intro quality improvement
TRANSCRIPT
Introduction to Quality Improvement
Author: Nazanin Meshkat MD, FRCPC, MHSc, Assistant Professor, University of Toronto
Date Created: September 2011
Global Health Emergency Medicine Teaching Modules by GHEM is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Objectives
To gain an understanding of what quality improvement is
To present the Model for Improvement and PDSA cycle
To introduce measurement in quality improvement
To introduce flowcharts
What is Quality Improvement?
A formal approach to the analysis of performance and systematic efforts to improve it Different from Quality Assurance
Quality Improvement versus Quality Assurance
Quality Improvement Quality Assurance
What can we do to improve? What went wrong?
Proactive Reactive
Avoids blame Often Punitive
Fosters System change Tries to find who was at fault
Focuses on the entire system
Focuses on the specific incident
What is quality?
Definition of quality depends on stakeholders The client/customer (the patient) The provider/employer (health care providers) Management (hospital management) Payer (Ministry of Health)
“Every system is perfectly designed to get the results it gets”
How can you improve a system to achieve better results in the 6 pillars of quality?
To improve a system…
You need a good understanding of the system
You need to understand where it is failing - Identify what is wrong Make sure it is the step that needs fixing
Then you can implement a change to the “system”
What is a system?
System = any assembly of procedures, resources and routines to carry out a specific activity
How do you map out a system?
Use a flow chart/diagram
Use different perspectives (a doctor’s perspective is different to a nurse’s or a porter’s to a patient’s perspective)
Quality Improvement Models
Model for Improvement = Three questions + PDSA cycle FADE = Focus, Analyze, Develop, Execute and Evaluate Six Sigma CQI = Continuous Quality Improvement TQI = Total Quality Management 7 step method
The Three Questions
The Model for Improvement begins with three fundamental questions
1. The Aim: What are we trying to accomplish? (How good do we want to get and by when?)
2. The Measures: How will we know a change is an improvement?
3. The Changes: What change can we make that will result in improvement?
PDSA Cycle
Enables rapid testing and learning Allows for incremental testing Instead of spending weeks or months
planning out a comprehensive change, then putting it into practice only to find that it is fundamentally flawed
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
STUDY
ACT PLAN
DO
The Problem
Patient’s at Black Lion’s Hospital emergency department are often in pain
We want to change that
Ehm…how do we do that?
Executing the Model for Improvement Form a team Three Questions: The
Aim, The Measures, The changes
Test changes - PDSA Cycle
Implement changes that work
Spread the changes to other areas
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
You need a team
Why? Need different
perspectives It’s a lot of work Increased buy-in by
staff Different levels of
support (e.g. management)
To come up with the right team you have to have an idea of what your aim is…
The Aim
A strong, measurable aim with a clear time frame will help keep your project on course
It has to be important to those involved
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
The Aim
A good aim: Is Specific Is Measurable Determines a time frame Addresses who the change is for, and what
has to be achieved Is Sustainable
The Aim
I will become a good runner
I will run 10 kilometers per week by May 31st
I will run more often
The Aim
Back to the Problem: Patients at Black Lion’s Hospital emergency department are often in pain
We decide to focus on emergency department patients with fractures
The Aim
All emergency department patients with fractures
We will provide analgesia to 100% of our pts with a suspected fracture within 15 minutes of arrival to the emergency department by the end of December 2011.
Choose your team
Consider the system that relates to the aim i.e. what processes will be affected by the improvement efforts
Involve members familiar with all different parts of processes
Back to our example All emergency department
patients with fractures
We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011.
What processes will be affected?
Back to our example All emergency department
patients with fractures
We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011.
What processes will be affected? Nursing/Triage Pharmacy Stocking Doctors Registration ED chief/director/
manager
Choose your team
Effective teams require three kinds of expertise System leadership Clinical -Technical expertise Day to day leadership - Project leader
Your team
Team leader: Medical director of the emergency department
Technical expert: Hospital Quality Management member
Day to day leader (project leader): an emergency doctor or nurse
Additional team members: pharmacist, person responsible for stocking, charge nurse, registration clerk
Measurement
Measurement is critical for testing and implementing changes
Different from measurement for research
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
MeasurementMeasurement for Research
Measurement for Improvement
Purpose To discover new knowledge To bring new knowledge into daily practice
Tests One large blind test Many sequential, observable tests
Biases Control for as many biases as possible
Stabilize the biases from test to test
Data Gather as much data as possible, just in case
Gather just enough data to learn and complete another cycle
Duration Can take a long time Short duration
Measurement
3 types of measures for quality improvement Outcome measures Process measures Balancing measures (+/- Structure Measures)
Outcome Measure
= Where are we ultimately trying to go Are your changes actually leading to
improvement
Process Measures
= Are we doing the right things to get there?
To affect an outcome you have to improve your processes
Are the parts/steps in the system performing as planned
Balancing Measures
Tells you if changes designed to improve one part of the system are causing new problems in other parts of the system
Structure Measures
“Physical” measures Human resources, equipment, facilities
Often included in Process Measures
Measurement
Aim = Decrease sepsis mortality by 20% by January 2011
Outcome Measure Process Measure Balancing Measures
Measurement
Aim = Decrease sepsis mortality by 20% by January 2011
Outcome Measure
Process Measure Balancing Measures
Mortality rates -Time it takes to register and triage-% of patients being appropriately triaged-Time from triage to initiation of resuscitation-% of patients getting properly fluid resuscitated-% of patients getting antibiotics-Availability of medications and supplies-Time to antibiotics-Delay to getting to hospital
Costs
Neglect of other patients (e.g. increase in mortality for another patient population)
(e.g. increase in time to be seen for other patients)
Developing Changes
Depends what you are trying to change
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
Basic techniques
Critical Thinking Flow Chart/Diagram
Benchmarking Compare to best practice
Using Technology Barcodes for medications
Creative Thinking Become a patient for a day
Using Change Concepts
Basic techniques
Critical Thinking Flow Chart/Diagram
Benchmarking Compare to best practice
Using Technology Barcodes for medications
Creative Thinking Become a patient for a day
Using Change Concepts
Critical Thinking
Use a Flow Chart/Diagram
A flow chart allows to “visualize” the system you are trying to change
Allows ALL to see the system the same way
Flow Chart/Diagram
It helps to clarify complex processes
It identifies steps that do not add value to the internal or external customer, including: Delays Needless storage and transportation Unnecessary work, duplication, and added expense Breakdowns in communication
Flow Chart/Diagram
It helps team members gain a shared understanding of the process and use this knowledge to collect data, identify problems, focus discussions, and identify resources.
It serves as a basis for designing new processes.
Flow Chart/Diagram
High-level flowchart, showing six to 12 steps, gives a panoramic view of a process
Detailed flowchart is a close-up view of the process, typically showing dozens of steps. These flowcharts make it easy to identify rework loops and complexity in a process.
Example: High Level Flow Chart
From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart
Example: Detailed Flow Chart
From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart
Change Concepts
Eliminate Waste - an activity or resource that does not add value
Improve Work Flow
Optimize Inventory - is your work being held up because items are not properly organized or available
Change Concepts Change the Work Environment (does the work
culture enhance or impede change)
Manage Time
Focus on Variation - what aspect of the system vary and make your outcomes unpredictable
Focus on Error Proofing (checklist)
Testing Changes: PDSA Cycle
All improvement will require change, but not all change will result in
improvement.
Testing Changes
Why test changes (even if they are already proven elsewhere)? To learn how to adapt the change to the
particular conditions in your setting To evaluate the costs and side effects To minimize resistance when implementing the
change in the organization Increase your belief that the change will result
in improvement
PDSA Cycle
Plan Objectives Questions and
predictions Plan to carry out
the cycle (who, what, where, when)
Plan for data collection
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
PDSA Cycle
Do Carry out the plan Document
problems and unexpected results
Begin Analysis
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
PDSA Cycle Study
Complete analysis of the data
Compare data to prediction
Summarize what was learned
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
PDSA Cycle Act
What changes are to be made
Next cycle?
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
Testing Changes
Much can be learnt
from a failed test
PDSA
PDSA
PDSA
PDSA
PDSA
STUDY
ACT PLAN
DO
STUDY
ACT PLAN
DO
STUDY
ACT PLAN
DO
How easily is change adopted?
Process of “Normalization”
People have a tendency to fall into old habits
People have a tendency to resist change
People may feel threatened by a change
Executing the Model for Improvement Form a team Three Questions: The
Aim, The Measures, The changes
Test changes - PDSA Cycle
Implement changes that work
Spread the changes
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO
Implementation
Usually comes after a series of successful tests
It requires that staff and leaders build the change into formal plans, job definitions, training, and explicit reviews
The change does not depend on the individuals doing the work, but on the way the work is organized - as part of the system.
Hardwire Change
Market your change Train everyone involved Make changes to job descriptions, policies, procedures, forms Addressing supply and equipment issues Assigning day-to-day ownership for the maintenance of the
new process Have senior leaders remove any barriers
Social System Social System - understand the relationship among the
people who will be adopting the new ideas
Remember there is an emotional component to change Stress of learning and executing something new Initial disruption to workflow Maybe they feel their job/position is threatened
Social System Those who are supportive
Enlist on your side
Those who are not supportive Don’t try to change their attitude Listen to what concerns them, identify barriers
Those who don’t really care, and will follow when others do
Implementation
PDSA in Pilot Phase
PDSA in Implementation Phase
Support Requirements Low High
Tolerance for failure High Low
Number affected by a test Low High
Resistance Low Potentially high
Time for each cycle Short Longer
Summary
In this modules we have presented an introduction to: Quality Improvement The Model of Improvement
3 questions (What is your aim, measures, change) and PDSA cycle
Types of Measures Change and Implementation
References: Institute of Healthcare Improvement http://www.ihi.org/Pages/default.aspx Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical
Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996;60.
Deming WE. The New Economics for Industry, Government, and Education.2nd ed. Cambridge, MA: MIT Center for Advanced Engineering Study; 1994. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996:6-7.
Using the Model for Improvement. In: Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009:89-108.
Accelerating the pace of improvement: interview with Thomas Nolan. Journal of Quality Improvement. 1997;23(4).
Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619-622. Lloyd R. Quality Health Care: A Guide to Developing and Using Indicators. Sudbury, MA: Jones and
Bartlett Publishers; 2004. Moen R, Nolan T, Provost L. Quality Improvement Through Planned Experimentation. 2nd ed. New
York, NY: McGraw-Hill Companies; 1998. The Improvement Handbook. Austin, TX: Associates in Process Improvement; 2005.