8923333quality improvement models presented by donna m daniel phd1401

7/25/2019 8923333Quality Improvement Models Presented by Donna m Daniel Phd1401

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Quality Improvement

ModelsPresented by: Donna M. Daniel, PhD

Atlantic Health

Morristown, New Jersey



Quality Basics eries

!au"ht #y $uality e%perts &or sta' inQuality Improvement (r"ani)ations,Quality Basics &ocuses on the&undamentals o& $uality in areas such asthe history o& $uality improvement,

methods and models, per&ormancemeasurement and other *ey topics.



Quality Basics:

Quality Improvement Models

Presented by Donna M. Daniel, PhD

September 25, 2!



Quality Improvement "Models#

$r%ani&ational 'rame(or)s * Quality Mana%ement Models

Baldri%e +valuation Process

IS$ - erti/ication

Balanced Scorecard 0pproach

Quality Improvement Methods

Si1 Si%ma

uman 'actors

3ean or 4PS 4oyota Production System6

PDS0 ycles or Model /or Improvement

Quality Improvement 4heories

7eliability 4heory

Spread 4heory



Main oncepts

Baldri%e: Performance Excellence

(value/quality service)

IS$ : Performance Excellence

(internal processes)

Balanced Scorecard: Performance Excellence (measurement of business processes and external

outcomes)



Baldri%e 0(ard

4he Malcolm Baldri%e 8ational Quality

0(ard is an a(ard %iven, by the

President o/ the 9nited States, to

applyin% or%ani&ations that meet

desi%nated criteria.

Mana%ed by 9.S. ommerce

Departments 8ational Institute o/

Standards and 4echnolo%y 8IS46

Malcolm Baldrige

1922-1987

26th Secretary of

Commerce Award As Quality Model

;More than any other pro%ram, the Baldri%e Quality 0(ard is

responsible /or ma)in% <uality a national priority and

disseminatin% best practices across the 9nited States.;

==4he Private=sector ouncil on ompetitiveness



riteria /or Per/ormance +1cellence

3eadership

Strate%ic plannin% ustomer and mar)et /ocus

Measurement, analysis, and )no(led%emana%ement

uman resource /ocus

Process mana%ement

Business results

4he Baldri%e riteria is a /rame(or) that or%ani&ations can use toimprove their overall per/ormance.



>ey 4ools

4he Baldri%e riteria does not instruct or%ani&ations to

use any speci/ic improvement tool, but allo(s the

or%ani&ation to select the tool appropriate to their

improvement e//orts.



In ealthcare?

Baldri%e 0(ard 7ecipients

2@ A 8orth Mississippi Medical enter = 4upelo, MS

25 A Bronson Methodist ospital A >alama&oo, MI

2 A 7obert Cood ohnson 9niversity ospital

amilton A amilton, 8

2E = Baptist ospital, Inc. = Pensacola, '3F Saint

3u)es ospital o/ >ansas ity = >ansas ity, M$

22 = SSM ealth are = a health care system in

/our states I3, M$, $> and CI



IS$ - erti/ication

IS$ - is a series o/ international standards initially

published in -G! by the International $r%ani&ation /or

Standardi&ation IS$6, Heneva, S(it&erland.

4he standards speci/y re<uirements andrecommendations /or desi%n and assessment o/ a

mana%ement system, the purpose is to ensure products

and services meet customer re<uirements.

IS$ re%istration determines (hether a company

complies (ith its o(n <uality system.



riteria /or IS$ erti/ication

ustomer 'ocus

3eadership

Involvement o/ People Process 0pproach

System 0pproach

ontinual Improvement

'actual 0pproach to Decision Ma)in%

Mutually Bene/icial 7elationships

oyle, David. IS$ Quality Systems andboo). Butter(orth=einemann 34D, $1/ord, -G



>ey 4ools o/ IS$

+lowchartin"

Process mappin"

ause and e'ect dia"rams

Plan-Do-hec*-Act ycles

and more



ealthcare applications o/ IS$

ompanies and health care or%ani&ations re%istered to IS$

have reported si%ni/icant reductions in customer

complaints, improved client relations, decreased employee

turnover and reductions in operatin% costs.-

It supports the business (hile assistin% (ith sa/ety, <uality andimprovement on a continuin% basis. 2

3eelanau Memorial ealth enter improved overall /inancial

per/ormance by - , reduced annual employee turnover /rom

J to -2 , and their lon%=term care /acility no( meets -

o/ their customers e1pectations.E

- K E. Dillon, 3. 7ad, ealthcare and IS$ . 0n intervie( (ith Dr. Michael ra%o. QualityMana%ement, Sept*$ct 22. E=!.

2. Quality Drives Business Improvement in ealthcare.http:**(((.standards.or%.au*S408D07DS*8+CS7$$M*40S*2E-*+03407+*+03407+.4M

http://www.standards.org.au/STANDARDS/NEWSROOM/TAS/200310/HEALTHCARE/HEALTHCARE.HTM






Balanced Scorecard

Developed in the early -Ls by Drs. 7obert >aplan

and David 8orton

Distin%uishin% /eature is based on "(hat companies

should measure in order to LbalanceL the /inancialperspective#

More than a measurement system A a mana%ement

system



omponents

'or each o/ the /our perspectives, obectives, measures,tar%ets and initiatives are outlined.

3earnin% K Hro(th A 4o achieve our vision, ho( (ill (e

sustain our ability to chan%e and improveN ustomer A 4o achieve our vision, ho( should (e

appear to our customersN

'inancial A 4o succeed /inancially, ho( should (eappear to our shareholdersN

Internal Business Processes A 4o satis/y ourshareholders and customers, (hat business processesmust (e e1cel atN



Improvement Methodolo%ies

3ean

uman 'actors

Si1 Si%ma

Model 'or Improvement



Main oncepts

3ean: ↓ CasteF ↑ +//iciency internal processes6

uman 'actors: ↑ Per/ormanceF ↓ Oariation sta//

abilities6

Si1 Si%ma: ↑ Per/ormanceF ↓ Oariation cost savin%,

business %oals6

Model 'or Improvement: ↑ Processes



3ean 4hin)in%

De/inition

3ean 4hin)in% is a (ay to do more and more (or)(ith less and less=less human e//ort, lesse<uipment, less time, and less space=(hile comin%closer and closer to providin% customers (ithe1actly (hat they (ant.

4he aim o/ lean is to eliminate (aste.



De/inin% characteristics: - Principles Base your mana%ement decisions on a lon%=term philosophy, even at the e1pense o/ short=

term /inancial %oals.

reate continuous process /lo( to brin% problems to the sur/ace.

9se "pull# systems to avoid overproduction.

3evel out the (or)load.

Build a culture o/ stoppin% to /i1 problem, to %et <uality ri%ht the /irst time.

Standardi&ed tas)s are the /oundation /or continuous improvement and employeeempo(erment.

9se visual control so no problems are hidden.

9se only reliable, thorou%hly tested technolo%y that serves your people and process.

Hro( leaders (ho thorou%hly understand the (or), live the philosophy, and teach it toothers

Develop e1ceptional people and teams (ho /ollo( your companys philosophy.

7espect your e1tended net(or) o/ partners and suppliers by challen%in% them and helpin%them improve.

Ho and see /or yoursel/ to thorou%hly understand the situation.

Ma)e decisions slo(ly by consensus, thorou%hly considerin% all optionsF implementdecisions rapidly.

Become a learnin% or%ani&ation throu%h relentless re/lection and continuous improvement.

The Toyota Way: 14 Management Principles From The World's Greatest Manufacturer. by e//ery 3i)er, . McHra(=ill. 2E.



>ey 4ools o/ 3ean 4hin)in%

Tools include but are not limited to t!efollowin"

Oalue Stream Mappin%

Process Mappin% Po)a=o)e error=proo/in%6

Pull Systems >anban A "si%nal#6

Oisual (or)place 5S = Sort, Strai%hten, Shine,Standardi&e, Sustain6

On ean !nterprise and "ts Potential #ealthcare $pplications, by Martin, >. ournal /or ealthcare

Quality. Ool 25. 8o 5. Sept*$ct 2E.



ealthcare 0pplications o/ 3ean 4hin)in%

ospitals that are employin% 3ean 4hin)in%

Denver ealth

ohns op)ins

0lle%heny Heneral 9niversity o/ Io(a ospitals and linics

9niversity o/ Cashin%ton Medical enter

Oir%inia Mason

0tlantic ealth 0nd many more?

e// Mc0uli//e, 4om Moench and oan Cellman, "4he 3ean +nterprise Meets ealth are,# #ospitals

and #ealth %et&ors, anuary -5, 2.



ospital +1ample

#efore

25

! min.

= -!--

-E2

-

i%h

i%h

Steps

Oalue=0dded Steps

4otal 4ime

Oalue=0dded 4imeQueues

$rders in Process

ando//s

Inspection Steps

Oariation in Methods

Oariation in ycle 4ime

After

2 min.

E2 = 2E

E

5

2

3o(

3o(

22 orporate Strate%ies and Development, 33

22 oan Cellman and 0ssociates, Inc.



uman 'actors

De/inition

uman 'actors is the science o/ desi%nin% tools, tas)s,

in/ormation, and (or) systems to be compatible (ith the

abilities o/ human users. 4his includes both physical and co%nitive abilities.

Mi*e ilver, MPH, An Introduction to Human +actors - Desi"n &or /se #y Humans.HealthInsi"ht, 0as 1e"as N1, 2334.



De/inin% characteristics

Dia%nosin% the type error e1ecution errors, plannin%

errors, violations 6

Execution errors = orrect Plan → /ailure in

e1ecution o/ the plan

Plannin" Errors A 'la(ed Plan

$iolations % Intentionally deviated /rom plan →

ne%ative conse<uence not intended

Desi%n interventions based upon the error type



>ey 4ools o/ uman 'actors

Tools include but are not limited to t!e followin"&

0nalysis 4ools e.%. 0nalytic ierarchy Process, 4echni<ue /or

uman +rror 7ate Prediction, Decision Matri1 /or the 0llocation o/

'unctions6 0ssessment 4ools e.%. Situation 0(areness, Hlobal

0ssessment 4echni<ue, Situation 0ssessment 7atin% 4echni<ue,

Situation Present 0ssessment Method, Situation 0(areness

Oeri/ication and 0nalysis 4ool6

'or a listin% o/ uman 'actor 4ools please see, http:**(((.h/./aa.%ov*Portal*4oolsBy4ype4ally.asp16

http://www.hf.faa.gov/Portal/ToolsByTypeTally.aspx





ealthcare applications

HealthInsi"ht5s pilot pro6ect and Quality and a&ety eries

Io(a ealth System IS6 Des Moines, I0 is applyin% human

/actors to their health system. Quote /rom Hail 8ielsen, ISs

Patient Sa/ety 0dministrator, "uman /actors en%ineerin% touches

nearly every aspect o/ patient care, /rom e<uipment use and thephysical environment to sta//in%, (or)load, and patients ability to

use devices prescribed by their clinicians.#

uman /actors en%ineers*en%ineerin% '+6 is reco%ni&ed

as use/ul in criti<uin% medical device desi%n, conductin%

usability testin%, and is credited (ith aidin% remar)ableimprovements in some areas o/ patient sa/ety.

http:**(((.<ualityhealthcare.or%*ihi*4opics*PatientSa/ety*MedicationSystems*3iterature*Improvin%Patien

tSa/etyByIncorporatin%uman'actors.htm

http:**ase.tu/ts.edu*mechanical*+7+3*Publications*0=-.pd/



Si1 Si%ma

De/inition

Si1 Si%ma is de/ined as "a comprehensive and /le1ible

system /or achievin%, sustainin%, and ma1imi&in% business

success. Si1 Si%ma is uni<uely driven by close understandin% o/

customer needs, disciplined use o/ the /acts, data, and

statistical analysis, and dili%ent attention to mana%in%,

improvin% and reinventin% business processes.#

Pande, P, 8euman, 7, and avana%h, 7. 4he Si1 Si%ma Cay. McHra( ill 2




Si1 critical elements

Henuine /ocus on the customer

Data=and /act=driven mana%ement Processes are (here the action is

Proactive mana%ement

Boundary less ollaboration

Drive /or per/ection



>ey 4ools o/ Si1 Si%ma

4ools include, but are not limited to the /ollo(in%:

Brainstormin%

0//inity

Dia%rammin%

Statistical Process ontrol

4ests o/ Statistical Si%ni/icance

'orce 'ield dia%ram

Balanced Scorecards



ealthcare application o/ Si1 Si%ma

Bed dischar%e process

7eduction o/ e1ternal, temporary employees

7adiation oncolo%y treatment plannin%throu%hput

ycle time to dia%nose breast cancer

3uc Pelletier, "Beth 3anham on Si1 Si%ma in ealthcare.# (ournal for #ealthcare )uality . Ool

25. 8o 2, March*0pril 2E.



Model /or Improvement M'I6

De/inition

4he M'I is based on a "trial and learnin%# approach. 4his trial

and learnin% approach revolves around three <uestions.

Chat are (e tryin% to accomplishN 0IM6

o( (ill (e )no( that a chan%e is an improvementN

riteria or Measures6

Chat chan%es can (e ma)e that (ill result in improvementN

4estin% han%es6

'ocusin% on these <uestions accelerates the buildin% o/)no(led%e by emphasi&in% a /rame(or) /or learnin%, the use o/

data and the desi%n o/ e//ective tests or trial.




0ddress the E /undamental <uestions

PDS0 ycle

Plan A han%e or 4est

Do A arry out plan

Study A Summari&e 3earnin%s

0ct A Determine 0ction

4o address the items mentioned above this methodolo%y

includes the /ollo(in% steps: Settin% 0ims, +stablish

measures, Select han%es, 4est han%es, Implement

han%es, Spread Improvement



>ey 4ools o/ M'I

Tools include but are not limited to t!e followin"&

II Brea)throu%h Series ollaborative

PDS0 ycle

7un harts

ontrol harts

Measures: Balance, Process, $utcome

'lo(charts

omparison harts

Standardi&ation



ealthcare applications o/ M'I

4he Model /or Improvement has si%ni/icantly a//ected

healthcare throu%h the II Brea)throu%h Series

ollaborative (hich incorporates the Model /or

Improvement.

= (((.<ualityhealthcare.or%

= (((.improvin%chroniccare.or%

= (((.ihi.or%

http://www.qualityhealthcare.org/

http://www.improvingchroniccare.org/

http://www.ihi.org/

http://www.ihi.org/

http://www.improvingchroniccare.org/

http://www.qualityhealthcare.org/



7evie( o/ the Main oncepts

Baldri%e: Performance Excellence (value/quality service)

IS$ : Performance Excellence (internal processes)

Balanced Scorecard: Performance Excellence (measurement of business processes and external

outcomes)

3ean: 'aste Efficiency (internal processes)

uman 'actors: Performance $ariation (staffabilities)

Si1 Si%ma: Performance $ariation (cost savin"business "oals)

M'I: Processes



omparison o/ sta// involvement across

methodolo%ies

S3 Mid=3evel 'ront=3ine

Baldri%e i%h i%h i%h to Med

IS$ i%h Med 3o(

BalancedScorecard

i%h Med 3o(

3ean i%h i%h i%h

uman

'actors

Med Med i%h

Si1 Si%ma Med i%h "Belts# Med

M'I Med Med i%h

Rlearly varies by or%ani&ation



Shared oncepts

Similar concepts /or the si1 methodolo%ies include:

3eadership

Measurement*0nalysis A base decisions on

)no(led%e Product A business*customer*mar)et

People = human resources*mana%ement*sta//

involvement and or satis/action

Processes



II Spread 4heory: 0 'rame(or) /or Spread

et*up-Target population

-Adopter audiences

-Successful sites

-Key partners

-Initial spread plan

ocial ystem-Key messengers -Communities

-Technical support

-Transition issues

+ o m

m u n i c a t i o n ( a w a r e n e s s , t e c ! n i c a l )

-nowled"e Mana"ement

Measurement and .eedbac

0eaders!ip*Topic is a ey strate"ic initiative

*1oals and incentives ali"ned*Executive sponsor assi"ned

*2ay*to*day mana"ers identified

#etter 3deas-Develop the case -Describe the ideas

From IHI, Boston, Massachusetts



977+84 C0

Cait /or cardiolo%ist

7eliance on memory

7eliance on memory, lac) o/ability to reco%ni&e /ailure

+D on divert

B+44+7 ID+0

+D activate ath 3ab

Standin% 0S0, beta bloc)erorder /or 0MI

Pharmacist in +D

8o $7 "bloc)in%#

$n Better Ideas

4han)s to Qualis ealth*Sharon +loranta, MD.



$n Set=9p: 0dopter ate%ories

Innovators

EarlyAdopters

EarlyMajority

LateMajority

Traditionalists

2.5% 13.5% 34% 34% 16%

From Rogers,

1995



! 3eadership 3evera%e Points

-. +stablish and oversee system=level aims /or

improvement at the hi%hest Board and leadership level

2. 0li%n system measures, strate%y and proects in a

leadership learnin% system

E. hannel leadership attention to system=levelimprovement

. Het the ri%ht team on the bus

5. Ma)e the '$ a <uality champion

@. +n%a%e physicians: 0void "monovo1ople%ia# or

"paralysis by one loud voice#

!. Build improvement capability

II Chite Paper by ames 3. 7einertsen, MD, Michael D. Pu%h* Maureen Biso%nano, "Seven

3eadership 3evera%e Points 'or $r%ani&ation=3evel Improvement in ealth are.#



$n ommunication:

"ampai%n# concept

Practice Passion Pull

P4A+T3+E: Chat people actually do and ho(

they do it. ou must %et to this level o/ chan%e.

PA356: 'i%ure out ho( to attach theener%ies o/ the people (ho are passionate

about (hat you are tryin% to do.

P700: 0n e//ective campai%n attracts people

rather than e1hortin% them to oin

4han)s to '07*4om Hilmore and Qualis ealth*Sharon +loranta, MD.



Seven Spreadly Sins

-. Start (ith lar%e pilots

2. 'ind one person (illin% to do it all

E. Be vi%ilant and C$7> 07D+7

. I/ a process (or)ed in the pilot, then it should be spread9808H+D

5. 7e<uire the person (ho drove the pilot team to beresponsible /or hospital=(ide spread

@. 3oo) at de/ects on a Q9074+73 basis

!. +arly on, e1pect mar)ed improvements in outcomes(ithout re%ard to process improvements

4han)s to II and Qualis ealth*Sharon +loranta, MD.



IIs 7eliability 4heoryII Chite Paper by 4homas 8olan, PhD, 7o%er 7esar, MD,arol araden, PhD, 'rances 0. Hri//in, 774, MP0, "Improvin%the 7eliability o/ ealth are.#



De/inin% "7eliability#

i%hly 9nreliable TG

-=-

- or 2 /ailures in - cases6 UG=

-=2 5 /ailures or less in - cases6 5

-=E 5 /ailures or less in - cases6 .5

-= 5 /ailures or less in -,6 .



0ppropriate are Measure(uly +,,- through (une +,,

6ational avera"es as reported to t!e Quality6et data ware!ouse8 lide provided by 2ale '8 #rat9ler 25 MP: 5.MQ :ospital3nterventions Q35 upport +enter8

;<= :i"!

=><> 0ow

;?; :i"!

?<; 0ow

@? :i"!

BCB 0ow

C>; :i"!

=<C> 0ow



-=2 56 is the $83 %oal /or?.

8on=catastrophic processes

De/inition: /ailure o/ the process does not lead to death or

severe inury (ithin hours o/ the /ailure

-=- per/ormance or (orse is commonly seen in these

processes

Chy are (e operatin% at -=- despite all o/ our talents and

resourcesN



4hree=tier Desi%n Strate%y

Prevent initial /ailure usin% intent and standardi&ation

Identi/y de/ects usin% redundancy6 and miti%ate

Measure and then communicate the learnin% bac) into

the desi%n process

' 7eliability



' 7eliability

3evel - chan%es only Step -6

CHF Protocol For All

Admitted Patients

All itemson protocol

done

Protocol Not Used

Portionsof

protocol

not used

50-80%

10-25% 10-25% Best

ffort

10-1

!tandardi"ation mostl# structure

$eminders

Aareness and trainin&

Feed'ac( of data

Hard or(

Usual !trate&ies

)e*el 1

' 7 li bilit



' 7eliability

3evel - and 3evel 2 chan%es Step 26

CHF Protocol For All Admitted Patients

All items on

protocol doneProtocol Not Used Portions of

protocol not used

50-80% 10-25% 10-25% Best ffort

10-1

*er# patient&ettin& lasi+

re*ieed '#

p,armac# for a d+

of CHF

P,armac# starts

t,e protocol if d+

CHF

Best effort

'arel# 10-2

$eminders 'uilt into s#stem

efault desired action

$edundanc#

!tandardi"e process

)e*el 2 c,an&es at

indi*idual process le*el

' 7eliability



' 7eliability

3evel - and 2 J %lobal chan%es Step E6

CHF Protocol For All Admitted Patients

All items on

protocol doneProtocol Not Used Portions of

protocol not used

50-80% 10-25% 10-25% Best ffort

10-1

*er# patient &ettin& lasi+re*ieed '# p,armac# for a d+ of

CHF

P,armac# starts t,e protocolif d+ CHF Best effort 'arel# 10-2

Portions of protocol not

used .,i&,est failure modes/!mo(in&

ad*ice .all

patients counseled

a'out smo(in& and

ris( of second ,and

smo(e/

etailed C

instructions .f

protocol on c,art cler(

prints out C instructions,eet at disc,ar&e/

AC use .f

protocol on c,art

p,armac# c,ec(s for use

of AC and calls ifnot ordered/

Best effort

10-2 to a

'arel# 10-3

$elia'ilit# esi&n



1-!pecif# t,e steps

2-Use 'ot, le*el 1 and le*el 2 c,an&es to attain 10-1

3-!e&ment population to test t,e desi&n

!tandardi"ation to ac,ie*e

10-1 .4ier 1/

10% not done at all10% onl#

partiall# done

dentif# Failures and iti&ate

failures if possi'le to ac,ie*e

10-2 .4ier 2/

Prioriti"e failure modes and

redesi&n steps 1 and or 2 if

articulated &oal ,as not 'een

reac,ed .4ier 3/

1-Utili"e a s#stem le*el redundanc#

2-easure failure rates from step 1

3-o not use unless step one is at least 10-1

1-$edesi&n onl# if articulated &oal not

reac,ed

2-4ac(le one failure mode at a time



oncepts associated (ith -=2

Decision aids and reminders built in

Desired action the de/ault

7edundant processes utili&ed

Schedulin% used in desi%n

abits and patterns

'alls in radiolo%y

Standardi&ation o/ process is the norm



Chere can you %o /rom hereNor o( to succeed in spite o/ the $ptions6

4hese tools allo( you to construct (hat you (ish:

Better trained (or) /orce

'ocused attention to obectives*%oals

It is about: Measurin%

7eco%ni&in%

0ccountability

0chievement



408> $9Donna M. Daniel, PhD

donna.danielVatlantichealth.or%

!E=@@=E2!2

mailto:[email protected]

mailto:[email protected]



!han* you &or your participation7

+or additional $uestions or resourcescontact the Per&ormance

Improvement QI( upport enter atpi$iosc8wa$io.sdps.or"

A recordin" o& this session will #eposted on www.MedQI.or"

8923333quality improvement models presented by donna m daniel phd1401

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