Toolkit for Providers Serving Children with Hearing Loss
Tip #10: Use a Table-Top Exercise (Virtual Walk-Through) as a Test of the System
Quality improvement typically revolves around the design or refinement of processes of care for patients with specific healthcare needs, using iterative testing and assessment to improve the reliability of services. The more frequently changes can be tested, the more rapidly improvement can occur. For patient populations which are small in a given practice, such as children with epilepsy, efforts at improvement are hindered by the simple fact that care processes are not exercised often enough to provide sufficient opportunities for testing. Table Top exercises (TTX), widely used by public agencies preparing for disastrous rare events such as hurricanes or floods, provide a promising means to address this problem.
The table-top exercise (TTX) brings together representatives from different agencies and organizations who are required to coordinate their actions in the case of some rare event, but who do not regularly work closely together. TTXs are commonly used by disaster-preparedness personnel to rehearse procedures that must be enacted during rare events e.g. earthquakes. This situation is analogous to the various government agencies, NGOs, provider organizations, parent groups, and others who jointly provide care and services for children with special healthcare needs.
In order to be effective, a TTX must include personnel who actually participate in the processes in question. A TTX is organized around a written scenario, which realistically describes a set of events that might occur during an actual incident. The scenario is divided into modules. Each module outlines a sequence of events, and is followed by a series of open-ended probe questions designed to challenge participants to think through the processes, to identify prescribed actions, responsible parties, available resources, and so on. Participants are instructed to 'keep it real', and think through what would actually be likely to transpire in this scenario, and not about what the rules or documentation prescribes. A key purpose of the TTX is to identify ill-defined procedures, missing resources, or other gaps that would pose problems during an actual event.
In the ISC Collaborative, we developed TTX scenarios based on fictitious patients that represent the clinical needs and personal incidents that typically drive care for children with epilepsy. TTX sessions conducted with state Epilepsy teams revealed gaps in processes of care that could impact care quality. TTXs show real promise as a method to help community-based care teams design coordinated processes of care for children with special healthcare needs. They provide a venue for community-based providers to meet together and rehearse cross-organizational handoffs and procedures. The atmosphere of the TTX is non-judgmental, which contributes to better evaluation.
By using a TTX early in the planning for a community-based improvement project, teams could readily identify critical gaps in care that should be addressed. The TTX could double as an organizational meeting, to define project aims and measures, and to help develop relationships among team members. Additional TTX exercises could be used periodically to assess progress and recalibrate priorities.
The TTX technique can be applied to many pediatric conditions. It can also be applied at the practice level, to walk-through processes of care, and to clarify common care processes such as referrals and communication between PCPs and specialists.
What We Learned
- The system of care for Children and Youth with Special Healthcare Needs (CYSHCNs) must be designed to perform well even when dealing with relatively rare diagnoses.
- Individual Primary Care Providers (PCP) practices may see only a few children with epilepsy per year, making it difficult to gain experience with the diagnostic and management processes.
What We Did
- We created a “virtual case history” of a child with a new presentation with seizures.
- We used a table-top exercise, a technique widely used by public agencies preparing for disastrous rare events to design and assess processes and procedures for the provision of services to children with epilepsy. For more information in using the TTX method please click here.
- State Epilepsy teams convened a “roundtable meeting” of stakeholder in the care process including specialists, PCPs, and parents to discuss the path that the child would take through the system, identifying any gaps and barriers to care.
- The group created an algorithm of the process of care.
- Participants used the results to identify priority areas for change in the system, and to identify potential change strategies to trial.
Questions for My Practice
- How would the patient in the virtual history interact with my practice?
- Would there be any gaps in care?
- Could I use a “table-top” exercise like this as a quality improvement tool in my practice?
Changes to Try in My Practice
- Use the TTX (Table Top Exercise) to do a “virtual test” of my practice’s system of managing a patient with a relatively rare condition e.g. new presentation of epilepsy.
- Try small tests of change using PDSAs in those areas with gaps and barriers to care.