QUALITY IMPROVEMENT METHODOLOGY: CHANGING PROCESSES TO IMPROVE OUTCOMES

Sarah Gimbel, RN, MPHAssistant Clinical ProfessorDepartment of Global Health University of WashingtonTechnical Advisor Monitoring & EvaluationHealth Alliance International

Quality Improvement MethodologyLate 1990s: Major transformation

Measuring mistakes process redesign

Traditional outcomes research tools Before and after Intervention and control groups Rigorous statistical analysis

Emphasis on rapid assessment, dynamic implementation, & simple techniques to measure progress in closing quality gaps

Far less academic and more results-oriented

Coming Together: Changes in Medicine & Other

Industries

1. Evidence-based medicine

2. Lean Methodology (Toyota)

Institute for Health Care Improvement (IHI)

Breakthrough Collaboratives* HIVQUAL- National and International

*handouts on Breakthough Collaboratives available

1. Evidence-based Medicine

“The conscientious, explicit and judicious use of the best current evidence”1

While the standards for what was considered high quality evidence have gone way up, the methods for applying it have been based more on individual practice/experience

And in the words of David Eddy: If it works, do it If it doesn’t work, don’t do it When there is insufficient evidence to decide, be

conservative

1-Sackett D, BMJ 1996;312:71-72 (13 January)

2. Lean Methodology-Toyota model Within healthcare services the core idea is to

maximize patient value while minimizing waste

Lean approach changes the focus of management from optimizing separate technologies, assets, and vertical departments to optimizing the flow of products and services through entire system

Map out processes and identify value and non-value added steps, and eliminate waste.

2. Lean – Some Key Principles Base decisions on long-term philosophy at

the expense of short term financial goals Create continuous flow to bring problems to

the surface Use “pull” systems to avoid over production Level out the work load Build a culture of stopping to fix problems Standardized tasks and processes are the

foundation for continuous improvement and employee empowerment

3. IHI Model for Improvement

“Every process is perfectly designed to give you exactly the outcome that you get.”

Step 1: The Three Questions: 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?

Step 2: PDSA Cycle—Testing Change in a Real World Setting

Plan: Design workflow changes; Identify tools to support the new

workflow; Decide what to measure & how

Do: Implement plan

Study: Look at what was measured; figure out what it means

Act: Fix the things didn’t work the first time and retest until it works right

One PDSA Cycle isn’t enough

The cycles are linked for continuous improvement

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP.

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance

.**The Plan-Do-Study-Act cycle was developed by W.

Edwards Deming (Deming WE. The New Economics for Industry, Government, Education

.).

But what do we measure?

Don’t waste time trying to get perfect data

Don’t wait for the technology

Learn to navigate on minimal data points

Use quick and dirty samples if necessary

Examples: Wait times Number of tests ordered Ask the people affected what worked and

what didn’t

Spread

It isn’t enough to simply do a demonstration

Spread across the organization/district/province/country Leadership is essential Replicate the process of education Replicate the data collection Replicate the PDSA cycles

Begin with the perfected workflow from the pilot Try it in other areas, but be prepared to modify as needed

The Collaborative Concept - 1995 Short 6-15 month learning sessions

bringing teams from different settings all seeking improvement on a focused clinical area

Team of 3 usually attend 3 learning sessions and report back to additional team members at the local organization

Examples of goals: Reduce ED wait times by 50% Reduce hospitalization for CHF Pts by 50% Reduce worker absenteeism by 25%

Collaborative Improvement Model

© 2002 Institute for Healthcare Improvement

Select Topic

Planning Group

Identify Change Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

E-mail Visits

Phone Assessments

Senior Leader Reports

IHI in Developing Countries

Projects use the classic IHI improvement strategies Model for improvement

Breakthrough Collaborative Series

Chronic Illness Care Model including spread

Example: IHI-Niger

Background Post partum hemorrhage leading cause of maternal

death & one of the highest maternal mortality risks in the world

Attributing common factors: high incidence of home births, poverty/malnutrition, lack of access to quality skilled maternal health care

Intervention: Focus on AMTSL On-site trng for all maternal health providers by

regional trainers Quarterly regional learning sessions for midwives &

MDs to share innovations (eg. 24-hr call schedule to assure skilled birth attendance at births, purchase of coolers in delivery areas made for oxytocin provision)

Niger: Challenges

Lack of medical records (no paper?!) Unfamiliarity with data collection and analysis Lack of skilled HR Low quality of existing HR (nurse/midwife has

2yrs professional training after equivalent of middle school education)

Lack of basic supplies Weak infrastructure & health system Lack of updated standards for evidence-based

high impact care

Large scale systems improvement is universally applicable: IHI/Post Partum Hemorrhage in Niger

Niger: Lessons Learned

Bring representatives from sites together regularly at learning sessions (cross-fertilization of ideas and best practices)

Pick a few focused pieces to gradually phase in. Don’t try to do everything at once.

3. HIVQUAL-US

Build capacity and capability among Ryan White Title III and IV grantees to sustain QI in HIV care (1995)

Goals & Objectives Improve the quality of care for persons with HIV

receiving care in Title III and IV-supported programs Promote QI activities Promote self-reporting of HIV performance

measurement data based on clinical guidelines Provide site-specific consultation to build quality

improvement capacity which is responsive to the specific organizational needs of grantees

HIVQUAL Model

Using the results of specific indicators to measurecare elements to ensure sustained success over

time1. Review, collect and analyze baseline data2. Develop a project team workplan3. Project team investigates the process4. Project team plans and tests changes5. Project team evaluate results with key

stakeholder6. Systematize change

HIVQUAL US Performance Data

HIVQUAL International

2003 Thailand: Pilot implementation in 12 sites, as of 2008 over 900 sites have integrated HIVQUAL-T frameworks into services to improve quality of HIV care

2006 Mozambique: Pilot implementation in 36 sites in 2007 followed by quality improvement trainings in 2008

Other countries in early process: Namibia, Guyana, Uganda, Rwanda, Nigeria, Haiti

Pilot results: HIVQUAL-T measurement

in 12 hospitals, 2002-2005

Example: Using QI Methodology to improve outcomes in Beira, Mozambique (2004)

Approximately 500 HIV positive patients newly enrolled each month and increasing

Only 10% were having their CD4 counts done within 1 month of enrollment

A registry existed to track patients Resources to buy reagents for CD4

testing were scarce Only those patients with resources to

obtain ART were CD4 tested

PDSA Cycle in Beira, Mozambique What were we trying to accomplish?

All HIV positive patients would have a CD4 count within 1 month of presenting to the clinic

How would we know that a change was an improvement? The percent of patients with CD4 count would

rise from 10% and approach 100% What changes could we make that would

result in an improvement? Remove barriers to testing Remove non-value added steps from the

workflow

Steady enrollment growth

Adults enrolled each month

0

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Feb-0

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-03

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Mapping the Initial Workflow

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Pt has access to

ARVs?

Intervention: Counselling CD4 test not

ordered

Intervention: Counselling CD4 testing

ordered

Lab open?

Yes

NoNo

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient schedules

appointment to review results of

CD4 count

Patient returns to lab

for appointment

Patient returns to clinic for

appointment

Patient registers

Patient seen by Physician

Patient seen by Physician

Treatment plan is

developed.

CD4 count reviewed with patient, and significance explained.

Patient Leaves Clinic

Patient Leaves Clinic

Patient Leaves Clinic

Outcome of a process perfectly designed get 10% CD4 Testing

% with CD4 <= 30 days within enrollment

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

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100.0%

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03

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Major System Barrier to CD4 Testing: Drugs!

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Pt has access to

ARVs?

Intervention: Counselling CD4 test not

ordered

Intervention: Counselling CD4 testing

ordered

Lab open?

Yes

NoNo

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient schedules

appointment to review results of

CD4 count

Patient returns to lab

for appointment

Patient returns to clinic for

appointment

Patient registers

Patient seen by Physician

Patient seen by Physician

Treatment plan is

developed.

CD4 count reviewed with patient, and significance explained.

Patient Leaves Clinic

Patient Leaves Clinic

Patient Leaves Clinic

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Pt has access to

ARVs?

Intervention: Counselling CD4 test not

ordered

Intervention: Counselling CD4 testing

ordered

Lab open?

Yes

NoNo

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient schedules

appointment to review results of

CD4 count

Patient returns to lab

for appointment

Patient returns to clinic for

appointment

Patient registers

Patient seen by Physician

Patient seen by Physician

Treatment plan is

developed.

CD4 count reviewed with patient, and significance explained.

Patient Leaves Clinic

Patient Leaves Clinic

Patient Leaves Clinic

Value

Added Step

Non-Value

Added Step

Value

Added Step Value

Added Step

Non-Value

Added Step Non-Value

Added Step

Value

Added StepValue

Added Step

Value

Added Step

Non-Value

Added Step

Non-Value

Added StepNon-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step Non-Value

Added Step Value

Added Step Value

Added Step

Value

Added Step

Non-Value

Added Step

Step 1: Remove the barrier

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Intervention: Counselling CD4 testing

ordered

Lab open?

No

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient schedules

appointment to review results of

CD4 count

Patient returns to lab

for appointment

Patient returns to clinic for

appointment

Patient registers

Patient seen by Physician

Patient seen by Physician

Treatment plan is

developed.

CD4 count reviewed with patient, and significance explained.

Patient Leaves Clinic

Patient Leaves Clinic

Patient Leaves Clinic

Value

Added Step

Value

Added Step Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step Non-Value

Added Step

Value

Added StepValue

Added Step

Non-Value

Added Step

Non-Value

Added StepNon-Value

Added Step

Value

Added StepNon-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added StepValue

Added Step Value

Added Step

Value

Added Step

Outcome after ART barrier is removed

% with CD4 <= 30 days within enrollment

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Feb-0

3

Apr-0

3

Jun-

03

Aug-0

3

Oct-03

Dec-0

3

Feb-0

4

Apr-0

4

Jun-

04

Aug-0

4

Oct-04

Dec-0

4

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Apr-0

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Jun-

05

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5

Oct-05

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Apr-0

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Step 2: Task shift CD4 ordering to non-physician provider

HIV Positive Patient comes

to Clinic

Enrollment Process with

RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Lab open?

No

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient returns to lab for

appointment

Patient seen by Physician

Treatment plan is developed.

Intervention: Counselling CD4 count reviewed with

patient,significance explained.

Patient Leaves Clinic

RN orders CD4 Count

Blood for CD4 count drawn

Patient Leaves Clinic

Value

Added Step

Value

Added Step Value

Added Step

Value

Added Step

Value

Added Step

Value

Added StepValue

Added Step

Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added StepNon-Value

Added Step

Non-Value

Added Step

Outcome after CD4 count order is “automatic”

% with CD4 <= 30 days within enrollment

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Feb-0

3

Apr-0

3

Jun-

03

Aug-0

3

Oct-03

Dec-0

3

Feb-0

4

Apr-0

4

Jun-

04

Aug-0

4

Oct-04

Dec-0

4

Feb-0

5

Apr-0

5

Jun-

05

Aug-0

5

Oct-05

Dec-0

5

Feb-0

6

Apr-0

6

What would Toyota do?

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Registration Process with Receptionist

includes order for CD4

count

Patient seen by Physician

Treatment plan is

developed.

Intervention: Counselling CD4 count reviewed with

patient,significance explained.

Rapid CD4 Drawn On-Site

Result of CD4 returns

Value

Added Step

Value

Added Step Value

Added Step

Value

Added StepValue

Added Step

Value

Added Step Value

Added Step

Value

Added Step

Recap of the tools used in this model

Evidence-based medicine: – target was designed to identify everyone who needs ART as early as possible

Improvement Methodology: Clear articulation what we are trying to

accomplish Changes tried out, adjusted to get them to work

better, all of them required overcoming resistance,

Measurement to track improvement Spread to other clinics

QUESTIONS?