Introduction to Quality Introduction to Quality Improvement

ImprovementAhmad Thanin

Ahmad Thanin

Objectives

0To gain an understanding of what quality improvement is

0To present the Model for Improvement and PDSA cycle

0To introduce measurement in quality improvement0To introduce flowcharts

What is Quality Improvement?

0A formal approach to the analysis of performance and systematic efforts to improve it0 Different from Quality Assurance

Quality Improvement versus Quality Assurance

Quality Improvement Quality Assurance

What can we do to improve? What went wrong?

Proactive Reactive

Avoids blame Often Punitive

Fosters System change Tries to find who was at fault

Focuses on the entire system

Focuses on the specific incident

What is quality?

0Definition of quality depends on stakeholders0 The client/customer (the patient)0 The provider/employer (health care providers)0 Management (hospital management)0 Payer (Ministry of Health)

6 Pillars of Quality

0Safety0Timely Access0Equitable0Efficacy0Efficient0Patient Centered

“Every system is perfectly designed to get the results it

gets”0How can you improve a system to achieve better results

in the 6 pillars of quality?

To improve a system…

0You need a good understanding of the system

0You need to understand where it is failing - Identify what is wrong 0 Make sure it is the step that needs fixing

0Then you can implement a change to the “system”

What is a system?

0System = any assembly of procedures, resources and routines to carry out a specific activity

System

0To understand a system and identify what is wrong with it Map it out!

How do you map out a system?

0Use a flow chart/diagram

0Use different perspectives (a doctor’s perspective is different to a nurse’s or a porter’s to a patient’s perspective)

Quality Improvement Models0 Model for Improvement = Three questions + PDSA cycle0 FADE = Focus, Analyze, Develop, Execute and Evaluate0 Six Sigma0 CQI = Continuous Quality Improvement0 TQI = Total Quality Management0 7 step method

Model for Improvement Model for Improvement = Three questions + PDSA cycle= Three questions + PDSA cycle

The Three Questions

0The Model for Improvement begins with three fundamental questions

0 1. 1. The Aim:The Aim: What are we trying to accomplish? (How good do we want to get and by when?)

0 2. 2. The MeasuresThe Measures: How will we know a change is an improvement?

0 3. 3. The Changes:The Changes: What change can we make that will result in improvement?

PDSA Cycle

0PPlan a change0DDo the change0SStudy the results0AAct on the results

STUDY

ACT PLAN

DO

PDSA Cycle

0Enables rapid testing and learning0Allows for incremental testing0 Instead of spending weeks or months planning out a

comprehensive change, then putting it into practice only to find that it is fundamentally flawed

PDSA Cycle

0Can aid you in:0 Developing a change0 Testing a change 0 Implementing a change

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

MODEL FOR IMPROVEMENT

STUDY

ACT PLAN

DO

Executing the Model for Executing the Model for ImprovementImprovement

Let’s do an example

The Problem

0Patient’s at XY - Hospital emergency department are often in pain

0We want to change that

0So…how do we do that?

Executing the Model for Improvement

0 Form a team0 Three Questions: The Aim,

The Measures, The changes0 Test changes - PDSA Cycle0 Implement changes that

work0 Spread the changes to other

areas

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

You need a team0Why?

0 Need different perspectives

0 It’s a lot of work0 Increased buy-in by staff0 Different levels of support

(e.g. management)

0To come up with the right team you have to have an idea of what your aim is…

The AimThe AimWhat are we trying to accomplish?

The Aim0A strong, measurable

aim with a clear time frame will help keep your project on course

0It has to be important to those involved

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

The Aim

0A good aim: 0 Is Specific0 Is Measurable0 Determines a time frame0 Addresses who the change is for, and what has to be

achieved0 Is Sustainable

The Aim

0 I will become a good runner

0 I will run 10 kilometers per week by May 31st

0 I will run more often

Which one of the above is a good aim?Which one of the above is a good aim?

The Aim

0Back to the Problem: Patients at XY - Hospital emergency department are often in pain

0We decide to focus on emergency department patients with fractures

The Aim

0All emergency department patients with fractures

0We will provide analgesia to 100% of our pts with a suspected fracture within 15 minutes of arrival to the emergency department by the end of December 2013.

Choose your teamChoose your team

Choose your team

0Consider the system that relates to the aim i.e. what processes will be affected by the improvement efforts

0 Involve members familiar with all different parts of processes

Back to our example0 All emergency department

patients with fractures

0 We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011.

0What processes will be affected?

Back to our example0 All emergency department

patients with fractures

0 We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011.

0What processes will be affected?0 Nursing/Triage0 Pharmacy0 Stocking0 Doctors0 Registration0 ED chief/director/

manager

Choose your team

0Effective teams require three kinds of expertise0 System leadership for authority 0 Clinical -Technical expertise0 Day to day leadership - Project leader

Your team

0Team leader: Medical director of the emergency department

0Technical expert: Hospital Quality Management member

0Day to day leader (project leader): an emergency doctor or nurse

0Additional team members: pharmacist, person responsible for stocking, charge nurse, registration clerk

Revisit the Aim

0Once you have chosen your team, review and modify the aim based on their input

MeasurementMeasurementHow will we know that a change is an

improvement?

Measurement0Measurement is critical

for testing and implementing changes

0Different from measurement for research

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

MeasurementMeasurement for Research

Measurement for 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 Short duration

Measurement

03 types of measures for quality improvement0 Outcome measures0 Process measures0 Balancing measures0 (+/- Structure Measures)

Outcome Measure

0= Where are we ultimately trying to go0Are your changes actually leading to improvement

Process Measures

0= Are we doing the right things to get there?0To affect an outcome you have to improve your

processes0Are the parts/steps in the system performing as

planned

Balancing Measures

0Tells you if changes designed to improve one part of the system are causing new problems in other parts of the system

Examples for our case scenario: Complications from Examples for our case scenario: Complications from analgesics (allergic reactions, hypotension, analgesics (allergic reactions, hypotension, infections at IM injection sites); increased times to infections at IM injection sites); increased times to nursing assessments for all other patients other nursing assessments for all other patients other than those with fracturesthan those with fractures

The ChangeThe Change

What change can we make that will lead to improvement?

Developing Changes

0Depends what you are trying to change The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

Basic Techniques

0 Critical ThinkingCritical Thinking0 Flow Chart/Diagram

0 BenchmarkingBenchmarking0 Compare to best practice

0Using TechnologyUsing Technology0 Barcodes for medications

0 Creative ThinkingCreative Thinking0 Become a patient for a day

0Using Change ConceptsUsing Change Concepts

Critical Thinking

0Use a Flow Chart/Diagram

0A flow chart allows to “visualize” the system you are trying to change

0Allows ALL to see the system the same way

Flow Chart/Diagram

0It helps to clarify complex processes

0It identifies steps that do not add value to the internal or external customer, including: 0 Delays0 Needless storage and transportation0 Unnecessary work, duplication, and added expense0 Breakdowns in communication

Flow Chart/Diagram

0It helps team members gain a shared understanding of the process and use this knowledge to collect data, identify problems, focus discussions, and identify resources.

0It serves as a basis for designing new processes.

Flow Chart/Diagram

0High-level flowchart, showing six to 12 steps, gives a panoramic view of a process

0Detailed flowchart is a close-up view of the process, typically showing dozens of steps. These flowcharts make it easy to identify rework loops and complexity in a process.

Example: High Level Flow Chart

Example: Detailed Flow Chart

7Change Concepts

0Eliminate Waste - an activity or resource that does not add value

0 Improve Work Flow

0Optimize Inventory - is your work being held up because items are not properly organized or available

Change Concepts

0Change the Work Environment (does the work culture enhance or impede change)

0Manage Time

0Focus on Variation - what aspect of the system vary and make your outcomes unpredictable

0Focus on Error Proofing (checklist)

Testing Changes: Testing Changes:

PDSA CyclePDSA Cycle

All improvement will require change, but not all change will result in improvement.

Testing Changes

0Why test changes (even if they are already proven elsewhere)?0 To learn how to adapt the change to the particular

conditions in your setting0 To evaluate the costs and side effects0 To minimize resistance when implementing the change

in the organization0 Increase your belief that the change will result in

improvement

To test your change use the PDSA cycleTo test your change use the PDSA cycle

PDSA Cycle0 Plan Plan

0 Objectives0 Questions and predictions0 Plan to carry out the cycle

(who, what, where, when)0 Plan for data collection

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

PDSA Cycle

0Do Do 0 Carry out the plan0 Document problems and

unexpected results0 Begin Analysis

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

PDSA Cycle0StudyStudy

0 Complete analysis of the data

0 Compare data to prediction0 Summarize what was

learned

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

PDSA Cycle0ActAct

0 What changes are to be made

0 Next cycle?

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

Testing Changes0Much can be learnt

from a failed test

PDSA

PDSA

PDSA

PDSA

PDSA

STUDY

ACT PLAN

DO

STUDY

ACT PLAN

DO

STUDY

ACT PLAN

DO

What happens when you identify what works?

0Are you done?

0Once you identify what works, change has to be SUSTAINED. Implementing a change is the hardest part.

How easily is change adopted?

0Process of “Normalization”

0People have a tendency to fall into old habits

0People have a tendency to resist change

0People may feel threatened by a change

Executing the Model for Improvement

0 Form a team0 Three Questions: The Aim,

The Measures, The changes0 Test changes - PDSA Cycle0 Implement changes that

work0 Spread the changes

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

ImplementationImplementation

Implementation

0Usually comes after a series of successful tests

0It requires that staff and leaders build the change into formal plans, job definitions, training, and explicit reviews

0The change does not depend on the individuals doing the work, but on the way the work is organized - as part of the system.

Implementing Change

0 “Hard-wire” the change into the system

Remember Remember

The implementation phase is the most common The implementation phase is the most common area where process improvements fails.area where process improvements fails.

Hardwire Change

0 Market your change0 Train everyone involved0 Make changes to job descriptions, policies, procedures, forms0 Addressing supply and equipment issues0 Assigning day-to-day ownership for the maintenance of the

new process0 Have senior leaders remove any barriers

Social System

0 Social System - understand the relationship among the people who will be adopting the new ideas

0 Remember there is an emotional component to change0 Stress of learning and executing something new0 Initial disruption to workflow0 Maybe they feel their job/position is threatened

Social System

0 Those who are supportive0 Enlist on your side

0 Those who are not supportive0 Don’t try to change their attitude0 Listen to what concerns them, identify barriers

0 Those who don’t really care, and will follow when others do

SummarySummary0 In this modules we have presented an introduction to:

0 Quality Improvement0 The Model of Improvement

03 questions (What is your aim, measures, change) and PDSA cycle

0 Types of Measures0 Change and Implementation

Thank YouThank You