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  • Comparing Lean and IHI Quality Improvement

    Richard Scoville, PhD

    IHQI Speaker Series

    February 9, 2015

    Richard Scoville, PhD

    Improvement Advisor for

    Institute for Healthcare Improvement

    Dentaquest Institute

    Cincinnati Childrens Hospital

    NHS UK

    Adjunct Associate Professor, Dept. Health

    Policy & Management, UNC Chapel Hill

  • http://www.ihi.org/resources/Pages/IHIWhitePapers/ComparingLeanandQualityImprovement.aspx

    "Do not seek to follow in the footsteps of the

    old masters. Seek instead what the old

    masters sought."

    Basho (1644-1694)

  • Subject Matter Knowledge

    Knowledge for Improvement

    Subject Matter Knowledge:Knowledge basic to the things we do in life. Professional knowledge.

    Improvement ScienceThe interaction of the theories of systems,

    variation, knowledge, and psychology.

    Profound

    Knowledge

    Improvement Science

    QI:Combining subject

    matter knowledge with

    improvement science

    to develop effective

    changes.

    Frederick Taylor Experiments in workplace Process analysis, measurement Top-down design: unskilled labor Japanese trainees visit U.S.

    Henry Ford Assembly line Standard product Vertical integration

    Walter Shewhart At Western Electric Statistical process control PDSA cycle

    Kiichiro Toyoda Toyota Motors founded 1937

    Edwards Deming Student of Shewhart Statistician/ mathematician SPC lectures in Japan 1950

    Joseph Juran Student of Shewhart Quality as a system of management Lectures to JUSE 1954

    Taiichi Ohno Toyota Production System 1950s-70s Kanban, andon, JIT, pull, Kaizen Workers solve problems

    Ford Motors Invests in SPC1980s, Mazda Lean Lessons

    Shigeo Shingo TPS rapid turnover

    Virginia Mason, Seattle Adopts Lean methods Virginia Mason Production System 2000

    Deming Consults in U.S. API Principals are students TV show 1980

    Don Berwick founds IHI Curing Healthcare 1989 API: Tom Nolan, Lloyd Provost are QI mentors

    1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

    Some Healthcare QI Milestones

    Womack et al. Machine That Changed The World 1990

  • Profound Knowledge

    A system cannot understand itself. [That] requires a view

    from outside a lens that I call a system of profound

    knowledge.

    System Psychology

    Learning Variation

    Domains of Profound Knowledge

    Appreciation of a SystemSystem = an interdependent group of items, people or processes working together to a common purpose.

    PsychologyHow do people respond to change? How can we encourage constructive

    change and commitment to excellence? How does human perception and

    decision making shape process design?

    Understanding VariationHow should we interpret and respond to the variation that continually

    occurs in every system?

    Theory of KnowledgeHow can we learn to predict the impact of planned changes? How can we

    develop sustainable changes that will lead to improvement?

  • Appreciation of a System

    A system is an interdependent group of items, people or

    processes working together to a common purpose.

    Every system is perfectly designed to achieve the results that it gets.

    - Paul Batalden

    Systems

    Functional systems(processes)

    Physical systems

    Social networks

  • Sizing the System

    Source: Commonwealth Fund

  • 5S

    seiri, seiton, seiso, seiketsu, shitsuke

    (sort, straighten, shine, standardize, sustain)5S =

    Where Do We Lay the Blame?

    http://www.aaos.org/news/aaosnow/jun11/managing4.asp

  • Understanding Variation

    Variability is an inherent characteristic of any system. Measures and data are

    useful to guide future action, provided we can discern patterns in such variation

    and respond appropriately A key distinction [is] between common cause

    variation produced by a stable, predictable process and special cause variation

    that results either from unstandardized, uncontrolled operations or from intentional

    process changes.

    Variation is a thiefThe enemy is not

    considered, intentional variation, but

    rather unintended or misinterpreted

    variation..

    Management is prediction!

    - Don Berwick

    - W. Edwards Deming

  • Schechter, M. S. and P. Margolis (2005). "Improving subspecialty healthcare: lessons from cystic fibrosis." J Pediatr 147(3): 295-301.

    Schechter, M. S. and P. Margolis (2005). "Improving subspecialty healthcare: lessons from cystic fibrosis." J Pediatr 147(3): 295-301.

  • Improvement is Temporal

    Did we improve?

    What will happen next?

    Should we do something?

    Source: R. Lloyd

    Percent of ER patients with Chest Pain Seen by a

    Cardiologist within 10 min

    Did We Improve?

    50%

    55%

    60%

    65%

    70%

    75%

    80%

    85%

    90%

    95%

    100%

    10

    /3/2

    007

    10/1

    7/2

    007

    10/3

    1/2

    007

    11/1

    4/2

    007

    11/2

    8/2

    007

    12/1

    2/2

    007

    12/2

    6/2

    007

    1/9

    /2008

    1/2

    3/2

    008

    2/6

    /2008

    2/2

    0/2

    008

    3/5

    /2008

    3/1

    9/2

    008

    Change

    here

    Source: R. Lloyd

    Did we improve?

    What will happen next?

    Should we do something?

    Percent of ER patients with Chest Pain Seen by a Cardiologist within 10 min

  • Run ChartsMedian

    Individual

    measure

    valuesTime-Ordered Data

    2/6 New data system, no

    data available

    8/6 New triage procedure

    2/5 Project Start

    2/12 Visual control for patient

    flow

    Run Charts

    Nonparametric rules for significant change (p

  • Shewhart Control Chart

    0%

    10%

    20%

    30%

    40%

    50%

    60%

    70%

    80%

    90%

    100%

    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

    Week

    Percent of Patients with Pressure Ulcers

    3-sigma control limits

    Mean

    Subgroup (1 or more observations)

    Shewhart Control Chart

    0%

    10%

    20%

    30%

    40%

    50%

    60%

    70%

    80%

    90%

    100%

    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

    Week

    Percent of Patients with Pressure Ulcers

    Tests for special cause - One data point that falls outside the limits- Eight or more consecutive subgroups above or below the mean- Six points all going up or all going down.- Two out of three consecutive points in either outer third of the limits.

    ?

  • Psychology

    Psychology deals with the behavior of humans as social actors, their

    interactions with one another, and their interactions with the systems of

    which they are a part.

    First we build people, then we build cars.

    - Toyota saying

    Drive out fear.- W. Edwards Deming

    Doh!- Homer Simpson

    Homo Economicus?

    Who are we really?

    Are we rational actors who evaluate options carefully and

    dispassionately?

    Or are our actions driven by appetites, reflexes, and faulty

    logic?

  • Do you use lung protective strategy In ventilating acute lung injury patients?

    Audit

    2.6%

    The Gap between Perception and Practice of Sepsis Therapy. FM Brunkhorst et al. for the German Competence Network Sepsis Crit Care Med 2008;36(10):2719-25.

    Results of A Level 1Reliability Processes.

    %

    0

    20

    40

    60

    80

    100

    80%

    YES

    Adhere to Best Practice?

    Slide courtesy of Terry Clemmer, MD

    Interview

    Audit

    %

    0

    20

    40

    60

    80

    100

    2.6%

    80%

    67%

    9%

    46%

    18%

    79%

    31%

    The Gap between Perception and

    Practice of Sepsis Therapy. FM

    Brunkhorst et al. for the German

    Competence Network Sepsis Crit Care

    Med 2008;36(10):2719-25.

    Of course we do it every time

    Slide courtesy of Terry Clemmer, MD

  • Heuristics

    Anchoring

    Manufacturers suggested retail price

    Availability

    High salience events over-predicted

    Representativeness

    Patterns, patterns everywhere

    Optimism

    All the children are above average

    Loss Aversion

    Losing is worse than not winning

    Status Quo Preference

    The whatever principle

    The Herd Instinct

    Everybodys doing it!

    Thaler, R. and C. Sunstein (2008). Nudge. New York, Penguin.

    A Choice Architecture

    http://www.youtube.com/watch?v=2lXh2n0aPyw

  • Culture

    Culture =

    Beliefs

    Ideas and values that the group accepts as self evident, reasonable, right, just, etc.

    Rituals

    Things we do together: work, play, worship, etc.

    Norms

    Whats right? cool? polite? bad? pitiable? disgusting? etc.

    To change culture, change behavior; the rest will follow.

    P39

    Transparency!

    An Effective Improvement Culture Requires

  • Principles from Social Psychology

    Asch: Collective Conservatism

    People are likely to conform when they know that other people will observe what they have to say

    Newly formed groups establish beliefs and norms quickly

    Gilovich: Spotlight Effect

    We tend to believe that others are attending to and care about what we do or believe

    Asch, S. E. (1955). "Opinions and Social Pressure." Scientific American 193(5): 31-35.

    Gilovich, T

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