Introduction to Quality Improvement

Author: Nazanin Meshkat MD, FRCPC, MHSc, Assistant Professor, University of Toronto

Date Created: September 2011

Global Health Emergency Medicine Teaching Modules by GHEM is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

“Every system is perfectly designed to get the results it gets”

Objectives

To gain an understanding of what quality improvement is

To present the Model for Improvement and PDSA cycle

To introduce measurement in quality improvement

To introduce flowcharts

What is Quality Improvement?

A formal approach to the analysis of performance and systematic efforts to improve it Different from Quality Assurance

Quality Improvement versus Quality Assurance

Quality Improvement Quality Assurance

What can we do to improve? What went wrong?

Proactive Reactive

Avoids blame Often Punitive

Fosters System change Tries to find who was at fault

Focuses on the entire system

Focuses on the specific incident

What is quality?

Definition of quality depends on stakeholders The client/customer (the patient) The provider/employer (health care providers) Management (hospital management) Payer (Ministry of Health)

6 Pillars of Quality

Safety Timely Access Equitable Efficacy Efficient Patient Centered

“Every system is perfectly designed to get the results it gets”

How can you improve a system to achieve better results in the 6 pillars of quality?

To improve a system…

You need a good understanding of the system

You need to understand where it is failing - Identify what is wrong Make sure it is the step that needs fixing

Then you can implement a change to the “system”

What is a system?

System = any assembly of procedures, resources and routines to carry out a specific activity

System

To understand a system and identify what is wrong with it Map it out!

How do you map out a system?

Use a flow chart/diagram

Use different perspectives (a doctor’s perspective is different to a nurse’s or a porter’s to a patient’s perspective)

Quality Improvement Models

Model for Improvement = Three questions + PDSA cycle FADE = Focus, Analyze, Develop, Execute and Evaluate Six Sigma CQI = Continuous Quality Improvement TQI = Total Quality Management 7 step method

Model for Improvement = Three questions + PDSA cycle

The Three Questions

The Model for Improvement begins with three fundamental questions

1. The Aim: What are we trying to accomplish? (How good do we want to get and by when?)

2. The Measures: How will we know a change is an improvement?

3. The Changes: What change can we make that will result in improvement?

PDSA Cycle

Plan a change Do the change Study the results Act on the results

STUDY

ACT PLAN

DO

PDSA Cycle

Enables rapid testing and learning Allows for incremental testing Instead of spending weeks or months

planning out a comprehensive change, then putting it into practice only to find that it is fundamentally flawed

PDSA Cycle

Can aid you in: Developing a change Testing a change Implementing a change

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

MODEL FOR IMPROVEMENT

STUDY

ACT PLAN

DO

Executing the Model for Improvement

Let’s do an example

The Problem

Patient’s at Black Lion’s Hospital emergency department are often in pain

We want to change that

Ehm…how do we do that?

Executing the Model for Improvement Form a team Three Questions: The

Aim, The Measures, The changes

Test changes - PDSA Cycle

Implement changes that work

Spread the changes to other areas

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

You need a team

Why? Need different

perspectives It’s a lot of work Increased buy-in by

staff Different levels of

support (e.g. management)

To come up with the right team you have to have an idea of what your aim is…

The Aim

What are we trying to accomplish?

The Aim

A strong, measurable aim with a clear time frame will help keep your project on course

It has to be important to those involved

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

The Aim

A good aim: Is Specific Is Measurable Determines a time frame Addresses who the change is for, and what

has to be achieved Is Sustainable

The Aim

I will become a good runner

I will run 10 kilometers per week by May 31st

I will run more often

The Aim

Back to the Problem: Patients at Black Lion’s Hospital emergency department are often in pain

We decide to focus on emergency department patients with fractures

The Aim

All emergency department patients with fractures

We will provide analgesia to 100% of our pts with a suspected fracture within 15 minutes of arrival to the emergency department by the end of December 2011.

Choose your team

Choose your team

Consider the system that relates to the aim i.e. what processes will be affected by the improvement efforts

Involve members familiar with all different parts of processes

Back to our example All emergency department

patients with fractures

We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011.

What processes will be affected?

Back to our example All emergency department

patients with fractures

We will provide analgesia to 100% of our patients with a suspected fracture within 15 minutes of arrival to the emergency department by the end of June 2011.

What processes will be affected? Nursing/Triage Pharmacy Stocking Doctors Registration ED chief/director/

manager

Choose your team

Effective teams require three kinds of expertise System leadership Clinical -Technical expertise Day to day leadership - Project leader

Your team

Team leader: Medical director of the emergency department

Technical expert: Hospital Quality Management member

Day to day leader (project leader): an emergency doctor or nurse

Additional team members: pharmacist, person responsible for stocking, charge nurse, registration clerk

Revisit the Aim

Once you have chosen your team, review and modify the aim based on their input

Measurement

How will we know that a change is an improvement?

Measurement

Measurement is critical for testing and implementing changes

Different from measurement for research

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

MeasurementMeasurement for Research

Measurement for Improvement

Purpose To discover new knowledge To bring new knowledge into daily practice

Tests One large blind test Many sequential, observable tests

Biases Control for as many biases as possible

Stabilize the biases from test to test

Data Gather as much data as possible, just in case

Gather just enough data to learn and complete another cycle

Duration Can take a long time Short duration

Measurement

3 types of measures for quality improvement Outcome measures Process measures Balancing measures (+/- Structure Measures)

Outcome Measure

= Where are we ultimately trying to go Are your changes actually leading to

improvement

Process Measures

= Are we doing the right things to get there?

To affect an outcome you have to improve your processes

Are the parts/steps in the system performing as planned

Balancing Measures

Tells you if changes designed to improve one part of the system are causing new problems in other parts of the system

Structure Measures

“Physical” measures Human resources, equipment, facilities

Often included in Process Measures

Measurement

For any improvement project you want to identify a family of measures

Measurement

Aim = Decrease sepsis mortality by 20% by January 2011

Outcome Measure Process Measure Balancing Measures

Measurement

Aim = Decrease sepsis mortality by 20% by January 2011

Outcome Measure

Process Measure Balancing Measures

Mortality rates -Time it takes to register and triage-% of patients being appropriately triaged-Time from triage to initiation of resuscitation-% of patients getting properly fluid resuscitated-% of patients getting antibiotics-Availability of medications and supplies-Time to antibiotics-Delay to getting to hospital

Costs

Neglect of other patients (e.g. increase in mortality for another patient population)

(e.g. increase in time to be seen for other patients)

The Change

What change can we make that will lead to improvement?

Developing Changes

Depends what you are trying to change

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

Basic techniques

Critical Thinking Flow Chart/Diagram

Benchmarking Compare to best practice

Using Technology Barcodes for medications

Creative Thinking Become a patient for a day

Using Change Concepts

Basic techniques

Critical Thinking Flow Chart/Diagram

Benchmarking Compare to best practice

Using Technology Barcodes for medications

Creative Thinking Become a patient for a day

Using Change Concepts

Critical Thinking

Use a Flow Chart/Diagram

A flow chart allows to “visualize” the system you are trying to change

Allows ALL to see the system the same way

Flow Chart/Diagram

It helps to clarify complex processes

It identifies steps that do not add value to the internal or external customer, including:  Delays Needless storage and transportation Unnecessary work, duplication, and added expense Breakdowns in communication

Flow Chart/Diagram

It helps team members gain a shared understanding of the process and use this knowledge to collect data, identify problems, focus discussions, and identify resources.

It serves as a basis for designing new processes.

Flow Chart/Diagram

High-level flowchart, showing six to 12 steps, gives a panoramic view of a process

Detailed flowchart is a close-up view of the process, typically showing dozens of steps. These flowcharts make it easy to identify rework loops and complexity in a process.

Example: High Level Flow Chart

From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart

Example: Detailed Flow Chart

From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart

Change Concepts

Eliminate Waste - an activity or resource that does not add value

Improve Work Flow

Optimize Inventory - is your work being held up because items are not properly organized or available

Change Concepts Change the Work Environment (does the work

culture enhance or impede change)

Manage Time

Focus on Variation - what aspect of the system vary and make your outcomes unpredictable

Focus on Error Proofing (checklist)

Testing Changes: PDSA Cycle

All improvement will require change, but not all change will result in

improvement.

Testing Changes

Why test changes (even if they are already proven elsewhere)? To learn how to adapt the change to the

particular conditions in your setting To evaluate the costs and side effects To minimize resistance when implementing the

change in the organization Increase your belief that the change will result

in improvement

PDSA Cycle

Plan Objectives Questions and

predictions Plan to carry out

the cycle (who, what, where, when)

Plan for data collection

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

PDSA Cycle

Do Carry out the plan Document

problems and unexpected results

Begin Analysis

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

PDSA Cycle Study

Complete analysis of the data

Compare data to prediction

Summarize what was learned

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

PDSA Cycle Act

What changes are to be made

Next cycle?

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

Testing Changes

Much can be learnt

from a failed test

PDSA

PDSA

PDSA

PDSA

PDSA

STUDY

ACT PLAN

DO

STUDY

ACT PLAN

DO

STUDY

ACT PLAN

DO

What happens when you identify what works?

Are you done?

How easily is change adopted?

Process of “Normalization”

People have a tendency to fall into old habits

People have a tendency to resist change

People may feel threatened by a change

Executing the Model for Improvement Form a team Three Questions: The

Aim, The Measures, The changes

Test changes - PDSA Cycle

Implement changes that work

Spread the changes

The Aim

The Measure

The Change

STUDY

ACT PLAN

DO

Implementation

Implementation

Usually comes after a series of successful tests

It requires that staff and leaders build the change into formal plans, job definitions, training, and explicit reviews

The change does not depend on the individuals doing the work, but on the way the work is organized - as part of the system.

Implementing Change

“Hard-wire” the change into the system

Hardwire Change

Market your change Train everyone involved Make changes to job descriptions, policies, procedures, forms Addressing supply and equipment issues Assigning day-to-day ownership for the maintenance of the

new process Have senior leaders remove any barriers

Social System Social System - understand the relationship among the

people who will be adopting the new ideas

Remember there is an emotional component to change Stress of learning and executing something new Initial disruption to workflow Maybe they feel their job/position is threatened

Social System Those who are supportive

Enlist on your side

Those who are not supportive Don’t try to change their attitude Listen to what concerns them, identify barriers

Those who don’t really care, and will follow when others do

Implementation

PDSA in Pilot Phase

PDSA in Implementation Phase

Support Requirements Low High

Tolerance for failure High Low

Number affected by a test Low High

Resistance Low Potentially high

Time for each cycle Short Longer

Summary

In this modules we have presented an introduction to: Quality Improvement The Model of Improvement

3 questions (What is your aim, measures, change) and PDSA cycle

Types of Measures Change and Implementation

References: Institute of Healthcare Improvement http://www.ihi.org/Pages/default.aspx Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical

Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996;60.

Deming WE. The New Economics for Industry, Government, and Education.2nd ed. Cambridge, MA: MIT Center for Advanced Engineering Study; 1994. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996:6-7.

Using the Model for Improvement. In: Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009:89-108.

Accelerating the pace of improvement: interview with Thomas Nolan. Journal of Quality Improvement. 1997;23(4).

Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619-622. Lloyd R. Quality Health Care: A Guide to Developing and Using Indicators. Sudbury, MA: Jones and

Bartlett Publishers; 2004. Moen R, Nolan T, Provost L. Quality Improvement Through Planned Experimentation. 2nd ed. New

York, NY: McGraw-Hill Companies; 1998. The Improvement Handbook. Austin, TX: Associates in Process Improvement; 2005.