MEASUREMENT FOR QUALITYIMPROVEMENTCarol Callaway-Lane, DNP, ACNP-BCVA-TVHS NashvilleNational VA Geriatric Scholars Program
Objectives   Identify strategies to routinely include systems    improvement in clinical practice   Use a tally sheet an...
Improvement in Clinical Practice   Clinical providers caring for our veteran    population who deserve best possible care...
Simple model;   Model of Improvement                                Complicated                   Aims                    ...
Model of Improvement                   Aims     What are we trying to accomplish?                 Measures     How will we...
Two Types of Measurement   Measurement for discovery     Brainstorming     Identify   common and uncommon causes   Mea...
Oyler J, Vinci L, Arora V, Johnson J. http://medqi.bsd.uchicago.edu/curriculum.html
Measurement for Discovery:    A Case Study   Problem: Clinical provider experiencing frequent    occurrence of patients b...
Tally Sheet   Count occurrences of events   Identify most frequent reasons a process isn’t    working     Not   always ...
Tally Sheet   Problem Statement: Desire to determine    causes for late rooming of patients in the    geriatric clinic.Re...
Pareto Chart   Bar graph of frequencies   Can be generated from tally sheet   Pareto Principle (80/20 Rule)     80%   ...
Measurement for Discovery              Reasons for Late Rooming3530      33      Total # per week = 53252015              ...
Measuring for Improvement                                                   Health         Health                         ...
The Institute for Healthcare   Improvement (IHI): different measures          Measurement for research        Measurement ...
Classifying Metrics•   Outcome Measures    •   Measure of a true effect on patients. Commonly reflects        cumulative i...
Outcome Measures   Prevent Disease      Quality of Life                             Social                             Me...
Challenge of Outcome Measures   Clinically important: reflect on all aspects of the    care process       Obvious and th...
Challenge of Process MeasuresProximal to the intervention and therefore sensitive to change…But is it clinically relevant...
Balancing Measures:   The Clinical Value Compass                    Functional Status                    Quality of lifeBi...
Measurement for Change:    Our Case Study   OUTCOME MEASURE:     Improved disease management     Improved patient and p...
Measurement for Baseline Status              Reasons for Late Rooming3530      33      Total # per week = 53252015        ...
Measurement for Change   What you measure is directed by your what you    want to evaluate    # patients placed in clini...
SMART Aim Statement Specific Measurable Achievable Relevant Time limited    We WILL improve X, by Y% for (defined    ...
SMART Aim Statement Specific Measurable Achievable Relevant Time limited     Working as an interdisciplinary team, we...
3 A’s of Good Metrics forQuality Improvement   Agile     Data   that you can collect and act upon quickly   Accurate   ...
Groups of Change Concepts       Eliminate Waste       Improve Work Flow       Optimize Inventory       Change the Work...
Groups of Change Concepts       Eliminate Waste       Improve Work Flow       Optimize Inventory       Change the Work...
Measurement for change:Process Measure   Clinic Room Availability     Baseline    data for 1 week– 53 occurrences      ...
Reasons for Rooming Delays              35              30              25              20                        Signific...
Improvement Impact: Week 1   Results of PDSA cycle # 1   Decrease of late rooming from 53 to 50 or    improvement of 6%...
PDSA Cycle # 2: Improve workflow:Add back room to Nurse Check-in                         Reasons for late rooming         ...
Improvement Impact: Week 2   Results of PDSA cycle # 2   Decrease of late rooming from 53 to 35 or    improvement of 34%...
Simple Measurement forReal Improvement to Care
Measurement: Impact of Change60504030                                                    Late Rooming Patients20          ...
Simple model;   Model of Improvement                                Complicated                   Aims                    ...
Intervention Strategy          Act            Plan       (New Cycle or   Improvement          Spread)        Study        ...
Multiple Small Interventions                         3                             D   S            2                P   A...
Measurement: Impact of Change   Simple strategies for improvement can be used in    any clinical setting, regardless of t...
Questions or Comments?
Improving clinical care_through_quality_improvement_april_23_2012_final
Improving clinical care_through_quality_improvement_april_23_2012_final
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April 26, 2012
Improving Clinical Care Through Quality Improvement

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  • Speak about why QI is important to us all as clinical providers and why we need to focus on the system of care around us to make the work we do for the patient more effective, efficient, safer, more timely, equitable.
  • When we think about needing to change something that we think needs to be improved, first we need to step back from the process and evaluate the current status of events to have a true sense of how things are– Would it not be nice to stand above the process and have a full view of the entire process much like Curious George? To do this in healthcare you will want to seek the perspective of all providers involved in the process, as well as the point of view of the patient for a full understanding of the process
  • Stress the importance of having an interprofessional team so all perspectives are considered
  • Now that you have a list of potential causes for delays you will want to determine how often these things are indeed the cause of delay. The provider counts the number of events– the number of times that a pt is late being placed into a clinic room for 1 full week and works with the team to determine the causes for the delays– What this offers is a method of evaluation or measurement of the burden of the problem--- and the results may surprise you----This method of tracking will guide your decisions on where to prioritize your efforts for change
  • As shown here– delays at the front desk did not seem to be a problem at all when the process was evaluated in a mindful manner. Interesting, lack of room availability instead was the main reason for the delays to care.
  • So, now that you have the information from the simple tally sheet, how can this information guide where you focus your improvement steps? The Pareto Chart was created by a 17th century economist who determined that 80% of the wealth in Italy was controlled by only 20% of the population– this theory held true from more than just monetary situations– The rule is that 80% of all effort comes from 20% of causes--
  • This is what a pareto chart looks like----
  • So, in our clinical scenario, we have 4 main reasons for delays that have been identified- which have been placed into a simple Excel spreadsheet- You can see from the diagram that the causes for delays are along the L hand side and the timeframe is at the top– with the initial column being BASELINE measurement. From this graph you can then create a bar chart as seen on the R- which allows you to visually see that not having a room available truly impacts the overall time to see patients in the geriatric clinic.
  • By utilizing a tally sheet you have not only identified the most common problem but you also have determined to overall burden of the problem– or your baseline measurement. Now that you have this information you can begin to consider how you can make improvement- and how you can measure these improvements
  • So, let us now take a minute to identify the metrics for our case study--
  • Arrow indicates the area of greatest impact– the best place to start for maximum impact on improvement
  • Identify data that is quick, easy, and measureable In this scenario we have established that measuring the # and causes of late rooming of patients an agile, accurate, and accessible measurement to use over the coming weeks as changes are made to the process.
  • Now that an area for improvement has been identified, you must begin to think of what you will change– You can look at the process in many different ways– one of the most common types of quick change is to identify and eliminate waste or to improve the work flow process.
  • When we consider our current clinical situation, improving work flow and optimizing inventory; in this case, physical space in the clinic; are two areas of potential improvement that will take minimal effort- Picking the low handing fruit or stating with the change ideas that are the most simple to implement.
  • Improving clinical care_through_quality_improvement_april_23_2012_final

    1. 1. MEASUREMENT FOR QUALITYIMPROVEMENTCarol Callaway-Lane, DNP, ACNP-BCVA-TVHS NashvilleNational VA Geriatric Scholars Program
    2. 2. Objectives Identify strategies to routinely include systems improvement in clinical practice Use a tally sheet and Pareto chart to identify specific areas of focus for improvement within clinical practice Create a well-defined process measure to collect baseline data and monitor improvement Utilize methods of measurement in order to determine the impact of steps of change
    3. 3. Improvement in Clinical Practice Clinical providers caring for our veteran population who deserve best possible care Great providers + Inefficient system ≠ Great Care We need great support systems behind us
    4. 4. Simple model; Model of Improvement Complicated Aims process What are we trying to accomplish? Guides us to: Measures  Think early How will we know if a change is an improvement? about defining success Process Analysis  Create concreteWhat changes can we make that will result in forms of improvement? measurement  Use these Act Plan measurements (Stop or Spread) Improvement to evaluate for PDSA Cycle improvement Study Do Results Improvement
    5. 5. Model of Improvement Aims What are we trying to accomplish? Measures How will we know if a change is an improvement? Process Analysis  Identify how weWhat changes can we make that will result in will know that a improvement? change is truly an Act (Stop or Spread) Plan Improvement improvement PDSA Cycle Study Do Results Improvement
    6. 6. Two Types of Measurement Measurement for discovery  Brainstorming  Identify common and uncommon causes Measurement for actual change  Baselinemeasurement  Rapid cycle improvement
    7. 7. Oyler J, Vinci L, Arora V, Johnson J. http://medqi.bsd.uchicago.edu/curriculum.html
    8. 8. Measurement for Discovery: A Case Study Problem: Clinical provider experiencing frequent occurrence of patients being placed into exam room well after appointment time. Why?  “it must be the clerks delaying the process” Identify potential areas for measurement  Assemble team  Brainstorm possible causes for delays  Ptarriving late  Delays at clerk desk  Room not available  Delays with the check in nurse
    9. 9. Tally Sheet Count occurrences of events Identify most frequent reasons a process isn’t working  Not always what you expect! Prioritize which area(s) to target changes
    10. 10. Tally Sheet Problem Statement: Desire to determine causes for late rooming of patients in the geriatric clinic.Reason for late-rooming CountPatient arrived late IIII IIII IIDelay at front desk IINo room available IIII IIII IIII IIII IIII IIII III
    11. 11. Pareto Chart Bar graph of frequencies Can be generated from tally sheet Pareto Principle (80/20 Rule)  80% of effect comes from 20% of causes Prioritizes area(s) to target changes
    12. 12. Measurement for Discovery Reasons for Late Rooming3530 33 Total # per week = 53252015 Baseline10 125 6 20 Room Not Patient Late Delays with Delays with Available Nurse Clerk
    13. 13. Measuring for Improvement Health Health Phase III Services Care Basic Prototype Phase I & II Studies Research PracticeScience Discovery Studies (RCTs) QI  Like research, quality improvement uses data to determine if a change in practice is an improvement in care  Quality improvement impacts clinical practice, not new research
    14. 14. The Institute for Healthcare Improvement (IHI): different measures Measurement for research Measurement for learning and process/quality improvementPurpose To discover new knowledge To bring new knowledge into daily practiceTests One large "blind" test Many sequential, observable testsBiases Control for as many biases as Stabilize the biases from test to possible testData Gather as much data as Gather "just enough" data to possible, "just in case" learn and complete another cycleDuration Can take long periods of time "Small tests of significant to obtain results changes" accelerate the rate of improvement
    15. 15. Classifying Metrics• Outcome Measures • Measure of a true effect on patients. Commonly reflects cumulative impact of multiple care processes Example: Number of foot amputations• Process Measures • Measure of services provided/healthcare delivered – Example: Completion of foot exams• Balancing Measures • Measure unintended consequences – Example: Number of late appointments
    16. 16. Outcome Measures Prevent Disease Quality of Life Social Mental Minimize Burden of Physical Disease Biological Maintain Function Conserve Resources
    17. 17. Challenge of Outcome Measures Clinically important: reflect on all aspects of the care process  Obvious and the not so obvious…But can you really make them change?Example: Adherence Family Hx..Improve diabetes Time…. # of Foot care Amputations Other Risk Detection Factors Rates
    18. 18. Challenge of Process MeasuresProximal to the intervention and therefore sensitive to change…But is it clinically relevant Assumed impactExample: # of Foot # of FootImprove diabetes Time…. Exams Amputations care Sensitivity Clinical Relevance
    19. 19. Balancing Measures: The Clinical Value Compass Functional Status Quality of lifeBiological Status Satisfaction Morbidity Patient Satisfaction Mortality Provider Satisfaction Cost of Care Direct Medical Indirect Social
    20. 20. Measurement for Change: Our Case Study OUTCOME MEASURE:  Improved disease management  Improved patient and provider satisfaction  Cost savings (overtime pay for lengthy clinics) PROCESS MEASURE:  Timely placement of patient in room for clinic visit  Adding an additional room to the clinic structure BALANCING MEASURE:  Additional rooms used has displaced another clinic group  Decreased space for Nurse check-in
    21. 21. Measurement for Baseline Status Reasons for Late Rooming3530 33 Total # per week = 53252015 Baseline10 125 6 20 Room Not Patient Late Delays with Delays with Available Nurse Clerk
    22. 22. Measurement for Change What you measure is directed by your what you want to evaluate # patients placed in clinic room late  Reasons why they are placed in room late A strong AIM statement is key to staying on track
    23. 23. SMART Aim Statement Specific Measurable Achievable Relevant Time limited We WILL improve X, by Y% for (defined population), by (date)
    24. 24. SMART Aim Statement Specific Measurable Achievable Relevant Time limited Working as an interdisciplinary team, we will reduce the number of late rooming of geriatric patients by 50% (from 53/week to 26/week) within the next 4 weeks.
    25. 25. 3 A’s of Good Metrics forQuality Improvement Agile  Data that you can collect and act upon quickly Accurate  Not a lot of weekly variation Accessible  Datathat you can easily obtain  Under your control
    26. 26. Groups of Change Concepts  Eliminate Waste  Improve Work Flow  Optimize Inventory  Change the Work Environment  Producer/Customer Interface  Focus on Time  Focus on Variation.  Error Proofing.  Focus on Product/ServiceLangley, Nolan, Nolan, Norman, Provost. “Change Directions: The Science and Art of Improvement.”Jossey-Bass, 1996.
    27. 27. Groups of Change Concepts  Eliminate Waste  Improve Work Flow  Optimize Inventory  Change the Work Environment  Producer/Customer Interface  Focus on Time  Focus on Variation.  Error Proofing.  Focus on Product/ServiceLangley, Nolan, Nolan, Norman, Provost. “Change Directions: The Science and Art of Improvement.”Jossey-Bass, 1996.
    28. 28. Measurement for change:Process Measure Clinic Room Availability  Baseline data for 1 week– 53 occurrences  Main cause- lack of room availability  Week 1: initial intervention  Team meeting to choose intervention  Add one additional room for clinical evaluation  Room previously used by an additional Nurse Check-in station
    29. 29. Reasons for Rooming Delays 35 30 25 20 Significant Improvement 15 10 Unintended consequence 5 0 Baseline Week 1 Week 2 Week 3Room Not Available 33 23Patient Late 12 11Delays with Nurse 6 13Delays with Clerk 2 3 52 50
    30. 30. Improvement Impact: Week 1 Results of PDSA cycle # 1 Decrease of late rooming from 53 to 50 or improvement of 6% What happened? Balancing Measure-  Check in process was slowed down  Next PDSA cycle: incorporate new data
    31. 31. PDSA Cycle # 2: Improve workflow:Add back room to Nurse Check-in Reasons for late rooming 35 30 25 34% Improvement 20 15 10 5 0 Baseline Week 1 Week 2Room Not Available 33 23 15Patient Late 12 11 12Delays with Nurse 6 13 6Delays with Clerk 2 3 2 53 50 35
    32. 32. Improvement Impact: Week 2 Results of PDSA cycle # 2 Decrease of late rooming from 53 to 35 or improvement of 34% Almost to goal- PDSA cycle # 3: continue to improve room availability
    33. 33. Simple Measurement forReal Improvement to Care
    34. 34. Measurement: Impact of Change60504030 Late Rooming Patients20 Goal10 0 Baseline Week 1 Week 2 Week 3 Week 4
    35. 35. Simple model; Model of Improvement Complicated Aims process What are we trying to accomplish? Measures Guided us to: How will we know if a change is an  Think about improvement? clearly defining Process Analysis successWhat changes can we make that will result in  Create concrete improvement? forms of measurement Act Plan (Stop or Spread) Improvement  Use these PDSA measurements Cycle to evaluate for Study Results Do Improvement improvement
    36. 36. Intervention Strategy Act Plan (New Cycle or Improvement Spread) Study Do Results Small tests of change
    37. 37. Multiple Small Interventions 3 D S 2 P A S A1 D P A P Complexity S D Time Joiner and Nolan
    38. 38. Measurement: Impact of Change Simple strategies for improvement can be used in any clinical setting, regardless of the size or complexity. Outcome measures can sometimes be too distal for measurement in a timely fashion. Process measures should be collected in the same method as baseline measurements. Simple Measurements over short periods of time offer a quick way to evaluate the impact of change.
    39. 39. Questions or Comments?

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