Identifying ProblemsRebecca S. (Suzie) Miltner, PhD, RNAssociate Professor, School of Nursing

Six Broad Aims of Quality Health Care S Safe T Timely E Effective E Efficient E Equitable P Patient-centered

Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

19601970198019902000200120022003200420052006200720082009201020112012$0

$1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000

$147 $356 $1,112

$2,851

$4,884 $5,240

$5,687 $6,131

$6,504 $6,900

$7,271 $7,651 $7,933 $8,157 $8,411 $8,658 $8,925

NOTE: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas and their dependents. SOURCE: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see National Health Expenditures by type of service and source of funds; file nhe12.zip); Gross Domestic Product data from Bureau of Economic Analysis, at http://bea.gov/national/index.htm#gdp (file gdplev.xls).

How Much Do We Spend?National Health Expenditures per Capita, 1960-2012

NHE as a

Share of GDP

5.0% 7.0% 8.9% 12.1% 13.4% 14.1% 14.9% 15.4% 15.5% 15.5% 15.6% 15.9% 16.4% 17.4% 17.4% 17.3% 17.2%

Avoiding underuse (e.g. not screening a person for high blood

pressure)

Avoiding overuse (e.g. performing tests that a patient doesn’t need)

Eliminating misuse (e.g. providing medications that may have

dangerous interactions)

Reducing Variation in Care

Putting a percentage of Medicare dollars at risk

By 2017, at risk = 6%3 areas of focus:

Value Based Purchasing Readmissions Hospital acquired conditions

The Impact of CMS Changes

Healthcare is almost 18% of the GDP and is headed for 20% of the GDP by 2020.

We can lower payments or pay for fewer services.

Or we could eliminate waste.

What can we do to reduce costs?

OvertreatmentFailures of care coordinationFailures in execution of care processes

Administrative complexityPricing failuresFraud and abuse

Six Categories of Waste

The waste that comes from subjecting people to care that cannot possibly help them.

Estimated waste: 158-226 billion/year

Overtreatment

The waste that comes when people, especially those with chronic illness-fall through the cracks.

Estimated waste: 25-45 billion/year

Failures of care coordination

The waste that comes with poor execution or lack of adoption of best practices.

Estimated waste: 102-154 billion/year

Failures in execution of care processes

The waste that comes when we create our own rules that force people to do things that make no sense.

Estimated waste: 107-389 billion/year

Administrative processes

The waste that comes when prices migrate far from the actual costs of production plus fair profits.

Estimated waste: 84-178 billion/year

Pricing failures

The waste that comes when thieves issue fake bills and run scams as well as the inspection and regulation costs due to these thieves.

Estimated waste: 82-272 billion/year

Fraud and Abuse

Lots of opportunity in the system…

Lots of opportunity in the system…

Undergraduate HonorsNursing Students

One semester project

Big problems:1. Unnecessary Caths2. No pericare documented3. No insertion note4. No Stat Lock

Big problems:1. Unnecessary Caths2. No pericare documented3. No insertion note4. No Stat Lock

Intervention:Educate the (day shift) staff.

Results

Lots of opportunity in the system…But what about things that WE can

fix?

Problem IdentificationWhat is the problem?

Where does it come from (up or down)?

How do you define it?

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Problem IdentificationHow do you feel about it?

What data do you have about your problem?

What will you do about it?

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Usual Ideas to Fix a ProblemWe need more people

We need more money

We need more time

We need to make people work harder

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Where ideas to fix problems comes from

Transformational Big changes Culture shift Usually top-down

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Where ideas to fix problems comes from

Transformational Major changes Culture shift Usually top-down

Incremental Small changes Slight change in a procedure to improve efficiencies Sometimes unnoticed by management

Barriers to Problem Solving

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Looking for perfection

Fear of failure

Gathering Data to Understand a Process: Suggested Steps

1. Observe processes (formal and informal)

2. Interview key personnel (voice of the customer)

3. Create a process map

4. Collect data

Observe the Process

Process Observation

Process Observation Worksheet

Data collection tool Determine time for and between

steps Time to complete a step (duration) Distance traveled (steps)

Standardized Ensure data is complete Reliable and Repeatable

Process Observation Worksheet Example

Process Observation WorksheetProcess: Patient check-in

Step # Description DistanceClock Time

Task Time

Wait Time Observations

0:001 Patient arrives 0:10 0:102 Clerk requests ID 0:13 0:033 Patient registered (Y/N) N

3A Patient sent to HBU 575 0:15 0:023B HBU registers patient 0:47 0:32 0:20

4 Appointment (Y/N) 575 N4A Make walk-in appointment 0:50 0:03

5 Check patient in 0:52 0:026 Patient sent to waiting room 100 0:56 0:04

Enter time that step was completed.

Distance traveledIn steps

Task time calculatedlater…

Intrapartum Nursing Observation Tool Check sheet to

record observed interventions

Twenty-three specific interventions and other categories

Observed care for 30 seconds and recorded data during next 30 seconds

All interventions observed were recorded

Kappa .95

In Pt Room 1 1 1 1Surv-HxSurv-MVSSurv-EFM 1 1Surv-Med EffectsSurv-post-epiSurv-Fetal ResusOther Surv 1IC-Document 1 1 1IC-Proc PrepIC-Assist HCP 1 1IC-Discuss HCP 1Other IC 1Info-RelaxInfo-PainInfo-FetusInfo-ProceduresInfo-PushingOther InfoEmo-PresenceEmo-coachEmo-PraiseEmo-EncourageOther Emo 1 1 1

Spaghetti DiagramsAlso known as a movement or

transportation diagram Shows the pattern of movement of

staff, patient, or objectVisually displays movementHelps identified unnecessary

movementGuides space redesign

Hagg- Woodbridge 2008

Spaghetti DiagramClinic 5 Room Turnover Project

Exam Room

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Exam Room

Exam Room

Exa

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oom

Exam Room

Exam Room

RN Station

Exam Room

Exam Room

Exam Room

Exam Room

Exam RoomE

xam

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Exa

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Check-in

ProviderCharting

Procedures

Calls Patient

“6+ Miles per Day”

Voice of the Customer

Voice of the CustomerOne of the first steps in

understanding the problem: Understand what the customer values

Customers are: Patients and their families Other stakeholders (e.g., community,

Board of Directors, etc.) Internal users of the service

Example from IAD projectFor nursing staff (MICU and 5M):1.  If you have an incontinent patient, what

makes it hard to take care of them?2.  If you have an incontinent patient, what

makes it easier to take care of them?3.  In a perfect world, what do you need to

take care of them?4.  Do you have any special interventions

(things you do, “tricks”) that you use to take care of incontinent patients?

Example from IAD projectFor Physicians:1.  What is your involvement in managing patients with incontinence?

2.  How does incontinence affect your plan of care for the patient? 

Questions for PatientsWe are working on a project to improve the way we

take care of patients who have problems with toileting while they are in the hospital.

1. Since you have been here, have you had a problem getting to the bathroom or using the bedpan or urinal in time?

2. While you have been here, what are the nurses or doctors doing to help you manage this problem?

3. What seems to be working?4. What seems not to work?5. What suggestions do you have that would make

this better for you?

Map the Process: next topic

Collect Data: throughout the QA!

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Skills Exercise: Problem Identification

Get in groups of 5-6 people and discuss the case study.Consider the following questions: What problem are you facing? How do you feel about it? What data do you have about your problem? What additional data do you need? What are your data telling you? What will you do about it?

Problem StatementsAfter gaining understanding,

describe the problem, opportunity or objective in concise, measurable terms.

Include a summary of the problem and the impact (aka the “PAIN”)

Problem StatementsA brief description of the problem

and the metric used to describe the problem

Where the problem is occurring by process name and location

The time frame over which the problem has been occurring

The size or magnitude of the problemhttp://www.dummies.com/how-to/content/how-to-write-a-problem-statement-for-six-sigma.html

Problem Statements Poor Problem Statement: Human

resources is taking too long to fill vacancies. Better Problem Statement: Recruiting

time for registered nurses on the medical surgical units at UAB is over 120 days when the stated goal is 60 days. With an average of 50 med/surg vacancies a month, this delay is adding $27,000 per month in overtime and contractor labor, and may result in poorer continuity of care and increased errors.

Example Problem Statement Low mobility is common among

hospitalized patients and is associated with adverse outcomes.

Example Problem Statement Low mobility (defined as bed and bed to chair

activity only) is common among hospitalized patients and is associated with adverse outcomes including functional decline and increased community care needs. In a study at the BVAMC, geriatric hospitalized patients spend an average of 83% of the time lying in bed. This can lead to acute decline in functional status rendering the patient dependent in ambulation which can lead to increased LOS. Financial data suggests an opportunity for improvement as well as there is > $41,000 per quarter spend on home health PT after hospitalization

Skills Exercise: Problem Identification

Using your work from the previous case study, WRITE a problem statement.

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An important thing to consider….

Readiness for change

Be aware of the organization’s readiness to change Is the timing right?Do you have support of leadership?Do you have resources?Does your team think they can do

it?

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Readiness for Change

Organizational Change influenced by:Commitment to change

Capability to change (change efficacy)

Weiner, BJ (2009). A theory of organizational readiness for change.

Adapted from Weiner, BJ (2009). A theory of organizational readiness for change.

Possible Contextual Factors

•Organizational Culture•Policies and Procedures•Past Experiences•Organizational Resources•Organizational Structure

Change Valence(Value of Change)

Capability•Task Demands•Resource Perceptions•Situational Factors

Organizational Readiness for Change•Change Commitment•Change Efficacy

Change Related Effort•Initiation•Persistence•Cooperative Behavior

Implementation Effectiveness

Organizational Readiness for Change