Overview of Quality Using the lessons from Deming to transform our system.

Louisiana Perinatal Care Improvement Summit

October 18, 2011

Ginna Crowe, RN, MS, Ed.D

This presenter has nothing to disclose

DISCLOSURE

• I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

Overview

Objectives

• Name the “Grand” of Improvement

• Describe the four components of the System of Profound Knowledge (Lens)

• Discuss application of the Lens of Profound Knowledge to a complex issue

Design

• Quiz

• Lecture

• Large Group Shout Out

• Pair Share

QUIZ

Who started the improvement movement?

Florence Nightingale (1820-1910)

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@ Virginia Leigh Hamilton Crowe

@ Virginia Leigh Hamiliton Crowe

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Quality Heroes

@ Virginia Leigh Hamiliton Crowe

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W. Edwards Deming (1900 -1993) •Shewhart Protégé •PDSA •Profound Knowledge

Walter A. Shewhart (1891-1967) •Father of SPC •Shewhart Cycle (PDCA- 1939 1st mention)

Joseph M. Juran (1904 -2008) •Human Aspect of Quality Management •Juran Trilogy

Quality Medical Heroes

@ Virginia Leigh Hamilton Crowe

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Ernest Codman (1869- 1940) • M & M Review • Outcomes • ACS (JCAHO) (TJC)

Avedis Donabedian (1910- 2000) •Quality Assessment •Structure Process Outcome

Evolution of Quality (in healthcare) 1820-1910

Florence Nightingale Uses Statistical Analysis and Plots the Incidence of Preventable Deaths in the Military (1820-1910)

American College of Surgeons/ Codman (1918) First Quality Manual Published (18 pages!) (1926) Deming and Juran become prominent figures in the field of quality management in industry (PDSA) (1945) JCAHO (1951)

Structure Process Outcome Donabedian (1966)

JCAHO Medical Audit & Performance Evaluation (1972) JCAHO Agenda for Change Announced—Use of Clinical Indicators (1986) ELI founded (1984) HCA 1st Healthcare client (FOCUS PDSA) (1987) Vermont Oxford Network (NICQ’s) (1988) Agency for Healthcare Research and Quality (AHRQ) Created (1989) QHR: Center for Continuous Improvement 1989 NCQA Founded (1990)

1910-1950 1950-1990 1990-Present

Institute for Healthcare Improvement Founded (1991) The Institute for Family-Centered Care, founded (1992) HIV QUAL National established (1995) The Improvement Guide published (1996) The California Perinatal Quality Care Collaborative (CPQCC) (1998) IOM publishes “To Err is Human” (1999) NICHQ Founded (1999) Ryan White Program Quality legislation (2000) IOM publishes Crossing the Quality Chasm (2001) AHRQ & CMS & DHHS partner to develop HCAHPS (2002) IPIP initiated (2005) Ohio Perinatal Quality Collaborative (OPQC) (2007) NC CPHQ founded (2010) Louisiana Birth Outcomes Initiative (2011)

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The first lesson is that blaming the fallible individuals at the sharp-end is universal, natural, emotionally satisfying, and legally convenient.

Unfortunately, it has little or no remedial value.

On the contrary, blame focuses our attention on the last and probably the least remedial link in the accident chain: the person at the sharp end.

James T. Reason

1990’s

The prevailing style of management must undergo transformation. A system can not understand itself. The transformation requires a view from the outside. The aim of this chapter is to provide an outside view—a lens—that I call a system of profound knowledge. It provides a map of theory by which to understand the organization that we work in.

New Economics pg. 92

System of Profound Knowledge

Overlapping Pull Apart

Process

System

Variation

Knowledge

Psychology

Appreciation for a System

Theory of Knowledge

Psychology

Knowledge about

variation

Process

Instructions

1) I will show you a picture or a cartoon

2) You will help identify the Lens component from the picture.

3) Think a bit about the component and share some of Deming’s views of the component.

4) Use Lens in a very short case study.

first component

SYSTEMS

What do we know or believe about systems? What is in our system lens?

• A system is a network of interdependent components that work together to try to accomplish the aim of the system.

• The beginning of the system starts with the customer

• The obligation of any component is to contribute its best to the system, not to maximize its own …measures.

• If each part of a system, considered separately, decides to operate as efficiently as possible, then the system as a whole will not operate to maximum effectiveness.

• We should work on our processes, not the outcome of our processes….

second component

KNOWLEDGE

What do we know or believe about knowledge? What is in our knowledge or learning lens?

• Information is not knowledge

• Knowledge is built on theory

• Without theory there are no questions: Without questions there is no learning

• There is no such thing as a fact

• No number of examples establishes a theory, yet a single unexplained failure of a theory requires modification or even abandonment of the theory

• A statement devoid of rational prediction does not convey knowledge

third component

System Lens

PSYCHOLOGY

What do we know or believe about psychology? What is in our psychology or human interaction lens?

• People are different from one

another. A manager of people must be aware of these difference, and use them for optimization of everybody's abilities and inclinations. This is not ranking ..

• Merit awards and ranking are demoralizing. Rewards motivate people to work for rewards.

• Some extrinsic motivation helps to build self-esteem. But total submission to extrinsic motivation leads to destruction of the individual.

Forces of destructions (New Economics p.122)

Life begins Life ends

Extrinsic motivation

• Gradually replaces intrinsic motivation

• Competition and recognition drives actions

• Focus on the Individual not the System

• Problems attributed to Individuals not System

• Resignation to external pressure - demotivational

Intrinsic motivation

Curiosity Cooperation

Joy in Learning Self esteem Dignity

fourth component

Variation exists……

(C) Virginia L H Crowe

VARIATION

• Variation Exists!

• Common cause variation is always present • Common causes tend to be numerous • Common cause variation is produced by the

aggregate of the variation in all the variables. It is also known as: random variation, chance variation, or unassignable cause of variation

• Special causes are not present at all times • Special cause is in addition to common cause • Special cause is produced by a non-typical

variable. Special causes are also known as assignable and non-random

• Mistake 1. To react to an outcome as if it came from a special cause , when actually it came from a common cause.

• Mistake 2. To treat an outcome as if it came from common causes of variation, when actually it came from a special cause.

What do we know or believe about variation? What is in our theory of variation lens?

Why?

The central problem of management in all aspects including planning, procurement, manufacturing,

research, sales, personnel, accounting is to understand better the meaning of … and to extract

the information contained in variation Dr. Lloyd Nelson

(C) Virginia L H Crowe

JUST DO IT!

Ginna Crowe

The lens of profound knowledge supports reflection, critical reflection, and critical self reflection which is necessary for learning and transformation.

• What is the contribution or influence of

the system? (system)

• What issue/s related to relationships, interactions, or motivation are evident? (psychology)

• What type of variation is evident? How did or how should that knowledge influence behavior or decision/s? (variation)

• What theories are evident? What questions were asked? What predictions were made or might be made for the future? (knowledge)

Lens Questions

Case Study

Another air traffic controller suspended for sleeping April 16, 2011

Another air traffic controller suspended for sleeping April 16, 2011

• The Federal Aviation Administration suspended Saturday yet another air traffic controller for sleeping on the job, the seventh apparent incident this year the agency has disclosed.

• Last week, Hank Krakowski resigned as the head of the FAA Air Traffic Organization amid revelations that several controllers fell asleep on the job this year.

• All the incidents occurred during the midnight shifts, but the similarity ends there. Some occurred at local control towers, one occurred at a regional radar facility and the latest at a high-altitude center.

• In at least one incident, the FAA has said the controller deliberately went to sleep, while some of the others appear to have been accidental.

• Prior to the start of the midnight shift at the Miami facility, all the controllers were given a briefing on professionalism and the importance of reporting to work fit for duty, the FAA said.

• The controller who fell asleep has been suspended, the agency said.

White House

“The individuals who are falling asleep on the job, that’s unacceptable. The fact is, when you’re responsible for the lives and safety of people up in the air, you better do your job. So, there’s an element of individual responsibility that has to be dealt with.”

• What is the contribution or influence of

the system? (system)

• What issue/s related to relationships, interactions, or motivation are evident? (psychology)

• What type of variation is evident? How did or how should that knowledge influence behavior or decision/s? (variation)

• What theories are evident? What questions were asked? What predictions were made or might be made for the future? (knowledge)

Lens Questions

Air Traffic Controllers Sleeping on the Job: A Problem of Scheduling

• Controllers often bounce from morning shifts, to afternoon, to night shifts, leaving little time for the body to adjust.

• Fatigue experts like Philip Gehrman, director of the Behavior Sleep Program at the University of Pennsylvania, said it is crucial that their shifts remain more constant.

– "It would be nice if there were a greater appreciation that our bodies have a limit -- we're not equally able to function at all hours of a 24-hour day," Gehrman said.

Other contributors…

• Controller fatigue is obviously a major factor…. the FAA implemented changes to scheduling practices that will allow controllers more time for rest between shifts.

• For decades, even predating the 1981 air traffic controller strike, controllers themselves have had the last word on the schedules they work.

• One of the most popular is called 2-2-1:, two day shifts, and one midnight shift.. Such a schedule disrupts circadian rhythms, creating fatigue on the midnight shift…...But controllers and their union have fought to keep 2-2-1 because it gives them a three-day weekend afterwards.

• The other cause of fatigue on midnight shifts is black backgrounds on controller display screens, which require dark rooms for best visibility. It is now common international practice to have light gray background screen displays that can be used in high-light environments, but in the U.S. we've all but ignored this advancement.

• The FAA has tolerated 2-2-1 schedules and dark control rooms for decades. Why? Because the Air Traffic Organization, whose job is to "move air traffic safely and efficiently," is within the FAA, which in effect means the agency is regulating itself.

Rational behavior requires theory. Reactive behavior requires only reflex action

W. Edwards Deming

39 Week Initiative

System of Profound Knowledge

Appreciation for a System

Theory of Knowledge

Psychology Knowledge

about variation

Process