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SAFETY IN PRACTICE
Principles of Quality
Improvement
Understanding the
problem
Testing change
Collaborative learning May 17th 2015
Andrew Jones
Quality Improvement Specialist
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Safety in Practice A regional approach to quality improvement in primary care
What improvements have you made in your practice before?
What is Quality Improvement?
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It is not a tool for management
Quality Assurance
Standards/safety focused
Judgmental
If issue fixed assumes system
is excellent
Quality Improvement
Process focused
Positive
Driven by desire to do better
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It is done for a finite period of time
Acknowledgment: Bennett, 2015. Source: Juran, 1998.pg 95
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It is not just a way to save money
Source: http://www.nhsiq.nhs.uk/media/2541082/improvement_leaders_guide_-_measurement_for_improvement.pdf
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Quality improvement is Quality Improvement is the
techniques and methods used to
take us from where we are to where
we want to be.
Brandon Bennett
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It has many names Continuous Quality Improvement
Total Quality Management
Toyota Production System
Lean Six Sigma
Model for Improvement
What is the Model for Improvement?
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The Model for Improvement
Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009
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A clear explanation….
Source: https://youtu.be/SCYghxtioIY
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What are we trying to accomplish?
Program:
To enhance quality
improvement capability of
General Practices (GPs) within
the Auckland region, by
focusing on patient safety.
Your practice
Set a target relating to your
audit bundle once baseline
data collected
Aim
Understand the problem
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Every system is perfectly designed to get the results it gets
Paul Batalden
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What we think a process involves
Doctor orders
test
Doctor orders
test
Patient goes
for test
Patient goes
for test
Doctor receives results
Doctor receives results
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But really more like this
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Data analysis
22Se
p14
01Se
p14
18Aug1
4
04Aug
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21Jul
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07Ju
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19May
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14Apr1
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03Mar
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10Fe
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20Ja
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6
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Date
Lab
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ult
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e
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*14
777
7
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728
211322
28
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Time Series Plot of INR ResultsHealth New Lynn: 2014
NHI: BWP8299 GP Managed
Data Labels: Time Between Tests
09Sep1411Jul1404Jun1423Apr1411Mar1425Feb1411Feb1428Jan14
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1
Date
Lab
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ltV
alu
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3026
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Time Series Plot of INR ResultsHealth New Lynn: 2014
NHI: FUW4688 Nurse Managed
Data Labels: Time Between Tests
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Cause and effect
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Plus much more
Affinity Diagrams
Force field analysis
Five whys
Brainstorming
Problem solving
Support
Model for Improvement
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The Model for Improvement
Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009
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How do we know if a change is an improvement?
Data is power
Without it, don’t know progress
Measurement can be a dirty word
Measure
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Measuring for improvement is different
Source: https://youtu.be/SAo0O4jSe28
Mike Davidge 7 Steps to Measurement Edited.mp4
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Types of data
Accountability
For comparison and reporting
Research
For development of new knowledge
Characteristics of Accountability Characteristics of Research
Evaluative Blinded/Controlled
Adjust to reduce bias Eliminates bias
100% data ‘Just in case’ data
No hypothesis Fixed hypothesis
No tests One large test
No change focus Statistical tests
Results are public Subjects anonymous
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Types of data
Improvement
Are we moving closer to improving our service?
Characteristics of Improvement
Observational
Consistent bias
‘Just enough’ data
Flexible hypothesis
Run/Shewhart charts
Data for service only
Source Solberg et al, 1995
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Displaying data
Current situation(where we are)
Target (where we want to be)
Gap (how do we get there?)
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What changes can we make that will result in improvement?
To make improvement need to
test new ideas
To bridge gap between current
state and targetChange
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The Model for Improvement
Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009
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Insanity is doing the same thingover and over again expecting different results
Albert Einstein
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All improvement will require change, but not all changewill result in improvement!
Don Berwick
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Rapid Cycle Improvements
Source: Health Quality Ontario, 2012 Acknowledgement: Langley et al, 2009
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Plan
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Do
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Study
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Act
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One builds on the next
Source: Langley et al, 2009
Very Small Scale Test (Qualitative/Quantitative Data)
Follow-up Tests
Tests under new conditions (Quantitative data)
Wide-scale tests of Change
Breakthrough Results
Hunches, Theories, Best Practices
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Sometimes doesn’t go to plan
Source: Ogrinc and Shojania 2013 Acknowledgement: Bennett, 2015
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Its worth it Some percentage of tests—perhaps 25 to 50 percent—is expected to result in no improvement, to “fail,” but to result in substantial learning nevertheless.”
Langley et al, 2009
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Documenting PDSAs
Challenging time wise Help you meet your Cornerstone requirements
Important to know what worked and what failed
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Documenting PDSAs
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Other ideas
Keep a note book with a page for each test
Have a tab on your spreadsheet with idea and result
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Quality improvement principles:
Improvement
Test changes
Understand Problem
Collect just enough data
Collaborative Learning
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Year One Collaborative
Warfarin
Medicine
Reconciliation
Results
Handling
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Year Two Collaborative
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Learning Sessions
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Learning sessions
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Story Boards
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Learning Sessions
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Often source for new ideas
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Steal Shamelessly
Ask questions PDSAs don’t have to be a new idea – steal shamelessly
Year one found lots of things worked or didn’t
Filter
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The beginning of a journey
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Medication Reconciliation
Lecture
Theatre
Ian Hutchby, Improvement Advisor, Ko Awatea, CMH
Diana Dowdle, Delivery Manager, KoAwatea, CMH
107 Opioid Prescribing
Vikas Sethi, Clinical Lead, Safety in Practice
Stuart Jenkins, Director Primary Care, WHDB/ADHB
Results Handling
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Campbell Brebner, Chief Medical Advisor, Primary Care, CMH
Dinner then breakouts
Andrew Jones, Quality Improvement Specialist, WDHB
Monique Davies, Project Lead, KoAwatea, CMH
Room 102 Warfarin Management
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References Associates in Process Improvement (2009). Model for improvement clip one. Retrieved from: https://youtu.be/SCYghxtioIY
Davidge, M (2011). 7 Steps to measurement for improvement. Retrieved from: https://youtu.be/SAo0O4jSe28
Juran JM, Blanton Godfrey A, Hoogstoel RE, Schilling EG (1998). Juran’s Quality Book (5th Edition). New York: McGraw-Hill Retrieved from: http://www.pqm-online.com/assets/files/lib/books/juran.pdf
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP,(2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). San Francisco, California, USA: Jossey-Bass Publishers.
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References NHS Institute for Innovation and Improvement, (2005). Improvement Leaders’ Guide :Measurement for improvement,Process and systems thinking. Retrieved from:http://www.nhsiq.nhs.uk/media/2541082/improvement_leaders_guide_-_measurement_for_improvement.pdf
Ogrin,G. & Shojania, KG. (2013). Building knowledge, asking questions. BMJ Quality & Safety. Retrieved from: http://qualitysafety.bmj.com/content/early/2013/12/23/bmjqs-2013-002703.full.pdf+html
Solberg L, Mosser G, McDonald S, The three faces of performance measurement: improvement, accountability, and research. Joint Commission Journal on Quality Improvement, 1997; 23(3): 135-147