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The Journey of a Thousand Miles Begins with a Single Step (2016 Compliance Institute P15)


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• Focus on the elements needed to get started on a successful quality improvement project; learn how to define and scope a problem and methods of obtaining sound and reliable measurement
• Elements of efficiently setting up a quality improvement project will be explored using both data/examples from a speaker’s completed project and information particular to participants’ home organizations
• Come prepared with the information needed to begin working on your own quality problem during the session. Leave with a well define plan for taking action upon your return home

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The Journey of a Thousand Miles Begins with a Single Step (2016 Compliance Institute P15)

  1. 1. The Journey of a Thousand Miles Begins with a Single Step Kristine Koontz, PhD, SSGB Amy Diane Short, MHSA, CSSBB
  2. 2. Kristine Koontz, Ph.D. • Clinical Psychology—Science Practitioner • Six Sigma Green Belt • Director of Quality and Performance Management • QPM Oversight of Behavioral Health Organization • Residential and Community Settings • Intellectual Disabilities, Mental Health, Autism Spectrum Disorders • Lifespan Services • USA: PA, DE & CT • International: Moldova, India
  3. 3. Amy Short, MHSA • BS Psychology • MHSA (Master’s Health Services Administration) • Certified Six Sigma Black Belt • Operational Oversight of Hospital Functions • QI Leadership of Implementation Research at Academic Health Center • Patient Advisory Council Mentor • University of Cincinnati IRB Member • Administrative Director of Center of Improvement Science, Cincinnati CCTST
  4. 4. Presentation Overview • A New Approach • Getting to Know You • Six Sigma and DMAIC • Data, Data, Data • Strong Project Starts • Making Improvements • Maintaining the Gains Active Learning
  5. 5. Changes from YOUR Feedback • Less Broad, a Deeper Dive • Examples from a Successful Project • More Time to Do Activities • Worksheet Sent Ahead of Time to Registered Participants
  6. 6. Who Are You? • Answer Privately in, • Type in Room Number: AMYSHORT • Login as Student • Enter at Least One Letter as a Name Click Here for Menu Click Here to Login Or Use the App
  7. 7. How Experienced Are You in QI? • Answer Privately in, • Type in Room Number: AMYSHORT • Login as Student • Enter at Least One Letter as a Name Click Here for Menu Click Here to Login
  8. 8. Keeping It Real • What Compliance Issue Keeps You Up at Night? Worksheet
  9. 9. DMAIC Define Measure Analyze Improve Control
  10. 10. Where the Journey Begins: Data
  11. 11. Why Data? • You Cannot Manage what You Cannot Measure • Data Information  Knowledge  Wisdom
  12. 12. What is Data? Data is…. •Plural of “Datum” Latin for “Something Given” •Set of Values of Qualitative or Quantitative Variables •Information in a Raw or Unorganized Form that Refer to, or Represent, Condition, Ideas or Objects • Facts that Can Be Analyzed or Used in an Effort to Gain Knowledge or Make Decisions •Information that has Been Translated into a Form that Is More Convenient to Move or Process
  13. 13. What Do We Measure? Characteristics of: •Individuals We Support • Outcomes • Demographics / Characteristics •Workforce • Outcomes • Demographics •Programs/Services • Outcomes • Processes • Environment
  14. 14. “Everyday” Data OUTCOME •Lab/Assessment Results •Satisfaction Ratings •Utilization Rate •Progress Note Content PROCESS •Timeliness of Expected Deliverable (E.g., 24 Hrs for a Progress Note) •Points of Contact with Caregivers •Critical Process Milestones
  15. 15. Quality Assurance or Improvement?
  16. 16. Data Are Our Friends
  17. 17. Data Types / Levels • Nominal Name • Ordinal Order • Interval Equal Units • Ratio Equal Units & “True 0” • Derived Linear Combination
  18. 18. Nominal Data • To Name an Object and Thus to Assign It to a Class (a.k.a. Categorical) • Statistics Can Be Applied to These Data Only After They Have Been Converted to Percentages or Proportions, for Example: • 45% Female and 55% Male • Gender • Program • Level of Delay
  19. 19. Ordinal Data • Objects Are Measured as Being Either Greater Than or Less Than, Higher or Lower Than a Comparative Object • Intervals Between Are Meaningless (Non-Standard) • Birth Order / Win, Place, Show • Likert Scale (Never, Sometimes, Always)
  20. 20. Interval Data • Interval: A Basic Standard Interval but Not Necessarily a True Zero / Starting Point • Difference Between Score of 1 and 2 is Same as Difference Between 2 and 3 Etc. • Zero Does Not Have a True Meaning Indicating the Complete Absence of Whatever We Are Measuring • E.g. Temperature (Fahrenheit and Celsius) • 60 Degrees Is Not Twice as Hot as 30 Degrees • 0 Degrees Is Not Absence of Kinetic Energy • E.g. Standard Scores (IQ, Adaptive Behavior)
  21. 21. Ratio • There Is a Basic Standard Interval as in Interval • Also Has a Meaningful Zero Value • E.g. Height, Weight, Duration of Time
  22. 22. Descriptive Statistics Term Given to the Analysis of Data that Helps Describe, Show or Summarize Data in a Meaningful Way •Measures of Central Tendency •Measures of Dispersion and Variability Hellloooooo! Let Me Tell You a Bit About Me and the Gang!
  23. 23. Central Tendency NAME DESCRIPTION BEST FOR… Mode Most Frequently Occurring Value (Can Have More Than One) Nominal Data Median “Middle Point” of the Distribution; Point Below which 50% of Values Fall Ordinal Data or for Use with a Skewed Distribution Arithmetic Mean Sum of All Data Values in the Distribution Divided by the Number of Values Most Commonly Used Statistic; Not for Use with Skewed or Bi-Modal Data
  24. 24. Distributions: “Eyeball your data” • The Importance of Visual Inspection • First Step in Analyzing and Understanding Your Data • Discrete Variables • Frequency Distribution Table • Bar Charts • Continuous Variables • Histogram
  25. 25. Behold……and Beware
  26. 26. Measures of Dispersion/Variability
  27. 27. Variability of Distribution • 1 5 5 5 5 5 5 5 9 • 1 2 2 3 5 6 7 8 9 • Both Distributions Have a Mean of 5 • In which Distribution Is Your Score of 9 More “Impressive”? • In which Distribution are the Scores More Spread Out?
  28. 28. Know Your Data Secure the Foundation and Trajectory of Your Project When in Doubt, Consult an Expert…. When Confident About Your Data, Still Consult an Expert….
  29. 29. (R)DMAIC Recognize Define Measure Analyze Improve Control
  30. 30. Recognize • The Secret Step BEFORE DMAIC • First, Look at Data: • Quality Control • Audits • Customer Service Surveys • Financial Performance Indicators
  31. 31. Recognize • Second, Make an Evaluation: • Nix if There Is a Known Solution • Implement! • Not Suitable if Problem Is a Management Issue • Make Sure the Problem Is Process Related
  32. 32. Recognize • Third, Prioritize: • How Important Is It to Your Organization? • Is It Worthy of Resources that Could Be Otherwise Deployed? • Are There Other Projects that Need to Happen First?
  33. 33. Recognize • Fourth, Define the Problem • Develop a High-Level Understanding of the Problem • Begin to Think About Scope • Helpful Tools: • Project Definition Worksheet • Macro Map Worksheet
  34. 34. Recognize 1. Fill in the LEAN Project Definition Worksheet Step Element Actual DescribetheBusinessProblem What is the specfic project idea? Is project idea tied to business strategy? Yes / No Is the project important to achieving the strategy? Describe. Who is the Customer of the output of the process? Will the project affect the Customer directly? Yes / No (CTx's) Will this project create value for the Customer? Describe. Can the project be completed in less than 4 weeks? Yes / No Where does the project Idea reside? (Process location) Has the process been documented? (existing Process flows and Maps; Current state, SIPOC-R) Yes / No Is the project location, a distinct process within a business unit? Yes / No Is there existing data on the problem that quantifies current performance results? How Much? What is the extent or magnitude of the problem? (as it relates to the Business issue) The Problem Statement: <what><who><where><how much> (sentence format) describing the opportunity. Is there a Champion identified to remove barriers and provide resources? Who? scribingtheCurrentState Identifiy and describe the types of wastes in the current state of the process below: Overproduction Conveyance Waiting Processing Correction Motion Intellect Inventory Of the 8 wastes of LEAN, are there sufficient amounts to warrant Macro Map
  35. 35. DMAIC Define Measure Analyze Improve Control
  36. 36. Define • Identify Team Members • Local Experts • People from Up and Down Stream • Helpful Tools: • Team Attribute Chart • Team Roster • Build Team Culture • Helpful Tool: • Ground Rules Worksheet
  37. 37. Define Team Attribute Worksheet Project Roster
  38. 38. Define • Meetings start and end on time. • Stick to the agenda. • No looping back. • Be honest/speak your mind. • Members will meet deliverables’ deadlines. • Treat each other with respect. • Challenge ideas, not people. • Be actively engaged. • All voices will be heard. • Silence equals agreement. • Limit side conversations. • Seek consensus. • Define how decisions will be made. • Cell phone used only for emergencies. Sample Ground Rules
  39. 39. Define • Review Project Definition Worksheet • Verify Macro Map • Refine the Project Statement • Verify Baseline Correct • Identify Additional Data that Are Needed • Define Project Metrics
  40. 40. Types of Project Metrics 1: Six Sigma Project Metrics Project Metric Definition Correlation to Primary Metric Use in Improvement Project Primary Metric Defines the project goal: “improve (primary metric) from (baseline) to (target) by (date)” N/A Measure baseline and improvement level when the project ends Secondary Metric Captures, validates and tracks welcome side effects of the project Strong (high relative predictive power, or R2 ). By default, there is a cause-and-effect relationship between the primary and secondary metrics. Measure baseline and impacts of project after improvement. Monitor during and after project if linked to financial metric. Consequential Metric Captures, validates and tracks non-welcome side effects of the project Strong (high R2 ). In the current design of the process, there is a cause- and-effect relationship between the primary and consequential metrics. Collect data before, during and after the project to prove no collateral damage was caused by the project. Financial Metric Links progress in the primary and secondary metrics to financial advantage. Most often this metric is tailor-made for the specific project Expected strong (high R2 ). Evaluate at project milestones (i.e., Define, Measure, Analyze and Control phases) and typically one year after the project ends. Business Metric Measures how an organization achieves one of its major goals. Typically weak (low R2 ). Monitoring is optional and mainly needed for communication purposes. From: Be Consistent in Six Sigma Project Metric Selection; M. Ohler;
  41. 41. Define Worksheet
  42. 42. Define • Create Project Timeline, Meeting Plan, and Communication Plan • Helpful Tool: • Project Charter Pro-Tip: Issues List Worksheet
  43. 43. Define
  44. 44. DMAIC Define Measure Analyze Improve Control
  45. 45. Measure Ambulatory Procedure for Direct Admits Created by Amy Short Last Updated 02/9/11 Contact nursing supervisor.4 In house pager: 59924, code 0813. Patient needsadmitted to the floor. Need a higher level of care than clinic provides 2,3 Provider callsreport to CEC (4-amen). Patient transported to CEC. Provider calls admitting (4-4740) to begin the admitting process1 . Orders implemented and monitored in clinic. Need a higher level of care than clinic provides 2,3 Provider calls report to CEC (4-amen). Patient transported to CEC. Bed within 2 hours or by 2pm? Patient admitted. Havebed by closing time? Patient admitted. Nurse supervisor and Clinic manager make decision about patient placement.5,6 Yes No Yes No Yes No Foot Notes 1. It is important to give a clear contact and number for call backs. It is Admitting's responsibility to obtain after hour contact information from clinic staff. 2. This decision should be made in conjunction with clinic based management. Usually means telemetry, ICU or step down care. All efforts should be made to avoid a CEC visit on the way to the floor as safety demands. 3. It is not appropriate to tell a patient to walk over to the CEC from a clinic. 4. The nursing supervisor will keep bed control in the loop and will make every effort to find a bed for the medical practice patient before the clinic closes, but there may be times when this is not possible. 5. On a case by case basis the patient will either get quickly expedited to an inpt bed, go to the CEC, or will be monitored by clinical staff in the clinic. 6.Once a bed is ready, report may be called to the unit. If report needs to be called early, it must go through the nursing supervisor. Bed immediately available? Patient admitted. Contact nursing supervisor.4 In house pager: 59924, code 0813. Bed available? Patient admitted. Yes No No Yes No Yes The Process Map
  46. 46. Why Process Map? • You Can’t Fix a Problem Until You Understand the Present State • … How It REALLY Works • …. Everyone Shares the Same Understanding • Process Maps Reveal Where Improvement Is Needed Most • Process Mapping Helps Keep a Project in Scope
  47. 47. How to Process Map • Gather Your Team • Define the End Points • Brainstorm the Process Steps • Put Process Steps in Proper Order Pro-Tip: Use Sticky Notes Activity
  48. 48. Process Map Errors • Only Working with Those Distal to the Process • Mapping the Improved Process First • Mapping the Way a Process is “Supposed to Work” • Incorrect Level of Abstraction • Not Verifying Accuracy
  49. 49. DMAIC Define Measure Analyze Improve Control
  50. 50. Analyze • Walk the Process Map and Refine It • Spend Time with the People Who Do the Work • Re-scope if Needed • Capture Cycle Times • Brainstorm Ideas for Improvement • Fishbone Diagrams • Affinity Diagrams
  51. 51. DMAIC Define Measure Analyze Improve Control
  52. 52. START HERE Improve
  53. 53. DMAIC Define Measure Analyze Improve Control
  54. 54. Now What? C O N T R O L •“Surface” Key Process and Outcome Measures •Timely Data Entry = “Knowable” Individual and Group Performance •Embed Use of Data into Management Repertoire
  55. 55. CONTROL • This is the Most Difficult Phase in DMAIC • Maintaining the Gains • Safeguards: What Will Be Done to Keep This on Track? • Responsibility Rests on the Process Owner (Role of KPI) • What Happens in this Phase? • Pick the Right Control Method (Checklists, Monitoring, Reporting) • What is Acceptable Variance? • Document the Response Plan
  56. 56. Focus and Streamline Typical Desired Data Collection/Measure Data Analysis Data Utilization/Improve Plan/Define Follow-up/Control Changing the Approach is Key to Success
  57. 57. Scorecard CASE NOTE STATUS CASE NOTE COMPLETION PRIOR TO AR BOOKING SERVICE PLAN GOALS NOT ENTERED INTO TOTAL: RECORD HCSIS: 24 HOUR REPORTING REQUIREMENT January 2016 - Acme ID Services – 2/9/16 KPI meeting Action Item(s) Follow-Up from last month: What From whom By when Finalize all rejected-open and open-late incidents DDs 1/31/2016 - DONE Discuss guidance to provide to PPs re: med error (abbreviated incidents) finalizations in EIM Regional IM committee 1/19/2016 – DONE; need to standardize DDs embed KPI scorecard review/actions into meetings using team mtg agenda format. Minutes will be created for all mtgs: leadership, division, service area, management, team/program RD & DDs Month from now – 2/12/2016 Try, again, to acquire EIM role definitions QPM 1/19/2016 - DONE EIM Point Person training – need more info to determine standardized guidance before we can develop this EIM Workgroup TBD ID KPI – INCIDENT FINALIZATION HCSIS “Management Review Report” ran 2/3/16; this report does not include Medication Errors. Please Note: Pie charts represent timeliness during the last quarter (October through January 4th, 2016); stacked charts show all incidents still open. Each Region is presented separately. *Please Note: Incidents entered into EIM beginning 1/4/2016 are not reflected in these data; therefore the reporting period is identical to last month’s finalization KPI. Per the HCSIS to EIM Reports Crosswalk Job Aid, the HCSIS Management Review Report is one of several reports “not available due to (EIM) system functionality at the present time.”
  58. 58. Active Management vs. Auditing Factor Active Management Auditing Time Close to “Real Time” 6 Months, Yearly Sample Size Population Served Sample Focus Current Time and Prospective Retrospective Action Point-in-Time and Proactive Reactive Ownership Operations & QPM Compliance & Operations
  59. 59. Whoever Owns the Process Assumes the Responsibility
  60. 60. Putting It All Together
  61. 61. Questions?