- -
? (IOM, 1990)
,
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Classification of Quality Problems
Overuse Underuse Misuse
From JAMA 1998;280:1000-1005
Some Examples from Medical Literatures- Overuse & Underuse -
Unnecessary surgery: 8 - 86%(Leape, 1992) No regular HbA1c & retinal exam. for many D.M.
patients(Weiner et al., 1995) Only14% of pt. with CV Ds. achieved recommended
lipid level(McBride et al., 1998). Failure to treat effectively AMI leads to 18,000
preventable deaths/yr(Chassin & Galvin, 1998).
Some Examples from Medical Literatures- Misuse -
In US 180,000 deaths/yr partly as a result ofiatrogenic injuries(Leape, 1994)
In US 106,000 deaths/yr by fatal ADR amonginpatietns(Lazarou et al., 1998)
Fatal medication errors in US doubled amongoutpatients btw. 1983 & 1993(Phillips et al, 1998).
Lower quality of care within hospitals for black &the uninsured(Kahn et al., 1994; Burstin et al, 1992)
QI Implicit case review Medical audit Problem-oriented studies Ongoing monitoring of departmental indicators Systems thinking Practice guidelines Outcomes management TQM/CQI Organization-wide continuous improvement in performance
Performance What How well
Results Health outcomes Costs Satisfaction
Judgment Quality Value
(JCAHO) What is done
(efficacy) (appropriateness)
How it is done (availability) (timeliness) (effectiveness) (continuity) (safety) (efficiency) (respect and caring)
(customer focus)
(understanding work as processes and systems)
(testing changes)
(emphasizing the use of data)
(teamwork)
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: (external customer)
(internal customer)
: 15%, : 85%
(root cause analysis) bad apple syndrome
: (medication error)
Inputs Processes Outputs/Outcomes
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PDCA Cycle: Plan-Do-Check-Act
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(Individual Problem Solving)
(Rapid Team Problem Solving)
(Systematic Team Problem Solving)
(Process Improvement)
Q1: ? : Process Improvement : Q2
Q2: ? : Individual Problem Solving : Q3
Q3: ? : Systematic Team Problem Solving : Rapid Team Problem Solving
When to use When you know the problem is dependent on only one person
Teams Unnecessary
Data Almost none
Time Little
When to use When the team needs quick results and has a lot of intuitive ideas
Teams Ad hoc
Data Can succeed with little data
Time Little
When to use When the problem is complex or recurring, requiring analysis
Teams Ad hoc
Data Need data to understand the causes of the problem
Time Limited to the time necessary
When to use When a key process or system requires ongoing monitoring or continual improvement
Teams Permanent
Data Data from continuous monitoring; may need to collect more
Time Continuous
QI 9: FOCUS-PDCA
FOCUS Find a process improvement opportunity Organize a team that knows a process Clarify the current knowledge of the process Understand causes of process variation Select the process improvement
PDCA Plan - Do - Check - Act
QI 9: FOCUS-PDCA
FOCUS Find, Organize, Clarify, Understand, Select
PDCA Plan the process improvement Do the improvement, data collection & analysis Check the results and lessons learned Act by adopting, adjusting, or abandoning the change
QI
Assessment : , , QI: FOCUS
Improvement : , QI: PDCA
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Brainstorming Data Collection The 7 Management Tools
Affinity Diagrams Interrelationship Diagrams Tree Diagrams Matrix Diagrams Prioritization Matrices Process Decision Program Chart Activity Network Diagrams
2:
(Internal customers) (External customers)
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: Brainstorming
3:
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(Common cause variation) (Special cause variation)
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Brainstorming Cause and Effect Diagram Inverse Tree Diagram Multi-Voting Scatter Diagrams Run and Control Charts Histograms
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Brainstorming Process Decision Program Charts
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Data Collection
Scatter Diagrams
Run and Control Charts
Histograms
Customer Surveys
9:
(Hold the gain)
(Adopt the change)
(Adjust the change)
(Abandon the change)
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Four Steps to Quality Improvement
Step 1: Identify
Determine what to improves
Step 2: Analyze
Understand what must be known or understood about the problem in order to make improvement
Step 3: Develop
Hypothesize about what changes will yield improvement
Step 4: Test & Implement
Test the hypothesized solution to see if it yields improvement; based on the results, decide whether to abandon, modify, or implement the solution
Identify Individual decision making for a small problem that is not interdependent on others
Analyze Relies on individual analysis, using existing data, observation, and intuition
Develop The change is usually minor and not interdependent on others
Test & Implement Trial and error approach to testing
Identify
An ad hoc team identifies an intuited or obvious problem based on intuition, observation, and existing data
Analyze
Generally requires minimal analysis using mainly existing data and group intuition
Develop
A series of small changes
Test & Implement
Many small to medium tests in similar systems
Identify An ad hoc team addresses a complex, recurring problem
Analyze The team examines the problem to try to identify its root causes; existing data and/or data collection is used
Develop Generally large change that addresses the root cause of the problem
Test & Implement Generally requires extensive testing before implementation.
Identify
A permanent team addresses a core process or issue in a large process or system
Analyze
Requires detailed process knowledge from on-going data collection and monitoring
Develop
A change in a key process
Test & Implement
Depends on the approach used and magnitude of the change; permanent teams continue to monitor and improve the process
:
Find ,
Organize
Clarify : 11.8( 9.1)
Understand (+)
Select
: Plan
(2nd) : 120 ml/day 3ml/Kg/day Do
4
Check : 9.1 6.1 : 0/19 0/18 : 11.8 10.1
Act
Make a new organizational culture Consider cost of poor quality Focus on System/Process Do the right thing right the first time Communicate success stories Use positive enforcements Encourage team approach & integration
- - ? (IOM, 1990)Classification of Quality ProblemsSome Examples from Medical Literatures- Overuse & Underuse -Some Examples from Medical Literatures- Misuse -QI (JCAHO) : QI 9: FOCUS-PDCAQI 9: FOCUS-PDCAQI 1: - - 1: - - 1: - - 1: - - 2: 3: 4: 4: - - 5: 6: 7: 8: 8: - - 9: 9: - - 9: Four Steps to Quality Improvement : :