who_mc_topic-7

8/11/2019 who_mc_topic-7

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Topic 7

Introduction to methods forquality improvement


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Learning objective

the objectives of this topic are to:

describe the basic principles of quality improvement

introduce students to the methods and tools for improving thequality of health care


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Performance requirement

know how to use a range of improvement activities

and tools


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Knowledge requirements

the science of improvement

the quality improvement model

change concepts

two examples of continuous improvement methods

methods for providing information on clinical care


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W Edwards Deming

The science of improvement

appreciation of a system

understanding of variation

theory of knowledge

psychology


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Measurement for research Measurement for learning

and process improvement

Purpose To discover new knowledge To bring new knowledge intodaily practice

Tests One large "blind" test Many sequential, observabletests

Biases Control for as many biases aspossible

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 long periods of time toobtain results

"Small tests of significant

changes" accelerate the rate of

improvement

The Institute for Healthcare

Improvement (IHI): different measures


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Three types of measures

outcome measures

process measures

balancing measures


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The quality improvement model-the

PDSA cycle

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?


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ACT PLAN

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?

DOSTUDY

The model for improvement

Langley, Nolan, Nolan, Norman & Provost 1999


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ACT PLAN

DOSTUDY

Determines what

changes are to be made

Summarizes what

was learned

Change or test

Carry out the plan

Langley, Nolan, Nolan Norman & Provost 1999

The PDSA cycle


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Change concepts

are general ideas, with proven merit

and sound scientific or logical foundation

that can stimulate specific ideas forchanges that lead to improvement.

Nolan & Schall, 1996


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9 categories of change

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 service

Langley, Nolan, Nolan, Norman & Provost 1999


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Two continuous improvement

methods

clinical practice improvement methodology (CPI)

root cause analysis


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D

P A

S

3

Intervention

phase

Diagnosticphase

2

1

Project

phase

4

5

Sustaining

improvement

phase

Impact

phase

Project mission

Project team

Conceptual flow ofprocess

Customer grid

Data

-fishbone

-Pareto chart-run charts

-SPC charts

2 months

Plan a changeDo it in a small test

Study its effectsAct on the result

2 months

1 month

Annotated

run chart

SPC charts

D P

A

SD

PASD P

ASD

PA

S

Ongoing monitoring

OutcomeFuture plans

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

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

SPCstatistical process control

The improvement process
http://www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdfhttp://www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf


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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

Interventions phase

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



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


ACT

What changescan be made forthe next cycle

(adapt change,another test,implementationcycle?)

PLAN

Objective

Prediction

Plan for change (who,what, when, where)

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

Carry out the change

Document observations

Record data

DO

Complete analysisof data

Compare results

to predictions

Summarizeknowledge gained

STUDY

How to use the PDSA Cycle

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


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

PDSA Cycles single testChanges that

result in

improvement

Hunches,

theories

and ideas

A

S D

P

AS

D

P

A

S

D

P

A

SD

P

PDSA cycle - single test


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PDSA Cycles multiple tests

A

S D

P A

S D

P A

S D

P

P

D A

S

P

D A

S

P

D A

S

D

P A

S D

P A

S D

P A

S

Test 1 Test 3Test 2

PDSA cyclemultiple tests

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


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1. Measure impact of changes/interventions

2. Record the results

3. Revise the interventions

4. Monitor impact

Impact and implementation phase

Implement the changes

Measure impact Annotated run chart

SPC charts

Other graphs

Impact and implementation phase



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1. Once an intervention has been

introduced, the intervention and anyimprovements need to be sustained

2. This may involve:

standardizationof existingsystems and processes

documentation of policies,procedures, protocols and

guidelines measurement and review of

interventions to ensure thatchange becomes past ofstandard practice

training and educationof staff

Sustainingimprovement phase

Sustain the gains

standardization

documentation

measurement

training

Sustaining the improvement phase



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Root cause analysis

a multidisciplinary team

the root cause analysis effort is directed towards finding

out what happened

establishing the contributing factors of root causes


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Performance requirements

Know how to use a range of improvement activities and tools

flowcharts

cause and effect diagrams (Ishikawa/fishbone)

Pareto charts

run charts


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0

2

4

6

8

10

12

14

LOS days

Hospital NSW Health Kehlet et.al

At the same time LBH executives and staff expressed a desire to improve LOS.

NSW

New South Wales.

Evidence for there being

a problem worth solving


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Flow chart of process

Something amiss

Referral to Hospital

Visit to generalpractitioner

Referral to surgeon

Investigations

Hospital admission

Admissions office

Operating theatre

Admitted to hospital

Preoperative clinic

Post anaesthetic care

Allied health

Surgical ward

Surgical team

Discharge plannerPre-op ward

Pain team

Home

Community health/

Peripheral hospital

Return to life

Accelerated Recovery Colectomy Surgery (ARCS)

Jenni Prince

Area CNC Pain Management

North Coast Area Health Service

NCHI Sydney Australia


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Multidisciplinary meeting to:-ask opinion

-brainstorm process of care

-how to improve the process

-who to include in the processof change

-how to communicate progress

standardization

Evidence-basedpractice

team approach

Customer and expectations list

surgical ward staff post-op anaesthetic care staff

physiotherapy dept

dietitian

peri-operative unit staff private hospital staff

pain team

anaesthetists

surgeons

intensivist


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Cause and effect diagram

Social issues Staff attitudes Complications

Procedure

Patient perception Post discharge support

ProlongedLOS

surgery

mobilization

nutrition

nil by mouth

LOS

mobilization

pain control

nutrition

expect long LOS

home support

often weak

poor understanding

of procedure

little knowledge of

support servicespain control

locus of control

family support

poor pain control

wound complications

weak/malnourished

community health

general practitioner

infection

family

colon care nurse

Accelerated Recovery Colectomy Surgery (ARCS)

Jenni Prince

Area CNC Pain Management

North Coast Area Health Service

NCHI Sydney Australia


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45

34

28

18

16

8

38

0

5

10

15

20

25

30

35

40

45

poor

patie

ntkn

owled

ge

non-s

tanda

rdize

dpain

contr

ol

imbe

dded

staf

fattit

udes

poorlyc

oordi

nated

discha

rge

slow

tomo

bilize

unde

rnouri

shed

patie

nts etc

24

57

42

7667

80

100

Pareto chart


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surgical incision trial of transverse incisionpain control wound infusion for transverse incisions

then

patient information bookletsurgeon pathwayanaesthetic pathwayARCS clinical pathway - surgical technique

- pain control

- bowelprep/care

- nutrition- mobilization

1

surgeon10patients

1surgeon1-6patients

PDSA cycles - implementation
http://e/TEMP/ARCS%20Handbook8.dochttp://e/TEMP/ARCS%20surgeon%20pathway.dochttp://e/TEMP/ARCS%20anaesthetic%20pathway.dochttp://e/TEMP/ARCS%20nurse%20pathway.dochttp://e/TEMP/bowel%20care%20patient%20brochure.dochttp://e/TEMP/bowel%20care%20patient%20brochure.dochttp://e/TEMP/bowel%20care%20patient%20brochure.dochttp://e/TEMP/bowel%20care%20patient%20brochure.dochttp://e/TEMP/bowel%20care%20patient%20brochure.dochttp://e/TEMP/bowel%20care%20patient%20brochure.dochttp://e/TEMP/ARCS%20nurse%20pathway.dochttp://e/TEMP/ARCS%20anaesthetic%20pathway.dochttp://e/TEMP/ARCS%20surgeon%20pathway.dochttp://e/TEMP/ARCS%20Handbook8.doc


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Average LOS (days) per month

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10 11 12

month

days

Run chart

Made change here


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Strategies for sustaining

improvement

document and report each patient LOS

measure and calculate monthly average LOS

place run chart in operating theatre, update run chartmonthly

bimonthly team meetings to report positives andnegatives

continuously refine the clinical pathways

report outcomes to clinical governance unit

Spread - all surgeons

- left hemicolectomy

- all colectomy surgery

- throughout North Coast Area Health Service

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