Quality Improvement. What Is it and How Can It Help Me?

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Pamela S. Gillam, MPA

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  • What model/methods are used by your organization?
  • Quality Improvement Training Family Planning Program Greenville County Health Departement August 3, 2009
  • 1. Testing provides evidence that a change really does result in the improvement that was expected. Even though a change may sound like a good idea, you don’t know until you actually use it in practice. There are often multiple changes that are needed in order to produce the desired effect on your system. Testing a change, or a group of changes, gives you information about how much improvement can be expected from a change or set of changes. It allows you to evaluate whether you need additional changes to reach your aim. 3. Even though a change may have produced the desired effect in a different setting, you don’t really know how it will work in your particular environment until you try it. 4. Change sometimes produces unintended consequences. Testing allow you to observe the costs (resources, time, equipment, etc.) that the new process might involve as well as the side-effects that might accompany the change. For example, providing same-day access for clinic patients may affect the process for locating medical records. 5. It is often easier for people to agree to try a new way of doing something if the change is presented as a short-term, small scale trial. “Let’s just try it with the next three patients…” In this way, they don’t have to immediately abandon the old way of doing something. Testing often shows people that the new way is really better and they are then more willing to embrace the new process.
  • This is a hypothetical example from a team working to improve access to a physician office practice or clinic. The change that they are testing is that reducing appointment types will reduce delays in patients obtaining an appointment. This test is based on a powerful concept that having too many appointment types creates delays by establishing queues or lines for specific types of appointments (e.g., a new patient physical, a return patient with diabetes, etc.). Fewer appointment types means that more patients can have access to more potential appointment slots. The tests begin with defining a small number of appointment types, comparing the appointment requests for a week and matching them to the new types (without actually assigning the new appointments), then actually trying the new appointment system with a small number of physicians’ patients. After making refinements in the new system, the team is ready to use the system throughout the clinic.
  • Quality Improvement. What Is it and How Can It Help Me?

    1. 1. QualityQuality ImprovementImprovement– What– What Is it and How Can It HelpIs it and How Can It Help Me?Me? Pamela S. Gillam, MPAPamela S. Gillam, MPA
    2. 2. OBJECTIVES:OBJECTIVES:  Recognize the definition of QualityRecognize the definition of Quality Improvement (QI)Improvement (QI)  Understand the difference b/w QI andUnderstand the difference b/w QI and Quality Assurance (QA)Quality Assurance (QA)  Demonstrate the use of the Model forDemonstrate the use of the Model for Improvement/PDSA CycleImprovement/PDSA Cycle
    3. 3. Why You Should Care About QIWhy You Should Care About QI If you plan to be a:If you plan to be a:  Health Educators- It is an effective approach forHealth Educators- It is an effective approach for implementing evidence based practices!implementing evidence based practices!  Researcher-- Evaluation is a requiredResearcher-- Evaluation is a required component of most research grants and QIcomponent of most research grants and QI enhances it; Funders (Feds!) are counting on itenhances it; Funders (Feds!) are counting on it  Administrator– Hospitals are using it;Administrator– Hospitals are using it; Reimbursement depends on it; manyReimbursement depends on it; many organizations are in desperate need for it!!!!organizations are in desperate need for it!!!!
    4. 4. What is Quality?What is Quality? American Society for Quality (ASQ)American Society for Quality (ASQ) definition—definition— 1. the characteristics of a product or service1. the characteristics of a product or service that bear on its ability to satisfy stated orthat bear on its ability to satisfy stated or implied needs;implied needs; 2. a product or service free of deficiencies.2. a product or service free of deficiencies. “Fitness for Use”- Joseph Juran “Conformance to Requirements”- Philip Crosby
    5. 5. 55 What is Quality?What is Quality? Quality is a never-endingQuality is a never-ending cycle of continuouscycle of continuous improvement.improvement. -Deming
    6. 6. 66 The Quality JourneyThe Quality Journey Quality Assurance Quality Improvement Rapid Cycle Quality Improvement
    7. 7. 77 Quality Alphabet SoupQuality Alphabet Soup lean
    8. 8. Quality ImprovementQuality Improvement  Aimed at improvement -- measuringAimed at improvement -- measuring where you are, and figuring out ways towhere you are, and figuring out ways to make things bettermake things better  Specifically attempts to avoid attributingSpecifically attempts to avoid attributing blameblame  Attempts to create systems to preventAttempts to create systems to prevent errors from happeningerrors from happening
    9. 9. Models for QIModels for QI Six Sigma (6s) Lean Model for Improvement Focus on Critical-to-Customer Quality Focus- Identify Value Focus- Improvement through Small Scale Testing Focus- Culture and Infrastructure Eliminate Waste Test ideas to meet overarching goals Reducing Variation Increase Processing Speed/Reduce WIP Test ideas under a variety of conditions Remove Causes of Defects Process Mapping, Takt time PDSA DMAIC, Cpk Use this when you have ideas of what can be done or adapting EBP Use this when you don't know what to do Common across all three: •Need to understand the process flows •Need to understand the overall goal and strategy of Operations •Need for leadership and organizational buy-in •Importance of the “voice of the customer” (internal and external) •Need for data and measurements, i.e., evidence-based changes •Use of teams
    10. 10. Common QI ToolsCommon QI Tools  Control Charts, Pareto Charts, GANTTControl Charts, Pareto Charts, GANTT chartscharts  Plan Do Study Act (PDSA) CyclePlan Do Study Act (PDSA) Cycle  Root Cause Analysis- Ishikawa/FishboneRoot Cause Analysis- Ishikawa/Fishbone DiagramDiagram  Nominal Group TechniqueNominal Group Technique  Flow chartsFlow charts  FMEAFMEA
    11. 11. QI isQI is ALWAYSALWAYS aboutabout THETHE CUSTOMER!!!CUSTOMER!!!
    12. 12. An Integrated Approach To ImprovementAn Integrated Approach To Improvement Top down Bottom up Leadership level • Determine aims • Identify resources (staff/$$) • Continuous support Strategies for Improvement: • Make changes in other areas • Use collaborative model in other areas • Fundamental change in how the organization/division does business • Local incremental improvements • Control what’s going to happen Local level • Understand capacity needs • Knows what will work/won’t work Results • Reduce cost/improve productivity • Provide different/ new services • Improve quality
    13. 13. 1313 QA vs. QIQA vs. QI Quality AssuranceQuality Assurance  Conform toConform to standardsstandards  Relies onRelies on inspectioninspection  Focus on itemsFocus on items  Quality is separateQuality is separate functionfunction  DepartmentalDepartmental functionfunction Quality ImprovementQuality Improvement  ImprovedImproved performanceperformance  Monitor over timeMonitor over time  System orientationSystem orientation  Quality integratedQuality integrated in organizationin organization  InterdisciplinaryInterdisciplinary functionfunction
    14. 14. QA vs. QI (cont’d)QA vs. QI (cont’d) Quality AssuranceQuality Assurance Focus on improvingFocus on improving individual's faultsindividual's faults ReactionaryReactionary Use of “minimum”Use of “minimum” standardsstandards Time-limitedTime-limited Quality ImprovementQuality Improvement Focus on systems andFocus on systems and process improvementprocess improvement ProactiveProactive Use of “benchmark” andUse of “benchmark” and “best practices”“best practices” ContinuousContinuous
    15. 15. Short Example of QI vs. QAShort Example of QI vs. QA From the following statements, which do you thinkFrom the following statements, which do you think have a QA focus and which have a QI focus?have a QA focus and which have a QI focus? 1.1. Which staff member failed to transfer the call to theWhich staff member failed to transfer the call to the correct extension?correct extension? 2.2. Are we creating an environment encouraging cliniciansAre we creating an environment encouraging clinicians to report errors?to report errors? 3.3. How do we reduce billing errors by our staff?How do we reduce billing errors by our staff? 4.4. Patient had a bad outcome; were the doctors orPatient had a bad outcome; were the doctors or nurses at fault?nurses at fault? 5.5. What could we do to increase the efficiency of chartWhat could we do to increase the efficiency of chart filing?filing?
    16. 16. The Model forThe Model for ImprovementImprovement TestingTesting and Implementingand Implementing ChangesChanges
    17. 17. Model for Improvement 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? Act Plan DoStudy From: Associates in Process Improvement AIM MEASURE CHANGES
    18. 18. Aim StatementAim Statement aka “What are you trying toaka “What are you trying to improve?”improve?”  Involve senior leadersInvolve senior leaders  Focus on issues that are important to yourFocus on issues that are important to your organizationorganization  Connect the team Aim statement to theConnect the team Aim statement to the Strategic PlanStrategic Plan  Build on the work of others (StealBuild on the work of others (Steal Shamelessly!)Shamelessly!)
    19. 19. Measures- 3 TypesMeasures- 3 Types 1.1. Outcome MeasuresOutcome Measures- Voice of the Customer.- Voice of the Customer. How is the system performing? What is theHow is the system performing? What is the result?result? 2.2. Process MeasuresProcess Measures- Voice of the workings of- Voice of the workings of the system. Are the parts/steps in the systemthe system. Are the parts/steps in the system performing as planned?performing as planned? 3.3. Balancing MeasuresBalancing Measures- Looking at a system from- Looking at a system from different directions. What happended to thedifferent directions. What happended to the system as we improved the outcomes/processsystem as we improved the outcomes/process (e.g. unanticipated consequences, other factors(e.g. unanticipated consequences, other factors influencing outcome)?influencing outcome)?
    20. 20. ChangesChanges  Practices from other industriesPractices from other industries  Evidence-based PracticesEvidence-based Practices  Promising PracticesPromising Practices  Ideas from staffIdeas from staff
    21. 21. Model for Improvement 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? Act Plan DoStudy From: Associates in Process Improvement AIM MEASURE CHANGES
    22. 22. PDSA Cycle for Learning andPDSA Cycle for Learning and Improvement: Use it All!Improvement: Use it All! Plan • Objective • Questions and Predictions (Why?) • Plan to carry out the cycle (who, what, where, when) Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data Study • Complete the analysis of the data • Compare data to predictions • Summarize what was learned Act • What changes are to be made? • Next cycle? What will happen if we try something different? Let’s try it!!Did it work? What’s next?
    23. 23. Use the PDSA Cycle for :Use the PDSA Cycle for :  Testing or adapting a changeTesting or adapting a change ideaidea  Implementing a changeImplementing a change  Spreading the changes to theSpreading the changes to the rest of your systemrest of your system
    24. 24. Why Test?Why Test?  Increase your belief that the change willIncrease your belief that the change will make improvementmake improvement  Predict how much improvement you canPredict how much improvement you can expect from the changeexpect from the change  Learn how to adapt the change in yourLearn how to adapt the change in your settingsetting  Figure out the costs and side-effects of theFigure out the costs and side-effects of the changechange  Minimize resistance upon implementationMinimize resistance upon implementation
    25. 25. To be considered a real testTo be considered a real test  Test was planned, including a plan forTest was planned, including a plan for collecting datacollecting data  Plan was carried out and data werePlan was carried out and data were collectedcollected  Time was set aside to analyze data andTime was set aside to analyze data and study the resultsstudy the results  Action was based on what was learnedAction was based on what was learned
    26. 26. Repeated Use of the PDSA CycleRepeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement A P S D A PS D A P S D D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change
    27. 27. Aim:Aim: Reduce smoking rates by implementingReduce smoking rates by implementing the 2 A’s and R CPG standardthe 2 A’s and R CPG standard Conducting 2 A’s and R will increase Fax Referrals Reduced Smoking Rate A P S D A PS D A P S D D S P A DATA D S P A Cycle 1: Test the 2 A’s and R with 5 patients on Tuesday. Cycle 2: Change forms, process. Cycle 3: Cycle 4: Standardize process Cycle 5: Educate staff in new process Test new form, process with 10 patients.
    28. 28. Let’s practice!!!Let’s practice!!!
    29. 29. Questions???Questions??? gillamps@sc.edugillamps@sc.edu OrOr 803-777-0304803-777-0304

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