Systems Change:
From a “Good Idea” to a Practice Culture
Your name, institution, etc. here
YOUR LOGO HERE
(can paste to each slide)
…dedicated to eliminating children’s exposure to tobacco
and secondhand smoke
Objectives
• To understand the importance of creating a system
to address parental tobacco use and SHS exposure of
children
• To understand how to implement changes in your
clinical system using the Plan-Do-Study-Act Cycle
Barriers to Change
• The system is designed
• For children with acute issues
• To provide preventive care and acute illness
management
• To support a single service encounter
• Lack of time
• Reimbursement issues
What Can We Do?
• We have the tools and the knowledge
• Evidence-based treatments exist
• Unique opportunities to use treatments exist
• How do we incorporate this into the day-to-day operations
of our practices?
• Implementation strategies exist
Think of Your Practice
as a “System”
• Include all the parts that make the practice run
• Staff, clinical and administrative
• Records, paper and electronic
• Rooms, hallways, waiting rooms
• Resources in the community and beyond
Analyze System Flow
Patient
checks in
and goes to
registration
or waiting
room
Patient returns to
waiting room after
registration or to
triage
Registration
Labs drawn
Follow-up
appointments
scheduled
LAB
Check In
Triage
Waiting Room
Check Out
Exam
Vitals signs Diagnoses and
taken
lab results
entered in chart
Rx
Prescription
written and/or
filled
Be Thoughtful In Your Implementation
• Understand the current system
• Research the areas most in need of change in your practice
• Start with the end in mind…how do you want your system to
function?
Decision Support* is CRUCIAL
• You need support from the top AND the bottom
• Who’s in charge of Implementation? Supplies? Tracking
outcomes?
• New tasks shouldn’t be added to anyone’s (already too long)
list – make time and space for them
*AKA “buy in”
Team Involvement
Is CRITICAL
• Involve your staff early!
• First meet with key staff, then invite participation by staff at
all levels
• Be sure to include:
• Front desk
• Nursing and clinical staff
• Administration
Get Input
• Brainstorm about implementation and barriers
• Invite ideas on logistics of asking and advising
• Develop implementation plans, using Plan-Do-Study-Act
cycles
The PDSA Cycle
The PDSA Cycle:
Plan, Do, Study, Act
• Prepare a plan for
implementing one small
step.
• Keep it very small!!
• Be very specific
• Include staff
• Prepare materials
• Set a time for the test
(like today!)
Plans Have Components
• How will success be measured?
• What are we doing?
• Who will be the subject(s)?
• How will we start? Finish?
• Where will it be done?
• When will it be done?
The PDSA Cycle:
Plan, Do, Study, Act
• Do it!
• Test it on ONE “sample”
• One family, visit, nurse, or
doc
• Observe flow of program in
the office
• Note places for improvement
The PDSA Cycle:
Plan, Do, Study, Act
• Study it!
• How did it go?
• How was clinic flow
affected?
• Were all materials available
and easy to access?
• What adjustments need to
be made?
The PDSA Cycle:
Plan, Do, Study, Act
• Do another cycle
• Slightly improved or
completely new
• Several cycles are typical
• Step back and take a look
at the “big” picture
The PDSA Cycle:
Plan, Do, Study, Act (Part 2)
• Implement in the entire
practice.
• Inform staff
• Prepare materials
• Make needed changes to
the office system
• Prepare a routine review
cycle
Monitor and Feedback
• Are procedures working as intended?
• Are staff completing assigned tasks?
• Is documentation evident?
• Are patient materials kept up to date?
• Does the team receive timely feedback and support for a job
well done?
Model for Improvement
What are we trying
to accomplish?
How will we know
that a change is an
improvement?
What changes can we
make that will result in
an improvement?
Your Aim
The Measures
The Cycle for
Learning and
Improvement
Now What?
• Mobilize your team!
• Start with an Aim statement…what do you want to
accomplish?
• Then develop small but measurable activities
• Create a PDSA (Plan, Do, Study, Act) cycle
Need more information?
The AAP Richmond Center
www.aap.org/richmondcenter
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control E-mail List
Pediatric Tobacco Control Guide