Fundamentals Fundamentals of Quality of Quality

ImprovementImprovementLisa Price, MDLisa Price, MD

AgendaAgenda

Why does quality matter?Why does quality matter?Brief detour into history of Brief detour into history of

quality managementquality managementPrinciples of quality Principles of quality

management and how does it management and how does it apply to the world of medicineapply to the world of medicine

Why does quality Why does quality matter?matter?

Institute of Medicine 2000Institute of Medicine 2000 CO + UT and NY studies– adverse events 2.9 and CO + UT and NY studies– adverse events 2.9 and

3.7% of hospitalizations3.7% of hospitalizations ‘‘97 there were 33.6 mil admissions97 there were 33.6 mil admissions Observed adverse events resulted in death 6.6 – Observed adverse events resulted in death 6.6 –

13.6% of time. Extrapolated 44,000 to 98,000 13.6% of time. Extrapolated 44,000 to 98,000 deaths every year due to medical errordeaths every year due to medical error

88thth leading cause of death leading cause of death Ahead of AIDS, breast cancer and MVA’sAhead of AIDS, breast cancer and MVA’s

Why does quality Why does quality matter?matter?

Population Health

Per capita costExperience of care

The Triple Aim=SurvivalThe Triple Aim=Survival

What is Quality?What is Quality?

qual-i-tyqual-i-tyAn inherent or An inherent or

distinguishing distinguishing characteristiccharacteristic

A degree or grade of A degree or grade of excellenceexcellence

A Brief History of Quality A Brief History of Quality ManagementManagement

Shewhart Deming Ohno

What are the principles of Quality What are the principles of Quality Management and how do they Management and how do they

apply to the world of medicine?apply to the world of medicine?

1. Work is a series of 1. Work is a series of processes.processes.

supplier processor customer

Who is your customer?

2. 2. Strong supplier-customer Strong supplier-customer relationships are critical for good relationships are critical for good quality managementquality management

3. The majority of quality 3. The majority of quality failure is due to a problem failure is due to a problem

in the process.in the process.

Why Do Errors Occur?Why Do Errors Occur?

Questions to AskQuestions to Ask Has this happened before?Has this happened before? Would another person have done the same Would another person have done the same

thing?thing? Could this have been anticipated?Could this have been anticipated?

If “yes” to any of these = System ErrorIf “yes” to any of these = System Error

94% of errors belong to the system94% of errors belong to the system Responsible people are necessary but not Responsible people are necessary but not

sufficient to ensure quality in complex sufficient to ensure quality in complex systemssystems

4. Poor quality is 4. Poor quality is expensive.expensive.2 types of quality improvement - 2 types of quality improvement -

improve features and reduce defectsimprove features and reduce defects

Defects/errors result in costsDefects/errors result in costs Discarding defective productDiscarding defective product Costly surveillance programsCostly surveillance programs ReworkRework Workarounds add complexity and not valueWorkarounds add complexity and not value Dissatisfied customers result in loss of Dissatisfied customers result in loss of

market sharemarket share LitigationLitigation

5. Understanding process 5. Understanding process variability is key.variability is key.

True understanding of a processTrue understanding of a process

Ability to separate out change in Ability to separate out change in outcome due to process change from outcome due to process change from “noise”“noise”

Unpredictable processes are Unpredictable processes are inherently flawedinherently flawed

6. Quality control should 6. Quality control should focus on the most vital focus on the most vital processes.processes.

Creation of “robust” processes at Creation of “robust” processes at critical steps can dramatically critical steps can dramatically improve quality.improve quality.

Resources are finite. How do you Resources are finite. How do you identify where to get the most “bang identify where to get the most “bang for your buck?”for your buck?”Value stream mapping - documents Value stream mapping - documents

steps in a process, how long each steps in a process, how long each takes, and identifies wastetakes, and identifies waste

7. Fundamentals of quality 7. Fundamentals of quality improvement are basic improvement are basic scientific thinking.scientific thinking.

8. Universal employee 8. Universal employee involvement is critical.involvement is critical.Quality Committee Culture Quality Committee Culture

of Qualityof Quality

Train all employees on basic quality Train all employees on basic quality methods and empowering them to methods and empowering them to identify waste and create solutions.identify waste and create solutions. Steering committeesSteering committees Project teamsProject teams Work done across departments and levelsWork done across departments and levels

SummarySummary

Errors most often come not from workers Errors most often come not from workers but systems. A culture of blame, shame but systems. A culture of blame, shame and exhortations to be “more careful” will and exhortations to be “more careful” will not improve the system.not improve the system.

QI is a managerial science guided by theory, QI is a managerial science guided by theory, statistics and psychologystatistics and psychology

It is the continuous search for small It is the continuous search for small opportunities to reduce waste, rework and opportunities to reduce waste, rework and unnecessary complexityunnecessary complexity

The greatest asset of any system is its The greatest asset of any system is its human thinkers, who with proper leadership human thinkers, who with proper leadership can identify these opportunities and actcan identify these opportunities and act

Next Steps-QI In ActionNext Steps-QI In Action

1. Understand the problem1. Understand the problem

2. Identify areas of improvement2. Identify areas of improvement

3. State the goal3. State the goal

4. Implement the change4. Implement the change

5. Measure5. Measure

6. Hold the gain and extend the 6. Hold the gain and extend the improvement.improvement.

Health Care Problem Addressed

Names of Team Members

1.Understanding the Problem

What do you already know about the problem?

What is the BUSINESS DRIVER behind the problem?

Are you aware of any data available about your problem?

What has been your experience with the problem?

Who are the stakeholders in this process?

Use a Cause-and-Effect Diagram to describe your problem in more detail

Cause-and-Effect diagram

Materials and Equipment People and management

Environment Process

Effect

2.Identify Areas for Improvement

Looking back at your cause and effect diagram, what are areas for improvement?

Which areas could result in the most change if improved?

What would the ideal process look like?

3. Measuring progress

What are the metrics that can help you assess improvement for your process?

4. Explicitly State Your Goals

Remember: they should result in meaningful improvement, they should be something that you really could influence,  and should be non-controversial.

State your goals in SMART format. Specific Measurable Attainable Relevant Time-bound

5. Effective Solutions

What are the solutions that can effect the changes/improvement you are hoping to achieve?

Remember, usually more than one change is needed and try to prioritize stronger intervention.

6.Building on Success

How could improvement be sustained long term?