Family Medicine and Public Health Clerkship RotationUniversity of Manitoba

2010 - 2011Amanda Condon MD CCFP

Define and understand basic quality terminology: quality and continuous quality improvement (CQI)

List 4 main concepts of CQI and provide clinical CQI examples

List and describe elements of PDSA cycle

Introduce tools and methods for improving quality of care

Construct and present an idea for a CQI project

Quality can be defined by how well we meet the needs of those we serve

Most problems are in process not peopleUnintended variation in processes can

lead to unwanted variation in outcomesContinual improvement can be achieved

through serial experimentation

In health care, quality defined as: “doing the right thing, the first time, in the right way at the right time”

“Right thing, for every patient, every time”

Quality = extent to which health services increase likelihood of desired health outcome and are evidence based (Institute of Medicine)

Measurement for research

Measure for learning and process improvement

Purpose To 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 to get results

“small tests of significant change” accelerate the rate of improvement

SafeEffectivePatient-CentredTimelyEfficientEquitable

eliminate waste improve work flow optimize inventory change the work environment enhance the producer/customer

relationship manage time manage variation design systems to avoid mistakes focus on the product or serviceLangley, Nolan, Nolan, Norman &

Provost 1999

DPIN MIMS Breast Cancer Screening Program Cervical Cancer Screening Program Colorectal Cancer Screening Program Care Maps (asthma, ACS etc.) Standing Orders Medication Reconciliation Bridging Specialist and Generalist Care

Store and ForwardPhysician Integrated NetworkEMR/EPR/EHR/PACS

1.Project Phase2.Diagnostic Phase3.Intervention Phase

• Plan a change• Do it in a small test• Study its effects• Act on the result

4.Impact Phase5.Sustaining Improvement Phase

Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

Identify appropriate interventionsImplement changes identified in the diagnostic phase Undertake one or more PDSA cycles

Interventions phase

Decide on interventions

Undertake one or more PDSA cycles

Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

use plan-do-study-act cycles to conduct small-scale tests of change in real settings plan a change do it in a small test study its effects act on what learned

team uses and links small PDSA cycles until ready for broad implementation

What are we trying to accomplish?How will we know that a change is

an improvement?What changes can we make that will

result in an improvement?

What are we trying to accomplish?

How we will know that a change is an improvement?

What change can we make that will result in an improvement?

ACT PLAN

DOSTUDY

Langley, Nolan, Nolan, Norman & Provost 1999

ACT PLAN

DO

STUDY

Determines what changes are to be made

Summarizes what was learned

Change or test

Carry out the plan

Langley, Nolan, Nolan Norman & Provost 1999

• Measure impact of changes/interventions

• Record the results• Revise the interventions• Monitor impact

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf

Standardization of systems and processes

Documentation of policies, procedures, protocols and guidelines

Measurement and review of practice to ensure that change has become “standard”

Training and education of staff

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

Identify an area for improvement, based on clinical experience

Prepare proposal for initiative implementation following PDSA method

Present proposal to clerkship group

What irritates people, slows them down or costs them money? Target your efforts at relieving the worst of these problems.

Design a "best guess" solution -- a new process model based on the best practice your community has to offer.

Ensure that the new process won't irritate people, slow them down or cost them money.

What are we trying to accomplish?

How we will know that a change is an improvement?

What change can we make that will result in an improvement?

ACT PLAN

DOSTUDY

Langley, Nolan, Nolan, Norman & Provost 1999

1. NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

2. Jain, Manoj. Road Map for Quality Improvement – A guide for doctors.

3. WHO Patient Safety Curriculum - Topic 7: Introduction to quality improvement methods.

4. Djuricich, Alexander. Curriculum in Continuous Quality Improvement for Residents. Indiana University School of Medicine, 2006.