Step Three: Implement the MFI Framework

Gather Baseline Data

It’s helpful to collect baseline QI data before selecting a target for your QI activity. Baseline data measure progress and benchmark success. Two examples for collecting QI baseline data are described below.

National SBH Performance Measure Assessment

The National SBH Performance Measures provide promising strategies for improving the care delivered by school-based health professionals (see National Performance Measures webpage for more information). If selecting QI based on these measures, use the tools and resources from the Alliance’s National Quality Count Initiative.

Patient-Centered Medical Home Assessment

Several tools exist to help you assess the extent to which you have integrated the PCMH principles. For formal PCMH recognition, you can use the tool of the accrediting/certifying body ‒ the National Committee for Quality Assurance, the Accreditation Association for Ambulatory Health Care, or the Joint Commission (see The Puzzle: Piecing Together Patient Centered Medical Care and School-Based Health Centers for more details).

Select a QI Focus Area

Review baseline data to narrow your focus area. Keep the following in mind:

  • Less is better. Begin by selecting one focus area.
  • Start with something that’s an easy win.
  • Select a measure that your staff want to improve. This will assure their buy-in and contribute to success.
  • Pick an area that your sponsor supports.*

*Note that buy-in from your sponsor organization is essential. Depending on the scope of your QI efforts, success involves staff time, clinic and school resources, organizational capacity, decision making authority, and financial resources from both the school and the sponsoring organization.

The table below can be used to evaluate your team’s capacity and motivation to implement change around specific focus areas. This table can be completed individually or as a QI team. Consider selecting the focus area that receives the highest score.

Develop an Aim Statement

An aim statement should answer the question, “What are we trying to accomplish?” Your aim statement needs to be SMART:

  • Specific: Sets a clear goal.
  • Measurable: Has concrete criteria for measuring progress and defines success numerically.
  • Achievable: Can actually be accomplished.
  • Realistic: Includes objectives that the team is willing and able to work towards.
  • Time-bound: Establishes a timeframe (usually 6-12 months).

The All About Aims video summarizes how to develop an aim statement. The Aim Statement Worksheet can help you develop your aim statement.

Sample aim statements for the National Performance Measures include:

  • “Increase the percentage of SBH clients aged 0-20 years (WHO) who have had a well-child visit in the last 12 months (WHAT) from 30% to 45% (HOW MUCH) by the end of the current school year (WHEN).”
  • “Increase the percentage of SBH clients ≥ 12 years (WHO) who have had a depression screen using the PHQ9 modified for adolescents (WHAT) by 30% (HOW MUCH) from the last school year to the current school year (WHEN).”
  • “Increase the percentage of SBH clients ≥ 12 years who have a positive depression screen (WHO) who have a documented follow-up plan (WHAT) to 95% (HOW MUCH) by the end of the current school year (WHEN).”
  • “Increase the percentage of sexually active SBH clients (WHO) who have been screened for chlamydia infection (WHAT) from 50% to 75% (HOW MUCH) by the end of the current school year (WHEN).”

Determine the Measure

Determine the measure by asking, “How will we know a change is an improvement?” There may be more than one measure for an aim. For example, if using the last aim listed above, the measure could be stated as such:

  • Numerator – # of unduplicated SBH female clients seen during the current school year (or during the month) identified as sexually active who had one or more tests for chlamydia documented in the past 12 months.
  • Denominator – Number of unduplicated SBH female clients seen during the current school year (or during the month) identified as sexually active.
  • Does it relate directly to aim? “Increase the percentage of sexually active SBH clients (WHO) who have been screened for chlamydia infection (WHAT) from 50% to 75% (HOW MUCH) by the end of the current school year (WHEN).” Yes, the numerator is the number of unduplicated SBH female clients seen during the current school year (or during the month) identified as sexually active who had one or more tests for Chlamydia documented in the past 12 months.
  • Does it specify the population served? Yes, the denominator is sexually active female clients seen during the current school year.
  • Are data available? Yes, they are in your EHR.
  • At what frequency can it be collected? Daily, weekly, monthly? Yes, monthly.
  • Is it worth measuring for at least 12 months? Yes, it’s a HEDIS, UDS, and CHIPRA measure and in PCMH recognition models.

Select Your First Change to Test

“What change can we make that will result in improvement?” Generate a list of possible changes to test. Welcome and consider all team member suggestions. The Performance Measure Change Package provides examples of successful changes that other SBH staff have implemented for each national performance measure focus area.

With the list complete, select which change to test first. The Impact Effort Matrix[i] (see below) can be used to help select a change strategy. For each change strategy, determine which level of difficulty to implement and how much impact it may have on the goal. Each strategy is placed on the Impact Effort Matrix based on the team’s decision.

Start with change strategies that are easy to implement and will have the greatest effect on the aim. You don’t need consensus to test a change. You do need consensus, however, in deciding to adopt a change permanently as a policy.

Example of Using Impact Effort Matrix

Impact Effort Matrix[i]

Test Change Using PDSA Cycle

The PDSA cycle[i] is used to test the change on a small scale to see if it results in the improvement you expected. Multiple PDSA cycles are often needed to make successful change and reach the aim. PDSA cycles provide an opportunity to assess if there are costs involved with the change, like resources, time, and equipment, and determine if the change had unintended consequences. All of these things are important considerations when deciding whether to implement a change as policy. Each PDSA cycle should be brief in duration (1-2 weeks).

Plan:

  • Determine test of your change.
  • List tasks to complete the test. Identify the person that is responsible for each task. Determine the timeframe for completing tasks. Tasks should not be confused with tests. Tasks are the steps required to run the test.
  • Predict what will happen.
  • Decide which data to collect (this is usually not the same as the measure determined in Step 3). For example, if the aim is to increase WCV, the measure is the percentage of SBH clients who had a comprehensive well-visit within the past 12 months. The first PDSA cycle might include scheduling a WVC every morning for one week. The data for this PDSA would be the number of mornings that week with a successfully scheduled well-visit.

Do:

  • Carry out the plan.
  • Make observations.

Study:

  • Study the process and ask the following questions:
    • Did the results match the prediction?
    • How did the results of the test compare to previous performance?
    • What was learned?

Act:

  • Decide whether to abandon, adapt, or adopt the change strategy.
    • Abandon: The change strategy is discarded.
    • Adapt: The change strategy will be tried again but with slight modifications. It may be tried with different staff, different patients, or under different conditions. You want to keep testing it to make it better.
    • Adopt: You will implement the change strategy on a larger scale and develop an implementation plan.

Repeat: To continue to test changes, the next PDSA cycle then begins with the goal of reaching the aim.

Consider using the PDSA Worksheet to document and track PDSA cycles or the Tracking PDSAs from Testing to Implementation document for tracking PDSAs over time.

Tips for Conducting PDSAs

  • Test with small numbers (—patients, locations, etc.).
  • Develop a hypothesis.
  • Test with willing staff.
  • Don’t try for buy-in or consensus for every small test.
  • Have consensus when adopting a change as policy.
  • Be innovative—don’t be afraid to try things in a new way.
  • Collect useful data (qualitative or quantitative) during each test. If you aren’t going to use results, don’t waste your time doing the test.
  • Test over a wide range of conditions (days of week, staffing variables, etc.)
  • Avoid the rush to adopt.
  • Plan multiple cycles to test a change.
  • Think a couple of cycles ahead.

View these brief videos to learn more about conducting PDSA cycles: PDSA Cycles, Part 1 and PDSA Cycles, Part 2.  Share these talking points with your team to explain PDSAs.

Go to Step Four

 

 


[i] Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP.  The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (Second Edition). San Francisco (CA): Jossey-Bass Publishers; 2009.

[i] Anderson B, Fagerhaug T,  Beltz M. Impact Effort Matrix. ASQ Web Site. http://asq.org/healthcare-use/why-quality/impact-effort.html. Updated 2010. Retrieved March 23, 2016.

[i] Anderson B, Fagerhaug T,  Beltz M. Impact Effort Matrix. ASQ Web Site. http://asq.org/healthcare-use/why-quality/impact-effort.html. Updated 2010. Retrieved March 23, 2016.

 

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