Note:
For a list of HDC Acronyms, please click HERE.
For a list of CHC-related Terms and Acronyms, please click HERE.
Please click or scroll down for terms and concepts beginning with:
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The period of time between learning sessions when teams work on improvement in their organization. They are supported by the Collaborative leadership team, faculty, and other Collaborative team members via a variety of resources such as listservs, virtual offices, web sites, teleconferences, etc.
A written, measurable, and time sensitive statement of the accomplishments a team expects to make from its improvement efforts. The aim statement contains a general description of the work, the population of focus, and the numerical goals.
A line chart showing results of improvement efforts plotted over time. The changes made are also noted on the line chart at the time they occur. This allows the viewer to connect changes made with specific results.
A numerical scale used to assess the progress of participating teams toward reaching their aim. 1= forming, and 5 = outstanding, sustainable improvement. In each Collaborative, cluster staff assesses teams and also asks them to evaluate their own progress using this scale. The expected level of attainment by the end of the Collaborative is a 4.0 (significant progress).
A model that represents the ideal system of healthcare for people with chronic disease and an approach to re-designing healthcare to mirror that ideal system. Developed by Improving Chronic Illness Care, the model has six components: community resources and policies, healthcare organization, self-management support, decision support, delivery system design, and clinical information systems.
The leader of the Collaborative, usually an expert in the topic.
An individual in the organization who believes strongly in quality improvement and is willing to work with others to test, implement, and spread changes. Teams need at least one clinical champion. Champions in other disciplines who work on the process are important, as well. This champion should have a good working relationship with colleagues and with the day-to-day leader(s) described below, and be interested in driving change in the system.
A general idea for changing a process, usually developed by an expert panel based on literature and practical application of evidence. Change concepts are usually at a high level of abstraction, but evoke multiple specific ideas for how to change processes. “Simplify,” “reduce handoffs,” “consider all parties as part of the same system,” are all examples of change concepts.
An action-oriented, specific idea for changing a process. Change ideas can be tested to determine whether they result in improvements in the local environment. An example of a change idea is, “Simplify process for data entry by having front desk staff enter visit information daily from a duplicate copy while the original is filed in the chart”.
A collection of change concepts and key changes.
A Clinical Information System (CIS) incorporates the development of a comprehensive, integrated information system that is “patient-centered”, includes patient registries, a practice management system including a billing system, an electronic health record and personal health records.
A systematic approach to healthcare quality improvement in which organizations and providers test and measure practice innovations, then share their experiences in an effort to accelerate learning and widespread implementation of best practices. “Everyone teaches, everyone learns”.
The group of experts on the topic who assist the chairpeople in developing the Collaborative and in teaching and coaching participating teams.
All individuals from the participating organizations that drive and participate in the improvement process. A core team of three to four individuals attends the learning sessions, but a larger team, often from various disciplines, participates in the improvement process in the organization.
Person responsible for many of the day-to-day activities of the Collaborative, including: meetings, materials, phone calls, website, reports, and information management.
The manager of a Collaborative in the cluster, who works with the faculty, Cluster Coordinators, and Information System Specialists to teach and coach teams, and is a part of the planning and execution of learning session and action period activities.
The members are those individuals who attend the learning sessions and are accountable to the senior leadership for the work of the Collaborative.
See “PDSA cycle”
A specific description of the data to be collected, the interval of data collection, and the subjects from whom the data will be collected. The plan is included in all senior leader reports.
This person manages the team, arranges meetings, assures tests are being completed, and data are collected. The day-to-day leader will be the critical driving component of the team, assuring that tests of change are implemented and overseeing data collection. It is important that this person understand not only the details of the system, but also the various effects of making change(s) in the system. This individual also needs to be able to work effectively with the physician champion(s). The day-to-day leader will be the “key contact” at the organization. This individual should be responsible for coordinating communications between the team, the sponsorship team and staff. Usually requires 0.25 FTEs or more to complete this role.
In the improvement process, the opinion leader within the organization who brings in new ideas from the outside, tries them, and uses experiences with positive results to persuade others in the organization to adopt the successful changes.
The individuals in the organization who will adopt a change only after it is tested by an early adopter (early majority) or after the majority of the organization are already using the change (late majority).
A communication system that allows teams to stay connected with the leadership team and each other during the action periods. Sharing information, getting questions answered, and solving problems are all part of e-mail list activity.
A meeting of HDC Pilot/Prototype teams to gather information, and evaluate the successes, improvements and barriers gained during the intensive one year program known as a Pilot/Prototype.
Taking a change and making it a permanent part of the system. A change may be tested first and then implemented throughout the organization.
Refers to the information system of an organization, usually the computerized information system.
An individual in the Cluster working with the Cluster Director and Cluster Coordinator to assist the teams with registry development and upkeep, reporting graphs, e-mail, listservs and presentations.
The list of essential process changes that will help lead to breakthrough improvement. Key changes are more focused and detailed than change concepts, but they are not specific to the local environment like change ideas. An example of a key change is, “Enter data into registry regularly”.
The individual on the organization’s team who takes responsibility for communication between the team and collaborative staff, including monthly reporting, and dissemination of information to team members.
A three-day meeting during which participating organization teams meet with faculty and collaborate to learn key changes in the topic area, including how to implement them, an approach for accelerating improvement, and a method for overcoming obstacles to change. Teams leave these meetings with new knowledge, skills, and materials that prepare them to make immediate changes.
An automatic mailing list. When e-mail is addressed to a LISTSERV mailing list, it is automatically broadcast to everyone on the list. The result is similar to a newsgroup or forum except that the messages are transmitted as e-mail and are, therefore, available only to individuals on the list.
A focused, reportable unit that will help a team monitor its progress toward achieving its aim. The collaborative has a list of required key measures for each condition, as well as a list of additional key measures that have been found to be helpful to the team in achieving excellent results.
An approach to process improvement, developed by Associates in Process Improvement, which helps teams accelerate the adoption of proven and effective changes. The model includes use of “rapid-cycle improvement”, successive cycles of planning, doing, studying, and acting (PDSA cycles).
Another name for a cycle (structured trial) of a change, which includes four phases: Plan, Do, Study, and Act. The PDSA cycle will naturally lead to the “plan” component of a subsequent cycle.
The first year of the Collaborative is called Phase I. A core team of individuals from each health center attends four learning sessions, separated by action periods. It is during this first year that teams are expected to successfully implement the care model for their population of focus (POF).
Sustain and Spread Phase - After the first year of a collaborative, health centers begin Phase II. Phase II involves sustaining the improvements that have been made in that first year, and spreading those improvements throughout the entire organization. Phase II also involves spread of the improved system of care to other chronic diseases or providers.
The clinic location for focused changes. After implementation and refinement, the process will be spread to additional locations.
A designated set of patients who will be tracked to determine whether changes have resulted in improvements. Ideal size for most chronic disease collaboratives is between 150-300 patients (this is a dynamic number and will fluctuate slightly from month to month). It is this sub-population that will then be the initial focus of the change in practice.
The time before the first learning session when teams prepare for their work in the Collaborative. Pre-Work activities include attending cluster conference calls, forming a team, registering for the first learning session, scheduling initial meetings, preparing an aim statement, defining a population of focus, selecting measures, and beginning to populate a registry.
A year-long, intensive Health Disparities Collaborative test program designed to evaluate the successes, improvements gained when focusing the Care Model toward a new chronic condition or patient population.
A list or database set of records that contain individual patient information. The registry should provide the following: clinically useful and timely information, reminders and feedback for providers and patients, identify relevant patient subgroups and support proactive care, and facilitate individual patient care planning. “Registry size” refers to the count of patients represented in the list.
See “annotated run chart”.
The executive in the organization who supports the team and controls all the resources employed in the processes to be changed. The senior leader works to connect the team’s aim to the organization’s mission, provides resources for the team, and promotes the spread of work of the team to other sites, providers, and conditions.
The standard reporting format for reporting monthly progress during the collaborative. This concise two-page report includes an aim statement, measures to be used, a data collection plan, a listing of the changes made, and the results displayed graphically on annotated run charts. Report to be prepared by pilot team and sent to the Cluster Director and the senior leader.
The intentional and methodical expansion of the number and type of people, units, or organizations using the improvements.
The board that displays information about a team and its progress and that is displayed at learning sessions to help create an environment conducive to sharing and learning from the experiences of others. For more information, see the “Pre-Work” section.
The ability to maintain the improved system of care. This implies that the changes implemented are no longer person-dependent, but are driven by the routine of the system. New procedures, staff roles, and staff responsibilities are documented in policies and procedures, job descriptions, new staff orientation, etc. Additionally, the Collaborative is part of the organizational performance improvement/quality improvement plan, strategic plan and business plan.
The core team member who has direct authority to allocate the time and resources to achieve the team’s aim, has direct authority over the particular systems affected by the change, and will champion the spread of successful changes throughout the department or service area. The system leader attends all three learning sessions as well as the national forum.
The group of individuals, usually from multiple disciplines that drive and participate in the improvement process. A core team of three individuals attends the learning sessions, but a larger team of six to eight people participates in the improvement process in the organization.
The team member in the organization who has a strong understanding of the process to be improved and changes to be made. A technical expert may also provide expertise in process improvement, data collection and analysis, and team function.
A small-scale trial of a new approach or a new process. A test is designed to learn if the change results in improvement, and to fine-tune the change to fit the organization and patients. Tests are carried out using one or more PDSA cycles.
A communication system that allows teams to stay connected with the leadership team and each other during the action periods. Sharing information, getting questions answered, and solving problems are all part of website activity.
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