qi theory: quality improvement in the hospital goals for this primer understand fundamental concepts...
TRANSCRIPT
QI Theory:Quality Improvement in the Hospital
Goals for this Primer
• Understand fundamental concepts in quality improvement
• Identify the environment and key steps for a successful quality improvement project
• Become familiar with several quality improvement tools and their use
Quality Improvement: Bridging the Implementation Gap
Patient care
Pro
gres
s
Time
How good is American healthcare?
Quality Improvement: Bridging the Implementation Gap
Patient care
Pro
gres
s
Time
We get it right 54% of the time.-Brent James, MD, MStat Executive Director, Intermountain Health Care
Quality Improvement: Bridging the Implementation Gap
Implementation Gap
Scientific understanding
Patient care
Pro
gres
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Time
Hospitalists and Quality Improvement
• Complex process problems need multidisciplinary solutions
• We are at the frontlines seeing system failures, process errors, and performance gaps with our own eyes -- which is our competitive advantage
• Improved quality delivers: better patient care… at lower costs… with potentially higher reimbursements (pay-for-
performance)…And it can make our jobs more interesting, fun, and rewarding.
Section I:
Quality Improvement and Change
in the Hospital Atmosphere
Definition of Quality
• Meeting the needs and exceeding the expectations of those we serve
• Delivering all and only the care that the patient and family needs
“Definition” of Improvement
It is NOT… yelling at people to work harder, faster, or safer creating order sets or protocols and then failing to
monitor their use or effect traditional Quality Assurance research (but they can co-exist nicely)
Principle #1: Improvement Requires ChangeImprovement Requires Change
Every system is perfectly designed to achieve Every system is perfectly designed to achieve exactly the results it getsexactly the results it gets
To improve the system, change the system…
Principle #2:
Less is MoreLess is More
You cannot destroy productivityYou cannot destroy productivity
When changing the system, keep it simple
Illustrating Principle #2: Less Is MoreProbability of Performing Perfectly
No.
Elements
Probability of Success, Each Element
0.95 0.99 0.999 0.999999
1
25
50
100
0.95
0.28
0.08
0.006
0.99
0.78
0.61
0.37
0.999
0.98
0.95
0.90
0.999999
0.998
0.995
0.99
Understanding Change in the Hospital Atmosphere
• Change = not just doing something different, but engineering something different
• at least one step in at least one process
• Hospital Atmosphere = hospitals tend to be viscous, complex systems with default levels of performance
• change engineered to improve performance can be a foreign concept - or even overtly resisted
Understanding Change in the Hospital
Atmosphere
A Common Strategy Which Commonly Fails:• Experts design a comprehensive protocol using EBM
over several months• Protocol is presented as a finished, stand alone
product• Customization of protocol is discouraged• Compliance depends on vigilance and hard work• Monitoring for success or failure is the exception to
the rule (with failures coming to light after patients are harmed)
• Flawed implementation leads to repetitive efforts down the road
Understanding Change in the Hospital
Atmosphere
High-Reliability Strategies Commonly Succeed:• Build a “decision aide” or reminder into the system• Make the desired action the default action (not doing
the desired action requires opting out)• Build redundancy into responsibilities (e.g. if one
person in the chain overlooks it, someone else will catch it)
• Schedule steps to occur at known intervals or events • Standardize a process so that deviation feels weird• Take advantage of work habits or reliable patterns of
behavior Build at least one - if not more - of these high-Build at least one - if not more - of these high-reliability strategies into any changed process.reliability strategies into any changed process.
Understanding Change in the Hospital Atmosphere
Change engineered to drive improvement depends on…• Workplace Culture: personnel must be receptive to change• Awareness: administrative and medical staffs must care
about performance and support its improvement through change
• Evidence: local experts must identify which research to translate into practice
• Experience: a skilled team must choose, implement, and follow up changes to ensure:
1) improvement efforts are ongoing and yielding better performance
2) productivity is preserved
An Atmosphere for Change
AAWARENESSWARENESS
OF THE LOCAL PERFORMANCE GAP Patient
Medical Staff
Administrative Support
EEXPERIENCEXPERIENCE
WITH SIMILAR IMPROVEMENT EFFORTS
Hospitalist Quality OfficerHospitalist Quality Officer
Multidisciplinary Team MembersMultidisciplinary Team Members
Success Stories From Other InstitutionsSuccess Stories From Other Institutions
EEVIDENCEVIDENCE
TO TRANSLATE INTO PRACTICE
“Bedside” Teaching
Didactic Teaching Sessions
Local Expertise in Disease Literature
WWORKPLACE ORKPLACE CCULTUREULTURE
READY TO ACCEPT CHANGE
Task Load
Culture of Improvement
Culture of Negative Expectations
An Atmosphere for Change
AAWARENESSWARENESS
OF THE LOCAL PERFORMANCE GAP Patient
Medical Staff
Hospital Administration
PatientAt mercy and increasingly aware of
underperforming status quo
Now can access a new resource promoting transparency in hospital performance: www.hospitalcompare.hhs.gov
Hospital AdministrationUnderstands status quo is unacceptable
(IOM, Leapfrog, NQF, JCAHO)
Sees fiscal health tied to performance against national benchmarks, ability to reduce costs & LOS, improve margins, and competitive reputation in the community
Medical StaffHas professional responsibility to improve
Knows all too well where system fails
Recognizes that professional livelihood will depend on paying attention to outcomes:
Pay-for-Performance
An Atmosphere for Change
EEXPERIENCEXPERIENCE
WITH SIMILAR IMPROVEMENT EFFORTS
Hospitalist Team Facilitator
Multidisciplinary Team Members
Successful Strategies Used By Others
Hospitalist Team Facilitator Technical expert on Quality Improvement
theory and tools
Owns the team process, enforces ground rules, helps judge feasibility
Teaches the team while doing
Multidisciplinary Team Members Chosen for hands-on, fundamental
knowledge of key processes
Inclusive, open, & consensus seeking
Impact not only the change(s) but the implementation
Successful Strategies Used By Others Learn from mistakes of others
Adapt successes of others (tools and methods): steal shamelessly
Get specific advice in ’Ask the Expert’ forums or other consortiums that collect and share experience
An Atmosphere for Change
EEVIDENCEVIDENCE
TO TRANSLATE INTO PRACTICE
“Bedside” Teaching
Didactic Teaching Sessions
Local Expertise in Disease Literature
“Bedside” Teaching
To an audience of residents or students
To build cadre of “experts” (and to help meet ACGME requirements)
Download teaching pearls from SHM resource rooms
Local Expertise in Disease Literature
Decide what changes to make based on the level of evidence
Establishes team’s credibility
Extends team’s authority when local sub-specialists or experts participate in selecting and implementing change
Didactic Teaching Sessions
To an audience of peers, administrators, nurses, or support staff
To boost awareness, knowledge, enthusiasm, and support
Download slide sets from SHM resource rooms
An Atmosphere for Change
WWORKPLACE ORKPLACE CCULTUREULTURE
READY TO ACCEPT CHANGE
Task Load
Culture of Improvement vs.
Culture of Negative Expectations
Task Load
Be sensitive about piling new tasks onto over-tasked personnel
Use the input of personnel who will be responsibile for implementing
Make it easy and desirable to do the right thing
Culture of Negative Expectations
Overcome it, one person and one project at a time
Attach pride to balance between performance successes and failures
Consider using a ‘cultural survey’ to identify problems and address them through proper channels
Culture of Improvement
Extend it, one person and one project at a time
Advertise successes
Use or adapt this online ‘cultural survey:’ http://www.patientsafetygroup.org/program/step1c.cfm
Section II:
The Multidisciplinary Team
The Driving Force for Change
TTHEHE MMULTIDISCIPLINARYULTIDISCIPLINARY TTEAMEAM
Leverages frontline expertise and experience. Impacts not only the change/interventions,
but also the implementation
The Driving Force for Change: The Multidisciplinary Team
A team is not the same as a committee…Committee• individuals bring representation• productive capacity = single most able member
Team• individuals bring fundamental knowledge• productive capacity = synergistic (more than the sum of all
individual team members together)
The Driving Force for Change: The Multidisciplinary Team
Features of a good team…• Safe (no ad hominem attacks)• Inclusive (values all potential contributors including
diverse views; not a clique)• Open (considers all ideas fairly)• Consensus seeking
The Driving Force for Change: The Multidisciplinary Team
Consensus…• definition: finding a solution acceptable enough
that all members can support it; no member opposes it
• It is not: A unanimous vote (consensus may not represent
everyone’s first priorities) A majority vote (in a majority vote, only the majority
gets something they are happy with; people in the minority may get something they don’t want at all, which is not what consensus is all about)
Everyone totally satisfied
The Driving Force for Change: The Multidisciplinary Team
Three types of team members…1) Team Leader
2) Team Facilitator
3) Process Owners (members with operational, hands-on fundamental knowledge of the process)
The Driving Force for Change: The Multidisciplinary Team
Team Leader…• schedules and chairs team meetings• sets the agenda (printed at each meeting)• records team activities (working documents in
binder)• reports to management (Steering Team)• often a member of Steering Team
The Driving Force for Change: The Multidisciplinary Team
Team Facilitator…• owns the team process (enforces ground rules)• technical expert on QI theory and tools• assists Team Leader• teaches while doing, within team
The Driving Force for Change: The Multidisciplinary Team
Process Owners…• chosen for fundamental knowledge• will help implement• should become leaders (so choose wisely)
The Driving Force for Change: The Multidisciplinary Team
Team Ground Rules…• All team members and opinions are equal• Team members will speak freely and in turn
We will listen attentively to others Each must be heard No one may dominate
• Problems will be discussed, analyzed, or attacked (not people)• All agreements are kept unless renegotiated• Once we agree, we will speak with "One Voice" (especially after leaving the meeting)• Honesty before cohesiveness• Consensus vs. democracy: each gets his say, not his way• Silence equals agreement• Members will attend regularly• Meetings will start and end on time
A Brief Digression into Quality Improvement Theory
Defining an Approach to Change
worse better Quality
After
Before
Quality Assu
rance
Bell Curve:Inpatient Population
Tail
Will the team target ‘all’ patients in the inpatient bell curve, or just a sub-group considered ‘at-risk’ (depicted in the outlying tail)? Is the quality of inpatient care which is not in the tail somehow ‘acceptable?’
Defining an Approach to Change
worse better Quality
After
Before
worse betterQuality
After
QualityQuality
Assurance
Bell Curve:Inpatient Population
Tail
If the team can identify and define an inpatient sub-group ‘at-risk,’ then improvement efforts could conceivably focus just on these ‘at-risk’ patients - this is similar to traditional Quality Assurance. Note that even if tail events are eliminated, the quality of care for the rest of the inpatient population (depicted by the unchanged position and shape of the bell curve) does not improve at all. While the mean does move toward better care, this is due only to eliminating statistical outliers.
Defining an Approach to Change
worse better
worse betterQuality
Quality
After
Before
Quality
worse betterQuality
After
QualityQuality
Assurance
Quality Improvement
Bell Curve:Inpatient Population
Tail
betterbetter
If the team identifies a performance gap applicable to a wider patient population, the team may design changes in processes with the potential for dramatic effect: improvement and standardization in processes reduces variation (narrows the curve) and raises quality of care for all (shifts entire curve toward better care). This radical change is what defines Quality Improvement.
Section III:
Tools for Engineering Change
Engineering Change
• Hospitals have two dynamic levels impacting performance:1) Processes
• tasks performed in series or in parallel, impacting patient care and potentially patient outcomes
2) Personnel • skilled people with hearts and minds, with variable levels of
attention, time, and expertise
Engineering Change: What Variables Impact Quality Outcomes of Care?
Structure Processes Outcomes of Care
Inputs Steps Outputs
•Patients•Equipment•Supplies•Training•Environment
•Inventory Methods•Coordination•Physician orders•Nursing Care•Ancillary staff•Housekeeping•Transport
•Physiologic parameters•Functional status•Satisfaction•Cost
Engineering Change: What Variables Impact Quality Outcomes of Care?
Processes
Steps
•Inventory Methods•Coordination•Physician orders•Nursing Care•Ancillary staff•Housekeeping•Transport
The two most dynamic levels impacting performance
Personnel
Engineering Change
• Processes all those affecting relevant aspects of patient
care • clinical decision making, order writing, admission
intake, medication delivery, direct patient care, discharge planning, PCP communication, discharge follow-up, etc
Engineering Change
• Personnel anybody who touches the patient or a relevant
process in the system• departments, physicians, clerks, pharmacy,
nursing, RT, PT/OT/ST, care technicians, phlebotomist, patient transport, administration
Engineering Change: The Multidisicplinary Team Asks “What?”
• What? is the right thing to do? will make the system more effective?
Engineering Change: The Multidisicplinary Team Asks
“Where?”• Where?
are the processes to improve?• Brainstorming• Multivoting & nominal group technique• Affinity grouping
do we start? (dissect and understand the processes)• Cause and effect diagrams (Ishikawa or ‘fishbone’ diagrams) • Tally sheets• Pareto charts• Flow (conceptual flow, decision flow) charts• Run charts• SPC charts• Scatter charts
Tools for Engineering Change: Cause-and-Effect Diagram
• sometimes also called a ‘fishbone’ or Ishikawa diagram• graphically displays list of possible factors, focused on one
topic or objective• used to quickly organize and categorize ideas during a
brainstorming session, often as an interactive part of the session itself (the added organization can help produce balanced ideas during a brainstorming session)
Tools for Engineering Change: Cause-and-Effect Diagram
PhysiologicFactors
PharmocologicFactors
Drug Administration
Errors
Ordering Errors
Transcribing
Spelling
Pharmacokinetics
Renal
Dilution
Time
Nurse
Route
Rate
ADE
NursePhysician
Pharmacist
PhysicianPharmacy
Nurse/Clerk
PharmacistPatient
PhysicianDietician
Patient
Wrong Drug
Dose
Scheduling
Dosage
Route
Past Allergic Reaction
Absorption
WeightAge
Gender
Electrolyte
Hepatic
RacePharmacodyamics
ExpectedDrug/Drug
Unforeseen
Drug/Food
Drug/Lab
Cognitive
Psychiatric
Compliance
Patient Errors
Order Missed
Place outcome here
Example: Adverse Drug Events (ADE)
Tools for Engineering Change: Pareto Chart
• graphical display of the relative weights or frequencies of competing events, choices, or options
• a bar chart, sorted from greatest to smallest, that summarizes the relative frequencies of events, choices, or options within a class
• often includes a cumulative total line
• used to focus within a broad category containing many choices, based on factual or opinion-based information
• can combine factors that contribute to each item's practical significance
0
10
20
30
40
50
60
70
80
90
100
Perc
en
t
CausesCauses
Tools for Engineering Change: Pareto Chart
Con
trib
uti
ng
Causes Contributing to Adverse Drug Events
Tools for Engineering Change: Sketching Processes or Flow
• Macro Process Maps• Decision Flow Diagrams
Tools for Engineering Change: Macro Process MapThe patient is
admitted to thehospital
The patient isclinically identified
as having heartfailure
The ejection fractionis evaluated
The ejection fractionis documented in the
chart
The ejection fraction< 40%
The ejection fraction> 39%
The patient isprescribed an ACEI
in hospital
The patient isprescribed an ACEI
at discharge
The patient is notprescribed an ACEI
in hospital
The contraindicationfor an ACEI is
documented in thechart
The patient isexcluded from thetarget population
Example: Heart Failure Core Measures 2-3
Deep Post-OpWound Infection
BacteremiaUTI Pneumonia Other
Prevention
Detection
Treatment
PatientPreparation
ProphylacticAntibiotics
Surgery
Post-OpWound Care
- Sterile Technique- Operative Findings
Prevention
PatientSelection
AntibioticSelection
Delivery
- Duration
Prophylaxis
- Timing
Tools for Engineering Change: Decision Flow Diagram
For iatrogenic infections, any given type of infection can be dissected into the hierarchy of
contributing layers.
Contributing layer dissected: Prevention
Contributing layer dissected: Prophylactic Antibiotics
Calling out the contributing layers helps the team think through the steps ripest for change.
• Our brains understand graphics better than tables• Tabular information doesn’t convey trends over time very
well• Keep it simple• In center of horizontal axis place: baseline mean
performance• In center of vertical axis place: implementation point• Can add upper and lower control limits, but usually not
needed
Tools for Engineering Change: Run Charts
Percent Sliding Scale Insulin Only
0
10
20
30
40
50
60
70
80
Perc
ent 10/20/03
New Order Set
01/20/04
CPOE - TH
Tools for Engineering Change: Run Charts
Percent with Frank Hypoglycemic Events
0
2
4
6
8
10
12
14
16
Perc
en
t
10/20/03New Order Set
CPOETH - 1/04HC - 8/04
March 2003Team Forms
Tools for Engineering Change: Run Charts
Percent with Optimal/Acceptable Glucose Readings
0
10
20
30
40
50
60
70
80
90
100
Perc
ent
CPOETH - 1/04HC - 8/04
10/20/03New Order Set
March 2003Team Forms
Tools for Engineering Change:
Run Charts
Engineering Change: The Multidisicplinary Team Asks “How?”
• How? can you make it easy to do the right thing?
• You cannot destroy productivity– Changes must maintain, or enhance, workplace efficiency or balance
• You must devote as much attention to fitting changes into clinical work flow as you do to the evidence-based guideline
– Changes must be blended into the flow of clinical care– Important variables to consider: staffing, training, supplies, physical
layout, information flow, and educational materials
Engineering Change
Improve incrementally. Learn through action.Improve incrementally. Learn through action.
PPlan lan DDo o SStudy tudy AActct
PDSA PDSA PDSA PDSA PDSA PDSA
Test your changes. Assess their effect.Test your changes. Assess their effect.
Then re-work the changes and do it again…and again…Then re-work the changes and do it again…and again…
Engineering Change: PDSA
(the Benefits of Repeated Cycles)
• Increases belief that change will result in improvement
• Allows opportunities for “failures” without impacting performance
• Provides documentation of improvement• Adapts to meet changing environment• Evaluates costs and side-effects of the change• Minimizes resistance upon implementation
Engineering Change: PDSA
• Overview: scientific method for action-oriented learning:
shorthand for testing a change in the real world setting test a change by: planning it, trying it, measuring its
results… and then trying to do it better the next time multiple rounds of changes – some failures and some
successes - should lead to improved aggregate outcome
Engineering Change: PDSA
• Principles for Success: start new changes on the smallest possible scale, e.g.
one patient, one nurse, one doctor run just as many PDSA cycles as necessary to gain
confidence in your change – then expand expand incrementally to more patients expand to involve more nurses, more doctors, more
departments balance changes within system to ensure other
processes not adversely stressed
What do we want to achieve?
How will we measure our progress?
What changes will drive our progress?
How should we modify our latest changes?
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Engineering Change
What do we want to achieve?Set an outcome aim. (It should be ambitious, must be measurable and must specify a time-period and a definite population in your hospital.)
List the outcome aim again, then:– ask “why” three times,– ask “how” three times,– look at the new aim statements, and– pick the best one
“Function Expansion”
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Engineering Change
What changes will drive our progress ? Select change(s) to your system, the one(s) most likely to improve outcomes.
(Recognize that not all changes improve outcomes or offer balance.)
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Engineering Change
How will we measure our progress?
Define what you will measure quantitatively.
(Collect data, chart measures regularly over specified time-period, and chart against benchmarks & goal lines.)
Principles of Measurement: Seek usefulness, not perfection. Integrate measurement into the daily routine. Use qualitative and quantitative data. Use sampling.Plot data over time.
Three Types of Measures: 1) Outcomes2) Process3) Balancing measures
(Use a balanced set of measures for all improvement efforts.)
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Engineering Change
How should we modify our latest changes? Test your changes.
(Run PDSA cycles to learn from the work setting.)
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Engineering Change:
Hints for Success• Empower nursing• Expedite order set and protocol passage through appropriate medical staff committees• Better to implement an imperfect, compromise change than no change at all• Pilot newest changes on smallest scale• Provide hot line or support for difficult implementation situations• Use your new system as a shared baseline, with clinicians free to vary based on individual patient
needs• Follow metrics continuously as you implement• Feed metrics back into subsequent PDSA cycles• Measure, learn, and over time eliminate variation arising from professionals; retain variation arising
from patients• Keep big picture in mind• Negotiate ‘speed bumps’
Time delays in getting data Incomplete buy-in Go around obstacles instead of through them (can always go back to them later) Some who disagree with you may be correct Make changes painless as possible: make it easy to do the right thing
QI Theory:Quality Improvement in the Hospital
• Suggested next steps:1) Share this primer in QI Theory with other hospitalists in
your group2) Identify an important QI project at your hospital3) Lead the QI project using all available resources4) Learn from your experience and be among the first to
mentor other hospitalists
Use SHM’s topic-specific resource rooms to ask questions, share experiences & tools, review the literature, and to download presentations to help you educate others.
Acknowledgments
• Brent James, MD, MStat (Intermountain Health Care's Institute for Health Care Delivery Research): concepts, content, figures
• Thomas Nolan, PhD (Institute for Healthcare Improvement): concepts, content, figures
• Greg Maynard, MD, MSc (University of California, San Diego): editorial composition and review
• Jason Stein, MD (Emory University School of Medicine): editorial composition