Applying Process Improvement Methods to Speech and ......Why Test? •Increase your belief that the change will result in improvement •Opportunity for learning from “failures”

Applying Process Improvement Methods to Speech and Language Waiting Lists Associate Professor Sharon Goldfeld CCCH/MCRI

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Variation in Daily Parent-Child Reading, By State

What Processes Could We Improve?

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• Better identification of children prior to referral

• Accurate triage of children to community health/ECIS/private services

• Children moved to assessment or intervention quickly from the waitlist through alternate management strategies eg group intervention/assessment

• Better utilisation of staffing and resources

SERVICE

ACTIVITIES

Regular

feedback and

reflection

Engage parents as observers of their child

Prioritize family needs to guide response

Know community resources and referral

requirements

Establish relationships with key services eg

MCH, ECIS, Medicare local

STRATEGIES FOR CONTINUOUS

IMPROVEMENT

IMPACT

►Late talking children are in playgroup

►Children with speech difficulties are

treated

►Children with language problems are

treated

OUTCOMES

► Lower rates of speech and language

problems by school

Create group /playgroup sessions for young

children

Prioritise vulnerable children

Prioritise 3-4 year old children

GOALS

(MEASURES)

Family centred

care

PROCESSES

►Parents report care is family centred

►Parent concerns are addressed

►Priority ages seen, assessed and

managed

► Key processes in place so no children

on a waitlist

Collect feedback from parents

Compare results with others

Exchange learning regarding effective

practices

Connections to

community

health and

education

services for

better triage

Focusing on Key Areas of Practice

Establish

alternate

strategies for

care

What are we trying to accomplish? By when?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

Source: The Improvement Guide, Langley et al. 2009, p 10


Aim

Measures

Changes



Using the Model for Improvement

Set SMART aims for the improvement:

Specific Measurable Action oriented Realistic Timely

Plan-Do-Study-Act cycles to learn what works, without disrupting the system or requiring consensus to get started

Prototypes, which are early samples or models built to test a concept or process, for possible replication at scale

Use testing as the engine for change:

A c t P l a n

S t u d y D o

W h a t a r e w e t r y i n g t o a c c o m p l i s h ? B y w h e n ?

H o w w i l l w e k n o w t h a t a c h a n g e i s a n i m p r o v e m e n t ?

W h a t c h a n g e c a n w e m a k e t h a t w i l l r e s u l t i n i m p r o v e m e n t ?

Why Test?

• Increase your belief that the change will result in improvement

• Opportunity for learning from “failures” without impacting performance

• 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

Source: The Improvement Guide, Langley et al. 2009

Using Small Scale Tests: The Power of “One”

Conduct the initial test with…

one facility

one office

one group

one participant

Source: The Improvement Guide, Langley et al. 2009

Repeated Use of the PDSA Cycle for Sequential Building of Knowledge

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

A P

S D

Small scale testing

Follow-up tests

Test under new conditions

Full implementation


Change Concepts, Theories, Ideas

Concept B

Concept C

Concept A

Concept D

Organized Testing in a Complex System

Children enter school with sufficient

language/communication


Every System Is Perfectly Designed to Produce Exactly the Results It Gets.

• Systems produce better results when there are clear goals, regular feedback on results, and aligned and mutually-reinforcing efforts.

• Simply adding new programs and activities:

• can create even more complexity

• may not reach all who need them

• often neglects family and community ecology

How Can Initiatives Seeking Systems Change Get Stuck?

• Working on too many complex problems and ideas at once

• Pursuing many small projects that have little collective impact

• Focusing all resources on a single outcome

• Neglecting the human and technical aspects of effective change

A Recipe for Improvement

System Change Concepts

Evidence-Based Programs and Content


Network for Continual Learning

Select

Topic

Expert

Group

Change

Concepts

Participants

LS 1 LS 2 LS 3

P

S

A D

P

S

A D

Prework

GLOBAL CQN AIM

We will build a sustainable quality

improvement infrastructure within our practice

to achieve measurable improvements in

asthma outcomes

Specific Aim

From fall 2009 to fall 2010, we will achieve

measurable improvements in asthma

outcomes by implementing the NHLBI

guidelines and making CQN’s key practice

changes

Measures/Goals

Outcome Measures:

>90% of patients well controlled

Process Measures

>90% of patients have “optimal” asthma care (all

of the following)

assessment of asthma control using a

validated instrument

stepwise approach to identify treatment

options and adjust therapy

written asthma action plan

patients >6 mos. Of age with flu shot

(or flu shot recommendation)

>90% of practice’s asthma patients have at least

an annual assessment using a structured encounter

form

Engaging Your QI Team and

Your Practice*The QI team and practice is active and

engaged in improving practice processes

and patient outcomes

Using a Registry to Manage

Your Asthma Population *Identify each asthma patient at every visit

*Identify needed services for each patient

*Recall patients for follow-up

Using a Planned Care

Approach to Ensure Reliable

Asthma Care in the Office * CQN Encounter Form

* Care team is aware of patient needs and

work together to ensure all needed

services are completed

Developing an Approach to

Employing Protocols * Standardize Care Processes

* Practice wide asthma guidelines

implemented

Providing Self management

Support * Realized patient and care team

relationship

Key Drivers

Interventions

Form a 3-5 person interdisciplinary QI Team

Formally communicate to entire practice the importance and goal of this

project

Meet regularly to work on improvement

All physicians and team members complete QI Basics on EQIPP

Collect and enter baseline data

Generate performance data monthly

Communicate with the state chapter and leaders within the organization

Turn in all necessary data and forms

Attend all necessary meetings and phone conferences

Select and install a registry tool

Determine staff workflow to support registry use

Populate registry with patient data

Routinely maintain registry data

Use registry to manage patient care & support population management

Select template tool from registry or create a flow sheet

Determine workflow to support use of encounter form at time of visit

Use encounter form with all asthma patients

Ensure registry updated each time encounter form used

Monitor use of encounter form

Select & customize evidence-based protocols for your office

Determine staff workflow to support protocol, including standing orders

Use protocols with all patients

Monitor use of protocols

Obtain patient education materials

Determine staff workflow to support SMS

Provide training to staff in SMS

Assess and set patient goals and degree of control collaboratively

Document & Monitor patient progress toward goals

Link with community resources

CQN Asthma Project Practice Key Driver Diagram Version 2.0

Peter Margolis, CCHMC; Ed Wagner, MD, MPH: MacColl Institute; Associates in Process Improvement; Institute for Healthcare Improvement

Whatarewetryingtoaccomplish?

Howwillweknowthatachangeisanimprovement?

Whatchangecanwemakethatwillresultinimprovement?

Act Plan

Study Do

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<10%ofyoungchildrenaredevelopmentallyvulnerableatschoolentry

10%annualincreasein%ofparentssharingbooksdaily

90%ofmothersreportaposi verela onshipwiththeirchild

90%ofparentshave estoneighbors

90%ofparentsreceiveempathiccare

90%ofparentsaskediftheyhavechilddevelopmentconcerns

90%ofparentsreporthavingdiscussedresourcesforfamiliesintheircommunity

90%ofparentsreporthavingdiscussedresourcesforsocialsupport

90%ofparentsaskedaboutdepression

90%ofparentsaskedaboutfamilystressors

90%ofparentshaveabankaccount

Improveflowtosupportsandservices

Supportparentstomanagetheirchild’sneeds&promote

development

Ac velymanagethecareofapopula onofchildren

Cul vateaccountableleadershipfocusedonpopula onoutcomes

Increaseaccessto&effec venessofservices&supports

Measure&sharedataonhowthesystemisworking

Ac vepar cipa oninanorganizedprocessimprovementeffor t

Buildnetworkstoinnovate,sustain,scale

andspread

GoalTargetsLeadershipandImprovementDrivers

CultureandPrac ceDrivers

Developcross-sectorcarepathways

Increaseeffec venessthroughgreaterempathyincare

Increaserela onshipsamongandbetweenresidents,community

groupsandorganiza ons

Supportthehumanelementofchange

Achieving Enduring Improvement:

Working as a System

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I’m sure glad the hole is not in our

end!

Documents

Applying Process Improvement Methods to Speech and ......Why Test? •Increase your belief that the change will result in improvement •Opportunity for learning from “failures”