This document outlines the use of quality improvement methods to improve patient care. It describes principles of quality improvement like understanding variation and using the Plan-Do-Study-Act (PDSA) cycle. Tools for improvement include root cause analysis, failure mode and effects analysis, and clinical practice improvement methodology. The PDSA cycle is the core model for testing changes. Measurement is important for both research and learning, and different measures include outcomes, processes, and balancing measures.

1. Topic 7
Using quality-improvement
methods to improve care
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2. Learning objectives
 The objectives of this topic are to:
•
•
Describe the basic principles of quality improvement
Introduce students to the methods and tools for improving the
quality of health care
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3. Knowledge requirements
 The science of improvement
 Change concepts
 Improvement principles
 Role of measurement in improvement
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4. Performance requirement
 Identify the opportunities for using safety science to
analyse errors
 Appreciate the range of improvement methods available
for reducing harm to patients
 Apply at least one improvement tool in a particular
clinical context
 Participate in an improvement activity (if possible)
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5. The science of improvement
 Appreciation of a system
 Understanding of variation
 Theory of knowledge
 Psychology
Source: Langley GL
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6. Change concepts …
… are general ideas, with proven merit and sound
scientific or logical foundation that can stimulate specific
ideas for changes that lead to improvement.
Source: Nolan TW, 1996
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7. The model for improvement
What are we trying to accomplish?
How we will know that a change is an improvement?
What change can we make that will result in an improvement?
ACT
STUDY
PLAN
DO
Source: Langley GL, Nolan, KM, Nolan, TW, Norman, CL & Provost, LP 1999
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8. The quality improvement model:
the PDSA cycle
 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 an
improvement?
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9. The PDSA cycle
Determines what
changes are to be made
ACT
STUDY
Summarizes what
was learned
Change or test
PLAN
DO
Carry out the plan
Source: Langley GL, Nolan, KM, Nolan, TW, Norman, CL & Provost, LP 1999
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10. The Institute for Healthcare Improvement
(IHI): different measures
Measurement for
research
Measurement for
learning and process
improvement
Purpose
To discover new knowledge
To bring new knowledge
into daily practice
Tests
One large "blind" test
Many sequential,
observable tests
Biases
Control for as many biases
as possible
Stabilize the biases from
test to test
Data
Gather as much data as
possible, "just in case"
Gather "just enough" data
to learn and complete
another cycle
Duration
Can take long periods of
time to obtain results
"Small tests of significant
changes" accelerate the
rate of improvement
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11. Three types of measures
 Outcome measures
 Process measures
 Balancing measures
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12. Three examples of improvement methods
 Clinical Practice Improvement methodology (CPI)
 Root Cause Analysis ( RCA)
 Failure Mode Effect Analysis ( FMEA)
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13. The improvement process
Project mission
Project team
Ongoing monitoring
Outcome
Future plans
Project
phase
Sustaining
improvement
phase
1
5
1 month
Annotated
run chart
SPC charts
Impact
phase
4
3
S
2 months
2 Diagnostic
phase
Conceptual flow of
process
Customer grid
Data
-fishbone
-Pareto chart
-run charts
-SPC charts
A
D
Intervention
phase
P
S A
D P
S
A
D
P
S
A
D
D S
P A
P
2 months
Plan a change
Do it in a small test
Study its effects
Act on the result
Source: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
SPC – statistical process control
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14. Interventions phase
Identify appropriate interventions
Implement changes identified in the diagnostic phase
Undertake one or more PDSA cycles
Interventions phase
Decide on interventions
Undertake one or more PDSA
cycles
Source: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
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15. How to use the PDSA Cycle
 Use 'plan-do-study-act' cycles
to conduct small-scale tests
of change
• Plan a change
• Do it in a small test
• Study its effects
• Act on what learned
 Team uses and links small
PDSA cycles for
broader implementation
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
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16. PDSA cycle - single test
PDSA Cycles – single test
D
S
A
A
P
S
S
D
P
A
S
P
A
Changes that
result in
improvement
P
D
D
Hunches,
theories
and ideas
Source: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
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17. PDSA cycle – multiple tests
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
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18. Impact and implementation phase
1.
2.
3.
4.
Measure impact of changes/interventions
Record the results
Revise the interventions
Monitor impact
Impact and implementation phase
Measure impact
• Annotated run chart
• SPC charts
• Other graphs
Implement the changes
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
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19. Sustaining and improvement phase


Once an intervention has been
introduced, the intervention and
any improvements need to be
sustained
Sustaining
improvement phase
This may involve:
•
•
•
•
Standardization of existing
systems and processes
Documentation of policies,
procedures, protocols and
guidelines
Measurement and review of
interventions to ensure that
change becomes past of
“standard” practice
Training and education of staff
Sustain the gains
•Standardization
•Documentation
•Measurement
•Training
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
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20. Flowchart of process
Example of a flow chart for a project titled: Accelerated
Recovery Colectomy Surgery (ARCS)
North Coast Area Health Service
Australia
Something amiss
Visit to general
practitioner
Investigations
Referral to surgeon
Referral to hospital
Hospital admission
Return to life
Post-anaesthetic care
Operating theatre
Surgical ward
Allied health
Surgical team
Pain team
Pre-op ward
Admitted to hospital
Discharge planner
Community health/
Peripheral hospital
Preoperative clinic
Admissions office
Home
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21. Cause and effect diagram
Social issues
Staff attitudes
home support
Complications
length of stay
poor pain control
wound complications
mobility of patient
pain control
little family
support
nutrition
Adequate nutrition
of patient
mobilization
nil by mouth
surgery
pain control
Procedure
weak/malnourished
infection
Prolonged
Length of
Stay
expect longer stay
poor understanding
of procedure
little knowledge of
support services
locus of control
Patient perception
general practitioner
community health
family
colon-care nurse
Post discharge support
Accelerated Recovery Colectomy Surgery (ARCS), North Coast Area Health Service, Australia
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22. Pareto chart
Source: Langley GJ, Nolan KM, Norman CL, Provost LP, Nolan TW. The Improvement Guide: A
Practical Approach to Enhancing Organizational Performance. 1996
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23. Run chart
Average Length of Stay (days) per month
60
50
Made change here
days
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
m onth
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24. Strategies for sustaining improvement







Document and report each patient Length of Stay ( LOS)
Measure and calculate monthly average LOS
Place run chart in operating theatre, update run chart monthly
Bimonthly team meetings to report positives and negatives
Continuously refine the clinical pathways
Report outcomes to clinical governance unit
Spread
- all surgeons
- left hemicolectomy
- all colectomy surgery
- throughout North Coast Area Health Service
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