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On Page 1 of 2:
4.A. Focusing on Microsystems
iv.B. Understanding and Implementing the Improvement Wheel

On Folio 2 of 2:
4.C. An Overview of Improvement Models
4.D. Tools To Enhance Quality Comeback Initiatives
References

cover of Section 4: Ways To Approach the Quality Improvement Process

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Health care delivery systems that are working to meliorate patient feel tin can face daunting challenges, reflecting the need to align changes in behavior and practices across multiple levels and areas of the organization. But the process of planning, testing, and eventually spreading those changes does not have to be overwhelming. Health care organizations can take advantage of established principles and approaches to quality improvement, which are already familiar to the many providers involved in clinical quality comeback (QI).

This section of the Guide suggests a fashion to use the concept of microsystems to focus the QI process on the locus of responsibility for patient experience, provides an overview of the process of quality improvement, discusses a few well-known models of quality improvement, and presents a few tools and techniques that organizations can utilise to address diverse aspects of patient experience.

Three Tips for Facilitating the Quality Improvement Process

Place a priority on encouraging communication, engagement, and participation for all of the stakeholders afflicted by the QI process. Learn what is most important to the people who make up the microsystem and wait for ways to assist them cover the changes and begin to take ownership of them.

Outset your implementation of improvements with small-scale-scale demonstrations, which are easier to manage than large-scale changes. Small-scale demonstrations or minor tests of change also allow you to refine the new processes, demonstrate their impact on practices and outcomes, and build increased support past stakeholders.

Keep in heed and remind others that QI is an iterative process. You volition exist making frequent corrections forth the style equally you learn from experience with each step and place other actions to add to your strategy.

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iv.A. Focusing on Microsystems

Ane useful way for health plans and medical groups to approach the process of comeback is to call up of the organization every bit a system, or more than specifically, as a collection of interrelated "microsystems." The term "microsystems" refers to the multiple modest units of caregivers, administrators, and other staff who produce the "products" of health care—i.due east., who deliver care and services on a daily basis.

The concept of microsystems in health care organizations stems from research findings indicating that the nigh successful of the big service corporations maintain a strong focus on the minor, functional units who carry out the cadre activities that involve interaction with customers.¹ In the context of wellness care, a microsystem could be:²

A core team of wellness professionals.
Staff who work together on a regular basis to provide intendance to discrete subpopulations of patients.
A piece of work expanse or department with the same clinical and business aims, linked processes, shared information environs and shared performance outcomes.

Examples of microsystems include a squad of primary care providers, a grouping of lab technicians, or the staff of a call center. In the patient-centered medical home model, a microsystem could be the patient's care team accountable for coordination of the patient's services that address prevention, acute care, and chronic care.^three

The goal of the microsystem approach is to foster an emphasis on small, replicable, functional service systems that enable staff to provide efficient, first-class clinical and patient-centered intendance to patients. To develop and refine such systems, wellness intendance organizations start past defining the smallest measurable cluster of activities.

In one case the microsystems have been identified, a practise or plan tin can select the all-time teams and/or microsystem sites to test and implement new ideas for improving piece of work processes and evaluating improvement.^five To provide high-quality care, the microsystem'southward services need to be constructive, timely, and efficient for all patients,⁴ and preferably designed in partnership with patients and their families.

Measurement and performance feedback must be part of the microsystem'due south principles to learn and better.^six

If a quality improvement intervention is successful for a microsystem, information technology can then be scaled to other microsystems or the broader organization. Withal, for successful scalability, organizations should adopt a framework for spread that will work within their construction and culture.

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4.B. Agreement and Implementing the Improvement Cycle

Although QI models vary in approach and methods, a basic underlying principle is that QI is a continuous activeness, not a erstwhile thing. As you implement changes, there will always be issues to accost and challenges to manage; things are never perfect. You can learn from your experiences and then utilize those lessons to shift strategy and endeavor new interventions, as needed, so y'all continually move incrementally toward your improvement goals.

The cardinal approach that serves every bit the ground for most process improvement models is known every bit the PDSA cycle, which stands for Plan, Do, Study, Human action. As illustrated in Figure 4-1, this cycle is a systematic series of steps for gaining valuable learning and noesis for the continual improvement of a product or process. Underlying the concept of PDSA is the idea that microsystems and systems are made up of interdependent, interacting elements that are unpredictable and nonlinear in operation. Therefore, modest changes tin have large effects on the system.

Effigy 4-1. Plan-Exercise-Study-Human activity Cycle

This image shows the Plan-Do-Study-Act (PDSA) cycle, which illustrates that the effort to improve performance is not a linear process with a beginning and end. It is a cyclical process that leaves room for testing, tweaking, and expanding interventions along the way. The components of the cycle are 1. Plan Strategy, 2. Develop, Test Strategy, 3. Monitor Strategy, and 4. Reassess & Respond.

The cycle has four parts:

Plan . This step involves identifying a goal or purpose, formulating an intervention or theory for modify, defining success metrics and putting a plan into action.
Practice . This is the step in which the components of the program are implemented.
Study . This pace involves monitoring outcomes to test the validity of the plan for signs of progress and success, or problems and areas for improvement. Short-cycle, small-scale tests, coupled with analysis of examination results, are helpful because microsystems or teams tin can learn from these tests before they implement actions more broadly.⁷ ^, ⁸
Act . This step closes the cycle, integrating the learning generated by the entire procedure, which can be used to suit the goal, alter methods, or even reformulate an intervention or improvement initiative altogether.

The PDSA wheel involves all staff in assessing problems and suggesting and testing potential solutions. This bottom-up approach increases the likelihood that staff will embrace the changes, a cardinal requirement for successful QI.⁹

When you are set up to utilise the PDSA cycle to improve performance on CAHPS scores, you will demand to decide on your goals, strategies, and deportment, and then movement forward in implementing them and monitoring your improvement progress. You may echo this cycle several times, implementing one or more interventions on a small-scale scale starting time, and so expanding to broader actions based on lessons from the earlier cycles.

4.B.1. Plan: Develop Goals and Activity Plan

This section discusses four key steps in the planning stage of a PDSA cycle equally part of a CAHPS-related quality improvement process:

Institute improvement goals.
Identify possible strategies.
Choose specific interventions to implement.
Set up a written activity program.

4.B.1.a. Establish Improvement Goals

The team'due south first task is to plant an aim or goal for the improvement piece of work. By setting this goal, you volition exist meliorate able to clearly communicate your objectives to all of the sectors in your organization that you might need to support or assist implement the intervention.

The goal should reflect the specific aspects of CAHPS-related functioning that the squad is targeting. It should also be measurable and viable. One of the limitations of an annual CAHPS survey as a measurement tool is the lag time between the implementation of changes, the touch on on people's experiences, and the cess of that impact. For that reason, the squad needs to define both ultimate goals also as incremental objectives that tin be used to gauge brusque-term progress. Subsequently defining your ultimate goals, ask "What is the gap betwixt our electric current land and our goals?" Make of listing of those gaps and apply them to make SMART (specific, measurable, doable, realistic, and time bound) incremental objectives.

For instance, a team concerned about improving performance on the "Getting Timely Appointments, Intendance, and Information" composite measure in the Clinician & Grouping Survey may set a i-year goal of a two percent increase in its composite score. At the same time, information technology could specify goals for the number of days it takes to get an appointment for non-urgent and urgent visits. Similarly, a squad focusing on overall ratings may set goals for complaint rates for the health plan as a whole or for private medical groups and and then review those rates monthly.

4.B.1.b. Identify Possible Strategies

With objectives in identify, the adjacent task of the team is to identify possible interventions and select 1 that seems promising. Keep in mind that all improvement requires making a alter, but not all changes atomic number 82 to improvement.

Section 6 of this Guide presents a number of dissimilar strategies that health care organizations can utilize to ameliorate different aspects of their CAHPS performance. In addition, yous may want to consult several case studies of health intendance organizations that take implemented strategies to amend performance on CAHPS scores.

These sources of comeback ideas offer an excellent starting signal, but they are past no means comprehensive. In that location are many other sources for new ideas or different ways of doing things both within and outside of health intendance. Consequently, improvement teams should make an endeavor to develop and maintain systematic ways of identifying constructive solutions.

New ideas and innovative solutions can be plant:

At conferences or workshops.
In the academic literature, the media, and/or the popular press.
Through the identification of criterion practices in health care as well equally other industries, i.eastward., noncompetitive benchmarks.
Through patients and their families—whether through straight interviews and focus groups, as partners on quality improvement teams, or as members of Patient and Family Advisory Councils.
In the Agency for Healthcare Enquiry and Quality's searchable clearinghouse of health care innovations.

One useful way to develop and learn innovative approaches is to visit other health care organizations. Resistant or hesitant staff members are frequently "unfrozen" by visiting another highly respected site that has successfully implemented a similar project. You can also visit a company outside of the health care manufacture to get new ideas. Some health plans, for example, have learned how to amend their phone call center operations past sending staff to visit postal service-gild itemize houses or brokerage firms. The Cleveland Clinic has required every doctor and senior administrator to make ane "innovation site visit" a year to learn about different approaches that can exist brought habitation and tested.

"Ideas for change can come from a variety of sources: critical thinking virtually the current organisation, creative thinking, observing the process, a hunch, an idea from the scientific literature, or an insight gained from a completely different state of affairs. A change concept is a general idea with proven merit and sound scientific or logical foundation that tin stimulate specific ideas for changes that lead to comeback."
—Plsek P. Innovative thinking for the comeback of medical systems. Ann Intern Med 1999;131:438-44. Accessed July 27, 2015.

4.B.1.c. Choose Specific Interventions To Implement

To make up one's mind which new ideas or benchmark practices to implement, the improvement team needs to consider several factors:

Compatibility with the organization and local culture . Serving Cuban java in the waiting room of the clinics of a Miami medical grouping may exist very patient-friendly, for instance, but it is not likely to be viewed with the same enthusiasm by patients in Arizona or Massachusetts.
Technical merit . The ideas that are most likely to be adopted are those that provide meaning advantages over existing practices for both patients and providers—whether in the class of increased efficiency, higher patient and employee satisfaction, or improved outcomes. All comeback efforts ultimately take to respond the question: "What's in it for me?"
Fit with the problem . The best intervention will exist one that suits the specific trouble yous need to address (or tin be tailored equally needed). To ensure a proficient fit, the improvement team should seek input from both affected staff likewise as patients or members. If you ignore either source of data in your planning, you may choose an intervention that volition not fix the existent problem.

Depending on the nature of the intervention, you may want to interruption it downwardly into a set up of related but discrete changes. For case, if the squad decides to implement a new specialist referral process, y'all could brainstorm past making changes to the procedures used to communicate with the specialist'due south function. The communication process with the health plan might and then be the target of a dissever change.

iv.B.i.d. Prepare a Written Activity Program

Although in that location is no one "right" mode to write an action plan for your organization or facility, it is important to have some course of written document that states your goals, lists your overall strategies to accomplish those goals, and then delineates the specific deportment you volition take to implement the interventions you lot take selected to address the identified bug. One mode to organize the action programme is to review the following central questions as a team and document your answers:

What areas practise you want to focus on for improvement?
What are your goals?
What initiative(s) will you implement? Describe the specific actions briefly.
Who will be afflicted, and how?
Who can pb the initiative? Identify a leader and/or champion to manage the project.
What resources will be needed?
What are possible barriers, and how tin can they exist overcome?
How will you measure progress and success? Specify the measures you plan to utilize to monitor progress in achieving the desired changes to organizational processes and CAHPS scores. Read more than most measures below.
What is the timeline? Record your planned get-go and end dates for the activity.
How volition you share your action plan?

It likewise helps to lay out the calendar for all actions in a Gantt chart format, so you can verify that the timing of sets of actions makes sense and is feasible to consummate with the staff y'all have bachelor.

four.B.ii. Exercise: Select Measures To Monitor Progress

When a team establishes its goal, it typically specifies i or more than functioning metrics to assess whether a change actually leads to improvement. These measures should exist conspicuously linked both to the larger goal and to the intervention itself. For example, if the goal is to speed specialist referrals, you could measure out the time information technology takes to get a response from the specialist's function or an approval from the health programme.

Resources on Measurement

Constitute for Healthcare Comeback. Science of Comeback: Establishing Measures.
Carey RG, Lloyd RC. Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control Applications. New York: American Society for Quality; 1995.
Wheeler D. Agreement Variation: Keys to Managing Anarchy. Knoxville, TN: Statistical Process Controls, Inc.; 1993.
American Board of Internal Medicine (ABIM) Foundation. Putting Quality Into Practice video series. This series shows the perspectives of physicians who take adopted quality measurement and improvement tools. The doctors speak candidly about why they decided to measure out their performance, and how the information empowered them to better the care they provide to patients.

4.B.2.a. Tips on Selecting Measures

Choose measures that allow you lot to runway each of three steps in the improvement procedure:

Test the credence and/or adherence to new or revised practices.
Examine how and how much the new practices are affecting the delivery of patient-centered care.
Assess how much patient experience of care is improving.

Communicate with staff well-nigh why the measures are beingness collected and how these data will help meliorate their quality of work life and the patient's experience.

Seek a feasible number of measures that address the most of import aspects of the improvements you are trying to achieve. Too many measures could create a burden on the staff, leading to loss of attending due to information overload; besides few measures may omit tracking of important aspects of the changes you are making.

4.B.2.b. Producing Visual Displays

In one case you lot have established practical measures, you volition exist able to produce visual displays of your operation over time by tracking the metric on command or run charts. Control and run charts are helpful tools for regularly assessing the impact of process improvement and redesign efforts: monthly, weekly, or even daily. In contrast to tables of aggregated data (or summary statistics), which present an overall picture of performance at a given point in time, run and control charts offer an ongoing record of the touch on of process changes over fourth dimension.

A run chart can show different information collection points plotted over time for a specific survey question, e.g., an item well-nigh patients' ability to reach the do past phone. By measuring and tracking results to this question at regular and frequent fourth dimension intervals, managers can discern how process comeback interventions relate to changes in survey results. If an intervention appears to have positive results, it tin can be continued and sustained; if not, it tin be modified or discontinued.

Dashboard reports are some other way to display performance. A dashboard written report presents important data in summary grade in order to make information technology easier to identify gap in operation and trend operation against goals. Dashboards can be a useful method for sharing consequent information beyond multiple levels of an organization. For case, the Massachusetts General Physicians Organization (MGPO) prepares quarterly leadership dashboards with benchmarks and targets, where relevant, at a summary level across clinical services, at the clinical service level, and at the practice level.^x

four.B.3. Do and Study: Test and Refine Actions on a Small Scale

Once you take selected interventions, the adjacent phase of the cycle is to develop and examination specific changes. It helps to call back of this stage equally a number of "mini-cycles" inside the larger improvement bicycle, in the sense that the microsystem or team is likely to get through multiple iterations of testing and refining before the specific changes add upwards to a existent intervention.

Minor-scale tests of the interventions y'all wish to implement help refine improvements by incorporating small modifications over time. Conducting these small tests of change inside a microsystem can be very powerful:

They let for incremental modifications of interventions to set problems, which helps the larger implementation run smoothly.
Failures are low-take a chance because you have non tried to change the entire culture.
Yous create enthusiasm and positive "word-of-oral fissure" for early on successes.
It is easier to accrue prove for implementation when people are engaged in making something work rather than focused on the "failure analysis."

Most comeback strategies require some adaptation to the civilisation of the organization. Patient-centered improvement strategies have to consider the needs of patients and their families as well every bit the staff. Moreover, front-line staff volition frequently resist new ideas if they are not allowed to modify them and test their own ideas.

4.B.4. Act: Aggrandize Implementation to Reach Sustainable Improvement

Edifice off of the development and testing of specific changes, the concluding stage of the PDSA cycle involve adopting the intervention and evaluating it against the goals of the improvement projection and the measures established for tracking improvement progress. For example:

Did the intervention succeed in reducing the fourth dimension required to run across a specialist?
Are members and patients reporting amend experiences with regards to getting care quickly?

This function of the improvement bicycle is really the ongoing work of health care and where your teams will spend nigh of their time. There are no set rules about how long this office of the cycle takes. Information technology depends in office on how frequently you monitor your CAHPS scores and other quality measures.

It is important not to let the work proceed too long without ongoing measurement in order to make sure you are making progress toward achieving your aims. Nigh monitoring takes place on a monthly or quarterly ground. The team can use information on the touch on of the intervention to see if it is making progress towards the goals and to decide whether to conduct a new fix of analyses of its CAHPS operation. The purpose of this effort is to get some sense of what worked, what did non work, and what further or new interventions may be needed. To the extent that the improvement initiative was successful, the team must also think about ways to sustain and spread the improvements over fourth dimension.

Resources on Sustaining and Spreading Improvements

Massoud MR, Nielsen GA, Nolan M, Schall MW, Sevin C. A Framework for Spread: From Local Improvements to System-Broad Change. IHI Innovation Serial white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006.
Nolan KM, Schall MA. A framework for spread. In Nolan KM, Schall MW, editors: Spreading Improvement Across Your Health Care Organisation. Oak Beck, IL: Joint Commission Resources, 2007,i–24.
Øvretveit J. Implementing, sustaining, and spreading quality improvement. In The Joint Committee: From Front Role to Front Line: Essential Issues for Wellness Care Leaders, 2nd ed. Oak Brook, IL: Joint Commission Resources, 2012, 159–176.

4.B.4.a. Identify and Deal With Barriers

As part of its work, the team will need to take a difficult look at the psychological, concrete, and procedural barriers it has to address in order to achieve its aim. Barriers to comeback come in many guises. Psychological barriers such as fear of change, fear of failure, grief over loss of familiar processes, or fear of loss of command or power can be meaning impediments to overcome. Other common barriers include the post-obit:

Lack of bones direction expertise.
Lack of training in client service, quality improvement methods, or clinical areas such as doctor-patient advice.
Inadequate staffing levels.
Poor it systems.
Outdated or misguided organizational policies. For instance, many organizations are so concerned well-nigh violating HIPAA regulations that they exercise not desire to give data to a patient nigh their own care for fear of violating patient confidentiality.

Despite the serious nature of some of these barriers, few are large enough to bring a project to a halt. Typically, they are cited as excuses for ii of the cardinal barriers to change: the fear of new means of doing things and the fright of failure.

Anticipating How the Improvement Process Affects Staff

An comeback procedure often requires pregnant changes in people's attitudes and behaviors, frequently requiring staff to surrender their onetime standards and practices and adopt new ones. As a result, yous can await pushback from some staff as y'all introduce new processes and habits.

Many staff will "get it" early on and pitch in enthusiastically. But introducing and reinforcing changes in behavior that "stick" in the form of sustainable practices will take some work and fourth dimension to succeed. Over time, equally less enthusiastic staff come across positive progress, they too will become more engaged and supportive.

When you succeed, the payoff is significant, with benefits not only for patients simply as well for clinicians and staff. Many organizations take institute that job satisfaction for their staff rises with improved patient experiences because the new, better practices normally reduce frustrating inefficiencies in the system that created actress work for staff.

Learn More than: Aligning Forces for Quality. The Center for Health Care Quality at the George Washington University Medical Center School of Public Health and Health Services. Good for Wellness, Proficient for Business: The Case for Measuring Patient Experience of Care. 2012.

four.B.4.b. Identify and Cultivate Facilitators

The squad besides needs to identify factors that could facilitate their work. Facilitators tin can include financial or nonfinancial incentives, such as proceeds sharing for staff if a specific target is met or better quality of life for the staff when a problem is fixed. Other facilitators include picking an aim that is function of the arrangement's strategic plan or 1 that volition meliorate other goals the staff care most, such equally clinical outcomes.

Sometimes, the facilitator is the ability of a change to help achieve secondary goals. For case, improvements in physician-patient communication may decrease medication errors, or the development of shared intendance plans may better clinical outcomes and reduce no-shows for appointments or procedures.

four.B.iv.c. Harness Social Interaction to Spur Adoption of Innovations

Research on the diffusion of innovation has found that social interaction plays a crucial role. Almost people exercise not evaluate the merits of an innovation on the basis of scientific studies; they depend on the subjective evaluations of "early on adopters" and model their behaviors later on people they respect and trust.¹¹ For that reason, choosing the right team members and opinion leaders (i.e., people within an organization who informally influence the actions and beliefs of others) is critical to efforts to diffuse innovation.

Depending on the projection, yous may want to try to place the opinion leaders that would be helpful to involve (assuming they are open to alter and new ideas). Interpersonal advice works best when the people communicating the bulletin are respected opinion leaders within the same staff group whose behavior they are trying to change. For example, an innovation to change the beliefs of receptionists volition oftentimes motion chop-chop if it is led by a respected receptionist or office managing director. But this person would probably not be equally constructive at getting physicians in a medical group to change their communication style with patients.

Inquire people whose opinion they respect. Who exercise they follow when they have adopted new clinical or improvement practices? Who do your staff wait to when they want advice or information about the arrangement?

4.B.4.d. Communicate Internally

One important footstep that is oftentimes neglected is the communication of successes throughout the organization—to organizational leaders likewise as clinical and administrative staff. By discussing successful projects, the team helps to reinforce the culture of quality improvement, build credibility for the intervention, reward those involved, and foster the spread of effective innovations.

The organization's leaders tin can also:

Use media and interpersonal communication to promote the work of specific improvement teams.
Highlight successful innovations in staff newsletters and in staff and board meetings.
Reinforce the importance of the project past sitting in on comeback squad meetings or visiting the do site or unit involved in the project.

A related do is the communication of changes beyond the walls of the arrangement to members or patients. By telling people about innovative practices—whether through newsletters, emails, function estimator screensavers, member Web sites, or handouts in the office—you lot can heighten the standard of expectations.

Learn About Encouraging Innovation

Blakeney B, Carleton P, McCarthy C, Coakley E. Unlocking the Ability of Innovation. OJIN: The Online Journal of Issues in Nursing. 2009 May 31;14(No. two, Manuscript 1). This article describes innovative methods and highlights specific examples of organizational structures that support innovations within health care organizations.
Christensen C, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev 2000 Sep-Oct;78(5):102- 12, 1999.
Langley GJ, Nolan KM, Norman C, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass; 1996.
Kelley T, Littman J. The x Faces of Innovation: IDEO'due south Strategies for Beating the Devil's Advocate & Driving Inventiveness Throughout Your Organization. New York: Doubleday; 2005.
Plsek PE. Innovative thinking for the comeback of medical systems. Ann Intern Med 1999;131(6): 438-44.
Plsek PE. Thinking differently. National Wellness Services Constitute for Innovation and Comeback. Accessed May 28, 2015.
Rogers East. Improvidence of innovations. fifth ed. New York City: Gratuitous Press, 2003.

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