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Quality Improvement
Basics
David R. Cook, Director of Operations,
HealthInsight Utah
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Introduction – Blame Free
The best people can sometimes make the worst errors……We cannot change the human condition. People will always make errors and commit violations. But we can change the conditions under which they work to make these unsafe acts less likely……Blaming people for their errors – though emotionally satisfying – will have little or no effect on their future fallibility…..Errors are largely unintentional. It is very difficult for management to control what people did not intend to do in the first place. James Reason – Managing the Risks of Organizational Accidents, p.153.
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Quality Assurance vs. Quality Improvement
Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook p. 18
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What Changes Can We Make that Will Result in Improvement?
“Nobody likes change,
unless it is a wet
baby!”
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Objectives
1) Understand the Model for Improvement*
2) Identify a Gap, develop an aim statement withmeasurement and develop an improvement plan
3) Understand rapid cycle improvement
4) Simple flow charting
*Associates in Process Improvement
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Concept Measure Operational definition
Data collection plan Data collection Analysis
Creative thinking
Action and Change
How to Get from Ideas to Action
AIM statement
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The Model for Improvement -- PDSA
Identify the Gap
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
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Recognition of Quality Gap – Opportunity for Improvement
• Can be a vague impression (hunch) • Report review • Sentinel events • We want a better outcome (hope) • Taking Stock Exercise
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Cause and Effect Tools – Quality Gaps
• Fishbone • 5 Whys – Toyota • Root Cause Analysis (RCA) – not covered today
(see healthinsight.org) • Failure Modes and Effects Analysis (FMEA) –
not covered today • Event Tree and Fault Tree Analysis
http:healthinsight.org
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Exercise #1
Take a minute and review from your recent experience one opportunity for improvement or
quality gap
Please write it down
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The Model for Improvement PDSA cycles
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Set the AIM
Establish MEASUREMENT
PLAN for Improvement
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
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Step #1 - Setting the AIM – What Are We Trying to Accomplish?
• State the aim clearly (SMART acronym) • Include numerical goal and time frame that
require fundamental system change • Set stretch goals • Avoid aim drift • Be prepared to refocus the aim
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Step #2 - Establishing Measures – How Will We Know That a Change is An Improvement?
• Plot data over time • Seek usefulness, not perfection • Use sampling • Integrate measurement into the daily routine • Use qualitative and quantitative data • Focus on outcome measures
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Exercise #2
Take a minute and write an AIM statement based on the improvement opportunity
identified in Exercise #1
Remember to include a numeric goal (measure) and time frame
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Step #3 – Overall Plan for Improvement
• Avoid “the same” responses • Implement recommended practices
guidelines • Think processes and systems of work
– Simplify processes – Reduce waste or unnecessary redundancies – Strengthen hand offs
• Creative thinking • Appropriate use of new or existing
technology
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Step #3 – Overall Plan for Improvement
1) Describe change (strategies) 2) Predict outcome 3) List steps needed 4) Plan for collection of data
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“Every system is perfectly designed
to get the results it gets.”
Paul Batalden, M.D.
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Exercise #3
Take three or four minutes and outline your Global Plan
1) Describe change (strategies) 2) Predict outcome 3) List steps needed 4) Plan for collection of data
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The Model for Improvement PDSA cycles
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Global AIM, Measure, and Plan (Strategies)
Smaller Tests (Tactics)
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
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PDSA (Plan-Do-Study-Act)
Also known as: • PDCA (Check instead of
Study) • The Deming Cycle/Wheel • The Shewart Cycle • The Learning and
Improvement Cycle
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
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Classifying PDSA cycles
The Chronic Care Model (Mid-level Theory) • Clinical Information
Systems • Delivery System Design
Community • Decision Support • Self Management • Organizational Support
Human Factors Science (Micro-level Theory) • Actors • Behaviors • Decisions • Habits
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Plan
Sequence:
1) Describe first (or next) change (tactic) 2) Predict outcome 3) List tasks needed 4) Plan for collection of data
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DO – Carry it Out
• Implement (preferably on a small scale) • Document problems and unexpected
observations • See plan through to completion • Motivations to carry it out
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Study or Check – What did we learn?
• Review the data/take survey • Compare the data to your predictions • What worked or went well? What did not? • Summarize and reflect on what was learned
-- draw conclusions
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ACT
• Adopt it • Abandon it • More study
needed • Modify overall
aim, measure, or plan • Create new plan
The Team Handbook (Scholtes, Joiner, Streibel). Madison, WI, USA: Oriel Incorporate, Inc.; 2003 page 5-27
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Stringing it Together
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Rapid Cycle - Multiple Cycles
Overall AIM Increase documented eye exams for our diabetes population by 45% in the next 12 months
Time
Expect Challenges and Barriers
Cycle #1 – Contact Eye Doctors
Cycle #2 – Patient Fax Back Form
Cycle #3 – Front Office track down eye results
Cycle #4 – Computer Network with eye doctors
Cycle #5 – Reminder letter from PCPs
Implement Final Changes
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Model for Improvement PDSA - Summary
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
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Gap:
Aim:
Overall Plan:
Plan
~ First (or next) change: Prediction:
r~~) Tasks Needed: List the tasks needed to set up this test ofchange (who, what, where, when) ~~ Data Collection: Plan for collection ofdata (who, what, where, when) Do Describe what actually happened, including problems and unexpected observations, when you ran the test.
Study Describe the measured results and how they compared to the predictions. Summarize and reflect on new knowledge learned.
Act Describe what modifications to the plan will be made for the next cycle from what you learned.
Adapted frcm Institute for Healthcare Improvement POSA Vl()rksheets -www.ihi.org
rhe enclosed material was prepared andasseMbled by Meal:hrnstgh:. under con:ract wnh the Centers for Medicare & Med1ca1d Servtces (CMS). Quality Improvement an agency of ;he U.S. Depar
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Tool - Workflow Analysis/Flowcharting
• Opportunity for end user to step back and
evaluate current processes and methods
• Linear visual representation of a process to facilitate discussion and improvement
• Complete previous to causal analysis • Various types (e.g. Swim Lane, Simple, Process
Mapping) • Current State/Future State
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Basic Flowchart Symbols
Start or End Symbol
“Flow of Control” Symbol
Process Step Symbol
No
Decision Symbol Yes
Connector Symbol (end of page)
Delay or Wait Symbol
Flowcharts can be created with stickies, whiteboards in Microsoft PowerPoint, Word, Visio and many other applications.
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References
• Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook • The Team Handbook (Scholtes, Joiner, Streibel). Madison, WI, USA: Oriel Incorporate,
Inc.; 2003 • Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619-622.
Available at http://www.bmj.com/content/312/7031/619.full • Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical
Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009.
• Moen R and Norman CL. "Circling Back: Clearing up myths about the Deming cycle and Seeing How it Keeps Evolving." Quality Progress, American Society for Quality. 2010; 22-28. Available at http://www.apiweb.org/circling-back.pdf
http://www.bmj.com/content/312/7031/619.fullhttp://www.apiweb.org/circling-back.pdf
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Evaluations – Share Your Feedback
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Questions ?
Contact Info: • David Cook, HealthInsight • 801-892-6623 • dcook@healthinsight.org
This material was prepared by HealthInsight, the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-CORP-16-89-UT
mailto:dcook@healthinsight.org
Quality Improvement BasicsIntroduction – Blame Free Quality Assurance vs. Quality ImprovementWhat Changes Can We Make that Will Result in Improvement?ObjectivesSlide Number 6Slide Number 7How to Get from Ideas to ActionThe Model for Improvement -- PDSARecognition of Quality Gap –�Opportunity for ImprovementCause and Effect Tools – Quality GapsExercise #1The Model for Improvement PDSA cyclesStep #1 - Setting the AIM – What Are We Trying to Accomplish?Step #2 - Establishing Measures – How Will We Know That a Change is An Improvement?Exercise #2Step #3 – Overall Plan for ImprovementStep #3 – Overall Plan for ImprovementSlide Number 19Exercise #3The Model for Improvement PDSA cyclesPDSA (Plan-Do-Study-Act)Classifying PDSA cyclesPlanDO – Carry it OutStudy or Check – �What did we learn?ACTStringing it TogetherRapid Cycle - Multiple CyclesModel for Improvement PDSA - SummarySlide Number 31Tool - Workflow Analysis/FlowchartingBasic Flowchart SymbolsReferencesEvaluations – Share Your Feedback Questions ?New slide Dave 508.pdfQuality Improvement BasicsIntroduction – Blame Free Quality Assurance vs. Quality ImprovementWhat Changes Can We Make that Will Result in Improvement?ObjectivesSlide Number 6Slide Number 7How to Get from Ideas to ActionThe Model for Improvement -- PDSARecognition of Quality Gap –�Opportunity for ImprovementCause and Effect Tools – Quality GapsExercise #1The Model for Improvement PDSA cyclesStep #1 - Setting the AIM – What Are We Trying to Accomplish?Step #2 - Establishing Measures – How Will We Know That a Change is An Improvement?Exercise #2Step #3 – Overall Plan for ImprovementStep #3 – Overall Plan for ImprovementSlide Number 19Exercise #3The Model for Improvement PDSA cyclesPDSA (Plan-Do-Study-Act)Classifying PDSA cyclesPlanDO – Carry it OutStudy or Check – �What did we learn?ACTStringing it TogetherRapid Cycle - Multiple CyclesModel for Improvement PDSA - SummarySlide Number 31Tool - Workflow Analysis/FlowchartingBasic Flowchart SymbolsReferencesEvaluations – Share Your Feedback Questions ?
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