Multi-Specialty MOC Portfolio
Approval Program
Progress Report
Version 1.0, as of July 1, 2012
Resource Page
Key Driver Diagram
What is a key driver diagram?
A key driver diagram is a tool intended to help organize your ideas and discover various causes that
contribute to the issue you are trying to improve. The key driver breaks down the aim of your project
into primary and secondary drivers, and helps you determine what changes to make.
• Primary drivers are factors that are part of your system that directly impact the outcome, or aim,
of your QI effort.
• Secondary drivers are the opportunities for change (interventions) in your QI effort. They directly
impact the primary driver of your aim.
Does my diagram have to look exactly like the one provided?
No. It is just a tool and may be modified based on the nature of your QI effort and discussions in your
QI team.
How does this relate to measures?
Primary drivers are usually outcome measures and secondary drivers are usually process measures,
though this is not always the case.
What is the benefit of a key driver diagram?
It quickly identifies the important aspects of your QI effort by explicitly defining the logic behind your
improvement effort. In identifying the aim you must identify what you want to change or improve
(primary drivers) and how you will improve (secondary drivers or interventions). The diagram, when
read right to left indicates that if you perform the secondary drivers (interventions) then the primary
drivers will improve, and the improvement of the primary drivers will satisfy the aim.
Applicable Program
Standards
QI Efforts
• 2.3
• 2.4
• 2.5
Corresponding
Narrative Questions
• 1 (Aim)
• 3 (Interventions)
Get Help
•
•
•
•
IHI: http://www.ihi.org/offerings/ihiopenschool/courses/documents/practicumdocuments/learnerhandbook.pdf
OPQC: https://opqc.net/about/frequently-asked-questions
Stanley Healthcare: http://www.stanleyhealthcare.com/sites/www.stanleyhealthcare.com/files/pdf/Aug08.pdf
NICHQ: http://www.nichq.org/pdf/Model%20for%20Quality%20Improvement.pdf
Revision Date:
Key Driver Diagram
Global Aim
Specific Aim
Attributes of a good
aim statement:
(Specific, Measurable,
Actionable, Realistic
Timely)
Key
What we’re
working on now
Primary Drivers
(outcomes)
Secondary Drivers
(interventions)
Resource Page
PDSA/PDCA Evidence
Why this format?
We believe that improvement occurs through multiple tests of change (improvement cycles).
How is this applied?
Usually improvement begins with a very small test of change, a follow-up change, and subsequent tests of
change that build toward wide scale implementation of successful interventions.
How do I use this form?
In each test of change (improvement cycle) briefly indicate:
• What: what is the objective of this test change . What is the IOM Quality Dimension addressed by this cycle?
This relates to the Plan stage.
• Who: define the patient population for this test of change. This relates to the Plan and Do stages.
• Where: identify the location of the test of change. This relates to the Plan and Do stages.
• When: indicate the timeframe of the test of change. This relates to the Plan and Do stages.
• Who executes: identify the individuals or groups that implemented the intervention(s). This relates to the Do
stage.
• Results: indicate the results of the test of change. This relates to the Study stage.
This represents evidence of multiple tests of change (improvement cycles) via presentation of data.
How many tests of change (improvement cycles) do I have to have?
The current program standards require a minimum of one full cycle of assessment. Future evolutions of the
standards will require more than one full cycle of assessment. Multiple cycles emphasize and encourage the
iterative learning process and potentially have the greatest impact on improving patient care.
Applicable Program
Standards
QI Efforts
• 2.3
• 2.4
• 2.5
• 2.6
Corresponding
Narrative Questions
• 2 (patient
population)
• 3 (interventions)
• 6 (IOM Quality
Dimension)
Note: The DMAIC format used in developing and testing change in the Six Sigma approach to quality
improvement was derived from the PDSA/PDCA format and doing multiple DMAIC efforts is equivalent to
doing multiple PDSA /PDCA cycles.
Get Help
•
•
•
•
IHI: http://www.ihi.org/offerings/ihiopenschool/courses/documents/practicumdocuments/learnerhandbook.pdf
OPQC: https://opqc.net/about/frequently-asked-questions
NICHQ: http://www.nichq.org/pdf/Model%20for%20Quality%20Improvement.pdf
Langley, GJ, Moen, RD, Nolan, KM, et al. The Improvement Guide (2nd edition). San Francisco, Calif: Jossey-Bass; 2009.
PDSA/PDCA Evidence
Plan
Do
Act
Study
TEST 1
What: Evidence knowledge
and application
Who:
Where:
When:
Who executes:
Results:
Plan
Do
Act
Study
TEST 2
What: Evidence knowledge
and application
Who (population):
Where:
When:
Who executes:
Results:
Plan
Do
Act
Study
TEST 3
What: Evidence knowledge
and application
Who (population):
Where:
When:
Who executes:
Results:
Plan
Do
Act
Study
TEST 4
What: Evidence knowledge
and application
Who (population):
Where:
When:
Who executes:
Results:
Resource Page
Results
Why a chart?
Plotting data over time is quick way to identify whether the interventions in your QI effort are leading
to improvement.
What is the benefit of a run chart?
There are several benefits of using run charts.
• They help determine when interventions truly led to improvement by displaying a pattern of data.
There are established rules for determining when statistically significant change has occurred in
data displayed in a run chart that you can investigate.
• They indicate the value of an intervention by temporally displaying whether change occurred at
the time of the intervention
• They identify how well or how poorly the interventions are doing toward achieving your aim
How do I make a run chart?
Plot time along the X axis and what you’re measuring along the Y axis. Make sure to provide a legend
for the chart, label the axes, and provide a relevant title for the chart so that it can be easily
interpreted. You can add pertinent information such as the goal as identified in the aim, the median,
and notes (called annotations) about when events occurred. A run chart can be created from most
spreadsheet tools.
How many run charts do I have to have?
Ideally you would have one chart per measure.
Applicable Program
Standards
QI Efforts
• 2.4
• 2.6
Corresponding
Narrative Questions
• 3 (interventions)
• 4 (measures)
Note: To address HIPAA issues, the run chart should represent aggregated data and not identify
individual patients or physicians.
Get Help
• IHI: http://www.ihi.org/offerings/ihiopenschool/courses/documents/practicumdocuments/learnerhandbook.pdf
• HCI: http://www.hciproject.org/sites/default/files/Annotating%20Run%20Charts%20using%20Data%20Labels.Oct11.pdf
• Langley, GJ, Moen, RD, Nolan, KM, et al. The Improvement Guide (2nd edition). San Francisco, Calif: Jossey-Bass; 2009.
Results
Resource Page
Lessons Learned
For the purposes of this report, a lesson learned is knowledge or understanding gained by
experience. The experience may be positive or negative. It should be significant in that it has a real or
assumed impact on the activity, valid (factually and technically correct), and applicable in that it
identifies a specific design process or decision that reduces or eliminates the potential for future
failures and mishaps or reinforces a positive result. Lessons learned highlight strengths or
weaknesses in preparation, design, and implementation that affect good performance, outcome, and
impact.
What is the distinction of a lesson learned?
A lesson is learned rather than just identified, when it has gone through the following steps:
1. Reflection on the experience.
2. Learning points are identified—what was the difference between what was planned and what
actually happened
3. Analysis has been performed—why was there a difference
4. The experience is generalized—what should be done in the future to avoid the pitfall or repeat
the success
5. Action is taken—a document, procedure, policy, structure, budget, etc. needs to be changed. If
nothing changes, nothing has been learned.
Why must I take action?
Talking about how things get done or working on how things get done does not, in and of itself,
accomplish anything. It is through action that real change occurs.
When are lessons learned captured?
Lessons learned can be captured at any point throughout the life of the activity. The best time to
capture lessons are when they occur.
How many lessons learned need to be documented?
As many as you feel are relevant or necessary to be shared.
Applicable Program
Standards
Sponsors
• 1.2
Participation
• 3.3
Corresponding
Narrative Questions
• 7 (Lessons
Learned)
Lessons Learned
• Lesson 1
• Lesson 2
• Lesson 3
Resource Page
Sustainability and Spread
Developing and implementing successful quality improvement efforts is important, but not
enough to make a measureable improvement on the quality of patient care. Too often
improvements remain unknown and unused by others within the organization. In this section,
identify how the improvement effort will be sustained and spread within the organization.
How is sustainability defined?
For the purposes of this program, sustainability is the maintenance of an improvement effort’s
results for a minimum of 6 months to a year following initial implementation of the
improvement.
Is there a prescribed way to spread improvement efforts that must be used?
No. Every organization is different. While tools exist to help you in this process, you are not
required to use a specific tool or methodology.
Applicable Program
Standards
Sponsors
• 1.2
QI Efforts
• 2.7
Participation
• 3.1
Corresponding
Narrative Questions
• 8 (Sustainability
and Spread)
Get Help
•
•
•
•
Framework for Spread: http://www.ihi.org/knowledge/Pages/IHIWhitePapers/AFrameworkforSpreadWhitePaper.aspx
Tool for Spread Planning: http://www.ihi.org/knowledge/Pages/Tools/SpreadPlanner.aspx
Factors for Spread (RWJ): http://www.rwjf.org/files/research/3628.36734.tcab.spread.ex.sum.pdf
Research on Sustainability: http://www.pcdc.org/assets/pdf/7515_commonwealth_study_-_sustainability_12-07.pdf
Sustainability and Spread
• Plan 1
– Status
• Plan 2
– Status
Resource Page
Physician Participation
Identify the participation requirements that must be met in order for physicians to obtain
MOC Part IV credit from the approved QI Effort.
What is meaningful participation?
For the purposes of this program, meaningful participation is demonstrated by having an
active role in the QI effort over a period of time in which the physician implements the
interventions related to the effort, collects data (if not automated or performed by another),
and reviews the measure data relative to the effort.
How is participation captured?
Physician participation in a QI effort should be captured in an attestation completed and
signed (electronically or via hard copy) by the physician and the leader of the effort.
Applicable Program
Standards
QI Efforts
• 2.1
• 2.2
Participation
• 3.1
• 3.2
• 3.3
Get Help
• Foster, Ogrinc, Hamby, Weeks (2002): “Improving the effectiveness of physician participation in local quality improvement
efforts.” Quality Management in Health Care. Spring, pages 25-30
• Center for Studying Health System Change: http://www.hschange.com/CONTENT/1087/
Physician Participation
• Requirements for participation in order to earn MOC Part IV credit
– Include length of time, involvement, etc.