Sustaining Quality Improvement: Lessons From and For the Adult Medicaid Quality GranteesFacilitated by Kamala AllenDirector, Child Health Quality, Center for Health Care Strategies

The CMS Healthcare Quality ConferenceBaltimore, MD | December 2 – 4, 2014

Follow us on Twitter:@QIOProgram

Tweet with our conference hashtag:#QualityNet14

Agenda

• Sustaining Quality Improvement: Lessons Learned from New York State– Lindsay W. Cogan

• Holding the Gains– Jane Taylor

2

Sustaining Quality Improvement: Lessons Learned from New York StateLindsay W. CoganOffice of Quality and Patient Safety, New York State Department of Health

Background

New York State Health Agencies* *

* Collaborating partners for AMQ grant4

New York State Quality Improvement Projects (QIPs)

Behavioral Health• Improving adherence to

antipsychotics for people with schizophrenia

• 168 participating clinics

Maternal Health• Improving documentation

of maternal education on the maternal and fetal risks and benefits of scheduled delivery without medical indication between 36 0/7 and 38 6/7 weeks gestation

• 13 participating regional perinatal centers

5

Office of Mental Health (OMH) Quality Improvement Initiative

• Builds on success of OMH medication-related quality improvement initiatives (2008-2012)

– Launched December 2012• Projects aligned with priorities in statewide systems

transformation (integrated mental/physical health, care coordination, hospital readmissions)

• Clinic project options– Behavioral Health Care Coordination – 168 (56%)– Health Promotion and Coordination – 134 (44%)

• Clinics use Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) to support quality improvement and clinical decision-making

6

The New York State Perinatal Quality Collaborative (NYSPQC)

• Builds on successes of New York Department of Health (DOH) collaboration with state’s Regional Perinatal Centers (RPCs) and National Initiative for Children's Health Quality– Began September 2010

• 18 RPCs Total– OB Education Project – 13 (72%)

• Project aligned with aims of collaborative to provide the best and safest care for women and infants in New York by preventing and minimizing harm through the use of evidence-based practice interventions

7

Overcoming Challenges of Statewide Project Implementation

• Staffing issues– Maternal Health QIP: Staffing delayed project kick-off

• Need for clinical resources to support project– Behavioral Health QIP: Full time project manager with clinical

experience hired in December 2013

• Approaches to maximize staff time and efficiency – Maternal Health QIP: In-person learning session (11 of 13 RPCs

attended) and bi-monthly coaching calls– Behavioral Health QIP: Distance learning methods (webinars,

on-line training modules) – Electronic forms for data collection to minimize manual data

entry

8

Antipsychotic Non-Adherence Indicator Trend by Participation Status

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%7/

1/20

12

8/1/

2012

9/1/

2012

10/1

/201

2

11/1

/201

2

12/1

/201

2

1/1/

2013

2/1/

2013

3/1/

2013

4/1/

2013

5/1/

2013

6/1/

2013

7/1/

2013

8/1/

2013

9/1/

2013

10/1

/201

3

11/1

/201

3

12/1

/201

3

1/1/

2014

2/1/

2014

3/1/

2014

4/1/

2014

5/1/

2014

6/1/

2014

7/1/

2014

8/1/

2014

Participating Clinics

Joinpoint Participating Clinics

Non-Participating Clinics

Joinpoint Non-ParticipatingClinics

Pro

ject

Sta

rt

Average Annual Percent Change (AAPC)from Baseline (January 2013) to August 2014

Group AAPC 95% CIParticipating Clinics -8.8 (-15.6, -1.5)

Non-Participating Clinics -0.6 (-1.8, 0.6)AAPC Difference -8.2 (-16.4, -0.8)

9

Percent of All Scheduled Deliveries with Maternal Counseling Documented

0

10

20

30

40

50

60

70

80

90

100

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep

-14

Perc

ent (

%)

Start of NYSPQC OB Prenatal

Education Project

10

Sustainability – Behavioral Health QIP

• Clinics sustain infrastructure to support improving adherence project goals (e.g., use of PSYCKES, changes in clinic workflow and clinical procedures)

• Clinics continue to deliver effective interventions that address clients’ low medication adherence

11

Sustainability – Maternal Health QIP

• Electronic data collection and entry tool with accompanying visualization tools will remain

• OB Scheduled Delivery Project Toolkit being developed with information on sustaining change

• OB Education Project involved participation with one prenatal clinic for each RPC, but lessons learned can be shared with networks and spread to other clinics

12

Lessons Learned

• Use existing collaborations• Build off successes• Structure projects to build skills and develop

infrastructure• Create tools and teach people how to use these tools

for quality improvement• Integrate quality improvement into the organization

processes and/or workflow (whether it is a freestanding mental health clinic or prenatal clinic)

• Engage other stakeholders (i.e., health plans)

13

Contact Information

Lindsay.Cogan@health.ny.gov(518) 486-9012

PSYCKEShttps://www.omh.ny.gov/omhweb/psyckes_medicaid/Terese Lawinski, PhD: Terese.Lawinski@omh.ny.gov

NYSPQCwww.NYSPQC.org NYSPQC@health.state.ny.us

14

Holding the GainsJane Taylor, Improvement Advisor

Objective

• Articulate components that support holding the gains achieved through quality improvement efforts

• State increments for planned scale up• State the 5 characteristics of ideas ready for

spread• Value the need to plan early for spread

16

What it Looks Like to ‘Hold the Gains’

• Collect data over time when conditions are expected to change

© Institute for Healthcare Improvement Impact Collaborative

Baseline

Testing

SuccessfulTesting

Begin implementation on pilot unit

Evidence of improvementduring implementation

17

What Supports Holding the Gains?

The Institute for Healthcare Improvement surveyed successful teams and found:• 97% of teams that achieved results could hold gains• 67% could exceed their gains • Successful teams:

• Continue to track their performance with data• Periodically report results to leadership after a

project’s end• Began early planning in the project to sustain

progress

18

What Supports Holding the Gains?

• Successful teams:• Documented the improvement process• Documented the process required to ‘hold’

new level of performance• Took specific actions to make the improved

processes permanent• Organizations developed a plan for spread

early

19

Forces That Pull Us Away From Gains: They Won’t Hold Themselves!

• Complacency about having met the goals • Assumption that once met, the performance level will

stick• Competing priorities reduce resources• Lack of leadership interest or attention• Lack of knowledge of what is required to hold the

gains• Infrastructure issues were not secured for holding the

gains or scale up and spread

Those Who Hold the Gains…

• Use data and continue to look at data on run charts

• Continue to report performance, challenges to structure and systems

• Continue a commitment to accountability• Keep leaders interested and supportive • Still meet as a team periodically – less often, but

still meet• Pounce on processes as soon as they see data

slip

21

• Develop and offer training• Account for turnover and integrate the process in

new hire orientation• Attend to policy and document procedures• Map out the flow process• Rewrite job descriptions if needed• Designate who is responsible for key tasks • Plan ahead early in the project for holding the gains

and spread• Address social aspects of the changes when

implementing them

Those Who Hold Gains…

22

Reflective Moment

• Think of a specific change you recently implemented.

• Assume your ‘team’ or key staffers all retire; will this change continue?

• What things can you anticipate might cause the change to revert back to its old way?

23

Developing Degree of Belief in Changes

© 2005 Institute for Healthcare Improvement24

• Improve• Implement • Hold the Gains• Scale Up• Spread

Sequence

25

• Test small• Test often• Test under a wide range of conditions• Expand scope of testing • Increase the degree of belief the change brings

about improvement• Expect some failures and learn from them• Fool-proof the change

Improvement is About Testing Ideas, Learning What Works and How It Works

26

• Redesign the process• No longer expect failures• Understand contexts for implementation

differ• Explore system and infrastructure barriers• Work with leadership to resource and

overcome the barriers to implementation

Implementation is About Making the Change Permanent

27

Pay attention to:• Communication• Infrastructure changes needed to secure gains• Use of data to receive signals of performance

Holding the Gains is About Vigilance

28

Scale Up: All About the Infrastructure and System Issues

• Ideas have been tested and are ready for “export”

• Pilot sites have shown the value of “good ideas”• A lot is now known about “how” to make change

useful• No longer expecting failure

29

• As scale up occurs, more organizations or units implement the change. • Barriers to the change emerge that the

pilot may not have experienced.• These barriers may be systemic or local.• The barriers need to be removed for the

change to succeed. • A useful spread strategy moves from

1 pilot setting to 5 to 25 to 125, etc.

Scale Up: A Strategy to Surface Systemic Barriers to Implementation

30

• Successful changes in pilot sites• Infrastructure and Systemic Barriers have been identified

and removed • Larger system is ready based on pilot site(s) testing and

implementation

Spread: Others in the System Want to Adopt the Change(s)

31

• Where are your pilot sites?• Are they robust enough to test-revise-implement-scale

up?• Do you have a system to learn from them?• Are they diverse enough to prepare for spread?• What, if any any cultural issues need addressing prior to

spread?• Do you have a spread plan?• Is there capacity and capability to manage and do

spread

Reflective Moment

32

1. See it – it is observable in use2. Try it – it can be trialed, tested, or used first3. It is compatible to how things are done now4. It is easy to use5. It has a relative advantage over the current

way

– Characteristics based on Everett Rogers book, Diffusion of Innovations

Five Characteristics That Make an Idea Spreadable

33

Adoption Curve

EarlyAdopters

EarlyMajority

LateMajority

Laggards

2.5% 13.5% 34% 34% 16%

Innovators

34

• What is the change?• Does it meet criteria of spread-ability?• Are the infrastructure issues and system barriers

removed or is the way prepared?• What are the social networks, relationships,

connections that will support and facilitate spread?

When Planning for Spread Consider These Questions

35

• How do we publish and promote success from pilot sites and the lessons learned?

• Do we have a good setup for spread?• A team to oversee it?• Leadership support in the receiving sites?

• Do we have vehicles to communicate change and rationale?• Lessons learned from the field for support?

When Planning for Spread Consider These Questions

36

• What policy and incentives accompany the change?

• How will spread be managed?• How will we measure the reach of spread?• What data can we look at that gives us frequent

enough feedback to understand spread progress and if gains are held or improved through spread?

• How do we build knowledge so that we can continue to improve during spread, so that spread becomes perpetual motion?

A Few More Questions for Consideration

37

In Closing, What We Want Determines How We Do It

SHAREINFORMATION

SHAPE BEHAVIOR

GeneralPublicationsFlyersNewslettersVideosArticlesPosters

PersonalTouchLettersCardsPostcards

InteractiveActivitiesTelephoneEmailVisitsSeminarsLearning setsModeling

Face-to-FaceOne-to-oneMentoringSecondingShadowing

PublicEventsRoad showsFairsConferencesExhibitionsMass meetings

Adapted from Ashkenas, 1995 IHI Impact Collaboratives © 2001, Sarah W. Fraser

38

References

• Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992

• Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.

• Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business SchoolPress, 2000.

• Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October 1997.

• Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000.• Fraser S. Spreading good practice; how to prepare the ground, Health Management,

June 2000.• Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000.• Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood, Il:Irwin ,1978.• Langley, Moen, Nolan, Nolan, Norman and Provost (2009 2nd ed.). The Improvement

Guide. Jossey Bass

39

Contact Information

• Jane Taylor, EdD• jane1taylor@mac.com

40

Discussion

Question and Answer

41