1 Quality 101 You can do this! Windy Stevenson, MD Medical
Director, Doernbecher Quality Program
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2 How do you feel about QUALITY? Quality is not rocket
science.
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3 How do you feel about QUALITY? Quality is not some lurking
danger to avoid.
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4 Maybe this? Quality is not someone elses job.
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5 This is probably the most common Quality is not about working
harder.
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6 Quality is about this Quality is what we all do every day to
provide the best care to kids and families in the most efficient
way we can. Quality is what we all do every day to provide the best
care to kids and families in the most efficient way we can.
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7 Quality Improvement makes the right thing for the patient
easy and cost effective. It makes your job easier!
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8 If I do my job, by the end of this session, You will get why
quality improvement is important You will understand that quality
improvement is part of your job You will see that you are already
doing it You will OWN one model for facilitating improvement
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9 Why do we care? U.S. outcomes are pitiful for the amount we
spend on healthcare For every dollar the U.S. government spends on
traditional biomedical research, it spends a penny on research to
ensure patients actually receive the interventions identified
through biomedical research Loscalzo J. The NIH budget and the
future of biomedical research. N Engl J Med. 2006; 354: 1665
Traditional models of vigilance and education arent working; Health
care reform will require us to behave differently There is an
urgent need for system improvement NOW
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10 How has quality evolved? 1800s: Quality Assurance-
credentialing, accreditation Did the dog get fed? Who forgot to
feed the dog? 1900s (mid): Statistical Quality Control & CQI-
variations, profiling How many times a week do we forget? Whos the
worst offender? 1900s(late) : Outcomes analysis- systems thinking,
patient focused Is the dog maintaining a healthy weight? Is Johnny
right for the job? Can we make it easy for Johnny to feed the dog?
Is the dog being fed the cats food? 2000s: Rise of Big Management
If we hire a consultant and report our results to the whole
neighborhood, will the dog get fed more often? Today: Quality
Cacophony- seeking the sweet spot of transparency, efficiency,
outcomes, and patient centeredness Does data demonstrate that we
transparently, accountably, efficiently, effectively, safely,
timely, equitably provide canine sustenance in a dog-friendly way?
(Tammy or Anja, can EPIC get me that data? ) Concepts courtesy
Donald Fetterolf, President of the American College of Medical
Quality
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11 Your brain is incredible! Aoccdrnig to rscheearch at
Cmabrigde Uinervtisy, it deosn't mttaer inwaht oredr the ltteers in
a wrod are, the olny iprmoatnt tihng is taht the frist and lsat
ltteer be in the rghit pclae. The rset can be a taotl mses and you
can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid
deos not raed ervey lteter by istlef, but the wrod as a wlohe.
Amzanig huh?
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12 Your brain is incredible! You have (at least) two jobs!
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13 OK. You work, and you improve how you work. Now what? IOM
Dimensions of Quality (STEEEP) For what system issue do you have
passion? Curiosity? What can you try next Tuesday? Dont get
paralyzed by how much there is to do Start before you are ready.
Godfrey et al; clinical Microsystems part 3; The Joint Commission
Journal on Quality and Patient Safety
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14 What is a system? Stop driving the systems to work harder,
and start intentionally creating better systems. Medication
administrationEvening sign-out How do you understand a system?
Every system is perfectly designed to achieve the results it
gets.
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15 Where do you start? You already do this every day!
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16 Lets say we have a new mascot Go! Noon Conference!
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17 But we have an issue Pablo has gained a whole pound in the 6
weeks weve had him!
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18 This is your aim statement: WHY? Aim:
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19 Is our Aim Statement SMART? Specific we chose ONE thing!
Measurable we can prove weve impacted it Actionable there are no
known insurmountable barriers Realistic its within our scope Timely
well do it within a time frame Aim:
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20 WHY? The Doernbecher Purpose
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21 Measurement We MEASURE! Outcomes measures Process measures
Balancing measures When we try to improve a system we do not need
perfect inference about a pre- existing hypothesis: we do not need
randomization, power calculations, and large samples. We need just
enough information to take a next step in learning. Donald Berwick
AIM:
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22 Measurement AIM: Outcomes measures: Are we getting there?
Process measures Are we doing the right things to get there?
Balancing measures Are we messing things up by getting there?
Arrival time DM complic. Routes, departure time HbA1c checks
Breakfast Clinic delays MEASURES : Not everything that can be
counted counts, and not everything that counts can be counted.
Albert Einstein, US (German-born) physicist (1879 - 1955)
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23 Measurement Outcomes measures Process measures Balancing
measures AIM: MEASURES:
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24 Testing Outcomes measures Process measures Balancing
measures MEASURES: TEST: Email reminder not to give Pablo donuts
AIM: No donuts for Pablo.
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25 Testing
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26 Testing Outcomes measures Process measures Balancing
measures MEASURES: TEST: Music Therapy TEST: Email AIM:
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27 Testing Outcomes measures Process measures Balancing
measures MEASURES: TEST: Music Therapy TEST: 2 nd years take over
Pablos fitness program TEST: Email reminder not to give Pablo
donuts AIM:
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28 You dont have to be perfect to be damn good.
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29 Another example- from your work @ DCH
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30 WHY? The Doernbecher Purpose
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31 Dont get paralyzed when theres lots to do
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32 Driving change is not easy
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33 Not all barriers are insurmountable.
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34 Using Six Sigma and Lean methodologies, I will invoke Deming
and Shewarts approaches while conducting a Kaizen event to reduce
the muda through process mapping, aggregate patient-level data, and
reliability analysis to create a standardized deliverable. Be as
smart as you can, but remember that it is always better to be wise
than to be smart - Alan Alda Alan Alda Be as smart as you can, but
remember that it is always better to be wise than to be smart -
Alan Alda Alan Alda I know a way to make this system work better
tomorrow.
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35 Take Home Points Real (sustainable) change comes from
changing systems, not changing within systems Be specific about
what you want to accomplish, and why Focus on patients Start before
you think you are ready Dont get paralyzed by lack of
research-level data or by how much there is to do
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36 What if you want to know more? IHI Open School
http://ihi.org/IHI/Programs/IHIOpenSchool/WhatstheIHIOpenSchool.htm
Call me, page me, email me 4-1321 15763 [email protected]
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37 Remaining slides are extras
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38 Dont get paralyzed!
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39 GO! QUALITY!
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40 Dont get paralyzed when no one else seems to be worried
about doing it right STEVES TRUCK + VAN LETTERING
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41 Dont get paralyzed when there is no $
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42 Maybe this? Quality is not a myth.
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43 Some people think of this Quality is not a bunch of Japanese
words.
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44 Why do we care? HBR Jeff Levin-Scherz April 2010
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45 So, what do we do? Start small Keep it simple Learn together
Realize our power
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46 What are we aiming for? IOM (Institute of Medicine)
dimensions STEEEPSafe, Timely, Effective, Efficient, Equitable, and
Patient-centered Safe: This means much more than the ancient maxim
"First, do no harm," which makes it the individual caregivers
responsibility to somehow try extra hard to be more careful (a
requirement modern human factors theory has shown to be
unproductive). Instead, the aim means that safety must be a
property of the system. No one should ever be harmed by health care
again. Timely: Unintended waiting that doesnt provide information
or time to heal is a system defect. Prompt attention benefits both
the patient and the caregiver. Effective: It should match science,
with neither underuse nor overuse of the best available
techniquesevery elderly heart patient who would benefit from
beta-blockers should get them, and no child with a simple ear
infection should get advanced antibiotics. Efficient: constantly
seeking to reduce the wasteand hence the costof supplies,
equipment, space, capital, ideas, time, and opportunities.
Equitable: Race, ethnicity, gender, and income should not prevent
anyone in the world from receiving high-quality care. We need
advances in health care delivery to match the advances in medical
science so the benefits of that science may reach everyone equally.
Patient-centered: The individual patients culture, social context,
and specific needs deserve respect, and the patient should play an
active role in making decisions about his or her own care. That
concept is especially vital today, as more people require chronic
rather than acute care.
