Quality Improvement Developing Psychology s QI Capability

Quality Improvement Developing Psychology s QI Capability APPIC May 2016 Liza Bonin, Ph.D. labonin@texaschildrens.org

Disclosure UpToDate clinical decision support resource Wolters Kluwer Health UpToDate contributions within Depression in children and adolescents Treatment of adolescent depression Suicidal behavior in children and adolescents Page 1 xxx00.#####.ppt 5/30/2016 9:51:12 AM

Educational Objectives Participants will be able to: 1. Describe why it is important to Psychology to develop QI competencies of our trainees and how QI knowledge, skills, and attitudes fit into established competencies for Health Service Psychology 2.Describe key principles and processes of quality improvement 3.Identify how your training programs, training faculty/supervisors, and trainees can develop QI competencies (including where to learn more about QI) Page 2 xxx00.#####.ppt 5/30/2016 9:51:12 AM

Institute of Medicine (IOM) seminal reports Significance for health care landscape Affordable Care Act / ACGME / MOC Introduction to QI principles & methods What is meant by quality Overview What are key quality improvement methods? How to build QI capability Ways psychologists and psychology training programs can engage in quality education and quality improvement initiatives Page 3 xxx00.#####.ppt 5/30/2016 9:51:12 AM

History of QI/PS movement Seminal IOM reports: To Err is Human: Building a Safer Health Care System (1999) Reframed medical error as a chronic threat to public health Crossing the Quality Chasm: A New Health System for the 21 st Century (2001) Between the healthcare we have and the healthcare we could have lies not just a gap, but a chasm PDF of Crossing the Quality Chasm Executive Summary available @ http://www.nap.edu/catalog/10027.html Page 4 xxx00.#####.ppt 5/30/2016 9:51:12 AM

Healthcare Landscape Heathcare Reform: Affordable Care Act National Quality Strategy / Health & Human Services Centers for Medicare & Medicaid, DSRIP Payments Accreditation / Certification Joint Commission, Medical Training / Education (ACGME, MOC) Page 5 xxx00.#####.ppt 5/30/2016 9:51:12 AM

Indicated Care for Outpatients Acute medical problems 67.6% Chronic medical conditions 53.4% Preventative care 40.7% Preventative services for adolescents 34.5% <50% Page 6 xxx00.#####.ppt 5/30/2016 9:51:13 AM

Improving the patient experience of care including both quality and satisfaction Improving the health of populations Reducing the per capita cost of health care Quality / Cost = Value Page 7 xxx00.#####.ppt 5/30/2016 9:51:13 AM

What about Psychology? Are we relevant to health care outcomes?? Page 8 xxx00.#####.ppt 5/30/2016 9:51:13 AM

What about Psychology? Are we relevant to health care outcomes? Management of health & health care is as much about behavior and behavioral health than medical procedures and practice. For population health and health care to improve, all health professionals, including Psychology, need to become proficient in QI Psychology has the potential to lead / assume key roles in Quality initiatives given our expertise Page 9 xxx00.#####.ppt 5/30/2016 9:51:13 AM

History Continued Changing Clinical Environment Joint Commission National Patient Safety Goals Affordable Care Act National Quality Strategy Better care Healthy people/communities Affordable care Agency for Healthcare Research & Quality Centers for Medicare & Medicaid Pay for performance; Value based purchasing; DSRIP Page 10 xxx00.#####.ppt 5/30/2016 9:51:13 AM

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History Addressing Waste/Overuse Resource Stewardship www.choosingwisely.org Choosing Wisely lists - Meant to spur conversations about what are appropriate and necessary tests or treatments Transparency About pricing, quality, safety Transformative Page 12 xxx00.#####.ppt 5/30/2016 9:51:14 AM

If you have to be naked, you had better be buff Tapscott & Ticoll The Naked Corporation: How the age of transparency will revolutionize business Page 13 xxx00.#####.ppt 5/30/2016 9:51:14 AM

New Health Care Landscape Changing Academic Environment Association of American Medical Colleges Accreditation Council for Graduate Medical Education Maintenance of Certification Page 14 xxx00.#####.ppt 5/30/2016 9:51:14 AM

Quality Improvement Capability QI central to effective practice in AMC Association of American Medical Colleges Vision: It is 2022. US Medical Schools and Teaching Hospitals are successfully leading enormous changes in health care, aided by educational programs that embed QI/PS across the continuum of physician development Goal: To ensure that every medical school and teaching hospital in the US has access to a critical mass of faculty that are ready, able, and willing to engage in, role model, and lead education in QI/PS, and the reduction of excessive health care cost. AAMC Teaching for Quality Report, 2013 Page 15 xxx00.#####.ppt 5/30/2016 9:51:14 AM

ACGME & Quality Improvement ACGME Competencies Patient Care Medical (Practice) Knowledge Practice Based Learning & Improvement Systems Based Practice Professionalism Interpersonal Skills & Communication Page 16 xxx00.#####.ppt 5/30/2016 9:51:15 AM

QI Basics Page 17 xxx00.#####.ppt 5/30/2016 9:51:15 AM

What is Quality?? Page 18 xxx00.#####.ppt 5/30/2016 9:51:15 AM

What is Quality? Institute of Medicine (IOM) Definition: The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Page 19 xxx00.#####.ppt 5/30/2016 9:51:15 AM

Institute of Medicine (IOM) Quality Dimensions Dimensions/Aims Safe Effective Patient Centered Timely Efficient Equitable Definition Avoid injuries to patients from the care that is intended to help them Provide services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit Provide care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Reduce waits and sometimes harmful delays for both those who receive and those who give care Avoid waste, including waste of equipment, supplies, ideas, and energy Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status Page 20 xxx00.#####.ppt 5/30/2016 9:51:15 AM

Donebedian s Conceptual Framework Structure Process Outcome Context How care is organized? Delivery of healthcare What is done? Health status The end results of care JAMA 1988 Page 21 xxx00.#####.ppt 5/30/2016 9:51:16 AM

Key QI Concepts CHANGE: All improvement requires change, but not all change will result in an improvement Use data to improve healthcare in daily work Rapid cycle improvement: iterative process/tests of change SYSTEMS: Every system is perfectly designed to get the results it gets -Paul Batalden, M.D. -Improvement depends on much more than having the right scientific evidence at hand. Requires change at the level of systems of care and knowledge about how to make changes. - System of Profound Knowledge -W Edwards Deming Page 22 xxx00.#####.ppt 5/30/2016 9:51:16 AM

QI SYSTEMS THINKING FOR EXAMPLE Structure Process Outcome Context How care is organized? Delivery of healthcare What is done? Health status The end results of care Page 23 xxx00.#####.ppt 5/30/2016 9:51:16 AM

Model of Improvement Framework for Improvement Initiatives

The Model for Improvement - Langley et al, 2009 Provides structure for diagnosing and treating systems of care Model for developing, testing, implementing and spreading change that yields improvement Three Fundamental Questions define the endpoint Plan-Do-Study-Act (PDSA) iterative cycles Spread improvement / Implementation to foster adoption Page 25 xxx00.#####.ppt 5/30/2016 9:51:17 AM

Model of Improvement: 3 Fundamental Questions AIM WHAT ARE WE TRYING TO ACCOMPLISH? Shared Vision & SMART Aim MEASURE HOW WILL WE KNOW THAT A CHANGE IS AN IMPROVEMENT? Outcome, Process, & Balancing Measures CHANGES WHAT CHANGES CAN WE MAKE THAT WILL RESULT IN IMPROVEMENT? Page 26 xxx00.#####.ppt 5/30/2016 9:51:17 AM

PDSA Cycle ACT Refine/change Next cycle STUDY Review data Compare to prediction Summarize learning PLAN Objectives Questions/Predictio ns Plan for test/cycle DO Carry out plan Document your observations / data collection Page 27 xxx00.#####.ppt 5/30/2016 9:51:17 AM

PDSA - Therapy ACT Refine Treatment Plan as Needed PLAN Case Formulation / Treatment Plan STUDY Evaluate Progress Benchmarking / TIB DO Implement Plan with Progress Monitoring Page 28 xxx00.#####.ppt 5/30/2016 9:51:17 AM

Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Aim Statements S Specific M Measureable A Actionable R Relevant T Time Bound Act Study Plan Do How good? By when? For whom? Includes the measure which answers the second question Involve senior leaders Page 30 xxx00.#####.ppt 5/30/2016 9:51:18 AM

Teams, Teamwork, and Collaboration Systems perspective / key stakeholders Including the right people on improvement teams is crucial to the success of improvement efforts Must be intentional and systematic about approach to teamwork Page 31 xxx00.#####.ppt 5/30/2016 9:51:18 AM

Process Analysis / Planning Tools Harness power of teams (Systems Thinking) Learn about processes of care (Where are we now?) Build shared vision (Where do we want to go?) Tools Brainstorming Process Flow Map Fishbone (aka Cause & Effect) diagram Failure Mode & Effects Analysis (FMEA) Gap Analysis (aka Spider diagram) Benchmarking / Learning from others Key Driver Diagram** Page 32 xxx00.#####.ppt 5/30/2016 9:51:18 AM

Faces of Performance Measurement Page 34 xxx00.#####.ppt 5/30/2016 9:51:19 AM

Key Driver Diagram Page 36 xxx00.#####.ppt 5/30/2016 9:51:19 AM

Depict variation Run Chart Depict data over time Shewhart Chart Distinguish bw special & common cause of variation -aka Control Chart -Include upper & lower limits Page 37 xxx00.#####.ppt 5/30/2016 9:51:19 AM

A Series of PDSA Cycles Act Study Plan Do Implementation of Change Act Plan Study Do Wider-Scale Tests of Change Act Plan Act Plan Study Do Follow-up Tests / New Conditions Study Do Very Small Scale Test Page 38 xxx00.#####.ppt 5/30/2016 9:51:20 AM

Developing QI Capability Page 39 xxx00.#####.ppt 5/30/2016 9:51:20 AM

Quality Improvement Capability Association of American Medical Colleges Vision: It is 2022. US Medical Schools and Teaching Hospitals are successfully leading enormous changes in health care, aided by educational programs that embed QI/PS across the continuum of physician development Goal: To ensure that every medical school and teaching hospital in the US has access to a critical mass of faculty that are ready, able, and willing to engage in, role model, and lead education in QI/PS, and the reduction of excessive health care cost. AAMC Teaching for Quality Report, 2013 Page 40 xxx00.#####.ppt 5/30/2016 9:51:20 AM

AAMC Vision / Objectives for Clinical Faculty Development / Capacity QI Scholars Education Leaders in QI Master Expert Clinical Faculty / Supervisors Proficient Page 41 xxx00.#####.ppt 5/30/2016 9:51:20 AM

Stages of Development in QI Education Novice Advanced Beginner Competent Proficient Expert Master Beginning Medical Student Graduating Medical Student Graduating Resident Faculty Education Leaders in QI/PS QI/PS Scholars Beginning Graduate Student Ready for internship Graduating doctoral intern Faculty Education Leaders in QI QI Scholars { Develop Faculty Capability } Adapted from AAMC Teaching for Quality 2013 Report Integrating QI and PS across the Continuum of Medical Education Page 42 xxx00.#####.ppt 5/30/2016 9:51:21 AM

Building Improvement Capability Engage & develop faculty as improvement leaders Different groups have different levels of need for improvement knowledge Interprofessional learning environment is critical to shifting mental models Project-based learning with coaching and feedback solidifies critical skills, knowledge and behaviors Kaminski, et al., 2014 Boonyasai et al., 2007 Page 43 xxx00.#####.ppt 5/30/2016 9:51:21 AM

Miller s Prism of Clinical Competence (aka Miller s Pyramid) Based on work by Miller GE. The Assessment of Clinical Skills/Competence/Performance; Acad. Med. 1990: 65(9); 63-67. Adapted by Drs. R. Mehay & R Burns, UK (Jan 2009) Page 44 xxx00.#####.ppt 5/30/2016 9:51:21 AM

Learning Domains Key Knowledge & Skill Sets Healthcare as process within a system Understanding variation in care and how to measure for improvement Knowing needs/preferences/effect of illness and health care on patients/families Leading change/improvement in health care Collaboration, working in teams Social context and accountability Developing and applying locally useful knowledge - Institute for Healthcare Improvement (IHI) - Batalden & Davidoff, 2007 Page 46 xxx00.#####.ppt 5/30/2016 9:51:21 AM

As a TD, how do I get up to speed in QI? Well, here is my journey Hospital s Advanced Quality Improvement Course IHI Open School On-line Curriculum Didactics to Psychology Interns & Fellows Hospital Wide Quality Education Initiative Psychology QI Program (Faculty Capability) Teach QI/PS to Medical Students Facilitator for Patient Safety & Value in Healthcare Courses QI Curriculum Development Team Department of Fellow s College Page 47 xxx00.#####.ppt 5/30/2016 9:51:22 AM

Effective Partnerships Leaders in education must partner with experts in quality and safety and their institutions as a whole to develop effective, replicable, and sustainable models that promote QI education Patrick J, 2014 Page 48 xxx00.#####.ppt 5/30/2016 9:51:22 AM

For more information about QI Institute for Healthcare Improvement www.ihi.org / IHI s Open School Agency for Healthcare Research & Quality www.ahrq.gov The improvement guide: A practical approach to enhancing organizational performance Langley, Moen, Nolan, Nolan, Norman, Provost, 2009 Based on Model for Improvement framework Other frameworks: Lean Improvement, Six-Sigma Page 49 xxx00.#####.ppt 5/30/2016 9:51:22 AM

Key References Boonyasai, R.T., Windish, D.M., Chakraborti, C., Rubin, H.R., & Bass, E.B. (2007). Effectiveness of teaching quality improvement to clinicians: A systematic review. Journal of the American Medical Association, 298, 1023-1037. Institute of Medicine, Committee on Quality of Health Care in America, Inst. (2001). Crossing the quality chasm: A new health system for the 21 st century. Washington, DC: National Academies Press. Kaminski GM, Schoettker PJ, Alessandrini EA, Luzader C, & Kotagal U. (2014). A comprehensive model to build improvement capability in a pediatric academic medical center. Academic. 14, 29-39 Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L, & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing organizational performance. San Francisco: Jossey-Bass. Patrick, J. Educating for quality: Quality improvement as an activity of daily learning to improve educational and patient outcomes. Academic, 14, 1-3 Philibert, I, Gonzalez del Rey, J.A., Lannon, C, Lieh-Lai, M. & Weiss, K.B. (2014). Quality improvement skills for pediatric residents: From lecture to implementation and sustainability. Academic, 14, 40-46. Page 50 xxx00.#####.ppt 5/30/2016 9:51:22 AM

Key References (Psychology) Schurman, J.V., Gayes, L.A., Slosky, L., Hunter, M.E., & Pino, F.A. (2015). Publishing quality improvement work in Clinical Practice in Pediatric Psychology: The Why and How To. Clinical Practice in Pediatric Psychology, 3, 80-91. Stark, L.J. (2010). Introduction to the special issue: Quality improvement in pediatric psychology. Journal of Pediatric Psychology, 35, 1-5. Page 51 xxx00.#####.ppt 5/30/2016 9:51:22 AM

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