quality improvement models presented by: donna m. daniel, phd
DESCRIPTION
TRANSCRIPT
Quality Improvement Models
Presented by: Donna M. Daniel, PhDAtlantic HealthMorristown, New Jersey
Quality Basics Series
Taught by quality experts for staff in Quality Improvement Organizations, Quality Basics focuses on the fundamentals of quality in areas such as the history of quality improvement, methods and models, performance measurement and other key topics.
Quality Basics: Quality Improvement Models Presented by Donna M. Daniel, PhD
September 25, 2007
Quality Improvement “Models”
Organizational Frameworks / Quality Management Models Baldrige Evaluation Process ISO 9001 Certification Balanced Scorecard Approach
Quality Improvement Methods Six Sigma Human Factors Lean or TPS (Toyota Production System) PDSA Cycles or Model for Improvement
Quality Improvement Theories Reliability Theory Spread Theory
Main Concepts
Baldrige: Performance Excellence (value/quality service)
ISO 9000: Performance Excellence (internal processes)
Balanced Scorecard: Performance Excellence (measurement of business processes and external
outcomes)
Baldrige Award
The Malcolm Baldrige National Quality Award is an award given, by the President of the United States, to applying organizations that meet designated criteria.
Managed by U.S. Commerce Department’s National Institute of Standards and Technology (NIST)
Malcolm Baldrige 1922-1987
26th Secretary of Commerce
Award As Quality Model
"More than any other program, the Baldrige Quality Award is responsible for making quality a national priority and disseminating best practices across the United States." --The Private-sector Council on Competitiveness
Criteria for Performance Excellence
Leadership
Strategic planning
Customer and market focus
Measurement, analysis, and knowledge management
Human resource focus
Process management
Business results
The Baldrige Criteria is a framework that organizations can use to improve their overall performance.
Key Tools
The Baldrige Criteria does not instruct organizations to use any specific improvement tool, but allows the organization to select the tool appropriate to their improvement efforts.
In Healthcare…
Baldrige Award Recipients 2006 – North Mississippi Medical Center - Tupelo, MS 2005 – Bronson Methodist Hospital – Kalamazoo, MI
2004 – Robert Wood Johnson University Hospital Hamilton – Hamilton, NJ
2003 - Baptist Hospital, Inc. - Pensacola, FL; Saint Luke’s Hospital of Kansas City - Kansas City, MO
2002 - SSM Health Care - a health care system in four states IL, MO, OK and WI
ISO 9001 Certification
ISO 9001 is a series of international standards initially published in 1987 by the International Organization for Standardization (ISO), Geneva, Switzerland.
The standards specify requirements and recommendations for design and assessment of a management system, the purpose is to ensure products and services meet customer requirements.
ISO 9000 registration determines whether a company complies with its own quality system.
Criteria for ISO Certification
Customer Focus
Leadership
Involvement of People
Process Approach
System Approach
Continual Improvement
Factual Approach to Decision Making
Mutually Beneficial Relationships
Hoyle, David. ISO 9000 Quality Systems Handbook. Butterworth-Heinemann LTD, Oxford, 1998
Key Tools of ISO 9000
Flowcharting
Process mapping
Cause and effect diagrams
Plan-Do-Check-Act Cycles
and more…
Healthcare applications of ISO 9000
Companies and health care organizations registered to ISO 9000 have reported significant reductions in customer complaints, improved client relations, decreased employee turnover and reductions in operating costs.1
It supports the business while assisting with safety, quality and improvement on a continuing basis. 2
Leelanau Memorial Health Center improved overall financial performance by 10 %, reduced annual employee turnover from + 40 % to 12 %, and their long-term care facility now meets 100 % of their customers’ expectations.3
1 & 3. Dillon, L. Rad, Healthcare and ISO 9000. An interview with Dr. Michael Crago. Quality Management, Sept/Oct 2002. 43-47. 2. Quality Drives Business Improvement in Healthcare. http://www.standards.org.au/STANDARDS/NEWSROOM/TAS/200310/HEALTHCARE/HEALTHCARE.HTM
Balanced Scorecard
Developed in the early 1990's by Drs. Robert Kaplan and David Norton
Distinguishing feature is based on “what companies should measure in order to 'balance' the financial perspective”
More than a measurement system – a management system
Components
For each of the four perspectives, objectives, measures, targets and initiatives are outlined.
Learning & Growth – To achieve our vision, how will we sustain our ability to change and improve?
Customer – To achieve our vision, how should we appear to our customers?
Financial – To succeed financially, how should we appear to our shareholders?
Internal Business Processes – To satisfy our shareholders and customers, what business processes must we excel at?
Improvement Methodologies
LeanHuman FactorsSix SigmaModel For Improvement
Main Concepts
Lean: Waste; Efficiency (internal processes)
Human Factors: Performance; Variation (staff abilities)
Six Sigma: Performance; Variation (cost saving, business goals)
Model For Improvement: Processes
Lean Thinking
Definition Lean Thinking is a way to do more and more work
with less and less-less human effort, less equipment, less time, and less space-while coming closer and closer to providing customers with exactly what they want.
The aim of lean is to eliminate waste.
Defining characteristics: 14 Principles Base your management decisions on a long-term philosophy, even at the expense of
short-term financial goals. Create continuous process flow to bring problems to the surface. Use “pull” systems to avoid overproduction. Level out the workload. Build a culture of stopping to fix problem, to get quality right the first time. Standardized tasks are the foundation for continuous improvement and employee
empowerment. Use visual control so no problems are hidden. Use only reliable, thoroughly tested technology that serves your people and process. Grow leaders who thoroughly understand the work, live the philosophy, and teach it to
others Develop exceptional people and teams who follow your company’s philosophy. Respect your extended network of partners and suppliers by challenging them and
helping them improve. Go and see for yourself to thoroughly understand the situation. Make decisions slowly by consensus, thoroughly considering all options; implement
decisions rapidly. Become a learning organization through relentless reflection and continuous
improvement.
The Toyota Way: 14 Management Principles From The World's Greatest Manufacturer. by Jeffery Liker, J. McGraw-Hill. 2003.
Key Tools of Lean Thinking
Tools include, but are not limited to the following
Value Stream Mapping Process Mapping Poka-Yoke (error-proofing) Pull Systems (Kanban – “signal”) Visual workplace (5S - Sort, Straighten, Shine,
Standardize, Sustain)
On Lean Enterprise and Its Potential Healthcare Applications, by Martin, K. Journal for Healthcare Quality. Vol 25. No 5. Sept/Oct 2003.
Healthcare Applications of Lean Thinking
Hospitals that are employing Lean Thinking
Denver Health
Johns Hopkins
Allegheny General
University of Iowa Hospitals and Clinics
University of Washington Medical Center
Virginia Mason
Atlantic Health
And many more…
Jeff McAuliffe, Tom Moench and Joan Wellman, “The Lean Enterprise Meets Health Care,” Hospitals and Health Networks, January 15, 2004.
Hospital Example
Before
25
4
70 min.
9% - 17%
11
132
10
4
High
High
Steps
Value-Added Steps
Total Time
% Value-Added Time
Queues
Orders in Process
Handoffs
Inspection Steps
Variation in Methods
Variation in Cycle Time
After
9
4
20 min.
32 - 42%
3
39
5
2
Low
Low
©2002 Corporate Strategies and Development, LLC©2002 Joan Wellman and Associates, Inc.
Human Factors
Definition
Human Factors is the science of designing tools, tasks, information, and work systems to be compatible with the abilities of human users.
This includes both physical and cognitive abilities.
Mike Silver, MPH, An Introduction to Human Factors - Design for Use by Humans. HealthInsight, Las Vegas NV, 2003.
Defining characteristics
Diagnosing the type error (execution errors, planning errors, violations )
Execution errors - Correct Plan failure in execution of the plan
Planning Errors – Flawed Plan
Violations – Intentionally deviated from plan negative consequence not intended
Design interventions based upon the error type
Key Tools of Human Factors
Tools include, but are not limited to the following:
Analysis Tools (e.g. Analytic Hierarchy Process, Technique for Human Error Rate Prediction, Decision Matrix for the Allocation of Functions)
Assessment Tools (e.g. Situation Awareness, Global Assessment Technique, Situation Assessment Rating Technique, Situation Present Assessment Method, Situation Awareness Verification and Analysis Tool)
For a listing of Human Factor Tools please see, http://www.hf.faa.gov/Portal/ToolsByTypeTally.aspx)
Healthcare applications
HealthInsight’s pilot project and Quality and Safety Series
Iowa Health System (IHS) Des Moines, IA is applying human factors to their health system. Quote from Gail Nielsen, IHS’s Patient Safety Administrator, “Human factors engineering touches nearly every aspect of patient care, from equipment use and the physical environment to staffing, workload, and patients’ ability to use devices prescribed by their clinicians.”
Human factors engineers/engineering (HFE) is recognized as useful in critiquing medical device design, conducting usability testing, and is credited with aiding remarkable
improvements in some areas of patient safety.
http://www.qualityhealthcare.org/ihi/Topics/PatientSafety/MedicationSystems/Literature/ImprovingPatientSafetyByIncorporatingHumanFactors.htm
http://ase.tufts.edu/mechanical/EREL/Publications/A-1.pdf
Six Sigma
Definition
Six Sigma is defined as “a comprehensive and flexible system for achieving, sustaining, and maximizing business success.
Six Sigma is uniquely driven by close understanding of customer needs, disciplined use of the facts, data, and statistical analysis, and diligent attention to managing, improving and reinventing business processes.”
Pande, P, Neuman, R, and Cavanagh, R. The Six Sigma Way. McGraw Hill 2000
Defining characteristics
Six critical elements
Genuine focus on the customer
Data-and fact-driven management
Processes are where the action is
Proactive management
Boundary less Collaboration
Drive for perfection
Key Tools of Six Sigma
Tools include, but are not limited to the following:
Brainstorming
Affinity
Diagramming
Statistical Process Control
Tests of Statistical Significance
Force Field diagram
Balanced Scorecards
Healthcare application of Six Sigma
Bed discharge process
Reduction of external, temporary employees
Radiation oncology treatment planning throughput
Cycle time to diagnose breast cancer
Luc Pelletier, “Beth Lanham on Six Sigma in Healthcare.” Journal for Healthcare Quality. Vol 25. No 2, March/April 2003.
Model for Improvement (MFI)
Definition
The MFI is based on a “trial and learning” approach. This trial and learning approach revolves around three questions.
What are we trying to accomplish? (AIM)
How will we know that a change is an improvement? (Criteria or Measures)
What changes can we make that will result in improvement? (Testing Changes)
Focusing on these questions accelerates the building of knowledge by emphasizing a framework for learning, the use of data and the design of effective tests or trial.
Defining characteristics
Address the 3 fundamental questions
PDSA Cycle
Plan – Change or Test
Do – Carry out plan
Study – Summarize Learnings
Act – Determine Action
To address the items mentioned above this methodology includes the following steps: Setting Aims, Establish measures, Select Changes, Test Changes, Implement Changes, Spread Improvement
Key Tools of MFI
Tools include, but are not limited to the following:
IHI Breakthrough Series Collaborative
PDSA Cycle
Run Charts
Control Charts
Measures: Balance, Process, Outcome
Flowcharts
Comparison Charts
Standardization
Healthcare applications of MFI
The Model for Improvement has significantly affected healthcare through the IHI Breakthrough Series Collaborative which incorporates the Model for Improvement.
- www.qualityhealthcare.org
- www.improvingchroniccare.org
- www.ihi.org
Review of the Main Concepts
Baldrige: Performance Excellence (value/quality service)
ISO 9000: Performance Excellence (internal processes)
Balanced Scorecard: Performance Excellence (measurement of business processes and external outcomes)
Lean: Waste; Efficiency (internal processes)
Human Factors: Performance; Variation (staff abilities)
Six Sigma: Performance; Variation (cost saving, business goals)
MFI: Processes
Comparison of staff involvement across methodologies
SL Mid-Level Front-Line
Baldrige High High High to Med
ISO 9000 High Med Low
Balanced Scorecard
High Med Low
Lean High High High
Human Factors
Med Med High
Six Sigma Med High “Belts” Med
MFI Med Med High
*Clearly varies by organization
Shared Concepts
Similar concepts for the six methodologies include: Leadership Measurement/Analysis – base decisions on
knowledge Product – business/customer/market People - human resources/management/staff
involvement and or satisfaction Processes
IHI Spread Theory: A Framework for Spread
Set-up-Target population -Adopter audiences -Successful sites -Key partners-Initial spread plan
Social System-Key messengers -Communities -Technical support-Transition issues
Communication (awareness & technical)
Knowledge Management
Measurement and Feedback
Leadership-Topic is a key strategic initiative
-Goals and incentives aligned-Executive sponsor assigned
-Day-to-day managers identified
Better Ideas-Develop the case -Describe the ideas
From IHI, Boston, Massachusetts
CURRENT WAY
Wait for cardiologist
Reliance on memory
Reliance on memory, lack of ability to recognize failure
ED on divert
BETTER IDEA
ED activate Cath Lab
Standing ASA, beta blocker order for AMI
Pharmacist in ED
No OR “blocking”
On Better Ideas
Thanks to Qualis Health/Sharon Eloranta, MD.
On Set-Up: Adopter Categories
Innovators
EarlyAdopters
EarlyMajority
LateMajority
Traditionalists
2.5% 13.5% 34% 34% 16%
From Rogers, 1995
7 Leadership Leverage Points
1. Establish and oversee system-level aims for improvement at the highest Board and leadership level
2. Align system measures, strategy and projects in a leadership learning system
3. Channel leadership attention to system-level improvement
4. Get the right team on the bus
5. Make the CFO a quality champion
6. Engage physicians: Avoid “monovoxoplegia” or “paralysis by one loud voice”
7. Build improvement capability
IHI White Paper by James L. Reinertsen, MD, Michael D. Pugh, Maureen Bisognano, “Seven Leadership Leverage Points For Organization-Level Improvement in Health Care.”
On Communication:
“Campaign” concept
Practice, Passion, Pull
PRACTICE: What people actually do and how they do it. You must get to this level of change.
PASSION: Figure out how to attach the energies of the people who are passionate about what you are trying to do.
PULL: An effective campaign attracts people rather than exhorting them to join!
Thanks to CFAR/Tom Gilmore and Qualis Health/Sharon Eloranta, MD.
Seven Spreadly Sins
1. Start with large pilots!
2. Find one person willing to do it all!
3. Be vigilant and WORK HARDER!
4. If a process worked in the pilot, then it should be spread UNCHANGED!
5. Require the person who drove the pilot team to be responsible for hospital-wide spread!
6. Look at defects on a QUARTERLY basis!
7. Early on, expect marked improvements in outcomes without regard to process improvements!
Thanks to IHI and Qualis Health/Sharon Eloranta, MD.
IHI’s Reliability TheoryIHI White Paper by Thomas Nolan, PhD, Roger Resar, MD, Carol Haraden, PhD, Frances A. Griffin, RRT, MPA, “Improving the Reliability of Health Care.”
Defining “Reliability”
Highly Unreliable <80%
10-1 (1 or 2 failures in 10 cases) ~80-90%
10-2 (5 failures or less in 100 cases) 95%
10-3 (5 failures or less in 1000 cases) 99.5%
10-4 (5 failures or less in 10,000) 99.99%
Appropriate Care MeasureJuly 2005 through June 2006
57.9
24.1 22.4 22.8
34.6
83.3
61.8
49.1
58.861.5
96.192.2
75
86.282.6
0
20
40
60
80
100
AMI HF Pneumonia SCIP All 23Measures
Per
cen
t
Low Performers National High Performers
National averages as reported to the QualityNet data warehouse. Slide provided by Dale W. Bratzler, DO, MPH, OFMQ, Hospital Interventions QIO Support Center.
201 High
1505 Low
272 High
702 Low
487 High
636 Low
352 High
1035 Low
10-2 (95%) is the ONLY goal for….
Non-catastrophic processes Definition: failure of the process does not lead to death or
severe injury within hours of the failure
10-1 performance or worse is commonly seen in these processes
Why are we operating at 10-1 despite all of our talents and resources?
Three-tier Design Strategy
Prevent initial failure using intent and standardization
Identify defects (using redundancy) and mitigate
Measure and then communicate the learning back into the design process
CHF ReliabilityLevel 1 changes only (Step 1)
CHF Protocol For All Admitted Patients
All items on protocol
done
Protocol Not Used
Portions of protocol not used
50-80%
10-25% 10-25% Best Effort 10-1
Standardization mostly structure
Reminders
Awareness and training
Feedback of data
Hard work
Usual Strategies Level 1
CHF ReliabilityLevel 1 and Level 2 changes (Step 2)
CHF Protocol For All Admitted Patients
All items on protocol done Protocol Not Used Portions of
protocol not used
50-80% 10-25% 10-25% Best Effort 10-1
Every patient getting lasix reviewed by pharmacy for a dx of CHF
Pharmacy starts the protocol if dx CHF
Best effort barely 10-2
Reminders built into system
Default desired action
Redundancy
Standardize process
Level 2 changes at individual process level
CHF ReliabilityLevel 1 and 2 + global changes (Step 3)
CHF Protocol For All Admitted Patients
All items on protocol done Protocol Not Used Portions of
protocol not used
50-80% 10-25% 10-25% Best Effort 10-1
Every patient getting lasix reviewed by pharmacy for a dx of
CHF
Pharmacy starts the protocol if dx CHF
Best effort barely 10-2
Portions of protocol not used (highest failure modes)
Smoking advice (all patients counseled about smoking and risk of second hand smoke)
Detailed D/C instructions (If protocol on chart clerk prints out DC instruction sheet at discharge)
ACEI use (If protocol on chart pharmacy checks for use of ACEI and calls MD if not ordered)
Best effort 10-2 to a barely 10-3
Reliability Design
1-Specify the steps
2-Use both level 1 and level 2 changes to attain 10-1
3-Segment population to test the design
Standardization to achieve 10-1 (Tier 1)
10% not done at all10% only partially done
Identify Failures and Mitigate failures if possible to achieve 10-2 (Tier 2)
Prioritize failure modes and redesign steps 1 and or 2 if articulated goal has not been reached (Tier 3)
1-Utilize a system level redundancy
2-Measure failure rates from step 1
3-Do not use unless step one is at least 10-1
1-Redesign only if articulated goal not reached
2-Tackle one failure mode at a time
Concepts associated with 10-2
Decision aids and reminders built in
Desired action the default
Redundant processes utilized
Scheduling used in design
Habits and patterns
Falls in radiology
Standardization of process is the norm
Where can you go from here?(or How to succeed in spite of the Options)
These tools allow you to construct what you wish: Better trained work force Focused attention to objectives/goals It is about:
Measuring Recognizing Accountability Achievement
Thank you for your participation!
For additional questions or resources contact the Performance
Improvement QIO Support Center at [email protected]
A recording of this session will be posted on www.MedQIC.org