Two Kinds of People

Two Kinds of People

Two Kinds of People
Quality Improvement in
Healthcare

Manu K. Malhotra, MD
Henry Ford Hospital
Mar 3, 2016
 Quality Improvement

 I. What is QI?
 II. Why do you need to know about it?
 III. Process improvement techniques
 IV. Root Cause Analysis
What is Quality Improvement?
 Methodical approach to measuring
performance and the effort to improve
it.
QA vs. QI
 QA: Quality Assurance
 A primarily retrospective review of
processes and making sure they are
followed and work as intended.
 QI: Quality Improvement
 A prospective and retrospective look at
results and processes with a focus on how
to improve them.
Why do I need to know about
QI?
 Continually improve your ability to care
for patients.
 Make the world a better place
 Empower yourself
 And…
Why do I need to know about
QI?
 Core Competencies
 Patient care
 Medical knowledge
 Interpersonal skills and
communication
 Professionalism
 Systems-based practice
 Practice-based learning
Why do I need to know about
QI?
 SBP: Systems Based Practice


…and improve their patient care practices.

 PBLI: Practice Based Learning and

Improvement


…effectively call on system resources to
provide care that is of optimal value.
Why do I need to know about
QI?
 Remain EM Board Certified
 Patient Care Practice Improvement Activity
(PI)
Why do I need to know about
QI?
 Meet existing and future performance
guidelines/mandates.

 E.g. Sepsis, ACS guidelines

 Sentinel events (Root Cause Analysis)
 Hospital Acquired Conditions
What is quality?
What is quality?
 Quality in Healthcare
 Mortality
 Morbidity
 Complications
 Quality of Life
 Perception of Care (wait times, etc)
 …
Process Improvement
 In many cases, Quality can be
improved by improving processes
(eg. sepsis).
 Throughput
 Time to see a doctor

 Time from admission to bed

 …
Process Improvement
Techniques
 Total Quality Management
 Process Re-Engineering
 Constraint management
 Six Sigma
 Lean Systems
Lean Manufacturing
 Attributed to Taichii Ohno of Toyota,
but actually, the ideas are rooted in the
work of Henry Ford and the Model T
factory…
Lean Manufacturing
 Basic concepts:
 Empower front-line workers to affect change
 Remove “waste” (errors and delays)
 Seamless flow of work/products
 Understand the current process first!
 Value Stream Maps
 Use Japanese words
Types of Waste (Muda)
 Transportation
 Inventory
 Motion
 Waiting
 Over-processing
 Over-production
 Defects
 HFH ED history with Lean
 2010: MHA Keystone: ED project
 Multihospital project to improve
healthcare delivery in MI
 Lean used as a tool
 HFH ED created a Lean team comprised
of 4 nurses, one doctor and one clinical
quality specialist.
Assess the Current Process
 “Current State” value stream map
created for the Door to Doc process
 Map was then “socialized”
 Reworked, more details added
 “Gemba” walks
 “Muda” identified
 All done by clinicians who work in the ED
Current State
Future State Map
 All ideas and findings incorporated and
changes to be made identified (“Kaizan
bursts”)
 Future State map created
HFH Emergency Department Door to
Provider Time
HFH Emergency Department Door to
Provider Time
But how do you decide what
to improve?
 Data collection

 Consensus

 Mandates

 Adverse Events
Adverse Events
 Sentinel events
 Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO) mandated
the use of RCA (root cause analysis) in the
investigation of sentinel events in all accredited
hospitals starting in 1997.

 M&M
 QA Process
M&M
 Provider Centered
 Defensive
 Retroactive
QI Process
 Patient Centered
 Quality Directed
 Proactive
Root Cause Analysis (RCA)
 Root Cause Analysis
 Try to get at the cause of the problem instead
of just dealing with the symptoms, or putting
out fires or placing blame.
 Data Collection
 Reconstruction of the events
 Analysis
 Recommendations
RCA
 Problem:
 Patient and family complaining (loudly)
about waiting too long to be seen
 Expeditious Solution:
 Go talk to patient and family and “get things
going” on the patient
 Result:
 Someone else ends up waiting a little longer
RCA
 This solution treats the symptoms, but
not the problem.
Reaching the Root cause
 The 5 whys
 Fishbone (Cause and
effect)Diagrams
 Causal Factor Chart
The 5 whys
 1. Why is the patient upset?
 He’s been waiting for 3 hrs to be seen .

 2. Why has he been waiting 3 hrs?

 He just got back from triage. That’s how long the

wait is.
 3. Why is the wait so long?
 There ain’t no beds, so the ED is crammed.

 4. Why are there no inpatient beds?

 Our transfer volume is on the rise.

 5. Why are we taking transfers when our patients

are waiting?
5 whys
 Incoming transfers are preferentially
placed in beds over ED patients.
Or may more than 5…
 6. Why are incoming transfers preferentially placed
in beds over ED patients.
 Because there is a belief that critically ill patients

in our ED are safer than patients waiting at St.

Elsewhere
 7. Why do we think that?
 Because it’s true
 Fishbone Diagram

Resources Facility

Too noisy
Waiting too long
Smells bad
Vending machine
not working Laying in hallway
Patient is upset

Pt. worried about dx

Nurse was mean

Lost her job Doctor was rude

Personal Staff
RCA
 5 whys is more useful for linear
problems, but is not well-suited for
multifactorial problems.
 Fishbone diagrams/Causal Charts can
be more useful when many causes need
to be explored and evaluated.
RCA

 Root cause analysis is a part of the

problem definition phase of almost all
process improvement systems.

 Find a solution that not only solves the

problem, but prevents its recurrence.
Take-home points
 QI will be a part of your life
 Lean Healthcare uses value stream
mapping and empowers front-line workers
to eliminate waste
 Root cause analysis is the first step in
addressing an adverse event
 Five Whys and Fishbone diagrams can be
used to assess the root cause