An introduction to Quality ImprovementModels

Learning Outcomes

• Learning about Model for Improvement

• Understanding and using Driver Diagrams

• Understanding and using Process Mapping

• Understanding and working on the PDSA cycle

• Being able to apply these to a change for

improvement scenario in your role

Quality and Improvement• Quality is the degree of excellence in healthcare

(Health Foundation Definition)

• Quality improvement is better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies

“At the core of any model is influence over clinical behaviour to improve quality and minimise waste. Most of the solutions lie within the hearts and minds of our frontline clinical/care staff. The perfect model of care does not exist, and we need to create the capacity to piece together all the learning from other systems.

The commitment, encouragement and resilience of the people who wish to progress this is our greatest asset and some of our answers may not appear so obviously to begin with.”

Extract from Improving quality and reducing inequities: a challenge in achieving best care

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1426185/

Six Dimensions of Quality• Safety - do no harm• Timely - without undue delay; who receive and those who give• Effective - produces desired results• Efficient - avoiding waste, including waste of equipment,

supplies, ideas, and energy• Equitable - providing care that does not vary because of gender,

ethnicity, disabilities etc. in the patient; or at population level• Patient-centred - providing care that is respectful and

responsive; needs, and values; seamless; provided with respect and compassion

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1426185/

Not a New Idea…

@NHS_HealthEdEng

More Modern Statistics• The NHS pays out around £400 million in settlement

of clinical negligence claims every year

• Leape et al (1993) found 2/3rd mistakes preventable - 28% due to mistake by health professional and 42% due to other factors

Quality Improvement in Healthcare

In the words of Dr Mike Evans

@NHS_HealthEdEng

Model for Improvement

What are we trying to accomplish?

How will we know that change is an improvement?

What change can we make that will result in improvement?

aims

measurements

change ideas

testing ideas before implementing changes

Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

• Carry out the plan

• Collect the data

• Analysis

• Complete the analysis• Compare with

predictions• Summarise

• Set objectives• Questions• Who, where

and when• Collect data to

answer questions

• What changes are to be made to the next cycle?

• Can the change be implemented?

Act Plan

DoStudy

PDSA Cycle

SOMETHING

BIG!

APDS

How can we achieve this?

APDS

APDS

APDS

APDS

APDS

APDS

APDS

APDS

APDS

A PDS

Continuous Improvement

Small Steps with data

Ideas/ theories

Meeting rooms

Real world

Approve

Design Design Design Design

Implement !

Spending more time on the WHAT than the HOW!

Courtesy of Patient Safety First

© NHS Institute for Innovation and Improvement 2010. All rights reserved.

Meeting rooms

Real world

Courtesy of Patient Safety First

Implement

Approve

Test & refine

Test & refine

Test & refine

Design

Measurement

Which is typical of your organisation?

© NHS Institute for Innovation and Improvement 2010. All rights reserved.

Traditional Approach to Activities

Suggested Approach

P D

P D S AS A

Time

PDSA Cycle

Which is typical of your organisation?

Time saved

© NHS Institute for Innovation and Improvement 2010. All rights reserved. 15

“Insanity: doing the same thing over and over again and expecting different results”

PDSA Measures• Accuracy

– 10: All pieces on Sam and positioned correctly

– 5: All pieces on Sam but one of more is out of place

– 1: No Pieces on Sam

• Time– Start: When time keeper says so– Stop: When colleague indicated

last piece is in place AND removes hand

Measurement for Improvement“You can’t fatten a cow by weighing it” (Palestinian Proverb)

• Improvement is not about measurement, but…

• How do we know if a change is an improvement?

• “if you can’t measure it, you can’t improve it”

Driver Diagrams• Used to plan improvement project activity• Provide a way of systematically laying out aspects of

an improvement project• Three columns:

– Aim/Outcome: What needs to be achieved– Primary Drivers: Set of factors that must be

addressed to achieve the aim– Secondary Drivers: Specific areas where we plan

changes.

Schematic view of a system on the left we depict outcome (aim) As we move right we drill down into the network of causes that drive the outcome, from ‘primary’ to ‘secondary’ drivers.

Aim: An improved system

PrimaryDriver

PrimaryDriver

Secondary

DriverSecondar

yDriver

Secondary

Driver

Secondary

DriverSecondar

yDriver

On the right we depict ideas for system changes that might ultimately impact the outcome. Diagrams represents our theory about how to modify the system to change the outcome.

Aim: An improved system

PrimaryDriver

PrimaryDriver

Projects Change

Projects Change

Projects Change

Secondary

DriverSecondar

yDriver

Secondary

Driver

Secondary

DriverSecondar

yDriver

Aim: 2 stones lighter!

Energy Out

Energy In

Walk daily commute

Stairs not lift

Exercise

Reduce alcohol intake

Eat Less

Pedometer

Gym work out 3 days

Squash weekends

No pub weekdays

Take packed lunch

Low fat meals

Driver Diagram – Weight Loss

Exercise: Driver Diagram• Using the template provided make a driver diagram

for reducing fuel costs

Decrease my Fuel Cost

Reduce fuel price per gallon

Reduce miles driven

Increase efficiency (miles

per gallon)

• Shop at a cheaper petrol station

• Take advantage of loyalty cards

• Walk to work instead of driving

• Utilise public transport• Use car pooling

• Increase car efficiency (buy a more fuel efficient car)

• Improve driving pattern (improving driving habits)

• Avoid unnecessarily accelerating and decelerating

Outcome Primary Drivers Secondary Drivers

Process Mapping• Views the system from patient perspective, following

their journey• Help staff understand the complexity of processes• Diagnostic and used as a basis for redesign, actively

involving staff in the process

Process Map - ExampleGo to sleep

Alarm goes off

Is this a work

day?

Groan heavily

Get up!

No

Yes

Process Mapping-2 Stages• Stage 1Understand what actually happens to the Patient. Where it happens and who is involved.

• Stage 2Use the map to identify steps that could be changed.

Using the map• Look for bottle necks/constraints (Queues)• Any delays? (eg. Wait for

clinician/consent/results/parking)• Repetition (eg.Patient identity check)• Unnecessary travel/movement in the

department. (eg. Patient or notes)• Unnecessary steps?• Inefficient order of events?

Mind the gap !

Look at the whole process, not just the individual steps.

Process Mapping

• What are you trying to achieve?Describe your aim. For example-To reduce the time Patients spend waiting in out patients.• Who do you need at the meeting? • Do you need to walk the journey yourself?• Do you need to plot the timings/experiences

of a series of cases?

Process Mapping-What do you need

• Your aim• The right people (not just clinicians)• Time• Paper (flip chart/backing paper)• Coloured pens• Post its• Facilitator

Process Mapping-What do you need

• Your aim• The right people (not just clinicians)• Time• Paper (flip chart/backing paper)• Coloured pens• Post its• Facilitator

Summary• Driver Diagram – understanding context of

outcome

• Process Mapping – understanding processes involved in achieving outcome

• PDSA – Testing changes in that process and their impact on the context to ensure they are an improvement

Resources Available• QI Resource website

http://www.vle.eastmidlandsdeanery.nhs.uk/course/view.php?id=934

Links to resources, example projects, events

www.hee.em.nhs.uk

www.hee.em.nhs.uk

SAVE THE DATE! Health Education England working across the East Midlands are pleased to announce that the next Quality Improvement Forum will take place on 29th June 2016 @ the Kube, Leicester Racecourse in Oadby, Leicester.

Key HEEMQIF16 activities for your diary:• Call for Quality Improvement Projects Abstracts – 1st February 2016• Call for bookings & workshop bookings open –1st February 2016• Abstract submissions close –March 2016• Bookings close –May 2016• HEEMQIF16 – 29th June 2016

Join in the conversation on Twitter using @HEE_EMids #HEEMQIF16 #loveourlearners  

Health Education East Midlands Quality Improvement Forum 2016

A Final Thought from Don Berwick

“The most important single change in the NHS in response to this report would be for it to become….a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”

Don Berwick. A promise to learn - a commitment to act. August 2013.