View
222
Download
2
Tags:
Embed Size (px)
Citation preview
Quality Quality Improvement Improvement
MethodsMethodsGreg Randolph, MD, MPHGreg Randolph, MD, MPH
Healthcare Quality Healthcare Quality DefinedDefined
” ”The degree to which health The degree to which health services for individuals and services for individuals and
populations increase the populations increase the likelihood of desired health likelihood of desired health
outcomes and are consistent with outcomes and are consistent with current professional knowledge.”current professional knowledge.”
--Institute of Medicine, 2001--Institute of Medicine, 2001
ExerciseExercise In pairs, define Quality In pairs, define Quality
Improvement (3 minutes)Improvement (3 minutes) Be prepared to share (2 Be prepared to share (2
minutes)minutes)
UNC Pediatrics Residency UNC Pediatrics Residency QI Program QI Program
“A systematic approach of measuring and identifying gaps between actual and desired quality of care and applying tools and improvement methods (e.g., PDSA cycles) to make changes to the system that result in measurable improvements (i.e., closing the gap)”
Quality Improvement Quality Improvement FocusFocus
Patient-centeredPatient-centered - care that is responsive to - care that is responsive to patient preferences, needs, valuespatient preferences, needs, values
EffectiveEffective - providing services based on - providing services based on scientific knowledge to all who could benefit scientific knowledge to all who could benefit and refraining from providing to those not and refraining from providing to those not likely to benefit likely to benefit
EquitableEquitable - providing care that does not vary - providing care that does not vary in quality because of personal characteristicsin quality because of personal characteristics
TimelyTimely - reducing waits and delays for care - reducing waits and delays for care EfficientEfficient - avoiding waste - avoiding waste SafeSafe - avoiding injuries to patients from care
--Institute of Medicine, 2001--Institute of Medicine, 2001
Fundamental Questions for Fundamental Questions for ImprovementImprovement
What are we trying to What are we trying to accomplish?accomplish?
How will we know that a How will we know that a change is an improvement?change is an improvement?
What changes can we make that What changes can we make that will result in an improvement?will result in an improvement?
Model for ImprovementModel for Improvement AimAim
MeasuresMeasures
Ideas/Change Ideas/Change ConceptsConcepts
What are we trying to accomplish?
How will we know that changes are an improvement?
What changes can we make that will result in
an improvement?
Model for ImprovementModel for Improvement
AIMAIM: : What are we What are we trying to accomplish?trying to accomplish?
MEASURESMEASURES:: How will we know that How will we know that changes are an changes are an improvement?improvement?
IDEASIDEAS:: What changes can What changes can we make that will result in we make that will result in an improvement?an improvement?
What is an Aim Statement?What is an Aim Statement?
AimAim:: A written statement of the A written statement of the accomplishments expected accomplishments expected
from from improvement effortimprovement effort
Key components:Key components: A general description of aim - should answer, “what are A general description of aim - should answer, “what are
we trying to accomplish?”we trying to accomplish?”
Rationale/importance Rationale/importance
Some guidance for carrying out the work Some guidance for carrying out the work
Specify target population and time periodSpecify target population and time period
Measurable goalsMeasurable goals
Goals Should Be:Goals Should Be:
MeasurableMeasurable NumericNumeric Preferably absolute rather than Preferably absolute rather than
relative relative
A stretch, not business as usualA stretch, not business as usual Achievable, not impossibleAchievable, not impossible
ExerciseExercise In pairs, critique aim In pairs, critique aim
statement – are key statement – are key components present (3 components present (3 minutes)minutes)
Then pick a problem and write Then pick a problem and write your own (5 minutes)your own (5 minutes)
Be prepared to share (2 Be prepared to share (2 minutes)minutes)
Model for ImprovementModel for Improvement
AIMAIM: : What are we trying to accomplish?What are we trying to accomplish?
MEASURESMEASURES: : How will we know that How will we know that changes are an changes are an improvement?improvement?
IDEASIDEAS: : What changes can we make What changes can we make that will result in an that will result in an
improvement?improvement?
Project MeasuresProject Measures
Goal
Project MeasuresProject Measures
The question: The question: How will we know that a How will we know that a change is anchange is an improvement? - improvement? - usually requires usually requires more than one measure. more than one measure.
A balanced set of measures helps assure that A balanced set of measures helps assure that the the systemsystem is improved: is improved: Related to aim’s measurable goalsRelated to aim’s measurable goals
Easy to collectEasy to collect
Show improvement quickly and include outcomesShow improvement quickly and include outcomes
Can display them graphically over timeCan display them graphically over time
Run charts Run charts
Balancing MeasuresBalancing Measures
Are we improving parts of our Are we improving parts of our system at the expense of others? system at the expense of others?
Usually not one of goalsUsually not one of goals
Great source is to listen to Great source is to listen to skeptics… “Yes, but…”skeptics… “Yes, but…”
Example of Measure SetExample of Measure Set
The delay for routine appointmentsThe delay for routine appointments
% of patient visits with the patient’s primary % of patient visits with the patient’s primary clinician clinician
Practice average cycle timesPractice average cycle times
% of patients rating the overall visit as excellent % of patients rating the overall visit as excellent
% of visits that are “no show/missed”% of visits that are “no show/missed”
Usual Display of Usual Display of MeasuresMeasures
0102030405060708090
100
Imm Rate
Before
After
QI Measures: Annotated QI Measures: Annotated Run ChartsRun Charts
Reduced appt
delays
Reminder system
Practice wide guidelines
Clinician education
Model for ImprovementModel for Improvement
AIMAIM: : What are we trying to What are we trying to accomplish? accomplish?
MEASURESMEASURES: How will we know that : How will we know that change is change is an improvement? an improvement?
IDEASIDEAS: : What changes can we make What changes can we make that will result in that will result in
an an improvement?improvement?
““PDSA Cycles”PDSA Cycles”
PDSA Cycles help teams adapt good PDSA Cycles help teams adapt good ideas to their specific situation:ideas to their specific situation: Force us to think smallForce us to think small
Force us to be methodical, make Force us to be methodical, make predictionspredictions
Allow rapid adaptation and Allow rapid adaptation and implementation of changes in busy implementation of changes in busy healthcare settings healthcare settings
The PDSA Cycle
Act Plan
• What changes are to be made?
• Next cycle?
• Objective• Questions and
predictions • Plan to carry out the
cycle (who, what, where, when)
Study Do• Complete the
analysis of the data• Compare data to
predictions•Summarize what was learned
• Carry out the plan• Document problems
and unexpected
observations
Example PDSA Cycle
Changes to bemade: Test 2 more days- Dr. R on time; nurse to bring charts for prescheduled
Objective: Test huddlesQuestions: Will they uncover capacity? Prediction: Yes Plan: Dr. R care team, huddle 5 mins in AM for 2 days at schedule
4 unused visits identified; took 15 minutes due to late arrivals; charts would be helpful
Mon and Tues - document problems, Unexpected observations; count uncovered capacity
Act Plan
Study Do
Key Points for PDSA CyclesKey Points for PDSA Cycles
Do initial cycles on smallest scale possibleDo initial cycles on smallest scale possible
Think baby steps…a “cycle of one” usually bestThink baby steps…a “cycle of one” usually best ““Failed” cycles are good learning opportunities when Failed” cycles are good learning opportunities when
small small
Successful testsSuccessful tests
As move to implementation, test under as many As move to implementation, test under as many conditions as possibleconditions as possible
Special situations (e.g., busy days)Special situations (e.g., busy days)
Factors that could lead to breakdowns (e.g., different staff or Factors that could lead to breakdowns (e.g., different staff or physicians involved)physicians involved)
Things “naysayers” worry about (e.g., “It will not work when Things “naysayers” worry about (e.g., “It will not work when Dr. Noonan is not here”)Dr. Noonan is not here”)
Questions?Questions?