quality improvement basics - healthinsight agent lan/in... · this material was prepared by...

Quality Improvement

Basics

David R. Cook, Director of Operations,

HealthInsight Utah

Introduction – Blame Free

The best people can sometimes make the worst errors……We cannot change the human condition. People will always make errors and commit violations. But we can change the conditions under which they work to make these unsafe acts less likely……Blaming people for their errors – though emotionally satisfying – will have little or no effect on their future fallibility…..Errors are largely unintentional. It is very difficult for management to control what people did not intend to do in the first place. James Reason – Managing the Risks of Organizational Accidents, p.153.

Quality Assurance vs. Quality Improvement

Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook p. 18

What Changes Can We Make that Will Result in Improvement?

“Nobody likes change,

unless it is a wet

baby!”

Objectives

1) Understand the Model for Improvement*

2) Identify a Gap, develop an aim statement withmeasurement and develop an improvement plan

3) Understand rapid cycle improvement

4) Simple flow charting

*Associates in Process Improvement

BL\e-MM: o:t ~H$ CAUS'lS er M&K~A1ITYt . 1 .

APRlL. 1855 l'O l!ARCH 16.56. IH TttE. ARMY IN THE EAS T. APRIJ, J85t~oMARCH 1655.

0 n

I .......... .

••-~·-· ····· r

-··" ...........-···"

.....~ ............

Tlu-Area.9 ~r tlL~ /tluv. rd. ,e;· blach1.lic,WtOui/Jlc, tJrJfdifJ1tN~Zynwl«>di.suues, II~ rettwaff/M ltWUUn.fb~ f/u,.cv1Jn.- lfte, iJral/u rl'Wrt. tlNFtNu/.J; ,(t;th,r, bll/Ck, waf.gum..uzsuru/,rr#71L (hQ C.€./J]r" fhulratJr.rf;VTI'- (l//,oiJ~rCPl4

Concept Measure Operational definition

Data collection plan Data collection Analysis

Creative thinking

Action and Change

How to Get from Ideas to Action

AIM statement

The Model for Improvement -- PDSA

Identify the Gap

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996

Recognition of Quality Gap – Opportunity for Improvement

• Can be a vague impression (hunch) • Report review • Sentinel events • We want a better outcome (hope) • Taking Stock Exercise

Cause and Effect Tools – Quality Gaps

• Fishbone • 5 Whys – Toyota • Root Cause Analysis (RCA) – not covered today

(see healthinsight.org) • Failure Modes and Effects Analysis (FMEA) –

not covered today • Event Tree and Fault Tree Analysis

http:healthinsight.org

Exercise #1

Take a minute and review from your recent experience one opportunity for improvement or

quality gap

Please write it down

The Model for Improvement PDSA cycles




Set the AIM

Establish MEASUREMENT

PLAN for Improvement


Step #1 - Setting the AIM – What Are We Trying to Accomplish?

• State the aim clearly (SMART acronym) • Include numerical goal and time frame that

require fundamental system change • Set stretch goals • Avoid aim drift • Be prepared to refocus the aim

Step #2 - Establishing Measures – How Will We Know That a Change is An Improvement?

• Plot data over time • Seek usefulness, not perfection • Use sampling • Integrate measurement into the daily routine • Use qualitative and quantitative data • Focus on outcome measures

Exercise #2

Take a minute and write an AIM statement based on the improvement opportunity

identified in Exercise #1

Remember to include a numeric goal (measure) and time frame

Step #3 – Overall Plan for Improvement

• Avoid “the same” responses • Implement recommended practices

guidelines • Think processes and systems of work

– Simplify processes – Reduce waste or unnecessary redundancies – Strengthen hand offs

• Creative thinking • Appropriate use of new or existing

technology

Step #3 – Overall Plan for Improvement

1) Describe change (strategies) 2) Predict outcome 3) List steps needed 4) Plan for collection of data

“Every system is perfectly designed

to get the results it gets.”

Paul Batalden, M.D.

Exercise #3

Take three or four minutes and outline your Global Plan

1) Describe change (strategies) 2) Predict outcome 3) List steps needed 4) Plan for collection of data

The Model for Improvement PDSA cycles




Global AIM, Measure, and Plan (Strategies)

Smaller Tests (Tactics)


PDSA (Plan-Do-Study-Act)

Also known as: • PDCA (Check instead of

Study) • The Deming Cycle/Wheel • The Shewart Cycle • The Learning and

Improvement Cycle


Classifying PDSA cycles

The Chronic Care Model (Mid-level Theory) • Clinical Information

Systems • Delivery System Design

Community • Decision Support • Self Management • Organizational Support

Human Factors Science (Micro-level Theory) • Actors • Behaviors • Decisions • Habits

Plan

Sequence:

1) Describe first (or next) change (tactic) 2) Predict outcome 3) List tasks needed 4) Plan for collection of data

DO – Carry it Out

• Implement (preferably on a small scale) • Document problems and unexpected

observations • See plan through to completion • Motivations to carry it out

Study or Check – What did we learn?

• Review the data/take survey • Compare the data to your predictions • What worked or went well? What did not? • Summarize and reflect on what was learned

-- draw conclusions

ACT

• Adopt it • Abandon it • More study

needed • Modify overall

aim, measure, or plan • Create new plan

The Team Handbook (Scholtes, Joiner, Streibel). Madison, WI, USA: Oriel Incorporate, Inc.; 2003 page 5-27

Stringing it Together

Rapid Cycle - Multiple Cycles

Overall AIM Increase documented eye exams for our diabetes population by 45% in the next 12 months

Time

Expect Challenges and Barriers

Cycle #1 – Contact Eye Doctors

Cycle #2 – Patient Fax Back Form

Cycle #3 – Front Office track down eye results

Cycle #4 – Computer Network with eye doctors

Cycle #5 – Reminder letter from PCPs

Implement Final Changes

Model for Improvement PDSA - Summary





Gap:

Aim:

Overall Plan:

Plan

~ First (or next) change: Prediction:

r~~) Tasks Needed: List the tasks needed to set up this test ofchange (who, what, where, when) ~~ Data Collection: Plan for collection ofdata (who, what, where, when) Do Describe what actually happened, including problems and unexpected observations, when you ran the test.

Study Describe the measured results and how they compared to the predictions. Summarize and reflect on new knowledge learned.

Act Describe what modifications to the plan will be made for the next cycle from what you learned.

Adapted frcm Institute for Healthcare Improvement POSA Vl()rksheets -www.ihi.org

rhe enclosed material was prepared andasseMbled by Meal:hrnstgh:. under con:ract wnh the Centers for Medicare & Med1ca1d Servtces (CMS). Quality Improvement an agency of ;he U.S. Depar

Tool - Workflow Analysis/Flowcharting

• Opportunity for end user to step back and

evaluate current processes and methods

• Linear visual representation of a process to facilitate discussion and improvement

• Complete previous to causal analysis • Various types (e.g. Swim Lane, Simple, Process

Mapping) • Current State/Future State

Basic Flowchart Symbols

Start or End Symbol

“Flow of Control” Symbol

Process Step Symbol

No

Decision Symbol Yes

Connector Symbol (end of page)

Delay or Wait Symbol

Flowcharts can be created with stickies, whiteboards in Microsoft PowerPoint, Word, Visio and many other applications.

References

• Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook • The Team Handbook (Scholtes, Joiner, Streibel). Madison, WI, USA: Oriel Incorporate,

Inc.; 2003 • Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619-622.

Available at http://www.bmj.com/content/312/7031/619.full • Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical

Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009.

• Moen R and Norman CL. "Circling Back: Clearing up myths about the Deming cycle and Seeing How it Keeps Evolving." Quality Progress, American Society for Quality. 2010; 22-28. Available at http://www.apiweb.org/circling-back.pdf

http://www.bmj.com/content/312/7031/619.fullhttp://www.apiweb.org/circling-back.pdf

Evaluations – Share Your Feedback

Questions ?

Contact Info: • David Cook, HealthInsight • 801-892-6623 • [email protected]

This material was prepared by HealthInsight, the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-CORP-16-89-UT

mailto:[email protected]

Quality Improvement BasicsIntroduction – Blame Free Quality Assurance vs. Quality ImprovementWhat Changes Can We Make that Will Result in Improvement?ObjectivesSlide Number 6Slide Number 7How to Get from Ideas to ActionThe Model for Improvement -- PDSARecognition of Quality Gap –�Opportunity for ImprovementCause and Effect Tools – Quality GapsExercise #1The Model for Improvement PDSA cyclesStep #1 - Setting the AIM – What Are We Trying to Accomplish?Step #2 - Establishing Measures – How Will We Know That a Change is An Improvement?Exercise #2Step #3 – Overall Plan for ImprovementStep #3 – Overall Plan for ImprovementSlide Number 19Exercise #3The Model for Improvement PDSA cyclesPDSA (Plan-Do-Study-Act)Classifying PDSA cyclesPlanDO – Carry it OutStudy or Check – �What did we learn?ACTStringing it TogetherRapid Cycle - Multiple CyclesModel for Improvement PDSA - SummarySlide Number 31Tool - Workflow Analysis/FlowchartingBasic Flowchart SymbolsReferencesEvaluations – Share Your Feedback Questions ?New slide Dave 508.pdfQuality Improvement BasicsIntroduction – Blame Free Quality Assurance vs. Quality ImprovementWhat Changes Can We Make that Will Result in Improvement?ObjectivesSlide Number 6Slide Number 7How to Get from Ideas to ActionThe Model for Improvement -- PDSARecognition of Quality Gap –�Opportunity for ImprovementCause and Effect Tools – Quality GapsExercise #1The Model for Improvement PDSA cyclesStep #1 - Setting the AIM – What Are We Trying to Accomplish?Step #2 - Establishing Measures – How Will We Know That a Change is An Improvement?Exercise #2Step #3 – Overall Plan for ImprovementStep #3 – Overall Plan for ImprovementSlide Number 19Exercise #3The Model for Improvement PDSA cyclesPDSA (Plan-Do-Study-Act)Classifying PDSA cyclesPlanDO – Carry it OutStudy or Check – �What did we learn?ACTStringing it TogetherRapid Cycle - Multiple CyclesModel for Improvement PDSA - SummarySlide Number 31Tool - Workflow Analysis/FlowchartingBasic Flowchart SymbolsReferencesEvaluations – Share Your Feedback Questions ?

quality improvement basics - healthinsight agent lan/in... · this material was prepared by...

Documents