UPDATES ON THE NHPCC

QUALITY IMPROVEMENT

COLLABORATIVE (QIC)

Karen Droze, MS

Regional Coordinator

Southeast Region Hemophilia Network

Hemophilia State Comprehensive Care Meeting

March 4, 2016

Objectives for Today

1. Understand the concept of Quality Improvement

2. Distinguish between QA, Research and QI

3. Describe the current models of QI

4. Define Clinical Microsystems

5. Provide overview of the NHPCC QI Collaborative

6. Review Coaching Model

7. Recap sites and coaches selected

8. Understand your role

9. Learn about future directions

Quality Improvement Defined

• What is QI?

Quality Improvement is a formal approach to the analysis

of performance and systematic efforts to improve it. There

are numerous models used.

Some common models:

• FADE

• PDSA

• Six Sigma (DMAIC)

• Microsystems

• Others

QA versus QI

• Quality Assurance – reactive, retrospective, policing,

and in many ways punitive. Assigns fault or blame. Older

term.

• Quality Improvement – both prospective and

retrospective reviews. It is aimed at improvement.

Attempts to avoid attributing blame, and to create systems

to prevent errors from happening.

QI versus Research

• QI:

• Intent is to improve current practice. For internal use only.

• By definition, the data is confidential.

• Action is within existing standards of care.

• Institutional Review Board (IRB) approval is not necessary.

• Research:

• Intended to create generalized knowledge.

• Desire to publish or present.

• Testing new methods.

• Needs IRB approval!

Benefits of Quality Improvement

• QI activities can be very helpful in improving how things

work. Trying to find where the “defect” in the system is,

and figuring out new ways to do things can be challenging

and fun. It’s a great opportunity to “think outside the box.”

• An effective QI program can really help make your life

better and Improve Care!

Measurement: Process and Outcome

Indicators

• Three types of measures used in quality work:

• Structure: Physical equipment and facilities

• Process: How the system works

• Outcome: The final products, results

A Healthcare Example

• GOAL: Reduce infant mortality

• Structure: Availability of physicians and/or midwives

providing obstetrical care

• Process: 1) Percent of mothers receiving prenatal care

prior to 12 weeks gestation 2) Percent of mothers taking

prenatal vitamins and 3) Percent of smoking mothers

counseled to quit

• Outcome: 1) Neonatal mortality rate and 2) Pre-maturity

rate

FADE Model FOCUS: Define and verify

the process to be improved

ANALYZE: Collect and analyze

data to establish baselines,

identify root causes and point

toward possible solutions

DEVELOP: Based on the data,

develop action plans for

improvement, including

implementation, communication,

and measuring/monitoring

EXECUTE: Implement the

action plans, on a pilot basis as

indicated, and

(EVALUATE): Install an ongoing

measuring/monitoring (process

control) system to ensure success.

PDSA Model

PLAN: Plan a change

or test of how

something works

DO: Carry out the plan

STUDY: Look at the

results. What did you

find out?

ACT: Decide what

actions should be taken

to improve

Six Sigma

• DMAIC:

• Define

• Measure

• Analyze

• Improve

• Control

An improvement system

for existing processes

falling below specification

and looking for

incremental improvement

Lean Six Sigma

Lean Six Sigma projects comprise aspects of

Lean's waste elimination and the Six Sigma

focus on reducing defects, based on critical to

quality (CTQ) characteristics

Clinical Microsystems Global

Aim

1

2

3

Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSA

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Flowchart

Cause & Effect

The Dartmouth Microsystem Improvement Ramp

* 5P Assessment/Effective Meeting Skills

10 Key Success Characteristics

• Leadership

• Organizational Support

• Staff Focus

• Education and Training

• Interdependence

• Patient Focus

• Community and Market Focus

• Performance Results

• Process Improvement

• Information and Information Technology

5 Ps

Very High Risk

Chronic

Very High Risk

Healthy

Healthy

Healthy

Chronic

Functional

& Risks

Biological

Costs

Expectations Chronic

Very High Risk

Healthy

P A C PP E

P A C PP E

P A E

Functional

& Risks

Biological

Costs

Satisfaction

People with

healthcare

needs

People with

healthcare

needs met

Measuring Team Performance & Patient Outcomes and Costs

Measure Current Target Measure Current Target

Panel Size Adj.

Direct Pt. Care Hours:

MD/Assoc.

% Panel Seeing Own

PCP:

Total PMPM Adj.

PMPM-Team

External Referral Adj.

PMPM-Team

Patient Satisfaction

Access Satisfaction

Staff Satisfaction

STAFF MEMBERS:

Skill Mix: MDs __ RNs __ NP/PAs ____ MA ____ LPN _____ SECs ___

Microsystem Approach 6/17/98

Revised: 03/04

c Eugene C. Nelson, DSc, MPH

Paul B. Batalden, MD

Dartmouth-Hitchcock Clinic, June 1998

Prevention

P

Acute

A

Chronic

C

Educate

E

Palliative

PP

Microsystem Name

Purpose/AIMPatients

Processes

Performance PatternsProfessionals

Palliative

Purpose

Patients

Processes

Professionals

Performance patterns

Common themes

• These models are all means to get at the same thing:

Improvement. They are forms of ongoing effort to make

performance better

• In industry, quality efforts focus on topics like product

failures or work-related injuries

• In administration, one can think of increasing efficiency or

reducing re-work

• In medical practice, the focus is on reducing medical

errors and needless morbidity and mortality, streamlining

processes and improving outcomes

NHPCC and Dartmouth Institute

Faculty and program support for coaching and

learning about microsystems

Margie Lisa Randy Maria Ashleigh

(eCTC Program

Coordinator)

National Quality Improvement

• HRSA requires that the NHPCC conduct Quality

Improvement Projects with the 8 Regions

• Regions will be required to conduct Quality

Improvement Projects in next grant cycle (starting

June 1, 2017)

• Agreement that the regions will collaborate on Nat’l QI

projects

• Focus on two topics for quality improvement projects

• Timeframe is two years

• HRSA requires we address at least one HP2020

measure

NHPCC Quality Improvement Collaborative

(QIC)

• National consultant Marjory Godfrey, PhD to work with

NHPCC, and regions to rollout 10 pilot sites

• Each region will have least one pilot HTC site

• ATHN Data Summit provided an introduction to Quality

Improvement concepts

• ATHN Data Summit had an Adolescent Transition

breakout that focused on the quality improvement

process for transition

Aim of NHPCC QI Collaborative (QIC)

To leverage ATHN Clinical Manager technology and ATHN

dataset to inform improvement activities that result in

improved care and outcomes for patients and providers

Develop the improvement capabilities of interprofessional

improvement teams specific to transition from pediatric to

adult care at Hemophilia Treatment Centers (HTCs) in the

USA

Selection of National QI Topic

• HRSA Program Priority

• HP2020 Measure

• Gap in care in Patient Needs Assessment

• Build upon work already done through the NHPCC Work Groups

• Regions and HTCs need buy in that it is an area of importance

• Needs to be doable in two years

Adolescent transition was chosen as first topic for national QI.

Goal of Transition in Hemophilia Care

The NHPCC in conjunction with the U.S.

network of

Hemophilia Treatment Centers (HTCs)

recommend adoption of a systematic approach

to support

youth, families, and young adults

in their transition from

pediatric to adult health care

The Discipline of Coaching

”…Building relationships among people who are

continuously learning about the changing environments in

which they live and work, intervening in and moving to set

aside ineffective and counter-productive habits, and

building new skills, practices, habits, and platforms for

collaborating in this ever changing world.”

Chauncey Bell, Foreward from

Coaching: Evoking Excellence in Others, by James Flaherty, 2010

Qualifications of Coaches

• Employed by HTC or consumer

• Their HTC collects HP2020 measures and quality

metrics

• Must be committed to participate in all aspects of

project in pilot project

• Willingness to assist in training future coaches and

work with future QI projects

Coaches ⁻The National Hemophilia Program is committed to training up to 8

coaches from different regions to assist with the rollout of the

national Quality Improvement (QI) pilot project as required under

the new 2 year grant with MCHB

– The coaches will participate in a one year structured learning

process consisting of in-person and e-meetings, independent

learning, and interactions with experienced coaches to learn about

QI and its implementation.

– Selected coaches will guide another HTC (cannot be their

own HTC) with the QI project

– The process of coaching a QI project involves interacting,

guiding and problem solving with the HTC as they implement their

QI project

– The coaches must be committed to assisting with national and

regional QI project in subsequent years

Commitment

• Complete written assignments

• Interaction with Pilot Site

Attend monthly pilot project team meetings via conference calls

Travel to pilot HTC site for one visit

Consult with experienced coach as needed

Assist pilot HTC in collecting and reporting measures as needed

• In Person Meetings

Pilot and coach meeting

E-coach Face to Face Meeting

Face to Face meeting at the ATHN Data Summit 2016

Qualifications of QI Pilot Site

• HTC team committed to Transition QI Project

• Specific areas of transition to be selected

• Subject matter experts in adolescent transition

• HTC specific requirements

• Monthly team meetings

• Work with QI coach

• Collect and submit QI data

• In person two day meeting

• Collaborative Learning

QI Sites

Yale

Hem Ctr of Western PA

Emory

Nationwide

Children’s

Cincinnati

Children’s

Hemophilia Outreach Ctr

Gulf States

Colorado (Denver)

Ctr for Inherited Blood Disorders

Rady Children’s

NHPCC QIC Phases

Baseline Assessments

Quality Improvement Assessment (QIA)

Your Coach will review with you to plan coaching and a teaching plan to advance your learning

Improvement Teams

Individual QIA assessments

Set up regular improvement meetings using effective meeting skills

Action Phase

Coaching Site Visit between now and March 1st

The 5Ps

Dartmouth microsystem improvement curriculum

Adobe Connects

F2F meetings

Reflection

October 2016

Final Session October 6-7, 2016

ATHN Data Summit, Chicago, IL

Opportunity for all HTCs to Participate

• Webinar on Transition to guide staff though the

Got Transition website

• HTCs complete transition readiness assessment

annually

• HTC complete at least one core element

• HTC collect HP2020 measure administered by survey

Summary

• Key points to remember:

• Improving Healthcare quality is our responsibility

• Measurement and improvement are possible

• Identify the root cause before making changes

• Be creative in developing solutions

• Do what you can to get ready for

the enhanced rollout

Resources

Ann Forsberg Director, NHPCC aforsberg@athn.org

Marjory Godfrey, Co-Director & Founder, The Dartmouth

Institute Microsystem Academy margiegodfrey@gmail.com

Institute for Healthcare Improvement www.ihi.org

GotTransition www.gottransition.org