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Slide 2 1 The Science of Improvement: Creating Reliable Health Systems Debbie Barnard,MS,CPHQ SHN Project Manager, CPSI October / November 2007 Slide 3 Atlantic Node 2 Introduction Current State of Healthcare Slide 4 Atlantic Node 3 Canadian Adverse Events Study (Hospital settings) (Baker, R. & Norton, P. et al. (2004) Incidence rate of 7.5% in hospitals (2000) 70,000 preventable adverse events (est.) 9,000 - 24,000 preventable AE deaths in Canada (2000) One in 9 acquire infection in hospital One in 9 given wrong medication More deaths occur due to adverse events than from breast cancer, vehicle accidents and HIV Canadian Experience Slide 5 Atlantic Node 4 How Hazardous Is Health Care? (Leape) Slide 6 Atlantic Node 5 How Hazardous Is Health Care? (Leape) Copyright 2002 Institute for Healthcare Improvement The Goal Slide 7 Atlantic Node 6 Seeing Differently Slide 8 Atlantic Node 7 The real act of discovery is not in finding new lands, but in seeing with new eyes. Marcel Proust (1871-1922) Slide 9 Atlantic Node 8 Nine Box Puzzle On your sheet there are nine dots arranged in a set of three rows. Your challenge is to draw four straight lines which go through the middle of all of the dots without taking your pen off the sheet of paper. You can start from any position on the paper and draw the lines one after the other without moving your pen from the paper. Each line must start where the last line finishes. Slide 10 Atlantic Node 9 System of Profound Knowledge Appreciation for a system Knowledge about variation Theory of knowledge Psychology The System has four parts Source: Horn, Steve, Deming's System of Profound Knowledge http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007] http://home.clara.net/hornsc/spk/spk_intro.htm Slide 11 Atlantic Node 10 Aim or Values Lens of Profound Knowledge Appreciation of a system Understanding Variation Theory of Knowledge Psychology The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations. Deming, The New Economics, 1993 Provost, L.; Godlee, F., Connecting the Science of Improvement to Medical Research International Forum on Quality and Safety in Health Care [Online Access Oct. 2007] Slide 12 Atlantic Node 11 Demings System of Profound Knowledge Source: Margolis,P & Lannon L; NRSA AHRQ Workshop: Quality and Quality Improvement Slide 13 Atlantic Node 12 Understanding Systems Slide 14 Atlantic Node 13 What is a System? A system is a network of interdependent components that work together to try to accomplish the aim of the system. W Edwards Deming, The New Economics, p. 50 Slide 15 Atlantic Node 14 System Source: Horn, Steve, Deming's System of Profound Knowledge http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007] http://home.clara.net/hornsc/spk/spk_intro.htm Slide 16 Atlantic Node 15 Common View of a System CEO VP Manager Director VP Director RN Director Assistant Slide 17 Atlantic Node 16 Common Conception of a System CEO VP Manager Director VP Director RN Director Assistant NO!!!! According to Deming Slide 18 Atlantic Node 17 Slide Slide 19 Atlantic Node 18 System of Improvement - Five Activities for Leaders Source: Harries, Bruce: Presentation to SHN Education Resources Committee January 2007Quality as a Business Strategy Associates in Process Improvement (API), Austin Texas - copy write Slide 20 Atlantic Node 19 Types of Processes Mainstay processes - those processes that directly relate to the mission of the organization and add value to the external customers of the organization. Source: Quality as a Business Strategy - Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006 Slide 21 Atlantic Node 20 Types of Processes Driver processes - those processes that "drive" the mainstay of the organization. These processes are usually associated with the need that the organization intends to fulfill (from the mission statement of the organization). Examples: customer feedback, planning, research, development, budgeting, etc. Source: Quality as a Business Strategy - Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006 Slide 22 Atlantic Node 21 Types of Processes Support processes - those processes that are necessary to support the mainstay processes. Examples for a healthcare organization are IT, HR, Communications, etc. Source: Quality as a Business Strategy - Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006 Slide 23 Atlantic Node 22 Harries, Barnard, Hoffman 2006 EXAMPLE Slide 24 Atlantic Node 23 Understanding Variation Slide 25 Atlantic Node 24 In God we trust. All others bring data. W.E. Deming, Ph.D. Slide 26 Atlantic Node 25 Measurement Has Two Purposes Helps you to know: Where you are? Where you are going? Without measurement it is impossible to know whether you have improved Slide 27 Atlantic Node 26 Types of Measures Type of measureExamples Outcome measures Process measures Balancing measures Rates Failures Re-admits Mortality, LOS % use order set, guideline, etc % treated in required time % receiving 100% of bundle Times, durations Etc Costs Delays Resources % detected by redundant process Etc Slide 28 Atlantic Node 27 Process vs. Outcome Measures Outcome = Voice of customer/patient: How is the system performing? What is the result of systems? How is the health of patients affected? Process = Voice of workings of the system: Are the parts/steps in the system performing as planned? Are key changes being implemented? Slide 29 Atlantic Node 28 Common Terms Variation - difference in the output of a process (or inputs to a process) over time. Variation consists of common cause variation, special cause variation and structural variation (and some include tampering). Common Cause Variation - variation resulting from the system. Every system will have some amount of variation of results. Special Cause Variation - variation resulting from a assignable cause. Special causes should be addressed by finding the special cause and taking action.. Source: Horn, Steve, Deming's System of Profound Knowledge http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007] http://home.clara.net/hornsc/spk/spk_intro.htm Slide 30 Atlantic Node 29 Common Terms Structural Variation - trends within the data. They often take the form of seasonal variation and growth or decline Tampering - taking action based on the belief that a common cause is a special cause. Most variation (97% +) is common cause variation Source: Horn, Steve, Deming's System of Profound Knowledge http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007] http://home.clara.net/hornsc/spk/spk_intro.htm Slide 31 Atlantic Node 30 Understanding Variation Source: Horn, Steve, Deming's System of Profound Knowledge http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007] http://home.clara.net/hornsc/spk/spk_intro.htm Stable Process - one in statistical control. Unstable Process - a process not in statistical control. Slide 32 Atlantic Node 31 Common Cause Variation Variation exists in all aspects of life Peoples Behavior Weight Stress Time required to travel to work People how they learn, intelligence Slide 33 Atlantic Node 32 Psychology Slide 34 Atlantic Node 33 Psychology This is Demings language for the dynamics of people in the workplace, team performance, learning styles and organizational culture. Deming opines that managers need to know how people interact, their individual needs, their working and learning styles. Slide 35 Atlantic Node 34 Theory of Knowledge Slide 36 Atlantic Node 35 Knowledge for Improvement Profound Knowledge Subject Matter Knowledge Improvement Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Provost, L.; Godlee, F., Connecting the Science of Improvement to Medical Research International Forum on Quality and Safety in Health Care [Online Access Oct. 2007] Slide 37 Atlantic Node 36 Introduction to PDSA Deming argued that inspection at the end of the process is too late and too expensive. Quality results from studying and changing the system, not inspecting the product Measurements used to monitor the processes Slide 38 Atlantic Node 37 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements we seek ? ActPlan StudyDo Model for improvement Aims Measurement The three fundamental questions for improvement The fourth question: how to make changes Langley, Nolan et al 1996 Ideas, evidence, hunches, Other people etc. Slide 39 Atlantic Node 38 Repeated Use of the PDSA Cycle Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow- up Tests Wide-Scale Tests of Change Implementation of Change What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Slide 40 Atlantic Node 39 Why Test Why Not Just Implement then Spread? Increase degree of belief Document expectations Build a common understanding Source: IHI Slide 41 Atlantic Node 40 Why Test Evaluate costs and side-effects Explore theories and predictions Test ideas under different conditions Learn and adapt Source: IHI Slide 42 Atlantic Node 41 We Know That Every system is perfectly designed to get the results it gets. If we want different results, we must change (transform) the system Source: Maher,L. and Plsek, P. Bringing Creativity and Innovation to Health Services Presented at the Quality Improvement in Healthcare Forum, Prague, April 2006 Slide 43 Atlantic Node 42 Reliability in Healthcare Slide 44 Atlantic Node 43 Why reliability? Implementing reliability concepts has been found to reduce defects in care, increase the consistency with which appropriate care is delivered and improve patient outcomes. ( IHI 2004) Reliability means keeping a promise (Don Berwick) Source: Murkin, J. Reliability Theory in Action. www.nhsscotlandevent.com/.../1330%20wed%20alsh%20%20Reliability%20Theor y%20in%20Action%20FULL%20SESSION.ppt [Accessed Oct. 2007] Slide 45 Atlantic Node 44 Reliability Rates in Healthcare A large study in US health care using detailed case notes review concluded that the defect rate in the technical quality of American healthcare is approximately - 45% (McGlynn, et al The quality of healthcare delivered to adults in the United States NEJM 2003; 348) Slide 46 Atlantic Node 45 3 Steps Towards Reliability 1. Prevent failure (a breakdown in operations or functions). 2. Identify and Mitigate failure: Identify failure when it occurs and intercede before harm is caused, or mitigate the harm caused by failures that are not detected and intercepted. 3. Redesign the process based on the critical failures identified. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)www.IHI.org Slide 47 Atlantic Node 46 Reliability Equation Reliability = Number of actions that achieve the intended result Total number of actions taken Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)www.IHI.org Slide 48 Atlantic Node 47 ReliabilityWhat does the system look like? Less than 10 -1 (