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Transcript of Quality improvement
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
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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