Quality Improvement Primer - GotTransition.org

©2020GotTransition®.Non-commercialuseispermitted,butrequiresattributiontoGotTransitionforanyuse,copy,oradaption.GotTransitionissupportedbytheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices(HHS)(U1TMC31756).Thecontentsarethoseoftheauthor(s)anddonotnecessarilyrepresenttheofficialviewsof,noranendorsement,byHRSA,HHS,ortheU.S.Government.

QIPrimer:UsingQualityImprovementtoImprovetheHealthCareTransitionProcess

AboutThisPrimer.....................................2

I. WhatisQualityImprovement?......3

II. SelectingImprovementProjects.....5

III. SuccessfulTeams...........................7

IV. TheModelforImprovement........11

V. MeasuringforImprovement........17

VI. ToolsforImprovement.................22

VII. SustainingImprovement..............31

VIII. SpreadingImprovement...............32

IX. HealthLiteracy.............................34

X. Co-Production..............................38

XI. ResourcesandReferences............39

Appendix.................................................41

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QI Primer: Using Quality Improvement to Improve the Health Care Transition Process 2

AboutThisPrimerWehavedesignedthisQualityImprovement(QI)PrimerasacompanionpiecetousewiththeGotTransition®SixCoreElementsofHealthCareTransition™(HCT).ThisdocumentisintendedtohelpyouunderstandQIandapplyittoyourwork.Withineachcoreelement,youwillfindbriefcommentsaboutandillustrationsofrelevantQIaspectsoftheHCTwork,withalinktotheappropriatesectioninthisQIPrimerformoredetailedinformation.

WithinthisQIPrimer,youwillfindthefollowingsections:

I. WhatisQualityImprovement?II. SelectingImprovementProjectsIII. SuccessfulTeamsIV. TheModelforImprovementV. MeasuringforImprovementVI. ToolsforImprovementVII. SustainingImprovementVIII. SpreadingImprovementIX. HealthLiteracyX. Co-ProductionXI. ResourcesandReferencesAppendix

SectionsIthroughVIIIwillgiveyouthebackground,knowledge,tools,andexamplesyouneedtogetstartedinimprovementwork.HealthLiteracy(SectionIX)andCo-Production(SectionX)arekeyelementsofpatient-centeredcarethatlinkcloselywithQI;incorporatingtheseprincipleswillhelpensureyouareprovidingthebestcarepossibleforyourpatientsandtheirfamilies.Ifyouwouldliketodelvemoredeeplyintothesetopics,youwillfindmaterialsinResourcesandReferences(SectionXI).

www.gottransition.org/six-core-elements/

www.gottransition.org/six-core-elements/


I. WhatIsQualityImprovement?IntroductionInthissection,wewilldevelopanunderstandingofqualityimprovement(QI),includingitshistory,itsrelationshiptoresearchandotherrelatedsciences,andhowitcanbenefithealthcareteamsandpatients.

Qualityimprovementisdefinedas“acontinuousandongoingefforttoachievemeasurableimprovementsintheefficiency,effectiveness,performance,accountability,outcomes,andotherindicatorsofqualityinservicesorprocesseswhichachieveequityandimprovethehealthofthecommunity.”1Changeisnotthesameasquality–youcanhavechangewithoutimprovement.However,allimprovementdoesinvolvechange.Likewise,researchandimprovementarenotthesameandhavedifferentobjectives.

Furthermore,notethatasyoudelveintoQI(alsosometimescalled“improvementscience”),youarelikelytoencountertworelatedfields:reliabilityscienceandimplementationscience.

• ReliabilitysciencestrategiesarealsousedbyQIteamstoensurehighreliability.• Thetopicofimplementationsciencehasbeengainingpopularity–youwillseethatmanyofthetools

andvocabularyusedindiscussionsofimplementationscienceechowhatyou’velearnedaboutinQI,butbeawarethatimplementationscienceistiedmuchmorecloselytotraditionalresearchthanitistoQI.

Table1providesasnapshotofthedifferencesbetweenQIandtraditionalresearchincludingimplementationscience.Forthepurposesofthisprimer,wewillfocusonQI.

Table1.DifferencesBetweenQualityImprovementandTransitionalResearch

QualityImprovement(QI) ImplementationScience/TraditionalResearch

Aim Careimprovement NewknowledgeTestObservability Observable BlindedorcontrolledBias Acceptconsistentbias DesigntoeliminatebiasWhattoMeasure “Justenough”data,smallsequentialsamples “Justincase”dataHypothesisFlexibility Flexible,changesbasedonlearning FixedTestingStrategy Sequentialtests OnelargetestDeterminingifChangeisImprovement Runcharts,Shewhartcontrolcharts Hypothesis,statisticaltests(t-test,F-test,

chisquare),p-valuesResponsetoContextVariation Usetotestresilienceofprocessdesign Controloreliminateeffectsofconfounding

variables

DataConfidentiality Datausedonlybythoseinvolvedwithimprovement Researchsubjects’identitiesprotected

AdaptedfromSolbergLI,etal.(1997).

EssentialLearning• Organizationalcommitmenttoquality

o Focusonsystems,notindividualso Helpsstaff,doesn’thinder

• Emphasisonwidespectrumof“teams”o Fosterteamworkandgroupproblemsolvingo Focusonthecustomer(colleagueorpatient)o Incorporatethevoiceoffront-linestaffandcustomers

• Structuredapproachtotheworko Usesmalltestsofchangeo Maintainfrequent,ongoingmeasurementfordata-drivendecision-makingo Continuousprocess,doesnotend


A. FrameworksandMethodsThereareseveralframeworksusedinQI,anyofwhichensuresthatchangesarecarriedoutinamethodical,controlledway.Aframeworkgivesyouastructuretomanagetheimprovementwork.AllcurrentframeworksarebasedontheunderlyingtheoriesofthepioneersinQI:WalterShewhart,W.EdwardsDeming,andPhillipCrosby.Whileseveralframeworkshaveapplicationsinhealthcare,themostwidelyusedistheModelforImprovement.IthasbeenadoptedbytheInstituteforHealthcareImprovement(IHI),themostwell-knownQIorganizationwhoseworkisaimedatimprovingpatientoutcomes,experience,andreducingthecostofcare.

Table2.QualityImprovementFrameworks

PDCA ModelforImprovement SixSigma Lean

DevelopedbyWalterShewhart,W. EdwardsDeming,Late1980s

AssociatesinProcessImprovement,1990s(usedbyIHI)

Motorola,1980s Toyota,1950s

Purpose

Problemsolving&processimprovement;aniterativefour-stageframework

Acceleratingimprovementeffortswithinasystem;composedofthreequestionsandthePDSAcycle

Reducingerrorsandvariationwithinasystem

Eliminatingallnon-valueaddedactivitiesfromasystem

AdaptedfromAHECQI101,aQualityImprovementcoursesponsoredbyCharlotteAreaHealthEducationCenter.

B. TheoryofProfoundKnowledgeCreatedbyDr.W.EdwardsDeming,theTheoryofProfoundKnowledgereflectsallthecomponentsyoumusttakeintoconsiderationwhenyouwanttodoimprovementwork.Dr.Demingrecognizedthatanorganizationisasystemofconnectedpeopleandprocesses;achangetooneimpactstheothers.TheTheoryofProfoundKnowledgehasfourcomponents:• Appreciationofasystem

o Allhealthcaresettingsareasystemo Understandoverallsystemprocesses,e.g.,supply,demand,flow,customers

• Knowledgeofvariationo Identifyandunderstandthevariationthatexistsinthesystemsinwhichweworkandinwhich

patientsreceivecareo Recognizethereisarangeofvariationanditisimportanttounderstandtheunderlyingcausesto

decideifactionisneeded

• Theoryofknowledge–investigatesthequestion“howdowelearn?”o Whatitis,howitisacquired,whatpeopleknow,howsurewearetheyknow

• Knowledgeofpsychologyo Humannature,behavior,motivation,limitations,interactions

Pleasenotethatasyouundertakeimprovementwork,youmayencounterelementsfromthenextthreesections(SelectingImprovementProjects,SuccessfulTeams,andTheModelforImprovement)inadifferentorderorsimultaneously.

KeyPoint:Whenyoucombinesubjectmatterknowledgeandprofoundknowledge,youfindthecrossroadsforimprovement.


II. SelectingImprovementProjectsIntroductionInthissection,wewilllookattheconsiderationsthatfactorintoidentifyingandprioritizingaproject.Successfulimprovementworkhingesonaligningstakeholders’perceptionsandpreferenceswithimprovementopportunitiesandrequiredresources.Whenselectingimprovementwork,considerseveralfactors:Whatisthecurrentenvironment?Isthereagap?Hasanewguidelinebeenpublished?Isthereastrategicconnectiontoyourorganization?Istherepassionforthework?Isthereseniorleadershipsupport?

EssentialLearningOftentheenvironment–whetheratalocal,state,ornationallevel–caninfluencetheproject.ExamplesincludetheIHI’s“5MillionLives”campaignorthenationaldiscussiononimprovingthetransitionofyouthtotheadulthealthcaresystem.Usingaprojectproposalformorfollowingaformalprocesshelpsteamsdetermineprojectfeasibility.Belowwewilldiscusssampleformstoselectandprioritizeimprovementwork.

EssentialToolsTheprojectproposalformandtheprojectselectionmatrixareplanningandcommunicationtoolsthathelpensureyourprojectiswellorganizedattheoutset,fillsaneededgap,meetsorganizationalpriorities,andhastheresourcesandsupportnecessaryforsuccess.

YoucanusetheSampleQualityImprovementProjectProposalForm(seeAppendix)tocommunicatewithyourteammembersandkeystakeholders,aswellasleadership.TheSample ProjectSelectionMatrix(seepage6)allowsyoutoscoreandrankprojectcomponentsandestablishalignmentwithsystemgoalsandfurtherprioritizework.Itisespeciallyusefulwhenacommitteeorotherdecisionmakerisdeterminingresourceallocation.


PracticeTip:AsyouwillnoticerepeatedlythroughoutthisPrimer,thepiecesyouneedtohaveinplaceforsuccessfulimprovementworkarethewill,theideas,andtheexecution.Formallyassessingandaligningtheseelementswhenyoufirstchooseyourprojectwillhelpensuremoreproductiveimprovementworkdowntheroad.

InstructionforUsingProjectSelectionMatrix:1.Listcriteriaforselectingprojectsonthey-axis(grayhighlightareas)2.Listalltheprojectsyouareconsidering*3.Revieweachprojectandassignavaluebasedoneachprojectselectioncriteria(criteriacanbeweighted)4.Totalthescoreforeachproject(bluehighlightedarea)5.Sortthescoresfromhighesttolowest*Alsoconsiderwhatsupportisneededforprojects:dataabstraction,dataanalytics,datadisplay,QIcoaching

Notethatthecolumnheadersinyourownselectionmatrixwillbepopulatedwiththeprioritiesthatmattertoyourorganization,whichwillhelpensureyouhavethecommitmentandsupportnecessaryforsuccessfulexecution.

SampleProjectSelectionMatrix

AdaptedfromPopulationHealthImprovementPartners,improvepartners.org.

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ProjectTitleAssignvaluetoeachcriterionbasedona1-5scale

(1=poorand5=excellent)NeonatalAbstinenceSyndrome 5 3 5 5 3 4 5 1 1 3 3 38

RheumatologyReferralProcess 5 5 3 4 5 5 5 1 1 1 5 40

TimetoAntibiotics 5 4 5 3 4 4 5 2 3 5 4 44

CareCoordinationforChronicCare 4 4 4 2 4 2 5 1 1 2 3 32

HPVVaccinationinIDClinic 4 4 3 2 3 3 5 1 1 1 3 30

ImprovingFluVaccination 3 4 4 2 3 4 5 1 4 3 3 36

www.improvepartners.org


III.SuccessfulTeamsIntroductionInthissection,wewillexplorethemanyfactorsthatinfluenceateam’ssuccess.Thisincludesteamcompositionandcharacteristics,specificrolesthatshouldbefilledandwhattaskstheyperform,whattoexpectregardinginterpersonalrelationships,andhowtofacilitatemoreeffectivecollaborations.

AQIteamisessentialtothesuccessofanyimprovementeffort.QIcannotbedoneinavacuumorasoneperson.Whomevertouchestheprocessmustimprovetheprocess.Andalldeliveryofcareisaprocess...somesimple,othersmorecomplex.

EssentialLearningAteamisagroupofpeopleworkingtogether,withspecificroles,towardacommonpurposeorgoal.Teamsout-performindividualswhenaddressingcomplexproblems,andimprovinghealthcareiscomplex.Therearedifferenttypesofteamsinhealthcare:careteams,work(virtual)teams,andQI(project)teams.Ataminimum,thehealthcaretransition(HCT)teamshouldincludeyouth/youngadults,parents/caregivers,andpediatricandadultclinicians.

QIteamsout-performindividualswhen:• Moreefficientuseofresourcesisrequired

• Taskiscomplexo Pathforwardisunclearo Creativityisneededo Fastlearningisnecessary

• Cooperationisessentialtoimplementationo Membershaveastakeo Taskorprocessiscross-functionalo Nooneindividualhassufficientknowledge

Forteamstobesuccessfultheyneed:• Aplanforimprovement(ModelforImprovement)

o Cleargoalso Scientificapproach(data/rootcause)

• Beneficialteambehaviorso Clearlydefinedroleso Clearcommunicationo Balancedparticipation

• Establishedgroundruleso Well-defineddecisionprocesso Awarenessofgroupprocess

A.FiveTeamBasics1. Maintainsmallnumberofteammembers–morethan12peoplecanmakeconsensusdifficult,

andmeetingdreadwilldevelopiftheteamisnotmovingforward.Besuretoinclude:• Representativesoftheowneroftheproblemorprocess• Naysayer• Culturecarrier• Decisionmaker/accesstodecisionmaker


2. Seekmemberswithinterpersonalandcomplementaryskills:• Technicalexpert• Problemsolver• Detail-orientedpersonandabigpicturethinker• Newcomerandaveteran

3. Identifycommonpurpose–takethetimetoexplore,shape,andagree• Setclearobjectives• Ensureallareequallymotivatedtoreachthegoal• Questionstonarrowdowntheproblem:

o Whatistheproblem?o Isthereachallengewithperformance?o Whatistheunifyingproblem?o Areyouincrisismanagementmode?

• Celebratethesmallwins

4. Useacommonlyagreeduponapproach,i.e.,ModelforImprovement,LEAN,SixSigma,etc.

5. Ensuremutualaccountability:individualaccountabilityand/orperformanceevaluation

B.RolesIdentifyingandunderstandingteamrolesalsocontributestosuccessfulteams.Effectiveteammembersshareopenly,contributefully,listentoothers,supporttheteamleader,completeassignmentsbetweenmeetings,communicateeffectively,andacceptresponsibilityfortestingchanges.

Role:Teamleader• Keepsworkontrack

o Followsadata-basedmethodo Participatesincarryingoutworkbetweenmeetingso Retainsauthority,participatingselectivelyandcarefully

• Managescommunicationbetweentheteamandorganizationo Meetswiththesponsorbetweenscheduledteammeetingsforperiodicupdateso Keepsofficialteamrecords

• Helpsteamresolveproblems

Role:Coach• Teachesbasicmethodology

o Teachesdatacollectionandanalysiso Helpsteamgraphicallypresentdatao Focusesonteam’sprocessmorethanproduct

• Guidesteam’seffortso Encouragesteamtoseekcausesofproblemso Attendsmeetingsbutisneitherleadernormember

• Workswithteamleaderbetweenmeetingso Assiststeamleaderinstructuringorbreakingdowntaskso Helpsteamleaderreviseplansinresponsetofeedback

Role:Sponsor• Maintainsoverallresponsibility,authority,andaccountabilityforeffort

o Selectsanddefinesimprovementprojecto Determinesresourceso Ensureschangesmadebytheteamaremonitored


• Reviewsandsupportsteam’seffortso Reviewsprogressandrunsinterferenceo Ensuresstakeholdershaveappropriateinvolvemento Feedsdataandlessonslearnedintoasystemforfutureimprovementso Meetsperiodicallywiththeteamleader

Tuckman:5StagesofTeamDevelopment:Teamswillgothroughseveralstages.Thereareover100groupformationmodels,howevermosthighlightTuckman’sfivestages.Thesestagesreflectbothpositiveandnegativeinteractions,whichcanhaveasignificantimpactonateam’ssuccess(orfailure).

Bytheendoftheproject,positiveteamstypicallyhave:• Beensuccessfulandachievedtheirgoal• Formedbondswithotherteammembers• Enjoyedworkingtogether

Meanwhile,negativeteamsreport:• Meetingfatiguewithoutanyresults• Feelingunderminedandunheard• Feelingdisengagedfromthepurpose

Lencioni:5DysfunctionsofaTeam:AccordingtoLencioni,therearefivecommondysfunctionsofateam.Understandingthestagesanddysfunctionshelpsteamsavoidthemorepainfulelementsofteamworkandfacilitatemoreeffectiveimprovementwork.

PracticeTip:Mostteamworkinvolveschanges,andchangeisseldomeasy.Peopleoftenseemresistanttochangebecausetheyfeartheimpactitwillhaveontheirpersonalexperienceandthepotentialforaddedwork.Theymayworryaboutrevealingtheirownshortcomings,associatechangewithnegativepastexperience’s,orsimplyfeartheunknown.Takingthetimetodevelopawell-structuredteamcanhelpalleviatethisresistance.

Table3.Tuckman’s5StagesofTeamDevelopment

Forming Awarenessandorientation

Storming Conflict

Norming Cooperationandcohesion

Performing Productivityandtaskperformance

Adjourning Separationanddissolution(orprojectorofteam)(transformation)

Tuckman’sstagesareshowntoleft.Theformingstageisatimeofawarenessandorientation,whilethestormingphaseistypicallymarkedbyconflict.Whenateamreachesnorming,theyareexperiencingcooperationandcohesion.Inperforming,theteamsucceedsintermsofproductivityandtaskperformance.Andinthefinalstage,adjourning,theteamconcludestheircollaboration.

TeamsofPain

Absenceoftrust

Fearofconflict

Lackofcommitment

Avoidanceofaccountability

Inattentiontoresults

TeamsofPleasure

Effectivecollaboration&communication

Establishedgroundrules

Involved,respectedleadership

Well-definedroles

Sharedgoals

Methodical,establishedprocedures


EssentialToolTheteammemberselectionmatrixisadecision-supporttoolthatwillhelpensureyouhavetherightmixofrepresentativesandtherightpeopleintherightrole.Usethistoolassoonasyoustarttoplanyourproject.Onceyouhavecandidateslistedintherows,usethecriteriaformembersandteamcharacteristicsincolumnstoassesseachone.Yourteamshouldnotexceed12members.

KeyPoint:Mostteamsfollowapredictablepath,whichcanbeinfluenced(forbetterorworse)byastandardsetoffactors.RecognizingtheserecurringpatternscanhelpQIteamsavoidfrequentpitfallsandachievegreatersuccess.

InstructionforUsingTeamMemberSelectionMatrix1. Reviewthecriteriaforteammemberandteamcharacteristicsinthetoprow.2. Listalltheteammembersyouareconsideringinfar-leftcolumn.Nomorethan6membersonthecoreteam.3. UsetheMemberCharacteristics(red)columnsandentera“Yes”or“No”toindicateifeachcriterionismetforateam

member.“No”responsesshouldbeaddressedandyoumayneedtorethinkamemberiftherearetoomany“No’s.”4. UsetheMemberSkills(blue)columnstoentereachcriterionstatedforeachperson.5. UsetheOutcome(green)columntoenter"Yes/No/Maybe"toindicateteammemberselectiondecisions.


TeamMemberSelectionMatrix

MemberCharacteristics MemberSkills Outcome

TeamLead:Knowledgeand

understandingofprocess*

TeamLead:Credible,informalorformal

positiveinfluence*

TeamLead:Communicationand

attentiontodetail*

Hasapassionforqualityand

improvement

Willingtotrynewthingsandtakerisks

Teamorientedcreatesteam“synergy”

Actionoriented(getitdone!)

AbilityanddesiretotrainotheronQI

methods/tools

Cross-functionalteam

(listperson’sworkfunction)

Diversetalentsandskills

(listsspecialskills)

ProcessOwner(thepersonwho’s

responsiblefortheprocess)(listYorN)

Personhasafreshperspective

(listYorN)

Balancethefrontlineand

manager/supervisorstaff(listForS/M)

EnterYes/No/Maybedecisionsforeach

personlistedtoindicatemember

selection

PotentialTeamMembers

(NOTE:*arecharacteristicsforTeamLead.Ateamcanhave2

TeamLeads)

AssignYesorNoresponsetoeachredcriterion Bluecriterionlistsdatatoenter

NOTE:Nomorethan6coreteammembers



IV.TheModelforImprovementIntroductionInthissection,wewilldelveintotherealheartofQIforhealthcare–theModelforImprovement(MFI).Byasking3keyquestions,theMFIgivesyoutheframeworktoensurechangesareplanned,tested,andcarriedoutinamethodicalwaythatresultsinmeasurableimprovements.Thissectionalsointroducesgoalsandmeasures,withmoredetailonmeasuresincludedinSectionV:MeasuringforImprovement.

TheMFIwasdevelopedbyAssociatesinProcessImprovementin1996andoverthelasttwodecadeshasbeenusedwidelyinhealthcarebyleadingQIorganizationssuchastheIHI.TheMFIisaneffectiveandeasilyunderstoodmethodthatproducesspecific,measurableresultsandcanbeimplementedbyeitherlargehealthcaresystemsorasmallofficepractice.

Tohavesystemchangetheremustbe:• Willtodowhatittakestochangetoanewsystem• Ideasonwhichtobasethedesignofthenewsystem• Executionofchangestothesystem

Allthreeareimportanttosystemchange.Weoftenhavethewillbutareunsurewhatchangesmightleadtoimprovement.Or,wehavegreatideas,butlacksupportforimprovement.Andfinally,wemayhavebothwillandideasbutareunsurehowtoexecutetheimprovementwork.TheMFIisasimplebutrobustframeworktoexecutetheimprovementneededtobuildwill,developideas,andcreateaplanofexecution.

EssentialLearningBeforestartingtheimprovementwork,weoftenrunintobarriers.Mostofushaveexperiencedlackof:

• Time• Energy(orasenseofoverwhelmingwork)• Administrativesupport• Knowledgeofhowtostartchange• TraininginQI

TheMFIisamethodologythatkeepsyourteamfocusedonwhatyouneedtodoandcanhelpmanagethesebarriers.Itisgeneralenoughthatitcanbeappliedtosmallprojectsorlarger,population-basedproblems.

Themodelconsistsofthreequestions:1. Aim:Whatarewetryingtoaccomplish?Thisquestion

focusesonwhatyouaretryingtoachieveandhelpsyourteamscopeyourprojecttoamanageablesize.

2. Measures:Howwillyouknowthatyourchangesareanimprovement?Thishelpsyourteamidentifymeasuresthatwillallowyoutoensurethechangesyoumakeareimprovements.

3. Changes:Whatchangescanwemake?Thisallowsyoutoassessthecurrentprocess/systemandidentifychangesthatwillleadtoimprovement. AdaptedfromLangleyGL,etal.(2009).


Thentestthechanges–oncechangesareidentified,PlanDoStudyAct(PDSA)cyclestestthechangesrapidly,onasmallscale.Thisallowsyoutolearnandadaptthechangestoyourspecificenvironment.

A.WhatAreWeTryingtoAccomplish?Writinganaimstatementiscriticaltosuccessfulimprovement.Anaimstatementisawrittendescriptionoftheexpectedaccomplishmentfromtheimprovementeffortandclearlydefinesthescopeoftheproblem.Aimstatementsusuallygeneratebrainstormingforideasthatcanlaterbetested.Theycaptureearlyteamdecisions,alignteammembers,andcanbeusedtocommunicatewithothers,especiallyseniorleaders.Itisatouchstonethroughouttheprojectandshouldbereviewedateveryteammeeting.Anaimstatementconsistsof4-5sentencesandasetofmeasurablegoals.

Keycomponents:• Describeswhattheprojectseekstoaccomplish• Establishesrationale/importance• Identifiesaframeworkthatwillbeusedtocarryoutthework• Specifiesthetargetpopulationandtimeperiod• Includesmeasurablegoals:usually4-6thatareconnectedtowhatyouaretryingtoaccomplish

o E.g.,90%ofpatients14-16willhaveonereadinessassessmentcompleted

B.HowWillWeKnowThataChangeIsanImprovement?Ensuringthatchangeisanimprovementusuallyrequiresmorethanonemeasure–abalancedsetofmeasureshelpsassurethatthesystemisimproved.Byincludingmeasurablegoalsintheaimstatement,themeasureshavethusbeencreated.Forexample:if“80%ofchildrenshouldgetX”,thenthemeasureis“What%ofchildrenreceivedX.”

Usingameasurementtableprovidesclarityandstandardizationforthepersonresponsibleforgatheringthedata.Operationaldefinitionsspellouthowanitem(orword,orvariable)istobeconsideredforthepurposesoftheproject,whichensureseveryoneisonthesamepage.Theyarecriticaltogoodmeasurementandshouldbeincludedinthemeasurementtable.

Therearedifferenttypesofmeasures,usuallycategorizedasoutcome,process,orbalancing.Whiletheimprovementworkusuallyfocusesonoutcomeorprocessmeasures,havingabalancingmeasuretellsusifwehaveharmedonepartofthesystemwhiletryingtoimproveanother.

Outcome(Global)Measures• Relatedtotheaim;i.e.,theytellyouifyouaremakingprogresstowardyouroverallgoal• Theyarethe“voiceofthesystem,”reflectinghigh-levelprogress• Usually“distal”intermsofcause-effect;resultsmaytakeplacewellintothefuture

Process(Intermediate)Measures• Relatedtokeychanges/interventions/system-levelchanges;I.e.,theyassesstheimpactofyour

smallPDSAcycles• Theyarethe“voiceoftheprocesses,”reflectingwhatishappeningatcloserange• Usually“proximal”intermsofcause-effect;resultsshouldbevisibleimmediately

BalancingMeasures• Areweimprovingpartsofoursystemattheexpenseofothers?• Usuallynotlinkedtooneofthegoals,butanaddedmeasure• Listentoskeptics.Theirconcerns(“Yes,butthenXwillhappen...”)canoftenbeusedforyour

balancingmeasure.


Formoredetailonthistopic,pleaseseeSectionV:MeasuringforImprovement.Onceyourmeasuresarechosenandyourmeasurementplanisdocumented,thinkaboutpresentingyourdatasoyourteamcanmakedata-drivendecisions.Runchartsarekeytounderstandingyourdata.

RunCharts:Theusualdisplayofmeasurehasbeen“beforeandafter”asseeninthefirstbarchartexamplebelow.Thisexampledemonstratestheresultsofateamtryingtoimproveimmunizationrates.Whileitappearsasiftheteamsawsomeimprovement,thisdatadisplaydoesnotanswerimportantquestions:

• Whatwasthegoal?• Whatchangesweremadethatledtotheimprovement?• Wastheimprovementsustained?

Arunchartisamorerobustandusefuldisplay,asshowninthesecondexample.Thisannotatedruncharthasatitleandtheideastheteamtestedtoimprovetransitionpolicydistributionandusefulness.Nowtheearlierquestionscanbeanswered.

• Thereisagoallineat70%,sotheteamdidnotreachthegoal.• Thechangesthatdidresultinimprovementarecreatingapolicy,identifyingpatientgaps,and

havingthepatientworkwithacommunity-basedorganizationonself-managementtasks.• Andfinally,itappearsasiftheteamisontracktoreachtheirgoalinthefuture.

PracticeTip:Often,trueclinicaloutcomemeasuresaretoofarinthefuturetobeavailableinthetimeframeoftheimprovementeffort.Inthiscase,aprocessmeasuremaybecometheproxyfortheoutcome.Forexample,indiabeticcare,theA1Cbloodtestisaprocessmeasure;however,italsoservesasaproxymeasureforalong-termoutcomerelatedtocardiovasculardiabeticdisease.

PracticeTip:Whenusedinteammeetings,runchartssupportdata-drivendecisions,stimulatefurtherdiscussionsaboutchangeideas,andcanbeusedformonitoringsustainability.ChangeideaswillbediscussedfurtherwhentalkingaboutthethirdquestionoftheMFI.SeeSectionV.MeasuringforImprovementforamorein-depthdiscussionofdataandmeasurement.

BarChart RunChart




C.WhatChangesCanWeMakeThatWillResultinImprovement?Answeringthisquestionisoftenthefunpartofimprovementwork.Theideastobetestedcomefrommanysources:patients,thepeopledoingthework(frontlinestaff),otherswhohavehadsuccess,clinicalguidelines,andformalchangepackagesthathavebeendeveloped.

Startwithachangeconcept,whichisabroader,generalapproachtochange(e.g.,atransitionpolicy/guide).Thishelpsteamsgenerateasmaller,morespecificideathatcanbetested(e.g.,asking5patientswhattheyunderstoodaboutthepolicy/guideorwhatwasmissinginthepolicy/guide).Changeconceptscomefromevidenceandmodelsthathavebeenshowntoworkinotherorganizations,industries,etc.However,changeconceptsneedtobeadaptedtothespecificsettingoftheteam.TestingandadaptationareaccomplishedusingthePDSAcycle.

ThePDSAcycleisfoundationaltoallimprovementmethodsincludingMFI,Lean,andSixSigma.DevelopedbyWalterShewhart,heoriginallycalleditthePDCAcycle(Plan,Do,Check,Act).W.EdwardsDemingmodifiedthe“check”to“study”formorereflection.PDSAcyclesforceustobemethodical,clarifywhatwearetryingtolearnwiththisidea,makeaprediction,andreflectonthelearningfromthecycle.Theyallowrapidadaptationandimplementationofchangesinbusyhealthcaresettings.

EssentialTools

TheModelforImprovementPDSAPlanningWorksheet(seeAppendix)captureskeydetailsofeachPDSAcycleateamcompletes.Teamsshoulduseitwhenpreparingtheirtestsofchange,includinginformationaboutwhattheyhopetolearn,predictionsaboutwhatwillhappen,andspecificplans(who,what,when,where)forthetestofchangeandthedatacollection.Resultsfromthetestwillalsobecapturedhere,whichwillbecrucialasyouanalyzeyourdataandannotateyourruncharts(moreonthisisSectionV:MeasuringforImprovement).Ideally,aformshouldbecompletedforeachPDSAtheteamdoes.Overtime,yourPDSAformswillbecomethenarrativeofyourimprovementwork,andthisrecordwillbeextremelyhelpfulasyoumoveforward–PDSAformscanrefreshyourmemoryondetailsyouforgetovertimeandareextremelyhelpfulinspreadingorsharingforfuturework.

AdaptedfromAHECQI101,aQualityImprovementcoursesponsoredbyCharlotteAreaHealthEducationCenter.


D.SizeofTests,TestsinParallelOftenthebiggestchallengewhentestingwithPDSAcyclesisthecyclesize.Teamstrytodolargecycleswithalotofpatientsoverseveralweeks.Largecyclesdonotenhancelearningandcandelayimprovement.InTheImprovementGuide,Langleyetal.illustratetherelationshipbetweencyclesizes,costsoffailure,andorganizationalcommitmentin“DecidingontheScaleoftheTest.”Yourstaff’sreadinessforchangewillalsoimpactyourapproachtotesting.YoucouldadaptTheImprovementGuide’sadvicetoassessstaffreadinessas:

Teamscanalsoaccelerateimprovementbytestingdifferentideasinparallel.Theexamplebelowdemonstratestestingdifferentchangeideasineverycomponentofthecaremodel;likewise,teamscantestdifferentchangeideasinparallelfromtheSixCoreElementsofHealthCareTransition™.

Table4.AssessmentofStaffReadinessConfidenceresultwillbringimprovement FailureImpact Resistant Indifferent Ready

LowBig Verysmallscaletest Verysmallscaletest VerysmallscaletestSmall Verysmallscaletest Verysmallscaletest Smallscaletest

HighBig Verysmallscaletest Smallscaletest LargescaletestSmall Smallscaletest Largescaletest Implement

AdaptedfromLangleyGL,etal.(2009)

AdaptedfromLangleyGL,etal.(2009).

Asillustratedontheleft,eachPDSAcycleforachangebuildsonthetestbefore:teamsstartwithanidea,gothroughnumeroustestandchangecycles,resultinginimprovement.

PDSATip:ChangesinParallel

ImagefromST3PUP,sponsoredbyPatientCenteredOutcomesResearchInstitute®(PCORI)AwardMCSC-1608-35861TitledAComparativeEffectivenessOfPeerMentoringVersusStructuredEducationBasedTransitionProgrammingForTheManagementOfCareTransitionsInEmergingAdultsWithSickleCellDisease.


KeyPointsandPracticeTipsforPDSACycles:• Doinitialcyclesonsmallestscalepossible

o “Cycleof1”isusuallybest

• “Failed”cyclesaregoodlearningopportunitieswhensmall.Ask:o Wasthetestconductedwell?o Doesthechangetestedneedmodificationinoursetting?o Wastheprediction/theorywrong?

• Whentestsare“successful,”testunderasmanyconditionsaspossibleo Specialsituations(e.g.,busydays)o Factorsthatcouldleadtobreakdowns(e.g.,differentstafforphysiciansinvolved)o Things“naysayers”worryabout(e.g.,“ItwillnotworkwhenDr.Diehardisnothere.”)

• The“study”isspecifictothePDSAcycleyouarerunning

• ThedatacollectedinaPDSAcycle:o UsuallynotoneofprimaryprojectmeasuresandisspecifictothatPDSAcycleo UsuallyendswithPDSAcycleo Canbequalitative,notjustquantitative


V.MeasuringforImprovementIntroductionInthissection,wewilladdressmeasurement’sroleinQI,includingthepurposeofmeasurement,whatcomprisesabalancedsetofmeasures,considerationsforquantityofandprocessesfordatacollection,andsomebasicprinciplesfordatadisplay.

Measuringisacrucialelementofimprovementwork.Withoutit,teamshavenoideaifchangesareleadingtoimprovement,whichchangescausewhatresults,andwhethertheyareontracktoachievetheiraim.

EssentialLearningA.WhyMeasure?Therearemanyreasonsandrolesformeasurementinimprovementwork.Asummaryofusesincludes:

• Toidentifygaps/needsforQIproject(s)• Tomonitorprogresstowardprojectgoals/aim

o Usuallyrequiresmorethanonemeasureo Abalancedsetofmeasureshelpsensurethatthesystemimprovedinmeasuresthat:

• Arelinkedtomeasurablegoalsintheaimstatement• Showimprovementquicklyandincludeoutcomes• Monitorforunintendedconsequences

• Togenerateideasforimprovement• Toevaluaterapidtestsofchange(PDSAs)• Tomonitorforsustainability• SeeSectionVI.A:KeyDriverDiagramforanillustrationofmeasuresatdifferentsystemlevels

Youmaydecidetomeasuresomelevelofcostorsimplereturnoninvestmenttobuildwillfortheworkandongoingsupport.Baselinedataisveryhelpfultoseewhereyourprocesswasbeforetheprojectstartedandissometimesneededtomakethecaseforchange.Itisalsoimportanttonotethatalldatawillhaveinherentvariation,especiallyinareal-worldsituation.

B.AspectsofGoodProjectMeasuresThereareseveralkeyfeaturesofgoodprojectmeasures.Ofgreatestimportance,teamsmustensuretheydonotcreatetoomuchofadataburdenyetcapturemeaningfulinformation.Teamsalsoneedtoconsiderhowdatawilltellthe“story”oftheirproject.Themostsuccessfuldatapackagesreflectthefollowing:

• Quantitative(numeric;outcome,process,andbalancing)+qualitative(non-numeric)data

• Meaningfulandunderstandableinformationforstakeholders,alignswithstakeholderprioritieso Notethat“stakeholders”encompassesawiderangeofindividuals,fromthosewhodothework

tothosewhoexperiencetheoutcome• Baselinelevelsarenottoohigh,thusconfirmingtheteam’sassertionthatanimprovement

opportunityexists.Furthermore,itwillbedifficulttoseeimprovementifthestartingpointishigh.

• Datamustbeperceivedasvalid,especiallyamongleaderso Ifpossible,usemeasuresbasedonorconsistentwithnationallyrecognizedguidelinesor

benchmarks.o Ifyoumustcreatenewmeasures,sharethemwithyourstakeholdersandtestthemusingPDSA

cyclestodetermineifthemeasureswillbeperceivedashelpful/valid.o Makesuretoclearlydefinethemeasuressothateveryonehasaclearunderstandingof“whatto

count”and“howtocountit.”Usingameasurementtableisagreatwaytodefinethemeasures.


Aspreviouslydiscussed,thereare3typesofmeasures:• Outcome:Thesearetheultimateresultswearetryingtoachieve.Forexample:

o Clinic’spercentageofoverallimprovementonhealthcaretransitionimplementation,asmeasuredbyGotTransition’sCurrentAssessmentofHealthCareTransitionorProcessMeasurementTool

o Numberofpatientswhohaveanadultvisitwithin3monthsoftheir18thbirthdayo Percentofpatientswhofelttheywerepreparedforthetransitiontoadultcare,asmeasuredby

GotTransition’sHealthCareTransitionFeedbackSurveysforyouth/youngadultsandparents/caregivers

• Process:Whatwedotoachievetheoutcome.Forexample:o Numberofpatientswhoreceivewelcomeandorientationpacketatnewadultpracticeo Numberofcompletedtransferpackagesgiventoadultprovidero Numberofcompletedtransitionreadiness/self-careskillassessmentso Numberofreferralsmadetocommunity-basedorganizations

• Balancing:Whatwecould“messup”whiletryingtoimproveprocessesandoutcomes;monitorsforunintendedconsequences.Forexample:o Satisfactionwiththetimespentwithproviderwhenincreasingefficiencyo Numberofadditionalminutesrequiredforvisittimeo Accuracyandcompletenessofaformwhentryingtostreamlineaprocesso Numberofprintedpoliciesleftbehindinexamroomorfoundinthetrasho Skepticsareagoodsourceforbalancingmeasures:“Greatidea,BUT…thiscouldmessupX”

C.DataSamplingManyteamsaretemptedtocollectasmuchdataaspossible.Ateamshouldcollectjustenoughdatatoconfirmthecurrentsituation,effectsofchangestested,etc.Itisunlikelythatadifferentconclusionwillbedrawnbasedonalargervolumeofdata.Thecostandeffortrequiredtoobtainlargeamountsofdata,particularlywhenitmaybedifficulttoaccess,outweighthebenefitsofacquiringit.

• Measuretospeedlearningandimprovement,nottoslowitdown• Measurementisnottheaim;improvementistheaim• Youmaylearnasmuchormorefromsmallsamples

Thereareseveraldatasamplingstrategies:Probabilitysampling:

• Simplerandomsampling(randomnumbergenerator)• Systematicrandomsampling(startatarandomnumberandfixedintervalthereafter)

Non-probabilitysampling:• Accidentalsamples(takenext“n”peoplewhowalkby)• Quotasamples(randomsamplinguntilquotabucketsfilled)• Judgmentsampling(use“knowledge”[endusers]toidentifymostinformativesamples)

PracticeTip:Qualitativedataalsoplaysavaluablepartinmeasuringimprovementwork.Bothquantitativeandqualitativedatacommunicatecrucialinformationaboutthework.Stakeholderswillhavedifferentpreferencesfordata.Somelikethehardnumbers,whileothersliketohearthestories.Makesureyourprojectincludesbothtypesbecausetogethertheycanenhancetheimpactofyourmeasurement.


Judgmentsamplingisthemostcommonformusedinimprovementwork.Forexample,youaredoingaprojecttoincreasethepercentageofteenswithsicklecelldiseasewhohaveanemergencycareplan.Lookforsampleopportunitiestomostrapidlyascertainifourinterventionsareleadingtoimprovement.Forexample:

• Findoutwhenthereissicklecellclinicorregularhematologyclinic• Do“drive-by”observationsofproviders• Dospotchecksofthetrashandroomtoseeifhandoutswereleftbehind

D. DataCollectionWhendevelopingadatacollectionstrategy,considertheutilityandaccessibilityofexistingdatasources.Insomehealthcaresettings,theelectronicmedicalrecord(EMR)servesasavaluablesourceofdata.Whenpossible,populationpullsfromtheEMRareideal.However,inabilitytoextractdatafromtheEMRshouldnotstoptheimprovementwork.Simpledatacollectiontoolscanbeusedinstead,suchas:

• Emailsurveys(e.g.,SurveyMonkey)• Checksheets(simplestructured,prepareddatacollectionform)• Smallchartaudits

Forexample,achecksheetisagenerictoolthatcanbeadaptedforawidevarietyofpurposes.• Whendataisobservedandcollectedrepeatedlybythesamepersonoratthesamelocation• Whendataiscollectedonthefrequencyorpatternsofevents,problems,errors,etc.

Mon Tues Wed Thurs FriPolicy/guidegiven || |||| ||| | ||Leftinroomortrash |||| |Patientquestions | |

Thisdataisthenconvertedtorunchartsasfollows:

PracticeTip:Rememberthatyourprocesswillhavevariation(andthatvariationwillfollowadistribution).Formoreinformationandanillustrationofthesepoints,seethe“RunChartRules”sectionbelow.Youneedjustenoughdatatoknowifthedistributionhaschanged,orifapointisoutsidetheexpecteddistribution.Strivetominimizethemeasurementburden:

• Trytolimitthenumberofmeasuresto3-5.• Measurefrequentlyusingsmallsamplesizes.• Keepdatacollectionaseasyaspossibleanduseexistingsourcestocollectneededdata.• Measuringisnotgoingtochangethings;usemeasurestoinformdecisionsthatdrivechange.

ExampleCheckSheet

012345

Mon Tues Wed Thu Fri

Policy/guidegiven

012345


Leftinroomortrash

012345


Patienthadquestions


EssentialToolTheProjectMeasurementPlan(seeAppendix)isacommunicationtoolthathelpsateamspellouthowmeasureswillbetrackedanddescribeswhowillcollectthem,when,howoften,etc.Theplanoftenincludesatabledocumentingmeasuresanddatacollectionplans,withdescriptionsofmeasuresandoperationaldefinitions.Thisensureseveryoneinvolvedagreesaboutthemeasurementprocess.Theprojectmeasurementplaniscreatedatthebeginningoftheprojectandrevisitedregularlythroughoutthelifeoftheproject.Thus,youmayusethistooltocapturechangesinyourmeasures,documentingwhatthechangewas,whoauthorizedit,when,andthereason.

E.DisplayingMeasuresOnceyoubegintocollectyourmeasures,thinkabouthowthemeasureswillbevisuallydisplayedandcommunicated,includingwhetheryouwillusearunchartversusabargraph.Whendisplayingdata,creategraphsthatareeasytoread.Onekeyprinciplefordevelopinggraphsistousetheleastinkpossible.Excelhasafunctionthatautomaticallyaddslegends,datapointtext,etc.

CommonQuantitativeDisplay• Barchartsareusedtoestablishagap(comparisontobenchmark,goal,beforeandafter).• InQI,runchartsaremostoftenusedtodisplaydataovertime.Runchartsareadynamicdisplayof

dataovertime.Theyrequirenostatisticalcalculationsandshouldbeeasilyunderstood.Datapointsareplottedaroundamedianline,andannotatedrunchartsincludeboxes(alsocalledannotations)thatcorrespondPDSAs.

BarChart RunChart


InstructionforCreatingaRunChart

1. Setthehorizontalscale(x-axis)–usuallytime2. Settheverticalscale(y-axis)–receiptofvariablebeingmeasured

o Makeverticalscalehighorlowenoughtoencompassvariationinfuturedataandyourgoalo Mostofthedatashouldlieinmiddlehalfofgraph

3. Createausefultitle4. Addadditionalinformation:goalline,annotationsofchangesorunusualevents

o Itisvitaltoaddannotationstoyourruncharts,asthislinksdatawithrelevanttestsofchange.Withoutrunchartannotations,youcannotbesurewhichchangeswereeffectiveordetrimentaltoyouroutcomes.

5. Plotthemedian



Therearefourpatternstohelpdetermineifimprovementsarebasedonarandomversusanonrandompattern.ProvostandMurray’sHealthCareDataGuidereferstotheseas“rules.”Ifyouseeoneofthesepatternsoccurinyourdata,itindicatessomethingnonrandomistakingplace.These“rules”shouldinformtheteamastotheimpactoftheirchanges.

Forexample,intherunchartonpage20(PercentofPatientsReceiveandUnderstandPolicy),weseeRules2and3apply,indicatingnonrandomchange.Thisinformstheteamthatthechangestheymade(creatingapolicy,identifyingpatientgaps,andinitiatingpatientself-management)areimpactingtherunchart.

KeyPoints:TorecapMeasuringforImprovement:Forallmeasures:• Useameasurementplantodocumentyourwork• Usesimplecollectiontools• Usetheleastinkpossibletodisplaydata(i.e.,userunchartsinsteadofbarcharts)

Forprojectmeasures:• Usequantitativeandqualitativedata• ChooseaconcisesetofmeasuresrelatedtoyourgoalswithProcess,Outcome,Balancing• Userunchartsfordisplayingdataovertime• Startcollectingyourbaselinedataassoonaspossible

RunChartRule1:Sixormoreconsecutivepointsabove

orbelowmedian.

RunChartRule4:Astronomicalvalue!

RunChartRule3:Toofewortoomanyruns(crossingsofthemedian)–PleaserefertotheHealthCareDataGuidebyProvost

andMurray,Table3.4,page80,toapplythis.

RunChartRule2:Fiveormoreconsecutivepointsgoing

upordown.


VI.ToolsforImprovementIntroductionInthissection,wewillreviewawidevarietyofQItools.Inadditiontothosespecificallyplacedinothersections,therearemanyqualitytoolsthathelpteamsgathertheinformationneededtoadvancetheirwork,severalofwhicharediscussedbelow.Formoreinformationontools,refertoNancyTeague’sTheQualityToolbox.

Askyourteam:• WhereareweintheQIprocess?• Doweneedtoexpandorfocusourthinking?• Isittimetoevaluate?

EssentialLearningTypically,QItoolscanbedividedintotwomaincategories–toolsrelatedtoplanningandtoolsrelatedtodatacollectionoranalysis.However,thereissignificantoverlap,whichprovidesvaluablelearning.

Whenyouareplanningthework,identifyingrootcause,ordevelopingideas,thesetoolsareoftenused:• KeyDriverDiagram(KDD)• Flowmap(processflows/valuestreammap/swimlaneflowmap)• SimplifiedFailureModeandEffectsAnalysis(sFMEA)• Fishbonediagram• 5Whys&5Hows• SevenStepMeetingProcess• Brainstorming• Affinitydiagram• Impact/prioritizationmatrix

Whenyouarecollectingoranalyzingdata,thesetoolsareused:• Checksheets• Paretochart• Runchart• Survey• Benchmarking

Afewofthemostcommonlyusedtoolsaredescribedindetailbelow.

A.KeyDriverDiagram(KDD)KDDshelpteamsunderstandasystemandthesystemdriversthatleadtooutcomes.Theycanincludestructures,processes,culture,personnel,andmuchmore.Understandingthesystemiscriticaltoimprovingoutcomes.KDDsmaybeusedtoprioritizeresources,developameasurementplan,orpresenttheworktostakeholdersorleadership.

UsingaKDDhelpsteams:• identifytheirtheories(“keydrivers”)• focusoncauseandeffectrelationshipsincomplexsystems• communicate• organizework


AKDDisstructuredasathree-levellogicchartandtypicallyshowsprimary(“key”)drivers,secondarydrivers,andusuallyafinalcolumnofchangestobetested.Secondarydriverswithcommonresources,management,equipment,patients,etc.canbegroupedtobecomeyourprimarydrivers.Primarydriverscanbeprioritizedandassignedtoateamtoworkon.Secondarydriversarethestructures,processes,oraspectsofculturethatcontributetodesiredoutcomes.Theyarenecessaryandsufficientforimprovement.Ideally,theyarealsoevidence-basedorshowntoworkelsewhere.Belowisagraphicofakeydriverdiagram.Thesecondexampleisforimprovingfinancialsavings.ThethirdexampleisaKDDforimprovingtransitionofcareforpatientswithsicklecelldisease.

Example:KeyDriverDiagram

Example:APlanforImprovedSavings


Example:ImprovingSickleCellCare

AKDDcanalsobeusedtodevelopthemeasurementplan.HavingmeasuresateachleveloftheKDDensuresabalancedset(seeSectionV:MeasuringforImprovement).ThefollowingKDDdemonstratesthedifferentlevelsofmeasurementwithintheKDD.

Example:MeasuringImprovement

AdaptedfromST3PUP,sponsoredbyPatientCenteredOutcomesResearchInstitute®(PCORI)AwardMCSC-1608-35861TitledAComparativeEffectivenessOfPeerMentoringVersusStructuredEducationBasedTransitionProgrammingForTheManagementOfCareTransitionsInEmergingAdultsWithSickleCellDisease.


B.FlowMapAflowmapisavisualdisplayofeachstepinaprocessplacedinsequentialorder.Itcanincludeactivities,decisionpoints,inputsandoutputs,staffinvolvement,timerequired,andmeasurement.Flowmapsareusefulforprocessesrangingfrommanufacturingtoservicestohealthcare.Theyillustratehowthingsareorhowthingscouldbe.Mostimportantly,aflowmapcanhelpteamsunderstandaprocessbetter,findimprovementopportunities,shareinformation,resolvecontradictingperspectives,orsimplyrecordaprocessorplanaproject.Postingtheflowmapgivesstaffanopportunitytoclarifythestepsandensureeveryoneisonthesamepage.

Thedetailedflowmap,shownbelow,breaksactivitiesintomajorandminorcategories;inadditiontoitemssuchasinputs,outputs,anddecisions,thisformatcapturesdelays,repetition,andotherdetails.Theseareespeciallyusefulwhenateamneedstothoroughlyunderstandaprocesstoidentifyandplanimprovementopportunities,helpingteamsmapout“as-is,”“should-be,”and“to-be”processes.Theycanbehelpfulwhentrainingpeopleonaprocess.

Buildingontheregularflowmap,detailedflowmapsincorporateadditionalexplorationafterarrangingthebrainstormeditems.Teamsshouldworkthroughstepsrequiredwhensomethinggoesawry,alternatepathsfromdecisionpoints,andinputsandoutputsateachstep.Afteraddingtheseitems,theteamshouldagainshareitwithawideraudienceforfeedback.Formoreinformationonthissubject,seeNancyTague’sTheQualityToolbox.

C.SimplifiedFailureModeandEffectsAnalysis(sFMEA)AnsFMEAisatooltoidentifypossiblefailures.Itcanbeusedatmanylevels(teamoralargerorganization)toprepareforfailuresinasystem,process,service,etc.Afteridentifyingpossiblefailures,teamsbrainstormsolutionstoeachpotentialproblem.

InstructionforCreatingaFlowMap

1. Haveaverycleardefinitionoftheprocessinquestionandagreeonthelevelofdetailneeded.2. Writetheprocessatthetopofthepageanddiscussparametersforwhere/whentheprocessstartsand

stops.Next,brainstormitemsforinclusion,usingsmallslipsofpaper.3. Oncealltheideasarecollected,arrangethemintheproperorder.4. Whentheteamisagreedonthesequence,addarrowstoshowtheflowbetweensteps.5. Finally,sharetheflowmapwithotherswhoparticipateintheprocessandaskiftheyfeelitisaccurate.


D.FishboneAfishbonediagramhelpsteamsbetterunderstandaproblem.ItmayalsobecalledanIshikawaorcause-and-effectdiagram.Identifyingpossiblecausesrequiresbroadthinkingandcanhelpateamgenerateideasoractions.

Fishbonediagramsprovidestructureforbrainstorming,corralcollectiveknowledge,andhelptheteamcastawidenetforideas.Thisisespeciallyusefulwhenaproblemhasmultiplecauses.Italsobreakstheproblemintosmallerpiecessoteamscanconsidercausesandprioritizeattentiononwhichcausestotacklefirst.

Aswithotherplanningtools,teamsneedtofirstagreeontheproblem(the“effect”),thenbrainstormcauses.Causesaregroupedintocategories,sometimeslabeledgenericallyasthe“4Ps”(People,Equipment,Policies,andPractices)and/orthe“5Ms”(Machines,Manpower,Materials,Methods,andMeasurement).(Youwillfindvariationsonandcombinationsoftheselabels.)Drawa“fishbone”oftheideas,placingtheproblematthe“head.”“Bones”linkcauseandeffect,withideasplacedonthebranchoftheappropriatecategory(ideascanappearinmultipleplaces).

InstructionforCreatingansFMEA

1. Startwithyourprocessflowmap.2. Gatherdatatoidentifyproblemsorbarriers.Directobservationsandinterviewscanbeanexcellent

sourceofthisinformation.Listallthebarriers,gaps,orproblemsrelatedtoeachstepintheredboxes.3. Listpossiblesolutionsforeachprobleminthegreenboxes.Informationcancomefromresearch,data

analysis,brainstorming,Paretocharts,andkeydriverdiagrams.4. Finally,choosesomesolutionsforpotentialPDSAs.

AdaptedfromthecopyrightedSimplifiedFailureModeEffectsAnalysisWorksheet(sFMEA)fromCincinnatiChildren'sHospitalMedicalCenter.ThisversionofthesFMEAhasbeenmodifiedandhasbeenreprintedwithpermission.


Todevelopthemostcompletepicture,teamsshouldconsiderallcauses,notjustthosewithintheircontrol.Facilitatorsshouldlettheteamdetermineideaplacement,andteamsshouldasksomeoneoutsidethegrouptoreviewthediagramforaccuracyandcompleteness.

ImagefromAHECQI101,aQualityImprovementcoursesponsoredbyCharlotteAreaHealthEducationCenter.



Therearemanytypesoffishbonediagrams,suchasprocessfishbone,time-delayfishbone,desired-resultfishbone,reversefishbone,causeenumerationdiagram,andCEDAC(cause-and-effectdiagramwiththeadditionofcards).

E.5Whysand5HowsThe5Whysand5Howsareaseriesofdetailedquestionsthathelpteamsdescribeaproblem,drilldowntotherootcause,andidentifyasolutiontotest.Theyarehelpfulwhenteamsneedtodigalittledeeperbutarehavingtroubledoingso.Bothhelpclarifytheproblem,with5Howsalsousedtodevelopadetailedsolution.Theypairwellwiththefishbonediagram.





F.ParetoChartsParetochartssupportdatacollectionandanalysisanddisplayinformationasabargraph.Theyhelpdeterminetheprevalenceofaproblem,identifythemostsignificantissueoutofseveralproblems,ordrilldownfrombroadcausestospecificpieces.Keybenefitsarethattheyrelatecauseandeffect,facilitatecommunication,andillustratewhichsituationsaremoresignificant(arrangedinorderfromlefttoright).

WhencreatingaParetochart,decidethedatatobeused,timeframe,andmeasures.Collectyourdataandsetthenumericscaleforthechart.Makeabarchartwiththeheightofeachlabeledbarsignifyingcostorfrequency(highesttolowest).

Example:ThisParetochartshowshownursesonthepediatricsurgeryfloorwanttoimprovethedischargeprocesstoopenbedsfornewpatients.1. Teambrainstormedandvotedon

whattheythoughtwerecausesofdelays.

2. Teamcollecteddatatoassesshypothesisandidentifythegreatestimprovementopportunity.

3. TeamcreatedaParetocharttodisplaywhattheylearnedaboutleadingcausesofdelays.

Example:ThisParetochartshowswhatwasmissingfromasampleof10ADHDinitialvisitrecords.All10chartsweremissingdocumentationofthefirst4categories,whichrepresent80%oftheproblem,andshouldbeaddressedfirstifpossible.

ImagefromAHECQI101,aQualityImprovementcoursesponsoredby

CharlotteAreaHealthEducationCenter.



Example:ThisParetochartillustratesdiseaseratesbyage.



VII.SustainingImprovementIntroductionInthissection,wewilldiscusstheroleofsustainabilityinQI.Wewillreviewthestepsteamsneedtocompleteinordertoprotecttheirworkfromentropy,toestablishareasonablelevelofmeasurementfrequency,andtomaintainstakeholdersupport.

Onceyouhaveprogressedthroughplanning,testing,andimplementingonlythosechangesthatleadtoimprovementdemonstratedbythedata,thinkaboutsustainingandspreadingthework.Ifyouareatorabovegoalfor6ormoremonths,considershiftingtosustainability.Beawarethatfailuretodevotesufficienttimetothisphaseresultsinerosionoftheimprovementwithinmonths.

EssentialLearningManycrucialstepsunderpinsustainability,suchasassigningownership,buildingthechangeintothesystem(ratherthanrelyingonindividuals),continuingtomeasure,andseekingseniorleadersupport.

Chooseanindividualto“own”thesustainment.Astheprocessowner,theywillprovidestatusreportstoseniorleaders,resumeteammeetingsasneeded,watchthedataforregression,andmanageongoingimprovement.Thispersonkeepsthenecessarystaffinformedandengaged,includingrepeatingtrainingandsharingtheproject’ssuccesses.

A.HardwiringChangesYoucanhelphardwirechangebyincorporatingthenewprocessintojobdescriptions,andincludingimprovementdiscussionsinrecruitment,performanceevaluations,andmeritincreases.Anticipatepotentialdisruptions,suchasstaffturnoverandabsences,bycross-trainingstaffonchangesandnewprocesses.ProvidingnewstaffwithQItrainingandinitiatingfrequentdiscussionsaboutimprovementwillhelpbuildacultureofQItosupportchanges.Youreffortswillbemostsuccessfulifthesestrategiesareemployedacrossthesystemorpractice,notonanindividualbasis.Remembertoinvolvepatientsandfamilieswhenplanningforsustainability.

B.OngoingKnowledgeManagementContinuedmeasurementiscrucialforsustainability,althoughyoucanbegintomeasurelessfrequently.Graduallyscalebacktoalternatingmonths,thenquarterly,andeventuallyannualmeasurement.Withoutdata,thechangesyou’veinstitutedwillerodeandentropywilltakeover–butyoumustreducethedataburdentoenableyourteamtomoveontootherimprovementwork.Chooseoneortwomeasuresfromyourbalancedset,whichwillindicateearlyonwhentheprocessstartstoslip.Sharethisdataatstaffmeetingsandhaveaplanreadyincaseyourdatadoesstarttoreveallossofreliability.

Seniorleadersremainimportantduringsustainability.Createaclear,succinctreportandshareitregularlytokeeptheminformed.Keepyourworkvisiblethroughpostersandpresentations,andrequestseniorleadersupportinremovingbarriersandprovidingresourcessuchassufficienttrainingtimefornewstaff.

EssentialToolsSustainabilityChecklist:MaintainingYourSuccess(seeAppendix)isanorganizationaltoolthathelpsyoumakesureallthepiecesareinplace–people,processes,measurement–tohelppreventyourimprovementworkfromrevertingbacktothepreviousstate.

PracticeTip:RememberthataswediscussedinSectionI:WhatisQualityImprovement?reliabilitysciencestrategiesarealsousedbyQIteamstoensurehighreliabilitywhenestablishingsustainability.


VIII.SpreadingImprovementIntroductionInthissection,wediscusshowtospreadyoursuccessfulimprovementworktootherareas.Thisincludesanunderstandingofthepiecesnecessaryforsuccessfulspreadandthepredictablepatternthatchangeadoptionoftenfollows.

Spreadingtheimprovementworkisanotherpartofchangemanagement.Itmaynotalwaysbethe“last”thingyoudo;sometimesit’sappropriatetospreadsomeelementsbeforethefullychangedprocessisinplace–whenthere’senoughdatatoshowthechangeisanimprovementandtheteamisconfidentthatthechangeideaisreadyforspread.

EssentialLearningInhisdefinitivebookDiffusionofInnovations,EverettRogersexplainedspread:

“Diffusionistheprocessbywhichaninnovationiscommunicatedthroughcertainchannelsovertimeamongthemembersofasocialsystem.”(RogersEM,DiffusionofInnovations,pg11.)

Theteammustworktogethertodeterminespreadreadiness.Questionstohelpguidethisinclude:• Didtheinitialteamsucceedinimprovingtheprocessoroutcomes?• IsstaffinthespreadlocationfamiliarwithQIandthechosenmethodology(e.g.,theModelfor

Improvement)?• Istherebuy-inatboththefrontlineandseniorleaderlevels?• Doyouhaveaveryspecificdefinitionandplanforthespread?

Manyfactorsimpactspreadsuccess.Firstisthe“perceivedattributes”ofthechange.Fiveattributesincreasethelikelihoodofspread:

1. Relativeadvantageovercurrentprocessorsystem2. Compatibilitywithcurrentprocessorsystem3. Complexity4. Trialability–canthechangebetestedwithlittleinvestment(risk/cost/time)?5. Observability–isthechangevisible?

Thesecondfactoristhetargetsocialenvironment.TheDiffusionCurveillustratesthenaturaldistributionofapopulation’swillingnesstoadoptachange,commonlydisplayedasabellcurve.Anindividual’spositiononthecurvecanshiftdependingonthespecificchangeinquestion.Innovatorsusuallyinitiateachange,buttherealmomentumlieswithearlyadopters.Earlyadoptersareopentochangeandmoresociallyintegratedthaninnovators.Peersfartheralongthecurvetrusttheearlyadoptersandrespecttheiropinions;thus,innovatorswillseethegreatestsuccessbytargetingearlyadoptersfirst.Teamsshouldidentifytheearlyadoptersandthebestwaystoreachthem,andtheearlymajoritywillsoonfollowsuit.Thelatemajorityarelikelytojoinafterthefirstgroupsembracethechange.Thefinalgroup,thetraditionalists,orlaggards,areleftwithnochoicebuttochangeorbeleftbehind.InhisclassicbookDiffusionofInnovations,EverettRogersallocatedthediffusioncurveasfollows:

• 2.5%Innovators• 13.5%EarlyAdopters• 34%EarlyMajority• 34%LateMajority• 16%Traditionalists

Itistemptingforimprovementteamstotargetthosewiththelargestgap,butinvestmentsarebestmadeintheothergroups.Focusingyoureffortsonthelaggardswastesresourcesandisunlikelytoresultinchangeanyway.


Lastly,strongleadershipiscrucialforsuccessfulspread.Theleadermustprojectasharedvision,inspirebuy-inandcommitment,andclearlystatethatstatusquoisunacceptable.Thismeansunderstandingthechanges,includingtheirimpactonpeopleandhowtheywillresultinimprovement.Thebestleadersknowhowtotargetinfluentialpeopleandhelpthemunderstandtheneedforchange.

Otherfactorsmaybespecifictothelocalsite.Inthesecases,dataandincentivescanhelpillustratetheneedforchange.Itoftenhelpstohighlightotherlocations’successes.Visitingthesesitescanbeinvaluable.

Spreadteamsmustcontinueconsistentmeasurement,butthevolumecanoftenbereduced.Sometimesspreadleadstonewimprovementstothechangeidea,andthisneedstobecapturedforfurtherlearning.Celebrateandcommunicateyoursuccessfulspreadwork.

EssentialToolsASpreadChecklist(seeAppendix)isastructuraltoolthathelpsensureallthepiecesareinplaceforsuccessfulspread.ItincludesconsiderationsyouneedtoaddressintheareasofOrganization,Communication,SocialSystem,Measurement,andKnowledgeManagement.Thisshouldbecompletedbeforeyoustarttospread.

KeyPoints:QItoolscontinuetobevaluableduringspread.Expectthatsomeadaptationswillbeneededinthenewlocation,andPDSAcycleswillberequired.Chooseaspreadchampionwhoisinvested,knowsthedata,canfacilitatestaffbuy-in,andsupporttheoverallprocess.


IX.HealthLiteracyIntroductionInthissection,wewillturntothetopicofhealthliteracy,whichisanimportantcompaniontoQI.Whenthetwoarecombined,theyareapowerfulforcetoimprovecareforpatients.Afterprovidingsomebackgroundinformationonhealthliteracy,wewilldescribestrategiesforimprovingwrittenandspokencommunication.

Healthliteracyisacriticalelementofthehealthcaresystem;withoutaddressingthisaspectofcare,wewillneverachievebetteroutcomes.Patientsmayonlyspend10minutesinaphysicianvisitbutareresponsibleontheirownathomeforunderstandinghowtofollowtreatmentinstructions,takemedications,navigatethehealthcaresystem,andcoordinatecareacrossdifferentsubspecialties.Thisaspectof“caredelivery”becomescomplicatedintheworldofhealthcaretransition:successfultransitionisentirelydependentonaneffectiverelationshipbetweenprovidersandpatients,includingclearcommunicationandunderstandableprocesses.

EssentialLearningHealthyPeople2020defineshealthliteracyas“thedegreetowhichindividualshavethecapacitytoobtain,process,andunderstandbasichealthinformationandservicesneededtomakeappropriatehealthdecisions.”Thiscanbeexpandedtoincludetheabilitytoaccessandnavigatethehealthcaresystem.

Dr.RichardCarmona,formerU.S.SurgeonGeneral,mentionedhealthliteracyin200outof260speecheswhileinoffice.2Hepointedoutthatprovidersoftendon’trealizepatientsdonotunderstandtheinformationandinstructionstheyaregivenandthatprovidersneedtoworkonnarrowingthegap.Patientsfaceanincreasing“continuumofconfusion,”astheyaretaskedwitheverythingfrompreventiveself-care,immunizations,andself-monitoringtoappropriateuseofamyriadofsystemfacilities,navigatingcomplexscheduling,understandinginsuranceandbilling,andtacklingextensiveprintedinformation.Historically,thehealthcaresystemhasplacedtheburdenandresponsibilityforallofthisonthepatientintheirmostvulnerabletime,insteadofsimplifyingthehealthcaresystem.

Thisdisconnectisnotsurprising.Providersspendmanyyearstrainingintheirfield,thenworkingwiththisinformationdaily.Patientsmustquicklyadapttonewinformationandtakeresponsibilityforunderstanding,remembering,andactingonit.Theyoftenreceivethisinformationduringtimesofgreatstress,whentheyarenotfeelingwell,and/orhavejustreceivedanewandscarydiagnosis.Manypatientsfeelshameabouttheirinabilitytounderstand,read,etc.andthushidethisdeficitfromtheircareteam.

QIcanhelpprovidersincorporatehealthliteracystrategiesandcanhelpprovidersseetheexperiencethroughthepatient'seyes.Whendoneproperly,healthliteracystrategiesshiftthebalancebydecreasingpatientburdenandincreasingpatientcapacity.Therearecluesaboutapatient’shealthliteracycapacitythatproviderscanlookforsuchas:

• Frequentlymissedappointments:lackoffollow-throughontestsorreferrals• Incompleteregistrationforms:inabilitytogivecoherent,sequentialhistory;rarelyasksquestions• Non-compliancewithmedication:inabilitytonamemedications,explainpurposeordosing;pills

identifiedbylookingatthem,notreadingthelabel

Afewstatisticshelptoillustratethemagnitudeoftheproblem.AccordingtotheNationalAssessmentofAdultLiteracy,36%oftheadultpopulationhavebasicorbelowbasicliteracyskills.3Somekeyfindingsinrecentstudiesdemonstratetheimpactlowliteracyhaswithinthehealthcareenvironment:

• ThecostoflowhealthliteracytotheUSeconomyisestimatedtobe$106billion-$238billionannually• Morethan3in4emergencyroompatientsdonotunderstandinstructionsdoctorsgivethemaftervisits• Adultswithlowliteracyskillsalsohavedifficultymanagingthehealthoftheirchildren


Committedcareteamsvaluepatientengagementandthevoiceofthepatient,butfamiliesmustalsounderstandwhatthecareteamistellingtheminordertoparticipatetotheirfullestcapacity.Allinformationmustbesharedinawaythatfamiliescanunderstand,andcommunicationmustbestructuredinawaythatencouragespatientsandfamiliestosharetheirideasopenly.

Healthliteracystrategiesbecomeveryimportantandtrickyinthecontextofhealthcaretransition.Aspatientsmovefrompediatrictoadultcare,theyaresuddenlyresponsiblefortheirowncare,oftenforthefirsttimeintheirlives.Thechallengesofthesenewresponsibilitiesareincreasedbythenaturalchangesinmaturation,judgment,anddecision-makingwhichyouthandyoungadultsexperience.

TheAgencyforHealthcareResearchandQuality(AHRQ)hasdevelopedacomprehensivetoolkittohelpcareteamsaddresshealthliteracyfrom4areas:writtencommunication,spokencommunication,self-managementskillsandempowerment,andsupportivesystems.Thefulltoolkitcanbeaccessedat(https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/index.html).Forthepurposesofthisprimer,wewillfocusprimarilyonwrittencommunicationandbrieflyonspokencommunication.

Improvingwrittencommunicationincludesmanystrategiesandtoolstomakematerialseasiertoread,understand,andactupon.Thepointsbelowwillapplytoanywrittencommunication,includingbutnotlimitedtoeducationpamphlets,researchresults,consentforms,patientinstructions,letters,andpolicies.

A.SummaryofGeneralPoliciesforWrittenCommunicationMessage(clarity):includeaclear,brieftake-awaymessageWordChoice:usecommon,easytounderstandwordsSentenceStructure:besimpleanddirectTone:makethereaderfeelempoweredandreadytoactNumbers:healthliteracyincludesproblemswithcalculationssuchasquantity,time,andriskFormat,Layout,andGraphics:makereadingeasierbyusingcertainfontstyles,spacing,anddesignLiteracyLevel:usea6thgradereadinglevelorlower,usingaformalscoringsystem

B.DetailsandExamplesforImplementationinWrittenCommunicationYourfirststepistoapplythefirstsixstrategiesbelowtosimplifyyourwriting,thenscorethedocumentforitsliteracylevel.Repeatthiscycleuntilyoureachthedesiredreadinglevel.

Message(clarity)• Limitcontenttoafewkeypoints• Focuson“needtoknow”points• Offerwaystolearnmore,includingnon-writtenoptions(hotlines,supportgroups,etc.)• Bespecific;don’tassumereadersknowwhattodo

WordChoice• Use“livingroom”language• Use1-or2-syllablewords• Avoidjargon• TheCDCprovidesafree“PlainLanguageThesaurus”tohelpreplacemedicalwords

(https://www.plainlanguage.gov/media/Thesaurus_V-10.doc)• Whenyoucannotreplaceamedicalterm,giveadefinitionorexample(e.g.,“rheumatologicdisease

[paininyourjoints]”)• Usetheexactsamewordingeverytime


SentenceStructure• Keepsentencesunder10–15words• Useanactivevoice• Usebulletedlists• Avoidextrawordslike“very”and“actually”

Tone• Use“you”and“your”toaddressthereader• Usepositivelanguage

Numbers• Verybig(over100)orverysmall(lessthan1)numberscanbehardtoimagine• Useabsolute(e.g.,“8outof16”)notrelative(e.g.,“twiceasmany”)terms• Usepicturesandstories.E.g.,iconarray.comconvertsriskorfrequencyintographics:

Format,Layout,andGraphics• Startwithkeypointsandrepeatthemattheend• Useheaders• Useshortbulletedlistsandgrouprelateditems• Buildinwhitespaceandusegraphics• Leftjustifyparagraphs• Use12-pointorlargertype,andatleast1.5spacebetweenlines• Limituseofbold,italics,andallcapitalletters• Useunderliningtodrawattentiontokeypoints

LiteracyLevelToassessgradelevel:

• ThebestoptionistoputmaterialsthroughHealthLiteracyAdvisorTM.Thisislicensedsoftware,whichmustbepurchased.Itmaybeworththeinvestmentforyourorganizationifyouwillbewritingmultipledocuments.

• TheFlesch-Kincaidgradescorecanbeobtainedfreeofchargeusing“ReadabilityStatistics”inMicrosoftWord.o ClickonReview→Spelling&Grammar→ReadabilityStatistics→Flesch-Kincaidgradelevelo Pleasenote,thismethodoftenunderestimatesadocument’sreadinglevel,soassumethereal

gradeisabithigher.

36%ofpeoplewith…


• Otherscoringtools*include:o PEMAT–PatientEducationMaterialsAssessmentTool,moreavailableat

https://www.ahrq.gov/ncepcr/tools/self-mgmt/pemat.htmlo SMOG–SimpleMeasureofGobbledygook,moreavailableat

http://prevention.sph.sc.edu/tools/SMOG.pdfo SAM–SuitabilityAssessmentofMaterials,moreavailableat

https://ogg.osu.edu/media/documents/health_lit/WRRSAM.pdfandhttp://aspiruslibrary.org/literacy/SAM.pdf

*Notethatthesetoolsgobeyondbasicgradelevelscorestoprovideamorein-depthassessmentofhowunderstandableadocumentis.

C. SpokenCommunicationStrategiesImprovingspokencommunicationincludesstrategiesthatfallintotwomaincategories:conveyinginformationandencouragingquestions.

Conveyinginformation:Therearestrategiesproviderscanusetoensuretheiroralcommunicationisclear:• TeachBack–Havethepatientrecapwhatyou’vediscussedintheirownwords.Revisitpointsthat

wereunclear.ItmighttakesomepracticetoincorporateTeachBackseamlesslyintoyourconversation.Beclearthatyoucarrytheburdenforsuccessfulcommunication,notthepatient.Forexample:“IwanttomakesureIdidagoodjobofexplainingthis.Tellmehowyouwilleducateyourspouseonthenewplan.”

• Useplainlanguage• Limittheteachingpointsto3pointspersession• ChunkandCheck–breakinformationintosmallerpieces,confirmpatientunderstandingbefore

movingon

Encouragingquestions:Encouragingquestionsarealittledifferent,astheyempowerthepatientandenhancecommunicationbetweenpatientandprovider.

• AskMe3®–astructuredformatthathelpsguideapatientinknowingwhattoaskhttps://cdn.ymaws.com/www.npsf.org/resource/resmgr/AskMe3/AskMe3_HealthLiteracyTrainin.pdfo Whatismymainproblem?o WhatdoIneedtodo?o Whyisitimportantformetodothis?

• Providersshouldaskopen-endedquestionsingeneralandespeciallywheninvitingquestionsfrompatients:o “Whatquestionsdoyouhave?”,not“Doyouhaveanyquestions?”

Ifyouarepartofalargerhealthcareorganization,looktoyourinstitution’sPatientExperience,PatientEducation,andHealthLiteracyconsultantstohelpyouwiththiswork.

PracticeTips:Remembertokeepthepatients’needsinmind,astheyareyourprimaryaudience:• Don’tassumethehealthliteracymanagementembeddedinyourEMRisenough.Takethestepsabove

toassessreadabilityforyourself.• Beawareofyourownpopulation.

o Forexample,iftheaveragereadinglevelinyourcommunityis3rdgrade,thatshouldbeyourtarget.Trytouseevenmorepictograms,etc.

• Writersmaybeconflictedabouttheaudience,tryingtoserveboththeproviderandthepatient.o Forexample,anasthmaactionplanthatincludesallpossiblemedicationsmakescompletioneasier

fortheproviderbutmuchmoredifficultforthepatient.

https://cdn.ymaws.com/www.npsf.org/resource/resmgr/AskMe3/AskMe3_HealthLiteracyTrainin.pdf


X.CO-PRODUCTIONIntroductionInthissection,wewillbrieflyaddressco-production.Likehealthliteracy,co-productionworkswellwithQItoimprovethecareexperienceforpatientsandtheirfamilies.Co-productionisadesignprocessinwhichpatients,families,andprovidersworktogethertodevelopthebestsystemofcare.

EssentialLearningThiskindofcollaborationwasinspiredbychangesincivilrightsandsocialcareintheUSduringthe1970s.PoliticaleconomistElinorOstromexploredtheimpactofadisconnectbetweenservicedeliveryandusers,basedonherobservationsthatpolicelosttheirrelationshipwithcommunitymemberswhentheyswitchedfromfoottocarpatrols,whichcoincidedwithanincreaseincrimerates–theirdirectinteractionhadhelpedkeepcrimeatbay.Ostromidentifiedseveralpublicserviceareasinwhichresultswereinfluencedmorebyhumanconnectionthanbyhighexpenditures–i.e.,bothpartiesperformbetterinareciprocalrelationship.ThisideawasspearheadedinthejusticesystembycivilrightslawprofessorEdgarCahn,whoimpactedcrimeandrepeatoffenderratesbyincludingfamiliesinthejudicialprocess.

TheconceptmadeitswayintohealthcarethroughAnnaCoote’sworkattheKing’sFundhighlightingtheinherentsymbiosisbetweendoctorsandpatients.Thisapproachisatoddswiththemarket-focusedmodelinwhichinterventionsaredonetoorforpatients,ratherthanwiththem.Amorecollaborative,participatoryapproachhasregainedfavorasthepublicandthehealthcareindustrylookformoreeffective,sustainablemodels.

Keyaspectsofco-productionincludethebeliefthateverypersonaddsvalue,withallinvolvedworkingasequals.Theuseofdataandend-userperspectivesthatarefundamentaltoco-productionarealsohallmarksofQI,makingthesetwoapproachestoimprovingcaredeliveryhighlycompatible.


XI. ResourcesandReferencesReferences1. RileyWJ,MoranJW,CorsoLC,BeitschLM,BialekR,&CofskyA.Definingqualityimprovementinpublic

health.JournalofPublicHealthManagement&Practice.2010;16(1):5-7.

2. CentersforDiseaseControlandPrevention,https://www.cdc.gov/healthliteracy/leaders-talk-about-health-literacy.html.

3. NationalAssessmentofAdultLiteracy.Availableathttps://nces.ed.gov/naal/.

SourcesforFiguresAHECQI101,aQualityImprovementcoursesponsoredbyCharlotteAreaHealthEducationCenter.

SimplifiedFailureModeEffectsAnalysis(sFMEA),JamesM.AndersonCenterforHealthSystemsExcellenceatCincinnatiChildren’s,https://www.cincinnatichildrens.org/research/divisions/j/anderson-center.

LangleyGL,MoenR,NolanKM,NolanTW,NormanCL,&ProvostLP.TheImprovementGuide:APracticalApproachtoEnhancingOrganizationalPerformance,2nded.SanFrancisco:Jossey-BassPublishers,2009.

PopulationHealthImprovementPartners,https://improvepartners.org/.

ScovilleR.“MoreAboutMeasurement.”PresentationatNCImpactRegionalLeadershipCollaborative,October22,2012.

SolbergLI,MosserG,&McDonaldS.Thethreefacesofperformancemeasurement:improvement,accountability,andresearch.JointCommissionJournalonQualityImprovement.1997;23(3):135-147.

ST3PUP,acollaborativesponsoredbyPatientCenteredOutcomesResearchInstitute®(PCORI)AwardMCSC-1608-35861TitledAComparativeEffectivenessOfPeerMentoringVersusStructuredEducationBasedTransitionProgrammingForTheManagementOfCareTransitionsInEmergingAdultsWithSickleCellDisease.

TagueNR.TheQualityToolbox,2nded.Milwaukee:ASQQualityPress,2005.


https://www.pcori.org/research-results/2017/comparing-transitional-care-teens-and-young-adults-sickle-cell-disease-and

https://www.pcori.org/research-results/2017/comparing-transitional-care-teens-and-young-adults-sickle-cell-disease-and


FurtherReadingBialekRG,DuffyGL&MoranJW.ThePublicHealthQualityImprovementHandbook.Milwaukee:ASQPress,

2009.

FedericoF.“IsYourOrganizationHighlyReliable?”HealthcareExecutive.2018Jan;33(1):76-79.

LencioniP.TheFiveDysfunctionsofaTeam:ALeadershipFable.SanFrancisco:Jossey-Bass,2002.

NolanT,ResarR,HaradenC&GriffinFA.ImprovingtheReliabilityofHealthCare.IHIInnovationSerieswhitepaper.Boston:InstituteforHealthcareImprovement;2004.

ProvostLPandMurraySK.TheHealthCareDataGuide:LearningfromDataforImprovement.SanFrancisco:Jossey-Bass,2011.

RogersEM.DiffusionofInnovations,5thed.NewYork:FreePress,2003.

ScholtesPR,JoinerBL&StreibelBJ.TheTeamHandbook,3rded.Edison,NJ:OrielIncorporated,2003.

TuckmanBW.“Developmentalsequenceinsmallgroups,”PsychologicalBulletin.1965;63(6):384-399.

TuckmanBWandJensenMC.“StagesofSmall-GroupDevelopmentRevisited,”Group&OrganizationStudies1977;2(4):419-427.

AvailableResourcesAHRQHealthLiteracyUniversalPrecautionsToolkit,https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/index.html

InstituteforHealthcareImprovement,http://www.ihi.org/

HelenOsborne,https://healthliteracy.com/helen-osborne/

PopulationHealthImprovementPartners,https://improvepartners.org/

ReliabilityScience,http://www.ihi.org/Topics/Reliability/Pages/default.aspx


https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/index.html

https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/index.html

www.ihi.org

www.healthliteracy.com/helen-osborne/

http://www.ihi.org/Topics/Reliability/Pages/default.aspx

Appendix


SAMPLEQUALITYIMPROVEMENTPROJECTPROPOSALFORMNameofProjectSubmissionDateTeamMembersProviderorLeadershipChampionDataSourceWhatarethewaysthisdatacanbemeasured?Whatistheevidencethereisaproblem(baselinedataifitexists)?Pleaseattach.

ProjectlocationE.g.department/floor/site

ProjectSharing/ScholarlyWorkWheredoyouwanttosharethisprojectlearning?E.g.nameofconferenceorjournal

ProjectDescription

Why/RationalePleaseincludeareferenceabstractdemonstratingthattheimprovementsproposedareevidence-based

Who/WhereTargetpopulationandlocation

WhatDescribetheimprovementyouwanttomake

HowIdeasforimprovement

WhenTimeframeforproject

DescribethepotentialimpactforthisprojectCheckallthatapply.Addcommentsifnecessary.¨ Improvespatientsafety¨ Decreasesthecostofcare¨ Improvesefficiency/savestime¨ Improvespatientsatisfaction¨ Improvesstaffsatisfaction¨ Improvespatientoutcomes¨ Highteammatebenefit¨ Other


Model for Improvement PDSA Planning Worksheet Team Name: ________________________________________________

Cycle: ____________ Date: ___________________________________

PLAN

Objective for this cycle:

Questions:

Predictions:

Plan for change or test: who, what, when, where:

Plan for collection of data: who, what, when, where:

DO

Carry out the change or test. Collect data and begin analysis. Describe observations, problems encountered, and special circumstances.

STUDY

Complete analysis of data. Summarize what was learned.

ACT Are we ready to make a change? Plan for the next cycle.


PROJECTMEASUREMENTPLAN

AimStatementIncludeherewhatyouplantoimprove,bywhen,theoverallreasonforimproving,andwithwhattools:

Goal MeasureName&OperationalDefinitionWhattypeofmeasure?• Outcome• Process• Balancing

DataCollectionSampleSizeHowmany?

Howwillitbecollected?Process&datacollectioninstrumentstobeused

Howoften?Frequency

Whenwillitbecollected?Timeperiod

Whowillcollect,analyze,&graphthedata?

Notes

Measurement Plan from Population Health Improvement Partners, www.improvepartners.org.

QI Primer: Using Quality Improvement to Improve the Health Care Transition Process

QI Primer: Using Quality Improvement to Improve the Health Care Transition Process

40

44


SUSTAINABILITYCHECKLIST:MAINTAININGYOURSUCCESS

Developingsystemstosustainhighqualitycarerequiresongoingeffort.Maintainingthesesystemsassuresthatallofyourhardworkpaysoffinthelongrun.Usethefollowingchecklisttoassistyouinsustainingyourimprovements.

o Ourseniorleader(s)areinvolvedinkeepingeveryonefocusedonsustainingourimprovements.Theyareknowledgeableabouttheprogramandcommunicateaboutitsimportanceanditsresultsatstaffmeetings,aswellasinformallyday-to-day.

o Wehaveaprogramcoordinatororteamwhoisresponsibleforreviewingourdata,designingongoingimprovements,andfacilitatingcommunicationamongthestaff.

o Wemakesureoursystemsareindependentofthepeopleinvolvedbyinforming/involvingallstaff,makingtrainingpartofournewemployeeorientation,andcross-trainingstaffforcriticalrolesrelatedtotheprogram.

o Weincludecriteriarelatedtotheprograminourrecruitingandhiringpracticestomakesureourcareteamshavetheknowledge,skills,andabilitiesneededtosustainourimprovements.

o Wecommunicateourimprovementstoourpatientsinordertoinvolvetheminsustainingtheimprovementsandcreateadditionalaccountabilityforourprogram.

o Wecreate,adapt,oruseexistingtoolstomakeiteasierforeveryonetofollowtheproceduresandsystemswehaveestablished.

o Wecontinuouslymeasureresultsinordertoknowforourselves:“Isitstillworking?”However,tosimplifymeasurement,onceourgoalsarereachedweshifttoanauditingmode(decreasingthefrequencyandquantityofdatacollected)sothatdatacollectioniseasiertosustain.

o Weshareoursuccesswithallofourstaff,includingsharingsuccessstories,data,andcelebratingourachievements.

Checklist from AHEC QI 101, a Quality Improvement course sponsored by Charlotte Area Health Education Center.


SPREADCHECKLIST

Establishingstructuresandpracticesthatpromoteandsupportsuccessfulspreadofchangesthroughoutyourorganizationisessentialforcontinuousimprovement.Usethischecklisttoassistinspreadingyourimprovements:

ORGANIZATIONo Leadership.Leadership(executives)isengaged;proposedchangesarealignedwith

strategicplan;incentiveshavebeenidentified;anddedicatedtimehasbeenestablishedforimprovementteammembers.

o BetterIdeas.Thecaseforchangeisestablished;datatosupportchangesisavailable;benefitsacrossgroupsareidentified;andstepsinvolvedinadoptingchangesaredocumented.

o Set-up.Keygroupsandtargetpopulationareidentified;rolesforpreviouslysuccessfulteamsareestablished;andclearspreadstrategyisidentified(communicationplan,IT,etc.)

COMMUNICATIONo Communication.Planforraisingawarenessisestablished;communicationchannelsare

identified;andastrategyfortransferringtechnicalknowledgeisselected.

STRENGTHENTHESOCIALSYSTEMo Keymessengers.Thoseresponsibleforexplainingthenewsystemtothetarget

populationareengaged;communitiesofpracticeareestablished;andstrategiestosupportbothgroupsareidentified.

o CommunitiesandTechnicalSupport.Successfulsiteshaveastrategyforhelpingnewteams;necessarytoolsanddocumentstosupportchangearereadilyavailableandorganized,includingstrategiesforovercomingbarriersintargetpopulation

o TransitionIssues.Strategiesforongoingleadershipsupportandconnectiontothefront-lineteamshavebeenidentified.

MEASUREMENT&FEEDBACKo Measurementandfeedback.Aplanformeasurementisestablished,includingstaffingto

supportmeasurementactivitiesandasystemfortwo-waycommunicationandfeedbackisestablished.

KNOWLEDGEMANAGEMENTo KnowledgeManagement.Aplanforcapturing,documentingandorganizingnewlearning

onthechanges,thespreadprocess,andovercomingbarriersisinplace.

Checklist from AHEC QI 101, a Quality Improvement course sponsored by Charlotte Area Health Education Center.



SuggestedCitation:NoonanL,MabusS,IlangoS,SchmidtA,McManusM,ShorrJ,WhiteP.QIPrimer:UsingQualityImprovementtoImprovetheHealthCareTransitionProcess.Washington,DC:GotTransition,TheNationalAlliancetoAdvanceAdolescentHealth,July2020.QIPrimer:UsingQualityImprovementtoImprovetheHealthCareTransitionProcess.Washington,DC:GotTransition,TheNationalAlliancetoAdvanceAdolescentHealth,July2020.

ThisworkwasdoneundertheauspicesofAtriumHealth’sLevineChildren’sCenterforAdvancingPediatricExcellence,fromthecombinedworkof:

• DavidBundy,MD,MPH• DarrenDeWalt,MD,MPH• CaroleLannon,MD,MPH• PeterMargolis,MD,PhD• NorthCarolinaHospitalAssociationQI101/AHECQI101• LloydProvost,MS• GregRandolph,MD,MPH• RichardScoville,PhD• JayneStuart,MPH• MaryWebster,MSN,RN,CPHQ

Dr.LauraNoonanwastheDirectorof“AHECQI101:AToolboxforImprovement”from2004to2017.ThisprogramwasaNorthCarolinaHospitalAssociationandNorthCarolinaAHECsponsoredcourseforhealthcareproviders.Formatwasafive-month,project-basedinteractivecourseinqualityimprovementmethodsandmeasurement.

GotTransition®issupportedbytheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices(HHS)undergrantnumber,U1TMC31756.Thecontentsarethoseoftheauthor(s)anddonotnecessarilyrepresenttheofficialviewsof,noranendorsement,byHRSA,HHS,ortheU.S.Government.

Formoreinformationaboutourworkandavailablepublications,[email protected].

Copyright©2020byGotTransition®.Non-commercialuseispermittedbutrequiresattributiontoGotTransitionforanyuse,copyoradaption.

THENATIONALALLIANCETOADVANCEADOLESCENTHEALTH1615MStreetNW,Suite290,WashingtonDC20036|202.223.1500

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