first steps in how to do a quality improvement project. dr s.a.cullis frcgp. associate postgraduate...
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First Steps in how to do a Quality Improvement Project.
Dr S.A.Cullis FRCGP.Associate Postgraduate Dean
HEEM.Dr Susan Hadley
Programme DirectorHEEM
Acknowledgements
• Dr Martyn Diaper NHSIQ
• Alison Tongue NHSIQ
• Orlando Hampton HEEM
• Prof. Jeany Penny O.B.E University of Derby.
Learning Objectives
• To learn about Quality and Safety and to understand the basic structure of a Quality Improvement Project.
• To find out about BMJ quality website as a tool to help
• To learn where to find more information/resources.
Do registrars need to learn this?
The Gold Guide says• ‘take part in systems of quality assurance and
quality improvement in their clinical work and training.’
RCGP curriculum says• Understanding how and when to apply tools and
metrics to improve the quality of care is a key skill that can and should be learnt during your training, as well as enhanced in lifelong learning
Why do we reliably fail?
What causes harm to patients?Where should we focus our improvement
efforts?
Be a good personTrain well
Maintain good intentionsWork hard
What is wrong with this plane?
Lessons from Human Factors Research
‘You can’t change the human condition,but you can change the conditions
under which humans work’
James Reason
Error is normal... what are you going to do about
it?
Be a good personTrain well
Maintain good intentionsWork hardMake it easier to do the right thing
Make it harder to do the wrong thing
Spot & stop inevitable errors
So How Can We Improve Quality?
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994
Change through small steps
Change ...• with a clear purpose• you can learn from (without fear of failure)• which is less exhausting• with fewer unintended consequences• which builds engagement and optimism
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
Change ideas: What have others done? What hunches do we have? What can we learn as we go along?
Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco
PDSA cycle for learning and improvement
Act
• what changes are to be made?
• next cycle?
Plan•objective• questions and predictions (why)• plan to carry out the cycle (who, what, where, when)
Study
•complete the analysis of the data
•compare data to predictions
•summarise what was learned
Do
• carry out the plan• document problems and unexpected observations• begin analysis of the data
Repeated PDSA cycles work towards the AIM
PDSA
PDSA
PDSA
PDSA
PDSA
Data Driven Change
Hunches
Theories
Ideas
Aim•What am I trying to achieve?•How will I know a change is an improvement?•What changes can I make that will result in the improvement
Need to start small!!
Benefits of this approach
• easier to start• produces better solutions more quickly• engages people better• reduces waste• easier to continue
How to decide what to improve?
Significant Event Audit.
• Pringle’s SEA definition:• A process in which individual episodes (when
there has been a significant occurrence either beneficial or deleterious) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care, and to indicate any changes that might lead to future improvements
Safety Walkrounds™
Try it yourself ...
The Pareto Principle
How not to change everything at once!
Making better decisions about prioritiesFocusing your effort where it matters
The Pareto Principle
The Principle
• We don’t have time to improve everything• A small number of issues account for the majority of
the challenge
• 20% of causes account for 80% of the problem
• We should focus on the ‘critical few’, not the ‘trivial many’
What does it look like?
Interruptions in surgeries
Tally by GPs of the causes of interruptions while seeing patients.
Category Count % of Total Cumulative %Cancellation msg 588 38.9 38.9Admin info 312 20.6 59.5Chaperone 198 13.1 72.6Sign script - urgent 78 5.2 77.8Other 72 4.8 82.6Sign script - contraception 72 4.8 87.4Clinical query - GP 66 4.4 91.8Equipment search 60 4 95.8Clinical query - NP 24 1.6 97.4Clinical query - learner 18 1.2 98.6Sign script - minor illness nurse 18 1.2 99.8Panic button 6 0.4 100.2TOTALS 1512 100
Cancel
lation m
sg
Admin info
Chapero
ne
Sign sc
ript -
urgent
Other
Sign sc
ript -
contra
ception
Clinica
l query
- GP
Equipmen
t sea
rch
Clinica
l query
- NP
Clinica
l query
- lea
rner
Sign sc
ript -
minor illness
nurse
Panic b
utton05
1015202530354045
0102030405060708090100
% of TotalCumulative %
What does it look like?
Cancel
lation m
sg
Admin info
Chapero
ne
Sign sc
ript -
urgent
Other
Sign sc
ript -
contra
ception
Clinica
l query
- GP
Equipmen
t sea
rch
Clinica
l query
- NP
Clinica
l query
- lea
rner
Sign sc
ript -
minor illness
nurse
Panic b
utton0
5
10
15
20
25
30
35
40
45
0
10
20
30
40
50
60
70
80
90
100
% of TotalCumulative %
Three categories of interruption (17%) account for 73% of the problem
Driver Diagrams
How to generate and organise ideas for improvement.
Driver Diagrams
AIM – an improved system
Primary driver 1
Primary driver 2
Secondary driver 1
Secondary driver 2
Secondary driver 3
Secondary driver 4
Secondary driver 5
CP1
CP2
CP3
CP4
CP5
CP6
CP7
AIM PRIMARYDRIVERS
SECONDARYDRIVERS
CHANGEPROJECTS
Pedometer
Gym work out 3 days
Squash weekends
No pub weekdays
Take packed lunch
Low fat meals
Buy only 1
sandwich
Water bottle for work bag
Fruit for dessert
Put away large wine
glasses
Put cycling days in diary
Cycling kit out night before
Get rid of Oyster card
Take stairs
2 stone weight loss in
6/12
Generate Change Ideas
Pedometer
Gym work out 3 days Squash
weekends
No pub weekdays
Take packed lunch
Low fat meals
Buy only 1
sandwich
Water bottle for work bagFruit for
dessert Put away large wine
glassesPut cycling days in diaryCycling
kit out night before
Get rid of Oyster card
Take stairs
Be more active during
the dayDo sport
Drink less alcohol
Substitute lower calorie
foods
Eat less
Marshall the mass of ideas
2 stone weight loss in
6/12
Driver DiagramsWeight loss example
Pedometer
Gym work out 3 days
Squash weekends
No pub weekdays
Take packed lunch
Low fat meals
Buy only 1 sandwich
Water bottle for work bag
Fruit for dessert
Put away the large
glasses
Put cycling days in diaryCycling kit
out night before
Get rid of Oyster card
Be more active during the day
Do sport
Drink less alcohol
Substitute lower calorie foods
Eat lessReduce calories
in
Increasecalories
out
Take stairs
2 stone weight loss in 6/12
Software for driver diagrams
–PowerPoint
–Dia–Freemind–VUE
–MindMeister–MindJet
Reliable Design
Deliberate reliable design
Segment?
What’s happening?
What’s the priority?
What’s going on?
eg How do at-risk infants get Vitamin D?
Deliberate reliable design – ???
Measurement for Improvement.
•70% of change fails
The traditions of measurement
• eg A-B comparison, average, huge dataset
Research
• eg one-to-many benchmarking comparison, average, large dataset
Judgement
• eg continual analysis of single changing process over time
Improvement
What mindsets are at play here?
Mindsets
Research
Improvement
Judgement
Research Judgement Improvement
Goal New knowledge (not its applicability)
ComparisonReward / punishmentSpur for change
Process understanding
Evaluating a change
Hypothesis Fixed None Multiple and flexible
Measures Many Very few Few
Time period Long, past Long/medium, past Short, current
Sample Large Large Small
Confounders Measure or control Describe and try to measure
Consider but rarely measured
Risks in improvement
settings
Ignores time based variation
Over-engineers data collection
Ignores time based variation
Over-reaction to natural variation
Incorrectly perceived as ‘inferior statistics’
Measurement mindsets
Based on L Solberg, G Mosser and S McDonald (1997) The Three Faces of Performance Measurement: Improvement, Accountability and Research, Journal on Quality Improvement, 23 (3): 135 - 147.
What to measure?
Structure Process Outcome
Avedis Donabedian
‘Outcomes remain the ultimate validators of the effectiveness and quality of medical care’ but they ‘must be used with discrimination’
The environment in which care occurs
What care is delivered, and how
The impact on patients and the
population
Balancing measures
OU
TPU
TS
HUMAN FACTORS
HUMANFACTORS
INTERNAL PROCESSES & PROCECEDURES
INPU
TSEXTERNALFACTORS
Process Measure(s)
Out
com
e M
easu
re(s
)
Balancing Measure(s)
What to measure?
Is it being done?
Is it working?
Unintended consequences?
Stru
ctur
e M
easu
re(s
)
system fit for use?
Period 1 Period 2
Poor performance
Good performance
Period 1 Period 2
Change made
Period 1 Period 2
Poor performance
Good performance
Improvement!
Improvement!
p<0.05
With summary data we make judgements about
improvementsWe may use summative statistics to justify it (e.g.
confidence intervals)But processes can change
over time and tell a different story!
Imagine this is mortality
data
Approaches to monitoring performance
Target
A change was introduced between the two periods. Was it a success?
48
Measurement for learning
Run charts: measurement for learning
0102030405060708090
Day
1 4 7 10 13 16 19
Seco
nds
to
answ
er p
hone
Seven one side
Seven down (or up)
DO
Look for a run of seven points all above or all below the centre line or all increasing or all decreasing
Just like a TPR chart
Average length of pre-ward stayStroke Ward
from 01/2007 to 07/2007
0
0.5
1
1.5
2
2.5
3
3.5
1 2 3 4 5 6 7Months
How often you measure can also have an effect on how you look at the results
Mike Davidge NHS Institute for Innovation and Improvement
Average length of pre-ward stayStroke Ward
from 01/2007 to 07/2007
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Weeks
Patient length of pre-ward stay Stroke Ward
from 01/2007 to 07/2007
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Patients
Control charts
Statistical process control (SPC)
Understand
Improve
Motivate
Frequent measures
Average line
(mean/median)
Upper control
limit(3 SDs)
Lower control
limit (3 SDs)
0.13th percentile
97
.4%
C.I
.
Understanding variation
“Common Cause”
• inherent in the design of the process
• variation is predictable and the process is stable
• affects process most of the time
• many factors, some “unknowable”
• “noise in the system”
“Special Cause”
• not part of the process• unpredictable variation• intermittently apparent• “assignable” causes• can usually be
identified
The five rules
Rule 1: Any point outside a control limit.
Rule 2: A run of 8 points all above or below the centre line.
Rule 3: A run of 6 points increasing/decreasing.
Rule 4: 2 out of 3 consecutive points beyond +/- 2 sigma.
Rule 5: A run of 15 points all within +/-1 sigma of the centre line.
Software suggestions
There is a huge number of software packages which perform analysis for statistical process control.
Among them, some of the most accessible are:• Very cheap.
• Baseline www.valuesystemdesign.com/Baseline/Baseline_01.htm
• Cheap. • Winchart prismeurope.co.uk/software/
• More comprehensive. • Minitab. www.minitab.com
• Chart Runner. www.pqsystems.co.uk
BMJ Quality
• This is an online guide to doing a quality improvement project with links to BMJ Learning modules on relevant topics.
• It guides you through the process from start to finish and you can publish your project in their online Quality Journal.
• Licenses are available on a first come first served basis by discussing with your PDs.
Links to Other Useful Resources.
• http://www.ihi.org• http://
www.vle.eastmidlandsdeanery.nhs.uk/mod/folder/view.php?id=15885
• http://www.qihub.scot.nhs.uk/default.aspx• (this is a link on the VLE to QI powerpoint
slides and other useful info. It will soon be updated and moved to a specific QI location on Moodle)
GP Primary Care Educator Leads
• Dr Sue Cullis. APD [email protected]• Dr Susan Hadley. PD [email protected]• Dr Christine Johnson.
[email protected]• Dr Graham Todd [email protected]• Dr David Young [email protected]• Dr Helen Tallantyre [email protected]
Areas Covered by the PCELs
• Overall Lead- Sue Cullis• Leicester, Kettering, Northampton- Susan
Hadley & Sue Cullis• Nottingham, Lincoln & Boston- Christine
Johnson• Chesterfield (and North Notts)- Graham Todd• Derby ( and Mansfield)- David Young• (Mansfield & North Notts- Helen Tallantyre)
Looking Forward?
• Write down 3 things you are going to do as a result of today’s session?
• And by when are you going to do them?
• Please share 1 action with the group.
• “ The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”
• Don Berwick. A promise to learn - a commitment to act. August 2013.
A Final Thought from Don Berwick