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Quality improvement
This document provides an introduction to quality improvement. It defines quality improvement as a formal approach to analyzing performance and systematically improving it, as opposed to quality assurance which focuses on finding faults. The Model for Improvement, consisting of setting an aim, establishing measures, and testing changes via the PDSA (Plan-Do-Study-Act) cycle, is introduced as a framework for quality improvement. Key aspects like establishing a team, choosing appropriate measures, developing potential changes using techniques like flowcharts, and testing changes through small tests of change are discussed. An example case focusing on reducing pain for emergency department patients with fractures is used to demonstrate applying the Model for Improvement.
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Quality improvement
- 1. Introduction to Quality Introductionto QualityImprovement Improvement Ahmad Thanin Ahmad Thanin
- 2. Objectives 0 To gainan understanding of what quality improvement is 0 To present the Model for Improvement and PDSA cycle 0 To introduce measurement in quality improvement 0 To introduce flowcharts
- 3. What is Quality Improvement? 0A formal approach to the analysis of performance and systematic efforts to improve it 0 Different from Quality Assurance
- 4. Quality Improvement versus QualityAssurance Quality Improvement Quality Assurance What can we do to improve? What went wrong? Proactive Reactive Avoids blame Often Punitive Fosters System change Tries to find who was at fault Focuses on the entire system Focuses on the specific incident
- 5. What is quality? 0Definition of quality depends on stakeholders 0 The client/customer (the patient) 0 The provider/employer (health care providers) 0 Management (hospital management) 0 Payer (Ministry of Health)
- 6. 6 Pillars ofQuality 0 Safety 0 Timely Access 0 Equitable 0 Efficacy 0 Efficient 0 Patient Centered
- 7. “Every system isperfectly designed to get the results it gets” 0 How can you improve a system to achieve better results in the 6 pillars of quality?
- 8. To improve asystem… 0 You need a good understanding of the system 0 You need to understand where it is failing - Identify what is wrong 0 Make sure it is the step that needs fixing 0 Then you can implement a change to the “system”
- 9. What is asystem? 0 System = any assembly of procedures, resources and routines to carry out a specific activity
- 10. System 0 To understanda system and identify what is wrong with it Map it out!
- 11. How do youmap out a system? 0 Use a flow chart/diagram 0 Use different perspectives (a doctor’s perspective is different to a nurse’s or a porter’s to a patient’s perspective)
- 12. Quality Improvement Models 0Model for Improvement = Three questions + PDSA cycle 0 FADE = Focus, Analyze, Develop, Execute and Evaluate 0 Six Sigma 0 CQI = Continuous Quality Improvement 0 TQI = Total Quality Management 0 7 step method
- 13. Model for ImprovementModelfor Improvement = Three questions + PDSA cycle= Three questions + PDSA cycle
- 14. The Three Questions 0The Model for Improvement begins with three fundamental questions 0 1.1. The Aim:The Aim: What are we trying to accomplish? (How good do we want to get and by when?) 0 2.2. The MeasuresThe Measures: How will we know a change is an improvement? 0 3.3. The Changes:The Changes: What change can we make that will result in improvement?
- 15. PDSA Cycle 0 PPlana change 0 DDo the change 0 SStudy the results 0 AAct on the results STUDY ACT PLAN DO
- 16. PDSA Cycle 0 Enablesrapid testing and learning 0 Allows for incremental testing 0 Instead of spending weeks or months planning out a comprehensive change, then putting it into practice only to find that it is fundamentally flawed
- 17. PDSA Cycle 0 Canaid you in: 0 Developing a change 0 Testing a change 0 Implementing a change
- 18. What are wetrying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? MODEL FOR IMPROVEMENT STUDY ACT PLAN DO
- 19. Executing the ModelforExecuting the Model for ImprovementImprovement Let’s do an example
- 20. The Problem 0 Patient’sat XY - Hospital emergency department are often in pain 0 We want to change that 0 So…how do we do that?
- 21. Executing the Modelfor Improvement0 Form a team 0 Three Questions: The Aim, The Measures, The changes 0 Test changes - PDSA Cycle 0 Implement changes that work 0 Spread the changes to other areas The Aim The Measure The Change STUDY ACT PLAN DO
- 22. You need ateam 0 Why? 0 Need different perspectives 0 It’s a lot of work 0 Increased buy-in by staff 0 Different levels of support (e.g. management) 0 To come up with the right team you have to have an idea of what your aim is…
- 23. The AimThe Aim Whatare we trying to accomplish?
- 24. The Aim 0 Astrong, measurable aim with a clear time frame will help keep your project on course 0 It has to be important to those involved The Aim The Measure The Change STUDY ACT PLAN DO
- 25. The Aim 0 Agood aim: 0 Is Specific 0 Is Measurable 0 Determines a time frame 0 Addresses who the change is for, and what has to be achieved 0 Is Sustainable
- 26. The Aim 0 Iwill become a good runner 0 I will run 10 kilometers per week by May 31st 0 I will run more often Which one of the above is a good aim?Which one of the above is a good aim?
- 27. The Aim 0 Backto the Problem: Patients at XY - Hospital emergency department are often in pain 0 We decide to focus on emergency department patients with fractures
- 28. The Aim 0 Allemergency department patients with fractures 0 We will provide analgesia to 100% of our pts with a suspected fracture within 15 minutes of arrival to the emergency department by the end of December 2013.
- 29. Choose your teamChooseyour team
- 30. Choose your team 0Consider the system that relates to the aim i.e. what processes will be affected by the improvement efforts 0 Involve members familiar with all different parts of processes
- 31. Back to ourexample 0 All emergency department patients with fractures 0 We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011. 0 What processes will be affected?
- 32. Back to ourexample 0 All emergency department patients with fractures 0 We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011. 0 What processes will be affected? 0 Nursing/Triage 0 Pharmacy 0 Stocking 0 Doctors 0 Registration 0 ED chief/director/ manager
- 33. Choose your team 0Effective teams require three kinds of expertise 0 System leadership for authority 0 Clinical -Technical expertise 0 Day to day leadership - Project leader
- 34. Your team 0 Teamleader: Medical director of the emergency department 0 Technical expert: Hospital Quality Management member 0 Day to day leader (project leader): an emergency doctor or nurse 0 Additional team members: pharmacist, person responsible for stocking, charge nurse, registration clerk
- 35. Revisit the Aim 0Once you have chosen your team, review and modify the aim based on their input
- 36. MeasurementMeasurement How will weknow that a change is an improvement?
- 37. Measurement 0 Measurement iscritical for testing and implementing changes 0 Different from measurement for research The Aim The Measure The Change STUDY ACT PLAN DO
- 38. Measurement Measurement for Research Measurement for Improvement PurposeTo 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 a long time Short duration
- 39. Measurement 0 3 typesof measures for quality improvement 0 Outcome measures 0 Process measures 0 Balancing measures 0 (+/- Structure Measures)
- 40. Outcome Measure 0 =Where are we ultimately trying to go 0 Are your changes actually leading to improvement
- 41. Process Measures 0 =Are we doing the right things to get there? 0 To affect an outcome you have to improve your processes 0 Are the parts/steps in the system performing as planned
- 42. Balancing Measures 0 Tellsyou if changes designed to improve one part of the system are causing new problems in other parts of the system Examples for our case scenario: Complications fromExamples for our case scenario: Complications from analgesics (allergic reactions, hypotension,analgesics (allergic reactions, hypotension, infections at IM injection sites); increased times toinfections at IM injection sites); increased times to nursing assessments for all other patients othernursing assessments for all other patients other than those with fracturesthan those with fractures
- 43. The ChangeThe Change Whatchange can we make that will lead to improvement?
- 44. Developing Changes 0 Dependswhat you are trying to change The Aim The Measure The Change STUDY ACT PLAN DO
- 45. Basic Techniques 0 CriticalThinkingCritical Thinking 0 Flow Chart/Diagram 0 BenchmarkingBenchmarking 0 Compare to best practice 0 Using TechnologyUsing Technology 0 Barcodes for medications 0 Creative ThinkingCreative Thinking 0 Become a patient for a day 0 Using Change ConceptsUsing Change Concepts
- 46. Critical Thinking 0 Usea Flow Chart/Diagram 0 A flow chart allows to “visualize” the system you are trying to change 0 Allows ALL to see the system the same way
- 47. Flow Chart/Diagram 0 Ithelps to clarify complex processes 0 It identifies steps that do not add value to the internal or external customer, including: 0 Delays 0 Needless storage and transportation 0 Unnecessary work, duplication, and added expense 0 Breakdowns in communication
- 48. Flow Chart/Diagram 0 Ithelps team members gain a shared understanding of the process and use this knowledge to collect data, identify problems, focus discussions, and identify resources. 0 It serves as a basis for designing new processes.
- 49. Flow Chart/Diagram 0 High-levelflowchart, showing six to 12 steps, gives a panoramic view of a process 0 Detailed flowchart is a close-up view of the process, typically showing dozens of steps. These flowcharts make it easy to identify rework loops and complexity in a process.
- 50. Example: High LevelFlow Chart
- 51.
- 52. 7Change Concepts 0 EliminateWaste - an activity or resource that does not add value 0 Improve Work Flow 0 Optimize Inventory - is your work being held up because items are not properly organized or available
- 53. Change Concepts 0 Changethe Work Environment (does the work culture enhance or impede change) 0 Manage Time 0 Focus on Variation - what aspect of the system vary and make your outcomes unpredictable 0 Focus on Error Proofing (checklist)
- 54. Testing Changes: Testing Changes: PDSACyclePDSA Cycle All improvement will require change, but not all change will result in improvement.
- 55. Testing Changes 0 Whytest changes (even if they are already proven elsewhere)? 0 To learn how to adapt the change to the particular conditions in your setting 0 To evaluate the costs and side effects 0 To minimize resistance when implementing the change in the organization 0 Increase your belief that the change will result in improvement To test your change use the PDSA cycleTo test your change use the PDSA cycle
- 56. PDSA Cycle 0 PlanPlan 0Objectives 0 Questions and predictions 0 Plan to carry out the cycle (who, what, where, when) 0 Plan for data collection The Aim The Measure The Change STUDY ACT PLAN DO
- 57. PDSA Cycle 0 DoDo 0Carry out the plan 0 Document problems and unexpected results 0 Begin Analysis The Aim The Measure The Change STUDY ACT PLAN DO
- 58. PDSA Cycle 0 StudyStudy 0Complete analysis of the data 0 Compare data to prediction 0 Summarize what was learned The Aim The Measure The Change STUDY ACT PLAN DO
- 59. PDSA Cycle 0 ActAct 0What changes are to be made 0 Next cycle? The Aim The Measure The Change STUDY ACT PLAN DO
- 60. Testing Changes 0 Muchcan be learnt from a failed test PDSA PDSA PDSA PDSA PDSA STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO
- 61. What happens whenyou identify what works? 0 Are you done? 0 Once you identify what works, change has to be SUSTAINED. Implementing a change is the hardest part.
- 62. How easily ischange adopted? 0 Process of “Normalization” 0 People have a tendency to fall into old habits 0 People have a tendency to resist change 0 People may feel threatened by a change
- 63. Executing the Modelfor Improvement0 Form a team 0 Three Questions: The Aim, The Measures, The changes 0 Test changes - PDSA Cycle 0 Implement changes that work 0 Spread the changes The Aim The Measure The Change STUDY ACT PLAN DO
- 64.
- 65. Implementation 0 Usually comesafter a series of successful tests 0 It requires that staff and leaders build the change into formal plans, job definitions, training, and explicit reviews 0 The change does not depend on the individuals doing the work, but on the way the work is organized - as part of the system.
- 66. Implementing Change 0 “Hard-wire”the change into the system RememberRemember The implementation phase is the most commonThe implementation phase is the most common area where process improvements fails.area where process improvements fails.
- 67. Hardwire Change 0 Marketyour change 0 Train everyone involved 0 Make changes to job descriptions, policies, procedures, forms 0 Addressing supply and equipment issues 0 Assigning day-to-day ownership for the maintenance of the new process 0 Have senior leaders remove any barriers
- 68. Social System 0 SocialSystem - understand the relationship among the people who will be adopting the new ideas 0 Remember there is an emotional component to change 0 Stress of learning and executing something new 0 Initial disruption to workflow 0 Maybe they feel their job/position is threatened
- 69. Social System 0 Thosewho are supportive 0 Enlist on your side 0 Those who are not supportive 0 Don’t try to change their attitude 0 Listen to what concerns them, identify barriers 0 Those who don’t really care, and will follow when others do
- 70. SummarySummary 0 In thismodules we have presented an introduction to: 0 Quality Improvement 0 The Model of Improvement 0 3 questions (What is your aim, measures, change) and PDSA cycle 0 Types of Measures 0 Change and Implementation
- 71.
Editor's Notes
- #4 Instructions: For differences between Quality Assurance and Improvement please refer to next slide (Slide 5) Notes: Quality improvement is also different from Performance management - which is used for administrative purposes
- #5 Notes: Quality Assurance is an old term and is not used in practice much anymore
- #6 Instructions: Ask the learner: What would you want as a patient? What would you want as a doctor? What would you want as a hospital manager? What would the Ministry of health want?
- #10 Instructions: Ask the learner: Describe your morning “system”…alarm goes off, you walk to the washroom, you turn on the water, grab your toothbrush etc Describe the triage system in your ED
- #12 Notes: Example of perspectives and role: Let’s say you identify that the flow of the emergency department is disrupted by the large number of patient family members and friends who are allowed in the department, leading to overcrowding and multiple interruptions/distractions to your staff. You decide to respond to the problem by limiting the number of patient family members and friends in the department to one at a time. You discuss this policy with the nurses and the doctors, who all agree with your decision. You create signs at the entrance that state the new “rule”. A week later you visit the emergency department and the place is still chaotic with patient families in the middle of the hallways etc. You go to the front of the department, and find your sign is on the door, but the door is wide open, the security guard is nowhere to be found (he is on break). It becomes clear to you that the perspective of the security guard was key here in devising a method to decrease the number of non-patients who come in the ED and how to keep them out. Notes: There will be more details on flow charts later in the presentation
- #13 Notes: There are many models of improvement. In this module we will only focus on the first model (Model for Improvement from the Institue of healthcare improvement - IHI http://www.ihi.org/Pages/default.aspx), though other models are similar. Some of the others are very briefly described here (most have overlapping elements) 1. FADE = (once complete a cycle, start all over again) Focus - Define and verify the process to be improved Analyze -Collect and analyze data to establish baselines, identify root causes and point toward possible solutions Develop -Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring Execute- Implement the action plans, on a pilot basis as indicated Evaluate-Install an ongoing measuring/monitoring (process control) system to ensure success. 2. Six Sigma = 6 sigma is equivalent to 3.4 defects or errors per million. Six Sigma is a measurement-based strategy for process improvement and problem reduction completed through the application of improvement projects. This is accomplished through the use of two Six Sigma models: DMAIC and DMADV -DMAIC (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement. -DMADV (define, measure, analyze, design, verify) is an improvement system used to develop new processor products at Six Sigma quality levels.
- #14 Notes: The rest of the presentation describes the different steps in the Model of Improvement
- #15 Notes: The three questions in the Model for Improvement give you the framework
- #17 Notes: PDSA cycles allow for rapid and frequent review of data and then adjustment based upon those findings. For example, if you find out that there is a high mortality amongst patients with pneumonia in your emergency department, instead of designing and implementing a new clinical care pathway in the ED that’s meant to improve pneumonia care, you decide to use a PDSA cycle that allows to identify that the reason your patients are dying of pneumonia is because there are no antibiotics stocked in the department and therefore it take the patients 24 hrs before they get their antibiotics. You design a process to change the stocking system (PLAN), and then implement the system and teach the nurses to give antibiotics on time during a one month pilot period (DO), and study your results after the month and find that mortality dropped by 20% (STUDY). Since the results were very impressive you take the results to the administration of the hospital who then supports you to change stocking system in the ED (ACT)
- #18 Notes: You can, and should, use the PDSA cycle in any of the above steps
- #19 Notes: This slide is a summary slide summarizing the steps described in slides 12-15. Your three questions create a working framework. Your PDSA cycle is your road map.
- #22 Notes: In order to execute your Model of Improvement you have to put in in the greater context of your setting. The first step is to create a team. See next slide
- #25 References: 1. Accelerating the pace of improvement: interview with Thomas Nolan. Journal of Quality Improvement . 1997;23(4). 2. Berwick DM. A primer on leading the improvement of systems. BMJ . 1996;312:619-622. 3. Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance . San Francisco, CA: Jossey-Bass Publishers; 1996. 4. Lloyd R. Quality Health Care: A Guide to Developing and Using Indicators . Sudbury, MA: Jones and Bartlett Publishers; 2004. 5. Moen R, Nolan T, Provost L. Quality Improvement Through Planned Experimentation . 2nd ed. New York, NY: McGraw-Hill Companies; 1998. 6. The Improvement Handbook . Austin, TX: Associates in Process Improvement; 2005.
- #26 Notes: And I would add manageable and realistic to that list as well. Changing cultures and attitudes in the workplace require a stepwise and incremental approach
- #27 Instructions: Ask the learner which of the above three is a good aim? Answer is the second one because it is specific, measurable, determines a timeframe
- #29 Notes: This is a good aim because it is specific, measurable, determines a timeframe, and delineates who the change is for
- #30 Notes: Once you have an aim, you can choose your team…
- #32 Instructions: Ask the learner to list some processes that will be affected by the aim. The next slide gives you some examples (Slide 30)
- #34 Notes: The System Leader has to have enough authority over the different processes, and have an understanding of the different parts of the system that will be affected
- #35 Notes: Here is an example of a team
- #37 Notes: The next steps is to determine how you will measure the changes stated in the aim
- #41 Notes: For our example of improving pain control for patients with suspected fractures an outcome measure would be the % of patients with fractures who report that their pain is well controlled
- #42 Notes: Example = % of patients with fractures that we actually identified at triage; % of patients who got analgesia; what analgesia they got; where the analgesia came from (pharmacy, stock room etc); how many patients received analgesia within 15 minutes; how long it took the patients on average to get their analgesia; available stock for analgesia
- #43 Notes: Examples for our case scenario: Complications from analgesics (allergic reactions, hypotension, infections at IM injection sites); increased times to nursing assessments for all other patients other than those with fractures Other Examples in other scenarios= For reducing time patients spend on a ventilator after surgery: reintubation rates (make sure they’re not increasing) For reducing patients' length of stay in the hospital: readmission rates (make sure they’re not increasing)
- #44 Notes: once you have identified what you want to change (the AIM) and what to measure, you have to design your change.
- #45 Notes: The design of your change will depend on what you are trying to change
- #46 Notes: These are some techniques that are used in determining what change to implement. Reference: Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide . San Francisco, CA: Jossey-Bass Publishers; 1996.
- #50 Notes: Typically start with a High-level flow chart followed by a Detailed flowchart We do not describe in detail how to do a flow chart in this module, but the next two slide present examples.
- #55 Reference: Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance . San Francisco, CA: Jossey-Bass Publishers; 1996:xxi.
- #61 Notes: Typically will require a few sequential PDSA cycles. Think ahead a few steps. Start small. Don’t need consensus from everyone, but involve many stakeholders.
- #67 Notes:
- #68 Notes: This is an ongoing endeavour