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Quality ImprovementPrinciples, Methods and Tools

Marlene Marni Mason

MCPP Healthcare Consulting

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Marni Mason BSN, MBA Thirty+ years in healthcare as clinician, manager

and consultant

Primary & specialty care clinic nurse and nursingdirector 15 years

Consultant in healthcare performance measurementand improvement 18 years

Public health performance management since 2000 Surveyor for NCQA (10 years) and Senior Examiner

for state Baldrige Quality Award (late 1990s)

Consultant for PHAB Standards Development (2008-

2009)

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Learning ObjectivesIn todays learning session, the participants will

develop a better understanding of:

Principles of Quality ImprovementSelected Quality Improvement Methods

Selected Quality Planning Tools

Learn about Rapid Cycle Improvement (RCI)And

Start development of QI team AIM statement

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Collaborative with a Capital C

Systems are perfectly designed

to produce the results theyachieve

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IHIs* Breakthrough Series Also known as the Collaborative Method

It is an improvement method that relies on

spread and adaptation of existing knowledgeto multiple settings to accomplish a commonaim

Methodology to accomplish organizationalsystem change

*Institute for Healthcare Improvement www.ihi.org

http://www.ihi.org/http://www.ihi.org/

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The Advantage of a Learning

Collaborative for Improvement Learning collaborative: a group of multi-

disciplinary teams from multiple organizations

which come together over the course of ayear in structured meetings and phonecontacts to accomplish specific learningobjectives.

National experience demonstrates significantboost in pace and level of achievement ofoutcomes by sharing lessons learned.

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Collaborative Process (IHI)SelectTopic

PlanningGroup

IdentifyChange

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

E-mail Visits Web-site Phone Assessments

Senior Leader Reports

Outcomes

Congress

A D

P

S

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Characteristics of a Collaborative Team approach

Performance measures

Teams from multiple organizations One for all, all for one

Promotes a culture of change

Standardizes practice Sustainable change

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MLC-3 Collaborative Targets In Illinois, participation in the MLC-3 Learning

Collaborative is focused on improvement in

two target areas for MLC-3: Community Health Improvement Plans

Chronic Disease Prevention-Obesity/PhysicalActivity (reduce preventable risk factors that

predispose to chronic disease)

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MLC-3 Collaborative Approach All sites receive training in:

Quality Improvement Methods & Tools

Data Analysis Tools Rapid Cycle Improvement Method

Site-based teams develop implementationplan for improvement

Series of web-based phone sessions withcoaching from consultant

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Principles of Quality Improvement

Quality is never an accident; it is always the result

of high intention, sincere effort, intelligent directionand skillful execution; it represents the wise choiceof many alternatives.

William Foster(many variations attributed to others)

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Performance Management

Source: Turning PointPerformanceManagement

Collaborative, 2003.

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The Quality Environment

Do you have an organization-wide commitment toassessing and continuously improving quality overtime?

Do you use data to decide on improvement initiativesand to know if the improvements are successful?

Are your system decisions basedon data?

Do you know if your agency isachieving its goals?

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Change vs. Improvement W. Edwards Deming stated Of all changes

Ive observed, about 5% were improvements,

the rest, at best, were illusions of progress.

We must become masters of improvement

We must learn how to improve rapidly

We must learn to discern the differencebetween improvement and illusions ofprogress

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Principles of Quality Management1. Know your stakeholders and what they need

2. Focus on processes

3. Use data for making decisions4. Understand variation in processes

5. Use teamwork to improve work

6. Make quality improvement continuous7. Demonstrate leadership commitment

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1. Know Your Stakeholders

Identify stakeholders andtheir needs

Set goals based onstakeholder needs

Monitor performance andsatisfaction to target

performance improvementopportunities

Improve or redesign howwork is done

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Sector Maps for Planning

Example of Public SectorOffice of the Insurance

CommissionerGovernor / Legislature

Indian Health Service

Health Care Authority

School Boards

Public Schools (K-12)Private Schools (K-12)

Public Library System

Tribal Government

Employment Security

Department

State Board of Health

Local Government

Local Health JurisdictionsDepartment of Health

Community & Family

Health

Women, Infants &

Children

Licensing BoardsDept. of Social & Human

Services

Bullets refer to examples of organizations and are not a comprehensive listing.

Rural & CommunityHealth Centers

Health & Human Services

Center for Disease

Control & Prev.

Center-Medicaid&Medicare Srvcs

Fed. Drug

Administration

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Example of Private Sector

PurchasersConsultingFoundations

Business and

worksite programs

Insurance Brokers

Health Plans

Hospitals

Media

PharmaceuticalCompanies

Home Health Care

Ancillary Service

Practitioners and

Groups

Providers

Professional

Organizations

Funding Foundations

Robt Wood Johnson

Bullets refer to examples of organizations and are not a comprehensive listing.

SNF and Nursing

Homes

Primary/Specialty

Medical Groups

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Example of Community-

Based SectorService Organizations

Thousands of

community-based

agencies: specific partners

will be identified in each

community

Community Centers

American Association

of Retired Persons

Faith-based Community

Organizations

Community Health

Centers

Federally Qualified

Health Centers

Migrant Health Centers

Youth Associations

YMCA / YWCA

Boys & Girls Club

Boy & Girl Scouts of

America

Campfire Girls and BoysCommunity-based

Daycare Sites

All ages

Birth to 3 childcare

Youth Sports Associations

Little League

Pop Warner

Soccer, etc

United Way

Senior Centers

Communities of Color

Organizations

Community HealthAlliances Churches, Temples &

Mosques

Bullets refer to examples of organizations and is not a comprehensive listing.

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Example of

Academic/Research SectorState Universities

Nursing

SchoolsAllied Health Professional

Schools & Training

Community

Colleges

Pharmacy Schools

Private Universities

Private Research Centers\Tribal

Colleges

Bullets refer to examples of organizations and is not a comprehensive listing.

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Example of Target Populations

CONDITION Age Racial/ethnicCommunities

Socio-economic/low literacy General Population

Public: Center for Medicaid &Medicare Services (CMS)

DOH -- CDRRP/DPCP Public Hospital Districts

Tribal Associations

Veterans Admin.

Dept. of Defense

Medicaid

DOH-Chronic Disease RiskReduction (CDRRP)

DOH- Diabetes Prevention& Control Program (DPCP)

Tribal Assns.

Indian Health Services

DOH-Chronic Disease RiskReduction (CDRRP)

DOH- Diabetes Prevention& Control Program (DPCP)

Dept. of Veterans Affairs

Maternal Support Services

Centers for Disease Control& Prevention (CDC)

Office of Insurance Governor/Legislature

Dept. of Corrections

Public Employees BenefitBoard

Local Health JurisdictionsPrivate: Qualis Health

Health plans

Media

Inland NW Business Coal.

Alternative health providers

Home health Student health centers

Community Health Plans ofWA(CHPW)

Association of Black HealthCare Professionals

Association of AmericanIndian Physicians Move It

program

Molina health plan Community Health Plans of

WA (CHPW)

Disease managementvendors

Critical access hospitals

Home Health

Washington HealthFoundation

Professional orgs Pharmaceutical. Co

Medical Supply Co.

Purchasers

Disease mgt

Hospitals Critical access hospitals

Primary/specialty groups

Community: Amer. Diabetes Assoc.

Juvenile Diabetes ResearchFoundation (JDRF)

Senior centers Service organizations

Community Aging ServiceProviders

Communities of colororganizations

Amer. Diabetes Assoc.(ADA)

CHOICE Health Commu. Health Centers

(CHCs)

CHOICE Health

Commu. Health Centers(CHCs)

Commu. Health Centers

Amer. Diabetes Assoc.(ADA)

Nutrition & Cultures Disease Management

Education Centers

Diagnosed

Academic: WSU Extension

Focused research programs,e.g. SEARCH for Diabetes

in Youth

WSU Extension

Focused research programs,e.g. SEARCH for Diabetes

in Youth

WA StateUniv. Extension Allied health training

UW Med school

Bastyr University Nursing Schools

Private Universities

Pharmacology Schools

Community Colleges

Tribal Colleges

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2. Focus on Processes

85% of poor quality is a result ofpoor work processes, not of staff

doing a bad job Processes often go wrong at the

point of the handoff

Attend to improving the overall

process, not just one partsomeof the most complex processes arethe result of creating a work

around

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Focus on Processes

Advice from NCQA, JCAHO and othersmeasure processes that are

High-risk

High-volume

Problem-proneAnd

Can be tracked and reported as summary oraggregate statistics

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Develop Process Flow Charts

High level flow charts [6-12 steps] initially

Identify customer-supplier relationships

More detailed flow charts as project unfolds[client flow, information flow, materials flow,decision making flow]

Use for process redesign

Use for adapting or adopting best practices

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The Logic ofPublic Health

There are fewer

incidents offoodborne illness

Conditions in therestaurant dont

create unsafe food

Public is soldfood that issafe to eat

We inspectrestaurants

# of inspections

% of criticalviolations corrected

within 24 hours

rate of foodborne illness

# of critical violations

So that

So that

So that

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Logic Models (Many Shapes/Sizes)

Connect what we do every day to why we do it

Show logical links between activities and goals

Link our process objectives to our outcomeobjectives

As long as the format is legible, logical, and itworks for you, its probably fine

Boxes and arrows are not required New computer software is not required

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Logic Model:Any Public Health Program

Inputs Outputs Short Term

Outcomes

Intermediate

Outcomes

Long Term

OutcomesResources Activities

Staff

Money Improved

knowledge,

beliefs,

attitudes

Improved

Behaviors

Program

Development

Program

Planning

Materials

Development,

Distribution

Informed,

Targeted

Program

Appropriate,Targeted

Materials

Reduced

Mortality

ReducedMorbidity

Improved

Quality of

Life

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3. Use Data to Make Decisions Use performance

assessment data to targetimprovement

Use data analysis tools todevelop information

Analyze data to identify root

cause Use data to monitor

performance outcomes

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Use Data to Make Decisions

Check Sheet Bar Chart

Histogram Pareto Chart

Control Chart

Run Chart

Affinity Diagram Brainstorming

Process Flow Chart Interrelational Diagraph

Matrix Diagram

Tree Diagram

Cause and EffectDiagram

Numerical ToolsConceptual Tools

[See Goal/QPC PH Memory Joggers]

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Use Data to Make Decisions

Brainstorming for root causestheorygeneration relies on divergent thinking, no

idea is a bad one What can go wrong in the process we are

studying?

Problems in hand-offs between steps

Problems in execution within steps Look at machines, materials, methods,

measurements, and people

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Cause-effect or Fishbone Diagram

Exercise: Constructing a Fishbone Diagram

Organizes and displays theories

Encourages divergent thinking Demonstrates the complexity of the problem

Encourages scientific analysis (rule-out)

Turn to page 23 in the PH Memory Jogger.

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4. Understand Variation

Sources of variation include: machines, materials,methods, measurements, people, environment

Common cause variation occurs if the process is

stablevariation in data points will be randomand obey a mathematical lawit is said to be instatistical control, with a large number of smallsources of variation

Reacting to random variation in a process that isstable/in statistical control, it is called tamperingand leads to further complexity, increasingvariation and mistakes

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Understand Variation

Special cause variation arises because ofspecific circumstances which are not part ofthe process all the time and may or may not

ever recurif the recurrence is periodic,clues to the root cause may emerge

Variation can be shown in control charts withmean and standard deviation

Control charts are pictures of trend data withan extra featurethe range of variation builtinto the system

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Understand Variation

A sentinel event is a special cause variationrequiring root cause analysis

Examine specific incident(s) of special cause

variation and make changes to a singleelement only after very careful analysis Need to investigate special cause variation

before making any conclusions aboutperformance level

Failure to distinguish between commonand special cause variation can behazardous to organizational performance!

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Variation Exercise

Joiner Associates Hunter Conferenceexercise

Attributed to Brian Joiners 9 year-old son

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5. Use Teamwork

QI efforts need buy-in fromall stakeholders

Creative ideas are needed Division of labor is needed

Process often crossesfunctions

Solution generally affectsmany

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Use Teamwork Teams should develop a clear charge and

support resources

Teams should adopt working agreements(cell phone etiquette to decision procedures)

Teams should assign roles of facilitators andrecorders

Team process has predictable stages that areuseful to keep in mind:

Forming, Storming, Norming, Performing

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Example of Alignment Wheel

Public Health and Partners Aligned with the 10 Essential Services

ES 1: M onitor

Health StatusES 10: Resear ch

ES 9: Evaluate

ES 2: Dia gnose

and Investiga te

ES 3: Inform, Educate

and Empower

ES 4: M obilize

Community

Partnerships

ES 5: Develop

Policies and PlansES 6: Enforce Laws

and Regulations

ES 7: Link Peopl e to

Needed Services

ES 8: Assure a

Competent Workforce

PH

Program

CDC

LHJs

LHJs

Health

Care

HHWADE

Pharm.

Assoc

ADA, FQHC

Faith-based,

Educ. Assoc.

Feds,

Schools,

Profession

al Assoc.,

OIC,

Legisla-

ture,

DSHS /

MAAHealth

Plans

U.W.WADE

Pharm

DSHS /

MAA

FQHC,

Qualis

,

V.A

U.W.,

Pharm.Co., N.I.H.

DM Ed

Center

PH

Program

Goal

StatementGoal

Statement

GoalStatement

Goal

Statement

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6. Make QI Continuous

QI is a system-wide approach to assessingand continuously improving quality of theprocesses and services over time

See inter-relationships, not parts Understand the flow of work, not the one-time

snapshot Detail the work processes

Determine cause and effect relationships Identify points of highest leverage Improve and innovate, not just change for

changes sake

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PDCA/PDSA Cycle definition

The Plan Do Check/Study Act Cycle is a trial-and-learning method to discover what is aneffective and efficient way to design or change a

process The check part of the cycle may require some

clarification; after all, we are used to planning,doing/acting. It compels the team to learn from

the data collected, its effects on other parts of thesystem, and under different conditions, such asdifferent communities

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The PDSACycle forLearning andImprovement

Act What changes

are to be made?

Next cycle?

PlanObjectiveQuestions and

predictions (why)

Plan to carry out the cycle(who, what, where, when) Plan for data collection

StudyComplete the

analysis of the data

Compare data topredictions Summarize

what waslearned

Do Carry out the plan Document problems

and unexpectedobservations

Begin analysisof the data

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Ongoing PDSA Cycles

PLAN

PLAN

ACT DO DO

CHECK

Self-Assessmentor Accreditation

PerformanceImprovement

Cycle

Accreditation

Evaluate

Report/Recommend

Areas forImprovement

Target Improvements

Improvementwork

Study ImprovementResults

Recommend

Improvement

Accreditation

PLAN

Evaluate

CHECK

Report/Recommend

Areas forImprovement

ACTDO

CHECK

ACT

Self-Assessmentor Accreditation

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Make QI Continuous Use assessment to identify areas for

improvement

Charge QI team and provide support Provide QI training

Use tools to understand root causes

Use data for baseline and analysis

Design process improvement to address rootcauses

Traintraintrain staff on the newly

designed process improvement

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Adopt or Adapt Model Practices

Use data to identify need for improvement

Identify exemplary practices in:

other local departments, Michigan state programs and other states,

CDC and other national organizations,www.naccho.org/topics/modelpractices

other industries Describe your process (Logic Model)

Study the exemplary practice process

Adopt or adapt as appropriate

http://www.naccho.org/topics/modelpracticeshttp://www.naccho.org/topics/modelpractices

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7. Demonstrate Leadership

Commitment Build a QI culture Connect the organizations

strategic plan to performance

improvement Know and use quality principles Encourage all staff to use quality

improvement in daily work Reward improvements Assure adequate QI infrastructure

for quality assessment andimprovement activities

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What questions do you have?

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Rapid Cycle Improvement (RCI)and PDSA Cycles

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Why do we need a systematicmodel for improvement?

All improvements require change but not all

change will result in improvement. A primaryaim of the science of improvement is toincrease the chance that a change will actuallyresult in sustained improvement from theviewpoint of those affected by the change.

--The Improvement Guide, 1996

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Rapid Cycle Improvement

Model for ImprovementWhat are we trying

to accomplish?

How will we know that achange is an improvement?

Act Plan

DoStudy

The idea behind rapid cycleimprovement is to first try a

change idea on a small scaleto see how it works, and thenmodify it and try it again untilit works very well for staff and

customers. Then, and onlythen, does a change becomea permanent improvement.

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Testing a Change: Why Test?

Level of risk

Confidencein

suc

cess

High

Low

Minor Major

-Smaller Scale Tests-More of them priorto implementation

Modified from Jane Taylor PhD

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Testing a Change: Why Test?

Minimize risks of potential failure and ofpotential adverse or unanticipated sideeffects

Predict how much improvement can beexpected from the change

Learn how to adapt the change to conditions

in the local environment Evaluate costs and side-effects of the change

Minimize resistance to implementation

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Rapid Cycle Improvement

Model for Improvement

What are we tryingto accomplish?

How will we know that achange is an improvement?

Act Plan

DoStudy

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What Are We Trying to Accomplish?

The first question is meant to establish an aimfor improvement that focuses group effort.

Aims should be as concise as possiblesometimes it takes a few trials of testing anaim before it becomes truly focused

Focus on what matters to the organization, staff

and patients Use numerical goals wherever possible

Guidance and resources (e.g. tools to be used,methods and systems to be changed)

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How Will We Know That aChange is an Improvement?

Measures and definitions are necessary toanswer this question.

Data is needed to evaluate and understand the

impact of changes designed to meet an aim.

When shared aims and data are used, learning isfurther enhanced because it can be shared. In thisway, superior performance and best practices are

more quickly identified and disseminated throughbenchmarking.

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What Change Can We Make thatWill Result in an Improvement?

This step is also known as How will we get

there?

Formulate change concepts that may improve theprocess outcomes

This is the who, what, when, and how of doingthe actual test

It compels the team to learn from the datacollected, its effects on other parts of the system,and under different conditions

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Consolidation of RelevantKnowledge and Experience

Develop a set of change concepts

Definition of Change Concepts - Ideas forinterventions and actions for improvementwith a greater likelihood of working based on

evidence,

quantitatively documented experience, and/or

internal data.

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Some Sources for ImprovementInterventions and Actions

Published literature in scientific journals

Documented (with data) experience from otherpublic health agencies

Internal qualitative analysis of work processes

Use qualitative analysis tools (e.g. fishbone diagrams,root cause concepts) to identify barriers

Internal quantitative analysis of work processes e.g. Pareto analysis

National experts (e.g. IHI, NACCHO, PHF, ASQ,Goal/QPC, MLC states and many others)

Sequential Building of Knowledge

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Sequential Building of KnowledgeIncludes a Wide Range of Conditions inthe Sequence of Tests

BreakthroughResults

Theories,hunches,& best practices

A P

S D

A P

S D

A P

S D

A P

S D

Test on a small scale

Test a wider group

Test new conditions

Spread

Implement

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Sequential Testing.when do youmove to implementation?

After each PDSA

Implement as is

Abandon it

Increase in scope

e.g. more clients, more programs

Modify it and test again

Test under different conditions

T ti D i M lti l Ch

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Aims:

ProductivityQualityCoordination

Access

RCI Team #4

Or 4th

Change

RCI Team #3 or 3rd Change

A P

S D

A P

S D

A P

S D

A P

S DA P

S DA P

S DA P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A P

S D

A PS D

A P

S D

A P

S D

A P

S DA P

S D

A P

S D

A P

S D

Testing Done in Multiple Change

Areas in Parallel

RCI Team #2or 2nd Change

RCI Team #1

Or 1st Change

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Testing a Change

Testing Trying and adapting existingknowledge on small scale. Learning whatworks in your system

Testing is not permanent

Often we have more failures than successes

Test on a small scale over a short period of time

Have experts comment on feasibility Anticipate a sequence of tests on one change idea

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Testing a Change: Tips

Move from ideas to action quickly

Decrease the scope of the test

Test of oneness

One stakeholder, one program, one day

As you are designing the test, ask What design

would enable us to do this test now, tomorrow ornext week

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Implementing a Change

Implementation Making this change apart of the day-to-day operation of thesystem

Implement a change ONLY if it will lead toimprovement

Involves more people and conditions: you willrun into more resistance and factors whichrequire design tweaks

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What Can We Do Now

by Next Week,

by Tuesday,by Tomorrow

that we can learn from withoutharming clients or burdening staff?

Modified from Jane Taylor PhD

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Rapid Cycle ImprovementExample

Wh W T i

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What are We Trying toAccomplish?

Increase accurate and complete reporting ofCD to 80% or more of all reports by 10/07,and more than 95% by 2/08 with cleardefinition of complete reports. We do this inorder to provide valid data for planning andprogram improvement

H Will W K Wh W G t

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How Will We Know When We GetThere?: Measurements

Increase (trended) in percent of accuratelycompleted CD reports

Decrease in staff time to input incompleteinformation

Trend in overall measures in right direction(direction of goodness indicated by arrow)

Other CD reporting measures Other process measures

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What Changes Can We Make?

Data analysis of reasons for incompletereports.

Identify reasons with definitions

Assure that database can capture each reason

Initiate data collection process

Train staff and providers in definition and reporting

process Address lack of knowledge of providers

Create plan to identify high volume providersand target for extra training

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RCI Team Planning Tool

Aim:

Measures

Cycle

Number

Change Tested Person(s)

Responsible

1

(9/4)

2 3 4 5

(10/2)

6 7 8 9 10

(11/6)

11 12 13

(11/28)

1 Data on staff cancellations to determine

reasons (Pareto analysis1a Identify reasons for staff cancellations Beth T., Margaret

1b Establish definitions of staff cancellations Bernie & Med Prov

1c Train staff and providers in definitions Donna, Beth T.

1d Pilot test in all provider practices for 7 weeks

10/9- 11/24

Beth, Margaret

Reduce staff cancellations of patient appointments to 5% or less by Dec 2006 and less than 2% by March 2007 with clear

definitions of types of appointments considered staff cancellations.We do this in order to provide high quality, accessible

services to our clients.

PROJECT: REDUCE PERCENT OF STAFF CANCELLATIONS (10-3-06)

3. Trend in overall measures in right direction (e.g. hospitalizations, staff and patient satisfaction)

2. Assess actual increase in productivity (measured by hours of direct service) that occur as a result of reducing the percent of

1. Trend of staff cancellations in right direction.

WEEK. (1 = Sept 5)

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Data Analysis- Pareto ChartNon-Reporting Facilities by School Type

0

10

20

30

40

50

60

70

80

90

100

CHILDCARE/PRESCHOOL Total PUBLIC Total PRIVATE Total CHARTER Total

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20.0

30.0

40.0

50.0

60.0

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80.0

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100.

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Data Analysis- Pareto ChartNon-Reporting Schools By District

62

11

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7

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10

20

30

40

50

60

70

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Results Error Rate

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Results Time Study

St t S t U R id C l

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Steps to Set Up a Rapid CycleImprovement

Establish a multi-disciplinary RCI team

Identify a positive opinion leader

Align leadership and administrative support Consolidation of relevant knowledge and

experience (national) for multiple changes

Development of an overall aim statement

(using the three questions at a high level)

Decide where to start and develop a strategyfor a series of rapid cycles.

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Guidance on Following the Steps

It is important not to try to write the perfectAIM statement and develop the mostthorough rapid cycle strategy at the start. It is

more important to start small, rapid tests ofchange through PDSA cycles as soon aspossible. The AIM statement and strategyevolve continually as you learn from testing.

The major objective is to build organizationallearning from small tests of change.

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Key Lessons from RCI

The rapid improvement work must be seen asThe Work and not a separate project

Implementation and holding the gains requiresintegration into daily work and meetings

Start work with those interested in change

Communicate what is happening persistently

Provide support to providers and staff who takeon this new work

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What questions do you have?