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PDCA/Process Improvement
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Objectives
• Discuss how processes are used in healthcare
• List the three types of outcomes any process can have
• List the implications of process improvement that relate to infection prevention.
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Definition: A Process
... a series of linked steps, often but not necessarily sequential, designed to ...cause some set of outcomes to occur
• cause some set of outcomes to occur
• transform inputs into outputs
• generate useful information
• add value
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You Get What You Design
Every system is perfectly designed to produce the results that it achieves.
Dr. Don Berwick, quoting Dr. Paul Batalben
Institute for Healthcare Improvement, Boston
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Perfectly Designed….
Jim Reinertsen, MD
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Process Management• Start with knowledge of
– Processes– Systems (processes interacting together)– Human psychology– Variation– A system for ongoing learning
• Build a rational system to manage processes
• What you get is quality improvement theory.
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Three Classes of Outcomes
• Physical outcomes– medical outcomes: complications and therapeutic
goals– includes functional status measures (patient
perceptions of medical outcomes)
• Service outcomes– satisfaction: patients and families, communities,
professionals, purchasers, and employees– includes access issues (e.g., waiting times)
• Cost outcomes– just another outcome of a clinical process– includes the cost of the burden of disease
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Physical Outcomes
• Four types:1.Appropriateness (referral and procedure
indications)
2.Complications (process failures / defects)
3.Therapeutic goals / biologic function (when stated in the negative, merges with defects)
4.The patient's ability to function (functional status, as reported by the patient)
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Service Outcomes
• Two types:1. The physician-patient relationship (bedside manner:
a "caring and concerned" clinician)2. Access issues: convenience vs. hassle (scheduling,
travel times, registration, physical comfort, wait times, etc.)
• Operate by a separate process independent of medical outcomes
• Service outcomes directly affect market share, community perceptions, customer relations, and rates of malpractice lawsuits
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Cost Outcomes
• Quality controls cost.
• More accurately, quality and cost are two sides of the same coin ...
• (Similarly, cost controls access.)
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Managing a Process Means
the right data
…in the right format
…at the right time (and place)
…in the right hands (the clinicians who operate the
process)
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Types of quality problem
1. Conformance problems - People They choose not to do it.
2. Unstructured/ non-standardized processes Variation in practice? Chaos?
3. Efficiency problems Waste
4. Process failure/ error issues – People & processes
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Identifying a problem• “Problem”:• any deviation between what “should be” and what “is” that is
important enough to need correcting
• Problem Solving:• the activity associated with changing the state of what “is” to
what “should be”• The reality is there are always problems/
“opportunities for improvement”
_Benchmarking against best-practices– Look at performance ‘outliers’ against defined standards– Wide variation in performance – Chaos?– Walk arounds – awareness as supervisors/ managers of
what happens by directly observing how things are done– Solicit feedback from customers– against best-practices– Look at performance ‘outliers’ against defined standards– Wide variation in performance – Chaos?– Walk arounds – awareness as supervisors/ managers of
what happens by directly observing how things are done
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Problem definition/ validation
• The more focused the problem definition, the fewer resources necessary to generate a solution:
– who does it affect / does not affect.
– what does it effect / does not affect.
– how does it effect / does not affect.
– when is it a problem / is not a problem.
– where is it a problem / is not a problem
– What are the various impacts of the problem?
– Where do we stand against benchmarks/ agreed standards?
– Why do we care?
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PDCA
Plan
• Plan 1 small change to test
• Predict what will happen
• Decide on data to evaluate test
Do
• Run the testi.e. put the change temporarily into
the daily process
• Collect data
Check • Analyze the data
• Compare results to predictions
• Summarizewhat was
learned
Act
• Determine
• Plan for next test
if change(s)should be made
• Act to hold gains, continue to improve
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Reflecting on the PDCA Cycle
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Identification of the issue
Define the problem
Theorize what is going on, understand/ diagnose problems
Identify potential alternatives
Try itDid it work?
Adapt, adopt or Abandon….
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First Focus - Select ONE focus area- Use small scale tests
Ideas and Hunches
Check
Act
Do
Plan
Improvement
Test in One Process
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Check
Act
Do
Plan
Testing and Implementing Changes
Cycle 6
Cycle 8
Cycle 1
Cycle 2
Cycle 3
Cycle 4
Cycle 5
Cycle 7
hunches, theories &
ideas
changes that result in improvement
Little by little we get better and better
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Specpecific boundaries – outcomes focused, specific target populations, short, succinct, clearific boundaries – outcomes focused, specific target populations, short, succinct, clear
Measeasurable goal – define measures to quantify achievement AND indicate frequency of monitoringurable goal – define measures to quantify achievement AND indicate frequency of monitoring
Agregreed upon/actionable – identify how/ general change strategy. Focus on an agreed important area/ high priority.ed upon/actionable – identify how/ general change strategy. Focus on an agreed important area/ high priority.
Reaealistic but a stretchlistic but a stretch
Time ime bound – set clear guidelines for achievementbound – set clear guidelines for achievement
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Setting SMART Aims
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Bad Aim Statement= To decrease number of total joint surgical site infections.
• Good Aim Statement= By December 31st 2018,
decrease the number of total joint
surgical site infections by 99% through
implementation of double gloving and 3x
antibiotic dosing.
Setting SMART Aims
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Process modeling
➢ Develop measures
➢ Develop a plan for collecting data
➢ Plan a test of changes (intervention)
➢ Predict the outcome of the change
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Plan–Intervention Design
Plan, Do, Check, Act
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Remember the definition of a ‘Process’?
... a series of linked steps, often but not necessarily sequential, designed to ...cause some set of outcomes to occur.. (inputs => outputs)
All work occurs in a system of interconnected processes
Remember - Processes cause Outcomes
Step 1 Step 2 Step 3
Take coffee out of cupboard
Put coffee in mug Add hot water
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Successive MeasurementsTime Series aka Run Chart
Dynamic display of information
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Frequency distribution
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Value observed
Nu
mb
er o
f ti
mes
ob
serv
ed(N
um
ber
, rat
e, p
erce
nta
ge, p
rop
ort
ion
)center (mean, median, mode)
spread (variance, standard deviation, range)
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Two Types of Variation
• Common cause (random)
– Inherent to the regular rhythm of a process
– Predictable within limits (bell-shaped curve)
– “In control” if only type of variation present
• Special Cause (assignable)
– Irregular causes not inherent to a process
– Unpredictable within limits
– Process “out of control” when present
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Variability guides QI decision making
Stable process Unstable process
Type of variation Common Special + Common
Right Choice Process change
Investigate origin
of special cause
variation
Wrong choiceTreat normal variation
as a special cause
Change the
process without
investigation
Consequences of
Wrong choice Increased variation Wasted resources
Carey, Measuring Quality Improvement in Health Care, p. 153
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Quality Assurance
27worsebetter worsebetter QualityQuality
Before After
Eliminate the
“bad apple.”
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Quality Improvement
28worsebetter worsebetter QualityQuality
Before After
Entire process considered
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D
C
P
A
D
C
P
A
D
C
P
A
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Baseline Improvement
Cycle 1
Improvement
Cycle 2
Quality Improvement Cycles
Changes in Variation and Mean
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Significance in QI
• Practical definition:
The likelihood that a difference is more than random chance.
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CMS Standards
• Q-0080
• (Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
• §416.43 Condition for Coverage: Quality Assessment and Performance Improvement
• The ASC must develop, implement and maintain an ongoing, data-driven quality assessment and performance improvement (QAPI) program.
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• CMS does not prescribe a particular QAPI program; it provides each ASC with the flexibility to develop its own program. Each program must, however, satisfy the regulatory criteria:
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• Ongoing – i.e., the program is a continuing one, not just a one-time effort. Evidence of this would include, but is not limited to, things like collection by the ASC of quality data at regular intervals
• Data-driven – i.e., the program must identify in a systematic manner what data it will collect to measure various aspects of quality of care; the frequency of data collection; how the data will be collected and analyzed; and evidence that the program uses the data collected to assess quality and stimulate performance improvement.
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Choosing Quality Indicators
• Look at National Patient Safety Goals
• Look at CMS requirements
• Administrative requirements
• Trends in infection rates
• Compliance with hand hygiene
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Statement of Purpose
• Describe the problem or suspected problem.
• What are the metrics?
• What is the baseline data?
• What does analysis of the data show?
include frequency and severity of the problem.
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Implementation of Corrective Action
• What changes were made?
– What education was provided?
– What product changes were made?
– What personnel changes were made?
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Re-Measurement
• After implementation of changes:
– What changes in data were noted
– What did these changes mean
– Are the changes working
– Are more changes necessary
– Is more education necessary
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Process Improvement
• Is not a one time fix all solution
• Is an ongoing process
• Finds problems with processes not people
• Is not a blame game
• Is the key to providing safe, quality patient care
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How does all this relate to infection control?
• We report monthly on infection rates and compliance rates.
• We monitor for trends that show an increase in infection rates and decreases in compliance rates.
• We need to understand process improvement in order to be able to address problems that are identified.
• Process improvement gives IC the means to impact patient care and patient safety.
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References
• Carey GR, Lloyd RC. Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control Applications. Milwaukee, WI: Quality Press; 2001.
• Juran JM, Godfrey AB. Juran's Quality Handbook. 5th ed. New York, NY: Mc-Grew Hill; 1999.
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Any Questions