Identifying ProblemsRebecca S. (Suzie) Miltner, PhD, RNAssociate Professor, School of Nursing
Six Broad Aims of Quality Health Care S Safe T Timely E Effective E Efficient E Equitable P Patient-centered
Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
19601970198019902000200120022003200420052006200720082009201020112012$0
$1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000
$147 $356 $1,112
$2,851
$4,884 $5,240
$5,687 $6,131
$6,504 $6,900
$7,271 $7,651 $7,933 $8,157 $8,411 $8,658 $8,925
NOTE: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas and their dependents. SOURCE: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see National Health Expenditures by type of service and source of funds; file nhe12.zip); Gross Domestic Product data from Bureau of Economic Analysis, at http://bea.gov/national/index.htm#gdp (file gdplev.xls).
How Much Do We Spend?National Health Expenditures per Capita, 1960-2012
NHE as a
Share of GDP
5.0% 7.0% 8.9% 12.1% 13.4% 14.1% 14.9% 15.4% 15.5% 15.5% 15.6% 15.9% 16.4% 17.4% 17.4% 17.3% 17.2%
Avoiding underuse (e.g. not screening a person for high blood
pressure)
Avoiding overuse (e.g. performing tests that a patient doesn’t need)
Eliminating misuse (e.g. providing medications that may have
dangerous interactions)
Reducing Variation in Care
Putting a percentage of Medicare dollars at risk
By 2017, at risk = 6%3 areas of focus:
Value Based Purchasing Readmissions Hospital acquired conditions
The Impact of CMS Changes
Healthcare is almost 18% of the GDP and is headed for 20% of the GDP by 2020.
We can lower payments or pay for fewer services.
Or we could eliminate waste.
What can we do to reduce costs?
OvertreatmentFailures of care coordinationFailures in execution of care processes
Administrative complexityPricing failuresFraud and abuse
Six Categories of Waste
The waste that comes from subjecting people to care that cannot possibly help them.
Estimated waste: 158-226 billion/year
Overtreatment
The waste that comes when people, especially those with chronic illness-fall through the cracks.
Estimated waste: 25-45 billion/year
Failures of care coordination
The waste that comes with poor execution or lack of adoption of best practices.
Estimated waste: 102-154 billion/year
Failures in execution of care processes
The waste that comes when we create our own rules that force people to do things that make no sense.
Estimated waste: 107-389 billion/year
Administrative processes
The waste that comes when prices migrate far from the actual costs of production plus fair profits.
Estimated waste: 84-178 billion/year
Pricing failures
The waste that comes when thieves issue fake bills and run scams as well as the inspection and regulation costs due to these thieves.
Estimated waste: 82-272 billion/year
Fraud and Abuse
Lots of opportunity in the system…
Lots of opportunity in the system…
Undergraduate HonorsNursing Students
One semester project
Big problems:1. Unnecessary Caths2. No pericare documented3. No insertion note4. No Stat Lock
Big problems:1. Unnecessary Caths2. No pericare documented3. No insertion note4. No Stat Lock
Intervention:Educate the (day shift) staff.
Results
Lots of opportunity in the system…But what about things that WE can
fix?
Problem IdentificationWhat is the problem?
Where does it come from (up or down)?
How do you define it?
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Problem IdentificationHow do you feel about it?
What data do you have about your problem?
What will you do about it?
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Usual Ideas to Fix a ProblemWe need more people
We need more money
We need more time
We need to make people work harder
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Where ideas to fix problems comes from
Transformational Big changes Culture shift Usually top-down
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Where ideas to fix problems comes from
Transformational Major changes Culture shift Usually top-down
Incremental Small changes Slight change in a procedure to improve efficiencies Sometimes unnoticed by management
Barriers to Problem Solving
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Looking for perfection
Fear of failure
Gathering Data to Understand a Process: Suggested Steps
1. Observe processes (formal and informal)
2. Interview key personnel (voice of the customer)
3. Create a process map
4. Collect data
Observe the Process
Process Observation
Process Observation Worksheet
Data collection tool Determine time for and between
steps Time to complete a step (duration) Distance traveled (steps)
Standardized Ensure data is complete Reliable and Repeatable
Process Observation Worksheet Example
Process Observation WorksheetProcess: Patient check-in
Step # Description DistanceClock Time
Task Time
Wait Time Observations
0:001 Patient arrives 0:10 0:102 Clerk requests ID 0:13 0:033 Patient registered (Y/N) N
3A Patient sent to HBU 575 0:15 0:023B HBU registers patient 0:47 0:32 0:20
4 Appointment (Y/N) 575 N4A Make walk-in appointment 0:50 0:03
5 Check patient in 0:52 0:026 Patient sent to waiting room 100 0:56 0:04
Enter time that step was completed.
Distance traveledIn steps
Task time calculatedlater…
Intrapartum Nursing Observation Tool Check sheet to
record observed interventions
Twenty-three specific interventions and other categories
Observed care for 30 seconds and recorded data during next 30 seconds
All interventions observed were recorded
Kappa .95
In Pt Room 1 1 1 1Surv-HxSurv-MVSSurv-EFM 1 1Surv-Med EffectsSurv-post-epiSurv-Fetal ResusOther Surv 1IC-Document 1 1 1IC-Proc PrepIC-Assist HCP 1 1IC-Discuss HCP 1Other IC 1Info-RelaxInfo-PainInfo-FetusInfo-ProceduresInfo-PushingOther InfoEmo-PresenceEmo-coachEmo-PraiseEmo-EncourageOther Emo 1 1 1
Spaghetti DiagramsAlso known as a movement or
transportation diagram Shows the pattern of movement of
staff, patient, or objectVisually displays movementHelps identified unnecessary
movementGuides space redesign
Hagg- Woodbridge 2008
Spaghetti DiagramClinic 5 Room Turnover Project
Exam Room
Exam Room
Exam Room
Exam Room
Exa
m R
oom
Exam Room
Exam Room
RN Station
Exam Room
Exam Room
Exam Room
Exam Room
Exam RoomE
xam
Roo
m
Exa
m R
oom
Exa
m R
oom
Check-in
ProviderCharting
Procedures
Calls Patient
“6+ Miles per Day”
Voice of the Customer
Voice of the CustomerOne of the first steps in
understanding the problem: Understand what the customer values
Customers are: Patients and their families Other stakeholders (e.g., community,
Board of Directors, etc.) Internal users of the service
Example from IAD projectFor nursing staff (MICU and 5M):1. If you have an incontinent patient, what
makes it hard to take care of them?2. If you have an incontinent patient, what
makes it easier to take care of them?3. In a perfect world, what do you need to
take care of them?4. Do you have any special interventions
(things you do, “tricks”) that you use to take care of incontinent patients?
Example from IAD projectFor Physicians:1. What is your involvement in managing patients with incontinence?
2. How does incontinence affect your plan of care for the patient?
Questions for PatientsWe are working on a project to improve the way we
take care of patients who have problems with toileting while they are in the hospital.
1. Since you have been here, have you had a problem getting to the bathroom or using the bedpan or urinal in time?
2. While you have been here, what are the nurses or doctors doing to help you manage this problem?
3. What seems to be working?4. What seems not to work?5. What suggestions do you have that would make
this better for you?
Map the Process: next topic
Collect Data: throughout the QA!
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Skills Exercise: Problem Identification
Get in groups of 5-6 people and discuss the case study.Consider the following questions: What problem are you facing? How do you feel about it? What data do you have about your problem? What additional data do you need? What are your data telling you? What will you do about it?
Problem StatementsAfter gaining understanding,
describe the problem, opportunity or objective in concise, measurable terms.
Include a summary of the problem and the impact (aka the “PAIN”)
Problem StatementsA brief description of the problem
and the metric used to describe the problem
Where the problem is occurring by process name and location
The time frame over which the problem has been occurring
The size or magnitude of the problemhttp://www.dummies.com/how-to/content/how-to-write-a-problem-statement-for-six-sigma.html
Problem Statements Poor Problem Statement: Human
resources is taking too long to fill vacancies. Better Problem Statement: Recruiting
time for registered nurses on the medical surgical units at UAB is over 120 days when the stated goal is 60 days. With an average of 50 med/surg vacancies a month, this delay is adding $27,000 per month in overtime and contractor labor, and may result in poorer continuity of care and increased errors.
Example Problem Statement Low mobility is common among
hospitalized patients and is associated with adverse outcomes.
Example Problem Statement Low mobility (defined as bed and bed to chair
activity only) is common among hospitalized patients and is associated with adverse outcomes including functional decline and increased community care needs. In a study at the BVAMC, geriatric hospitalized patients spend an average of 83% of the time lying in bed. This can lead to acute decline in functional status rendering the patient dependent in ambulation which can lead to increased LOS. Financial data suggests an opportunity for improvement as well as there is > $41,000 per quarter spend on home health PT after hospitalization
Skills Exercise: Problem Identification
Using your work from the previous case study, WRITE a problem statement.
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An important thing to consider….
Readiness for change
Be aware of the organization’s readiness to change Is the timing right?Do you have support of leadership?Do you have resources?Does your team think they can do
it?
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Readiness for Change
Organizational Change influenced by:Commitment to change
Capability to change (change efficacy)
Weiner, BJ (2009). A theory of organizational readiness for change.
Adapted from Weiner, BJ (2009). A theory of organizational readiness for change.
Possible Contextual Factors
•Organizational Culture•Policies and Procedures•Past Experiences•Organizational Resources•Organizational Structure
Change Valence(Value of Change)
Capability•Task Demands•Resource Perceptions•Situational Factors
Organizational Readiness for Change•Change Commitment•Change Efficacy
Change Related Effort•Initiation•Persistence•Cooperative Behavior
Implementation Effectiveness
Organizational Readiness for Change
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