Time you arrived at checkout. 9. Time you left the practice.

Metrics That Matter Measures are essential if microsystems are to make and sustain improvements and to attain high performance. All clinical microsystems are awash in data, but rela- tively few have the rich information environments that allow the daily, weekly, and monthly use of metrics that matter MTM. The key to having all the data that you actually need is to get started in a practical, doable way and to build out your metrics that matter and their vital use over time. Some guidelines for your con- sideration are listed here. Remember, these are just guidelines, and your microsys- tem should do what makes sense for its purpose, patients, professionals, processes, and patterns in the way it collects, displays, and uses metrics that matter. Primary Care Metrics That Matter Guidelines 1. What? Every microsystem has vital performance characteristics, things that must happen for successful operations. Metrics that matter MTMs should reflect your microsystem’s vital performance characteristics. 2. Why? The reason to identify, measure, and track MTMs is to ensure that you are not flying blind. Safe, high-quality, and efficient performance will give you specific, balanced, and timely metrics that show • When improvements are needed • Whether improvements are successful • Whether improvements are sustained over time • The amount of variation in results over time 3. How? Here are steps you can carry out to take advantage of MTMs. • Lead improvement team. Work with your lead team to establish the microsys- tem’s need for metrics and their routine use. Quality begins with the intention to achieve measured excellence. • Balanced metrics. Build a balanced set of metrics, one that will give everyone insight into what’s working and what’s not working. Some data categories to consider are process flow, clinical, safety, patient perceptions, staff per- ceptions, operations, and finance and costs. Do not start with too many measures. Each of your metrics should have an operational definition, data owner, target value, and action plan. Strongly consider using the Joint Com- mission on Accreditation of Healthcare Organizations JCAHO and Cen- ters for Medicare and Medicaid Services CMS metrics—ones that are already widely used by health care organizations across the nation— whenever they are relevant to your microsystem. Your own experience and strategic initiatives may suggest additional “vital” metrics for your system. Also consider what “gold standard” sets—such as measures from the National Quality Foundation NQF and from some professional organizations, such 416 Appendix A: Primary Care Workbook Appendix A: Primary Care Workbook 417 as the American Society of Thoracic Surgeons ASTS—have to offer your practice. • Data owners or captains. Start small. Identify one or more data owners for each metric. These data owners will be guided by the lead team. Each owner will be responsible for getting his or her measure and reporting it to the lead team. Seek sources of data from organization-wide systems. If the needed data are not available, use manual methods to get the required measures. Strive to build data collection into the flow of daily work. • Data wall displays. Build a data wall, and use it daily, weekly, monthly, and annually. Gather data for each metric and display them on the data wall. For each process being tracked or worked on, report on the Current value or outcome Target value or outcome Action plan to improve or sustain value or outcome Display metrics as soon as possible—daily, weekly, and monthly metrics are the most useful—using visual displays such as time trend charts and bar charts. • Review and use. Review your set of metrics on a regular basis—daily, weekly, monthly, quarterly, and annually. Use metrics in identifying and carrying out needed improvements whenever possible. Make metrics a fun, useful, and lively part of your microsystem development process. Discuss metrics that matter frequently with all staff and take action on these measures as needed. 418 Appendix A: Primary Care Workbook Review the currently determined metrics that your practice should be monitoring, your best metrics. Revise the worksheet in Figure A.14 so that it names and defines your best metrics. Use notes to identify measures sources if you wish. Then use the worksheet to list your microsystem’s current performance in these metrics and also the target values. FIGURE A.14. PRIMARY CARE PRACTICE METRICS THAT MATTER. Definition and Current and Action Plan and Name of Measure Data Owner Target Values Process Owner General Metrics Access 3rd next available appointment Staff morale Staff satisfaction Voluntary turnover Workdays lost per employee per year Safety and reliability Identification of high-risk patient diagnosis and associated medications that put patient at risk such as Coumadin and insulin, and related tests you must track Patient satisfaction Overall Access Finance Appendix A: Primary Care Workbook 419 Definition and Current and Action Plan and Name of Measure Data Owner Target Values Process Owner Patient-Centered Outcome Measures Assessment of Care for Chronic Conditions Visit www.doqit.org for Data Submission Process information Coronary artery disease CAD Antiplatelet therapy Lipid profile Drug therapy for lowering LDL chol. LDL cholesterol level Beta-blocker therapy— prior MI ACE inhibitor therapy Blood pressure Heart failure HF Left ventricular function LVF assess Left ventricular function LVF testing Patient education Beta-blocker therapy ACE inhibitor therapy Weight measurement FIGURE A.14. Continued . continued 420 Appendix A: Primary Care Workbook FIGURE A.14. PRIMARY CARE PRACTICE METRICS THAT MATTER. Continued Heart failure HF Blood pressure screening Warfarin therapy for pts. with atrial fib. Diabetes mellitus DM HbA1c management Lipid measurement HbA1c management control LDL cholesterol level Blood pressure management Urine protein testing Eye exam, foot exam Preventive care PC Influenza vaccination Pneumonia vaccination Blood pressure measurement Lipid measurement LDL cholesterol level Colorectal cancer screening Breast cancer screening Tobacco use Tobacco cessation Hypertension HTN Blood pressure screening Blood pressure control Plan of care OSHA Occupational Safety and Health Administration Safety Log measure. IHI Institute for Healthcare Improvement Whole System Measures 2004. Measures from CMS Center for Medicare and Medicaid Services; American Medical Association AMA Physician Consortium for Performance Improvement; National Diabetes Quality Improvement Alliance; National Committee for Quality Assurance NCQA. Appendix A: Primary Care Workbook 421 Step 3: Diagnose With the interdisciplinary lead team review the microsystem’s 5 P’s assessment and metrics that matter. Also consider your organization’s strategic plan. Then select a first theme, for example, access, safety, flow, reliability, patient satisfaction, communication, prevention, or supply and demand for improvement. The purpose of assessing is to make an informed and correct overall diag- nosis of your microsystem. First, identify and celebrate the strengths of your system. Second, identify and consider opportunities to improve your system: • The opportunities to improve may come from your own microsystem. They might arise from the assessment, staff suggestions, or patient and family needs and complaints. • The opportunities to improve may come from outside your microsystem. They might arise from a strategic project or from external performance or quality measures. • In addition to looking at the detailed data from each assessment tool, you should also synthesize the findings of all the assessments and metrics that matter to get the big picture of your microsystem. Identify linkages within the data and information. Consider Waste and delays in the process steps. Look for processes that might be re- designed to result in better functions for roles and better outcomes for patients. Patterns of variation in the microsystem. Be mindful of smoothing the vari- ations or matching resources with the variation in demand. Patterns of outcomes you wish to improve. It is usually smart to pick out or focus on one important theme to improve at a time. Then you can work with all the “players” in your system to make a big im- provement in the area selected. Finally, write out your theme for improvement and a global aim statement. Follow the information and examples in Chapters Fifteen and Sixteen. Use the global aim template in Figure 16.2. Step 4: Treat Your Primary Care Practice Draft a specific aim statement and a way to measure that aim using improvement models—PDSA plan-do-study-act and SDSA standardize-do-study-act. Now that you’ve made your diagnosis and selected a theme worthy of im- proving, you are ready to begin using powerful change ideas, improvement tools, and the scientific method to change your microsystem. This change begins with clearly identifying a specific aim and using the plan- do-study-act PDSA method, which is known as the model for improvement. After you have run your tests of change and have reached the target value for your specific aim, the challenge is to maintain the gains that you have made. This can be done using the standardize-do-study-act SDSA method, which is the other half of making improvement that has staying power. To identify your specific aim, follow the information and examples in Chap- ter Eighteen. Use the specific aim template in Figure 18.2. With your theme, global aim, and specific aim in hand, you are almost ready to begin testing change ideas with PSDA cycles. However, before you and your team brainstorm your own change ideas, you will be smart to avoid totally rein- venting the wheel by first taking into consideration the best-known practices and the change ideas that other clinical teams have found really work. Also be aware that good change ideas will continue to be developed as more field testing is done and more colleagues design improvements visit www.ihi.org and www. clinicalmicrosystem.org for the latest ideas. A list of some of the best change ideas that might be adapted and tested in your practice follows. This list also offers Web resources for additional support and tools. Primary Care Practice Change Ideas to Consider 1. Change ideas to improve access to care http:www.clinicalmicrosystem.org access.htm • Shape demand. • Match supply and demand. • Redesign the system. 2. Change ideas to improve interaction • Design group visits or shared medical appointments http:www. clinicalmicrosystem.orgsma.htm. • Use e-mail care. • Create a practice Web site. • Optimize professional roles for subpopulation care management. 3. Change ideas to improve reliability • Use a chronic care model, such as the Improving Chronic Illness Care ICIC model http:www.improvingchroniccare.org. 422 Appendix A: Primary Care Workbook Appendix A: Primary Care Workbook 423 4. Change ideas to improve vitality • Engage all staff in continuous improvement and research. • Develop strategies to actively develop individual staff. • Create a favorable financial status, which supports investments in the practice. • Begin holding a daily huddle with MDs, RNs, and clerical staff to review yesterday and plan for today, tomorrow, and the coming week use the worksheet in Figure A.16 on page 430. Also consider the change concepts discussed by Langley, Nolan, Norman, Provost, and Nolan 1996, p. 295. Here are Langley’s main change categories: • Eliminate waste • Improve work flow • Optimize inventory • Change the work environment • Enhance the producercustomer relationship • Manage time • Manage variation • Design systems to avoid mistakes • Focus on the product or service 424 Appendix A: Primary Care Workbook Now you are ready to complete the PDSA SDSA Worksheet Figure A.15 to execute your chosen change idea in a disciplined measured manner, to reach the specific aim. This worksheet offers preparation steps as well as specific PDSA and SDSA steps. Steps 1 to 3 remind you to focus on your theme and specific aim for improvement. They involve big-picture, from 30,000-feet kinds of questions. Then Steps 4 to 7 take you through the PDSA method to improve your process. Steps 8 to 11 help you prepare to standardize your improved process. Then Steps 12 to 15 take you through the SDSA method to standardize the process. FIGURE A.15. PDSA SDSA WORKSHEET. Name of Group: Start Date: TEAM MEMBERS: 1. Leader: 5. 2. Facilitator: 6. 3. 7. 4. 8. Coach: Meeting DayTime: Data Support: Place: 1. Aim What are we trying to accomplish? 2. Measures How will we know that a change is an improvement? 3. Current process What is the process for giving care to this type of patient? Appendix A: Primary Care Workbook 425 4. Plan How shall we plan the pilot? Who does what and when? With what tools or training? Are baseline data to be collected? How will we know if a change is an improvement? Tasks to be completed Tools or Training to run test of change Who When Needed Measures 5. Do What are we learning as we do the pilot? What happened when we ran the test? Any problems encountered? Any surprises? 6. Study As we study what happened, what have we learned? What do the measures show?

7. Act As we act to hold the gains or abandon our pilot efforts, what needs to be

done? Will we modify the change? Make a plan for the next cycle of change. FIGURE A.15. Continued. continued 426 Appendix A: Primary Care Workbook FIGURE A.15. PDSA SDSA WORKSHEET Continued .

8. Standardize Once you have determined this PDSA result to be the current best

practice, take action to standardize, do, study, act SDSA. You will create the conditions to ensure this best practice in daily activities until a new change is identified and then the SDSA moves back to the PDSA cycle to test the idea to then standardize again. 9. Trade-offs What are you not going to do anymore to support this new habit? What has helped you in the past to change behavior and help you do the “right thing?” What type of environment has supported standardization? How do you design the new best practice to be the default step in the process? Consider professional behaviors, attitudes, values, and assumptions when designing how to embed this new best practice. Appendix A: Primary Care Workbook 427 10. Measures How will we know that this process continues to be an improvement? What measures will inform us if standardization is in practice? How will we know if old behaviors have appeared again? How will we measure? How often? Who will measure?

11. Possible changes Are there identified needs for change or new information or a

tested best practice to test? What is the change idea? Who will oversee the new PDSA? Go to PDSA, Steps 4 to 7 on this work- sheet. FIGURE A.15. Continued. continued 428 Appendix A: Primary Care Workbook 13. Do What are we learning as we do the standardization? Any problems encountered? Any surprises? Any new insights to lead to another PDSA cycle? 14. Study As we study the standardization, what have we learned? What do the measures show? Are there identified needs for change or new information or a tested best practice to adapt?

15. Act As we act to hold the gains or modify the standardization efforts, what needs

to be done? Will we modify the standardization? What is the change idea? Who will oversee the new PDSA? Design a new PDSA cycle. Make a plan for the next cycle of change. Go to PDSA, Steps 4 to 7 on this worksheet. Tasks to be completed to embed standardization and monitor Tools or Training process to run test of change Who When Needed Measures Note: Create a standard process map to be inserted in your playbook. FIGURE A.15. PDSA SDSA WORKSHEET Continued .

12. Standardize How shall we standardize the process and embed it into daily

practice? Who? Does what? When? With what tools? What needs to be unlearned to allow this new habit? What data will inform us if this process is being standardized daily? Appendix A: Primary Care Workbook 429 Step 5: Follow Up Monitor the new patterns of results and select new themes for improvement. Embed new habits into daily work, using daily huddles, weekly lead team meet- ings, monthly “town hall” meetings, data walls, and storyboards. Improvement in health care is a continuous journey. New patterns need to be monitored to ensure improvements are sustained. Embedding new habits into daily work through the use of huddles to review and remind staff as well as weekly lead team meetings keeps everyone focused on improvements and results that can lead to sustained and continuous improvements. Data walls, storyboards, and monthly all-staff meetings are also methods that should be used to embed new habits and thinking for improvement. Finally, the lead team should continually repeat the improvement process described here for newly recognized themes and needed improvements that are identified by the microsystem’s ongoing assessments and metrics that matter. 430 Appendix A: Primary Care Workbook FIGURE A.16. HUDDLE WORKSHEET. What can we proactively anticipate and plan for in our workday or workweek? At the beginning of the day, hold a review of the day, review of the coming week, and review of the next week. Frequency of daily review is dependent on the situation, but a midday review is also helpful. This worksheet can be modified to add more detail to the content and purpose of the huddles. Practice: Date: Aim: To enable the practice to proactively anticipate and plan actions based on patient need and available resources and do contingency planning. Follow-ups from yesterday “Heads-up” information for today special patient needs, sick calls, staff flexibility, contingency plans, and so forth Meetings Review of tomorrow and proactive planning Meetings Appendix A: Primary Care Workbook 431 References Deming, W. E. 1982. Out of the crisis. Cambridge, MA: MIT Center for Advanced Engineering Study. Langley, G. J., Nolan, K. M., Norman, C. L., Provost, L. P., Nolan, T. W. 1996. The improvement guide: A practical approach to enhancing organizational performance. San Francisco: Jossey-Bass. Rubin H. R, Gandek, B., Rogers, W. H., Kosinski, M., McHorney, C. A., Ware Jr., J. E. 1993. Patients’ ratings of outpatient visits in different practice settings. Journal of the American Medical Association, 2707, 835–840. NAME INDEX 433 A Abraham, M. R., 41, 50 Alexander, J., 192, 196 Amalberti, R., 86, 102 Argyris, C., 90, 93, 102 Arrow, H., 13, 32 Ashling, K., 51 Auroy, Y., 86, 102 Ayto, J., 52, 67 B Baker, G. R., 102 Baker, L. S., 50 Barach, P., 86, 102, 165 Baribeau, P., 164 Barker, R. G., 94, 102 Barnes, B. A., 176 Barnhart, R., 52, 67 Barry, M., 151, 163 Batalden, P. B., 3, 11, 12, 32, 33, 34, 36, 44, 46, 49, 50, 51, 54, 67, 69, 75, 92, 93, 94, 95, 101, 102, 104, 106, 107, 119, 123, 124, 128, 131, 134, 146, 147, 148, 164, 165, 166, 176, 178, 191, 196, 205, 209, 227, 228, 229, 231, 232, 242, 261, 270, 310, 312, 333, 338 Bate, P., 211, 229 Bates, D., 166, 176 Beckham, V., 164 Beer, M., 82, 102 Bennis, W. G., 73, 103 Bensimon, E. M., 93, 102 Berdahl, J., 13, 32 Berwick, D., 6, 32, 86, 87, 102, 176, 205, 215, 235, 299, 381 Birnbaum, R., 93, 102 Bisognano, M., 102 Bladyka, K., 4, 7, 8, 9, 10 Blake, R. R., 65, 67 Blanchard, K. H., 121, 123 Blike, G., 165, 171, 176 Bodenheimer, T., 149, 152, 163, 164 Bohlen, C., 107, 123 Böjestig, M., 73, 212, 213, 214 Bolman, L. G., 65, 67, 78, 80, 81, 93, 94, 95, 102 Bonomi, A. E., 164 Bossidy, L., xxxii, xxxvii, 77, 78, 79, 100, 102 Box, G., 45, 49 Braddock, C. R., III, 157, 164 Brasel, K. J., 176 Brennan, T., 166, 176 Brown, P. W., 180, 196 Bruner, J. S., 216, 217, 218, 229 Bubolz, T., 131, 147 Buckingham, M., 121, 122, 123, 210, 229 Burck, C., xxxii, xxxvii, 90, 102 Burdick, E., 176 C Campbell, C., 50, 106, 147, 178 Capra, F., 12, 32 Carlson, R., 337, 338 Carthey, J., 166, 177 Charan, R., xxxii, xxxvii, 77, 78, 79, 100, 102 Christenson, P., 121, 123 Cisneros-Moore, K. A., 41, 49 Clifton, D. O., 210, 229 Codman, E. A., 131, 146 Coffman, C., 121, 122, 123 Cohen, D. S., 82, 103, 210, 229 Coker, K., 41, 49