Introduction to Quality Improvement

Author: Nazanin Meshkat MD, FRCPC, MHSc, Assistant Professor, University of Toronto Date Created: September 2011

Global Health Emergency Medicine Teachi ng Modules by GHEM is license d 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 Avoids blame Fosters System change Focuses on the entire system Reactive Often Punitive Tries to find who was at fault 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 doctors perspective is different to a nurses or a porters to a patients 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
ACT PLAN

STUDY

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?
ACT PLAN

STUDY

DO

MODEL FOR IMPROVEMENT

Executing the Model for Improvement

Lets do an example

The Problem
Patients at Black Lions Hospital emergency department are often in pain We want to change that Ehmhow 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

ACT

PLAN

STUDY

DO

You need a team

Why?
Need different perspectives Its 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

ACT

PLAN

STUDY

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 Lions 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

ACT

PLAN

STUDY

DO

Measurement
Measurement for Research
Purpose Tests Biases Data Duration

Measurement for Improvement

To discover new knowledge To bring new knowledge into daily practice One large blind test Control for as many biases as possible Gather as much data as possible, just in case Can take a long time Many sequential, observable tests Stabilize the biases from test to test Gather just enough data to learn and complete another cycle 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 Mortality rates Process Measure -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 Balancing Measures 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

ACT

PLAN

STUDY

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

ACT

PLAN

STUDY

DO

PDSA Cycle
Do
Carry out the plan Document problems and unexpected results Begin Analysis
The Aim
The Measure The Change

ACT

PLAN

STUDY

DO

PDSA Cycle
Study
Complete analysis of the data Compare data to prediction Summarize what was learned
The Aim
The Measure The Change

ACT

PLAN

STUDY

DO

PDSA Cycle
Act
What changes are to be made Next cycle?
The Aim
The Measure The Change

ACT

PLAN

STUDY

DO

Testing Changes
Much can be learnt from a failed test
ACT PLAN STUDY ACT PLAN DO

PDSA

STUDY

DO

PDSA

ACT

PLAN

PDSA
PDSA

STUDY

DO

PDSA

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

ACT

PLAN

STUDY

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

Dont try to change their attitude Listen to what concerns them, identify barriers

Those who dont really care, and will follow when others do

Implementation
PDSA in Pilot PDSA in Phase Implementation Phase
Support Requirements Low High

Tolerance for failure

Number affected by a test Resistance

High
Low Low

Low
High 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.