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Model for Improvement (MFI)

Developed by: Associates in Process Improvement

Model for Improvement What are we… How will we… What changes can we…

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ActAdapt? Adopt?

Abandon? What’s the

next cycle?

PlanObjective Questions& predictions (why).Plan to carry out cycle(who/what/where/when). Next cycle?

Study Do Complete the

analysis of the data.Compare data to

Predictions.Summarize

what was learned.

Carry out the plan(on a small scale). Document problemsand unexpectedobservations.Begin analysis.

The PDSA Cycle

W.E. Deming referred to this as the Shewhart Cycle 4

Task (www.thefreedictionary.com)

task (tsk) n.

1. Piece of work assigned or done as

part of one's duties.

2. Difficult or tedious undertaking.

3. Function to be performed; an objective.

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Test (www.thefreedictionary.com)

test 1 (tst) n.1. Procedure for critical evaluation; means of determining

the presence, quality, or truth; a trial: test of one's eyesight; subjecting a hypothesis to a test; test of an athlete's endurance.

2. Series of questions, problems, or physical responses designed to determine knowledge, intelligence, or ability.

3. Basis for evaluation or judgment: "A test of democratic government is how Congress and the president work together." (Haynes Johnson)

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Learning Your Way to Big Results (“Scaling Up”)

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Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP ADA

T

A

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

Benefits of “Testing Small”

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Simple (easy to learn and adapt)

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Simple (easy to learn and adapt) Rapid (short timeframe—minimize

resistance)

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resistance) Doable (doesn’t impact daily work as much

as a large test or implementation does-make it part of the work)

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resistance) Doable (doesn’t impact daily work as much

as a large test or implementation does-make it part of the work)

Immediate (results available immediately)

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Change Idea 1

Change Idea 3

Change Idea 4

Change Idea 2

Change Idea 5

Testing Changes in Multiple Areas

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ATKINSON FAMILY PRACTICEA PROMISES PRACTICE:

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Atkinson Family Practice:4 Simultaneous Test Ideas

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Test Idea #1: Pharmacy will not re-contact for scriptswithin 24 hours of first request (unless it is urgent)


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Test Idea #1: Pharmacy will not re-contact for scriptswithin 24 hours of first request (unless it is urgent)Test Idea #2: Practice will write on maintenance scripts:“11 refills” (or 90 days if insurance mandates 90 days)


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Test Idea #1: Pharmacy will not re-contact for scriptswithin 24 hours of first request (unless it is urgent)Test Idea #2: Practice will write on maintenance scripts:“11 refills” (or 90 days if insurance mandates 90 days)Test Idea #3: Practice will educate patients that if theyare told the “script is not there” to ask the pharmacy clerkto check their “patient profile”.


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Test Idea #1: Pharmacy will not re-contact for scriptswithin 24 hours of first request (unless it is urgent)Test Idea #2: Practice will write on maintenance scripts:“11 refills” (or 90 days if insurance mandates 90 days)Test Idea #3: Practice will educate patients that if theyare told the “script is not there” to ask the pharmacy clerkto check their “patient profile”.Test Idea #4: Practice will educate patients that if theycall for auto refill and get an automated voice that says“not authorized” to hang up and call pharmacy back andtalk to a live person

Plan: Question, Prediction, Measure

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Test Idea #1: Pharmacy will not re-contact for scripts within 24 hours of first request (unless it is urgent)


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Prediction: This agreement would result in:


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• Reduced work for the pharmacy


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• Reduced duplicate refill requests at the practice


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• Reduced duplicate refill requests at the practice

Measure: Number of duplicate script requests

Plan: The 5 Ws

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Who – Pharmacy Manager, Michelle

What – Pharmacy changed script request protocol from 3 to 24 hrs

When – Monday through Wednesday

Where – In both call-protocol and fax-protocol

Why – Practice protocol filled non-urgent scripts within 24 hours; sending additional requests added unnecessary paperwork

Do: Everyone’s Tasks

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Karen, Michelle, Tom: Tried 4 test ideas for 3 days

Karen: Tracked duplicate script requests (those 3 days)

All: Agreed to regroup and share findings

(Maybe there were other ideas to test?)

Study: The Findings

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Study: The Findings

Calls from local pharmacy dropped by >50%

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Study: The Findings

Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50%

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Study: The Findings

Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% Patients were not upset by the new system

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Study: The Findings

Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% Patients were not upset by the new system Staff was not confused by the new system

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Study: The Findings

Calls from local pharmacy dropped by >50% eFaxes from pharmacy dropped by >50% Patients were not upset by the new system Staff was not confused by the new system Everyone had less work

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Act: Abandon, Adapt, Adopt?

Actions: Changed workflow with the pharmacy Removed duplicate pharmacy #s from EMR

Results: Duplicate script requests dropped ≥90%

ACTION?

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Act: Abandon, Adapt, Adopt?

Actions: Changed workflow with the pharmacy Removed duplicate pharmacy #s from EMR

Results: Duplicate script requests dropped ≥90%

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ADOPT!

Two PDSA Tips

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YearsQuartersMonthsWeeksDaysHoursMinutes

Hamilton Consulting, LLC & Performance Management Group

ONE-NESS

SCALE DOWN (by 2)

Scaling Up Tests

4. Implementationtesting

1. Early tests are simple and designed to learn then succeed

2. Then test over a variety of conditions to understand scalability and identify weaknesses

3. Later tests are designed to predict and prevent failures

A P

S D

APS

D

A P

S DD SP A

DATA

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Your Toolkit: Essential Tools

Flow Mapping: How things work nowBrainstorming: Improvement ideas

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Flow Mapping

“You can’t improve something

you can’t draw a picture of.” -- W. Edwards Deming

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Brainstorming

Group decision-making technique… Designed to generate many ideas… Through interaction among team members.

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Brainstorming: How to

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Brainstorming: How to1. Clarify the brainstorming objective

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2. Call out ideas in turn around the group

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3. Record each idea (flip chart, white board, stickies, etc.)

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4. Build on and expand the ideas of others

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5. Pass when an idea does not come quickly to mind

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6. Generate as long a list as possible

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7. Resist stopping when ideas slow

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7. Resist stopping when ideas slow

8. Clarify ideas; eliminate duplicates

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What Could You Do Today?

Try this change? TEST IT! Plan * Do * Study * Act Can test be done in 1 hour with 1 patient?

What is your current flow? MAP IT! Brainstorm list of changes. SELECT ONE!

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Thank You!

Thank you

for your time

and attention today

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Assessment Question 1:

Name the benefits of testing things on a small scale.a) Rapid

b) Simple

c) Immediate

d) All of the above

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What is the suggested chronological order of “scaling up your tests of change”?

w - Implementation, x - Wide scale test

y - Very small scale test, z - Follow up test

a) wxyz

b) xywz

c) yzxw

d) zyxw

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List the two tools all improvers need in their toolkit (according to this module).a) Mind mapping and Flow charting

b) Flow Mapping and Brainstorming

c) Brainstorming and Mind Mapping

d) Flow Charting and Brainstorming

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Want to learn more?

Be sure to refer to Part 1

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improving your primary care practice: part 2 sue butts-dion improvement advisor institute for...

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