Improving Your Primary
Care Practice: Part I
Sue Butts-Dion
Improvement Advisor
Institute for Healthcare Improvement
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This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ).
The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.
Learning Objectives
By the end of this module you will be able to:
Describe
the evolution of quality improvement
Describe key principles of quality improvement
Use the MFI to test a small improvement


Personal improvement
Primary Care improvement
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PROMISES Project
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Evolution of Quality (in Healthcare)
1820-1910
1910-1950
1950-1990
Structure Process Outcome
Donabedian (1966)
JCAHO Medical Audit &
Performance Evaluation (1972)
American College of
Surgeons/
Codman
(1918)
JCAHO Agenda for Change
Announced—Use of Clinical
Indicators (1986)
First Quality Manual
Published (18 pages!)
(1926)
ELI founded (1984) HCA 1st
Healthcare client (FOCUS PDSA)
(1987)
1990-Present
Institute for Healthcare Improvement
Founded (1991)
The Institute for Family-Centered Care,
founded (1992)
QHR: Strategic Quality Management 1992
The Improvement Guide published (Model for
Improvement MFI) 1996
IOM publishes “To Err is Human” (1999)
Florence Nightingale
Uses Statistical Analysis
and Plots the Incidence
of Preventable Deaths
in the Military
(1820-1910)
Deming and Juran become
prominent figures in the
field of quality management
in industry
(PDSA) (1945)
JCAHO
(1951)
Vermont Oxford Network
(NICQ’s) (1988)
Agency for Healthcare Research
and Quality (AHRQ) Created
(1989)
NICHQ Founded (1999)
Ryan White Program quality
legislation (2000)
IOM publishes Crossing
the Quality Chasm (2001)
AHRQ , CMS & DHHS partner to
develop HCAHPS (2002)
QHR: Center for Continuous
Improvement 1989
IHI launches Improvement
Campaigns (2004)
NCQA Founded (1990)
IPIP initiated (2005)
NC CPHQ founded (2010)
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Underlying QI Principles



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Focus on systems, not people
Intervene iteratively using PDSA cycles
Use measurement and data for decision making
Remember that customers are key
Acknowledge that improvement requires change
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Improvement Requires Change
“While all changes do not lead to improvement,
all improvement requires change.” –IHI website
The proposed freeway to remove the
bottleneck created by the previous
proposed freeway to remove the bottleneck
created by…
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Model for Improvement (MFI)
Model for Improvement



What are we…
How will we…
What changes can we…
PDSA =
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Developed by: Associates in Process Improvement
How It Works…(or Doesn’t Work!)
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How It Works…(or Doesn’t Work!)
“I won’t do this
anymore!”
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How It Works…(or Doesn’t Work!)
“I won’t do this
anymore!”
“I will work harder
and faster!”
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How It Works…(or Doesn’t Work!)
“I will be more
vigilant!”
“I won’t do this
anymore!”
“I will work harder
and faster!”
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How It Works…(or Doesn’t Work!)
“I will be more
vigilant!”
“I won’t do this
anymore!”
“I will work harder
and faster!”
I was doing things the same way:
maybe a little faster, maybe with more
attention, maybe with more intention…
and expected different results.
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What Had I Been Missing?
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What Had I Been Missing?

Aim
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What Had I Been Missing?
Aim
 Measures

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What Had I Been Missing?
Aim
 Measures
 Changes

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What Are We Trying to
Accomplish? (My Aim)
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What Are We Trying to
Accomplish? (My Aim)
“Some is not a number.”
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Quotes from Don Berwick speech, 2004
What Are We Trying to
Accomplish? (My Aim)
“Some is not a number.”
“Soon is not a time.”
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Quotes from Don Berwick speech, 2004
What Are We Trying to
Accomplish? (My Aim)
“Some is not a number.”
“Soon is not a time.”
“Hope is not a plan.”
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Quotes from Don Berwick speech, 2004
What Are We Trying to
Accomplish? (My Aim)
“Some is not a number.”
“Soon is not a time.”
“Hope is not a plan.”
My aim: By Thanksgiving of this year,
I want to decrease the time spent working
past 5:30 PM ET from 180 to 60 minutes per day.
I want to increase my focus on:
(1) improving systems for triaging emails,
(2) improving systems for scheduling calls and meetings.
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Quotes from Don Berwick speech, 2004
How Will We Know That the Change
Is an Improvement? (My Measures)
Outcome Measures:



Average number of minutes
spent each week working past
5:30 PM ET.
Time spent on improving
quality of life (e.g., my time
spent with family, exercising,
reading, etc.)
Family satisfaction/feedback
(qualitative data).
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What Changes Can We Make?
(My Changes and Ideas)
Sources for ideas:



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
Customers, suppliers
Colleagues, coworkers
Literature, experts
Internet (e.g., Google)
Generic Changes

The Improvement Guide,
by Langley, et al.
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The PDSA Cycle for
Learning and Improvement
Act
Adapt?
Adopt?
Abandon?
What’s the
next cycle?
Study
Complete the
analysis of the data.
Compare data to
Predictions.
Summarize what
was learned.
Plan
Objective Questions
& predictions (why).
Plan to carry out cycle
(who/what/where/when).
Next cycle?
Do
Carry out the plan
(on a small scale).
Document problems
and unexpected
observations.
Begin analysis.
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W.E. Deming referred to this as the Shewhart Cycle
A PROMISES PRACTICE:
ATKINSON FAMILY PRACTICE
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Atkinson Family Practice
“We have at least 25 patients calling a day about prescription
refills. Probably 25 a morning.” Karen – Clinical Team Leader
“How can we reduce theses calls? It
seems like that’s all our front desk
staff do—take calls about refills from
patients.” Tom – Practice Manager
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What Are We Trying to
Accomplish?
Aim
Does this answer….
By March 2012 ( in two months),
our practice will:
 Improve the Rx refill process
 Reduce phone calls from
patients or pharmacies to verify
or check on prescription refills
 Reduce the duplicate
prescription requests
 Reduce these events by 50% in
this time frame
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What Are We Trying to
Accomplish?
Aim
Does this answer….
By March 2012 ( in two months),
our practice will:
 Improve the Rx refill process
 Reduce phone calls from
patients or pharmacies to verify
or check on prescription refills
 Reduce the duplicate
prescription requests
 Reduce these events by 50% in
this time frame

What to improve?
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What Are We Trying to
Accomplish?
Aim
Does this answer….
By March 2012 ( in two months),
our practice will:
 Improve the Rx refill process
 Reduce phone calls from
patients or pharmacies to verify
or check on prescription refills
 Reduce the duplicate
prescription requests
 Reduce these events by 50% in
this time frame


What to improve?
For whom?
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What Are We Trying to
Accomplish?
Aim
Does this answer….
By March 2012 ( in two months),
our practice will:
 Improve the Rx refill process
 Reduce phone calls from
patients or pharmacies to verify
or check on prescription refills
 Reduce the duplicate
prescription requests
 Reduce these events by 50% in
this time frame



What to improve?
For whom?
By when?
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What Are We Trying to
Accomplish?
Aim
Does this answer….
By March 2012 ( in two months),
our practice will:
 Improve the Rx refill process
 Reduce phone calls from
patients or pharmacies to verify
or check on prescription refills
 Reduce the duplicate
prescription requests
 Reduce these events by 50% in
this time frame




What to improve?
For whom?
By when?
By how much?
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Key Point About Data:
Improvement is Not Research
Quality improvement
 Aim: improvement
 Data: “just enough” data
Research
 Aim: new knowledge
 Data: “just in case” data
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How Will We Know That a
Change Is an Improvement?
Measures

Number of duplicate requests for the same
prescription refill. We’ll track:


Number of requests
Request method (i.e., calls, fax)
Balancing Measures


Staff Satisfaction
Patient Satisfaction
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What Changes Can We Make?
Identified changes to test
•Test Idea: Pharmacy will…
•Test Idea: Practice will…
•Test Idea: Practice will educate patients to…
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What Changes Can We Make?
Identified changes to test
•Test Idea: Pharmacy will…
•Test Idea: Practice will…
•Test Idea: Practice will educate patients to…
“We need to communicate more.
Otherwise, we are all just irritating
each other and getting upset.”
--Karen, Clinical Team Leader
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What Could You Do Today?
Identify one area that needs improving

Write the first draft of an “aim”
Choose one thing you could measure

Determine: Is it improving? Or not?
List change ideas to test now

Choose a few, or just one
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Thank You!
Thank you
for your time
and attention today
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Assessment Question 1:
What was the first quality improvement in healthcare that
we saw in the 1800s?
Deming became a prominent figure in industry
b) Ryan White Program quality legislation
c) F. Nightingale records preventable deaths
d) First quality manual published
a)
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Assessment Question 2:
Improvement methodologies have common underlying
principles, and recommend focusing on
Focus on people, not systems
b) Focus on systems, not people
c) Focus on systems and people
d) Focus on people to assess the blame
a)
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Assessment Question 3:
Name one place you can access to get ideas for something
to test or try in your practice
Customers/suppliers
b) Colleagues/experts
c) Literature/Internet
d) All of the above
a)
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A Few References
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Langley et al, The Improvement Guide,
1996, 2011
W. Edwards Deming, The New Economics,
2nd Edition, 2000
www.ihi.org
www.deming.org
Want to Learn More?
“Improving Your Primary Care Practice: Part 2”

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Learn more about the benefits of testing
things on a small scale
Learn about scaling up, sustaining, and
spreading changes
Learn about two tools that all improvers
should know about