Quality Improvement 101Quality Improvement 101

Barbara DeBaun, RN, MSN, CICKathleen Carrothers, MPH, CPHQ

Cynosure Health

Today’s Objectives

Describe the elements of process design

Explain how to flow chart a process

Describe the Model for Improvement

Demonstrate 2 Performance Improvement

tools

Describe the elements of process design

Explain how to flow chart a process

Describe the Model for Improvement

Demonstrate 2 Performance Improvement

tools

How Hazardous Is Health Care? (Leape)

4

2001

2003: Duke University Medical Center

2007

Complexity of Healthcare• 90,000 people in an ICU every day• Five million Americans will receive

care in an ICU in a year

• Average LOS in ICU is 4 days

• Survival rate is 68%• Average patient requires 178

individual actions per day (suctioning, medication, wound care, etc.)

• An error is made 1% of the time

• Average of 2 errors/day/patient

• Gawande, A. (2007, December 10). The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker.

Why We Come To Work• Pick a dot

– Goals, measure, current performance

• Move the dot– Select intervention, PDSA

• Share the dot

The Heart Motivates

Share a StoryShare a Story

Data Drives Decisions

10 Years Ago

Central Line Blood Stream Infections were a part of doing business

Ventilator Associated Pneumonia was an unfortunate consequence of being sick

Sepsis was defined as shock from infection and carried a 50% mortality rate

2012: Zero Tolerance

The Tennis Ball Exercise

How To Play• Break up into groups of 4-5 people• Select - Timer, Scribe, Leader• Using your tennis balls, spend 5 minutes designing a process that meets the

following specifications:

– Each ball must be touched by each person at least one time– The ball cannot be passed to the person directly next to you– The balls must be moved from person to person

• Time your process• The goal is to build a process that meets the design specifications in the

shortest amount of time• After 5 minutes we will get the best time from each team• You will then have another 5 minutes to improve your process

• Break up into groups of 4-5 people• Select - Timer, Scribe, Leader• Using your tennis balls, spend 5 minutes designing a process that meets the

following specifications:

– Each ball must be touched by each person at least one time– The ball cannot be passed to the person directly next to you– The balls must be moved from person to person

• Time your process• The goal is to build a process that meets the design specifications in the

shortest amount of time• After 5 minutes we will get the best time from each team• You will then have another 5 minutes to improve your process

What Did You Do?

– Formed a team– Designated roles– Brainstormed– Designed a process– Measured its performance– Benchmarked its performance– Analyzed the process design– Redesigned your process– Measured your new process, etc.

– Formed a team– Designated roles– Brainstormed– Designed a process– Measured its performance– Benchmarked its performance– Analyzed the process design– Redesigned your process– Measured your new process, etc.

Learning PI From Tennis Balls

• Before you can improve a process you need to know how it works

• Listen to all members of your team• Especially those who are closest to the process• Share improvement ideas• Try them

More Learning’s

• If at first you don’t succeed, try, try again

• Look at others who perform the process well both within and externally

• Borrow their ideas• Keep going• It’s the best process not the

best people

Performance Improvement Tools

Facts About Flowcharts

• Used to visually explain a process and the interrelationship between process steps

• Allows analysis and better understanding of a process

• Great way for a workgroup to better understand their environment

• Excellent training documents

Commonly Used Flowchart Shapes

Indicates starting or ending points of process

Names or describes an individual task or procedure

Indicates a conditional branch; a question or a decision; a variation in the process

Start or End Start or End

Task or Procedure

Branch

Start

Gather ingredients

Preheat oven to 325 F

Prepare baking pan…

Blend water, oil, and eggs in medium bowl

Add mix

Spread evenly

Bake as directed below

Cool completely in pan

Cut and serve

Spoon batter into prepared pan

Stir until moistened

Yummy Example

Start

Gather ingredients

Preheat oven to 325 F

Prepare baking pan…

Blend water, oil, and eggs in medium bowl

Add mix

Spread evenly

Cool completely in pan

Cut and serve

Spoon batter into prepared pan

Stir until moistened

Are you at high

altitude?

No

Add ¼ cup flour and

add’l 2 Tbsps. water

Yes

Pan type?

Bake 45-50

minutes

Glass

Metal

Bake 40-45

minutes

Flowcharts

• Identifies parts of the process where data can be collected

• Serves as a training tool to understand the complete process

• Identifies parts of the process where data can be collected

• Serves as a training tool to understand the complete process

Flowchart Analysis

• What does your process look like?• What does the desired process look like? • Compare both charts, looking for areas where

they are different• Focus improvement efforts on the differences

or areas of rework and delays

• What does your process look like?• What does the desired process look like? • Compare both charts, looking for areas where

they are different• Focus improvement efforts on the differences

or areas of rework and delays

24

Call between MDs office & OR

Room is booked

MD’s office faxes paper work

Complete?

Pt. arrives

Paperwork checked again

Complete?

Office called & reminded

Pt. taken to OR

Pt. held in pre-op for MD to complete paperwork

Give It a Try

• At your table pick one of the following

processes to flowchart:

– Packing for the last trip you took

– Preparing the last meal you cooked

– Getting here today

• Determine the start and ending point of the

process

• At your table pick one of the following

processes to flowchart:

– Packing for the last trip you took

– Preparing the last meal you cooked

– Getting here today

• Determine the start and ending point of the

process

Decisions to Make

• Decide on the level of detail

– Simple macro-flowchart shows only the

general process flow

– Detailed flowchart shows all actions and

decision points

Go For It

• Identify the major steps in the process

• Write each step on a post-it note

• Arrange the post-it notes in the desired

sequence

• Add directional arrows and decision diamonds

– Keep all yes choices in the same direction

• Identify the major steps in the process

• Write each step on a post-it note

• Arrange the post-it notes in the desired

sequence

• Add directional arrows and decision diamonds

– Keep all yes choices in the same direction

Flowchart Analysis

• What does your process look like?• What does the desired process look like?• Consider flowcharting to compare the ‘real

world’ with ‘the policy’ • Focus improvement efforts on the differences

or areas of rework and delays

• What does your process look like?• What does the desired process look like?• Consider flowcharting to compare the ‘real

world’ with ‘the policy’ • Focus improvement efforts on the differences

or areas of rework and delays

Fishbone

• Also called cause-and-effect diagram• Can reveal key relationships among various

variables, and the possible causes provide additional insight into process behavior

• Often used in root cause analysis– People– Processes– Equipment

• Also called cause-and-effect diagram• Can reveal key relationships among various

variables, and the possible causes provide additional insight into process behavior

• Often used in root cause analysis– People– Processes– Equipment

Catheter-Related Bloodstream

Infection

Poor/ImproperTechnique

Line Colonization/Contamination

Number ofCatheters and/or

Lumens

AntibioticUsage

ContaminatedSupplies

EducationStaffing

Acuity/TimeSite Selection

Lack of hand hygiene

Line inserted without

using sterile technique

Dressing not changed on time

Dressing not occlusive

Line accessed without clean technique including

alcohol swabbing of access site

Poor technique when obtaining blood cultures

More lumens on line than needed

Line not needed but not removed

More than one

central venous catheter

No gown, mask, gloves or hair

covering during insertion

Chloraprep not used for

skin prep prior to

line insertion

Line manipulation

Multiple attempts

Breaks in sterile technique

Inadequatedraping prior to insertion

Treatment basedOn false positive

/contaminatedblood cultures

Blood cultures drawn through

line and results

questionable

Antibiotic use outside hospital

guidelines

Blood leftIn line/end cap

Line from ED/field not changed

Blood at insertion site not

removed

Vascular end caps

not changed

Blood left in end caps

IV tubing hanging without covered end

IVF and components not changed

according to policy

Dressing changes done without appropriate

supplies

Inappropriate use of ultrasound devices

during line insertion

TPN infused via existing line

Inexperienced clinicians

Resident unfamiliar with policy

Nurses do not know dressing change

due; no dates on dressing

Policies not written or not current

Supplemental staff unaware of

policy/lack training

Policy unavailable to medical staff

Medical staff not supportive of policies

Internaljugular or femoral site used

Insertion site near

tracheostomy

Nurses too busy to change

dressing

MD inserts line alone-too

busy to get nurse assistance

Supplemental nursing staff

Inexperienced nursing staff

Other opportunity for dressing

Contamination

Line in place but no longer

needed

Line inserted via undesirable

site (i.e., femoral) not changed

Investigating Practices to Prevent CR-BSI

The Model for Improvement

So You Think You Can Change?

While all changes do not lead to improvement, all improvement requires change.

» Thomas Nolan, The Improvement Guide

While all changes do not lead to improvement, all improvement requires change.

» Thomas Nolan, The Improvement Guide

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

AIM

MEASURE

Selecting Change

Small Tests of Change

What Are We Trying to Accomplish?

• Developing the team’s Aim Statement

34

From Alice in in Wonderland

One day Alice came to a fork in the road and saw a Cheshire Cat.

“Which road do I take?” she asked.His response was a question: “Where

do you want to go?”“I don’t know, “ Alice answered.“Then,” said the cat, “it doesn’t matter.”

Lewis Carroll

BIG

BOLD

WHAT?

HOW MUCH?

WHERE?

By WHEN?

Clear and Unambiguous Target

AIM Statements

• Reduce heart failure mortality rate by 40% by September 1, 2012

• Reduce falls with injury on 4 West to zero by November 30, 2012

• Reduce heart failure mortality rate by 40% by September 1, 2012

• Reduce falls with injury on 4 West to zero by November 30, 2012

What Are You Trying to Accomplish?

• At your tables, for the next 5-10 minutes create an AIM Statement for a project you are working on or planning to start

• At your tables, for the next 5-10 minutes create an AIM Statement for a project you are working on or planning to start

Evaluation and Sharing• Did your AIM statement:

– Have a clear numerical goal?– Have a bold but realistic goal?– Clearly articulate what you want

to achieve and by when?

• Can your AIM statement be given in any elevator?

• Would you change your AIM statement?

• If so, what would you change and why?

How do you know if a change

is an improvement?

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

AIM

MEASURE

Selecting Change

Small Tests of Change

Why Measure?

• How else will you know that the change(s) you made resulted in improvement?

LimitationsOne Voice

Useful, not perfect

Sample

Select right measures

Rapid results

Adapt interventions

Types of Measures

49

Process Measures

What you get

Outcome Measure

Balance Measures

Outcome

Process

Balance

MEASURES

How Will We Know If A Change Is An Improvement?

• At your tables, for the next 5-10 minutes decide what measure(s) will help you know if you have made an improvement

• At your tables, for the next 5-10 minutes decide what measure(s) will help you know if you have made an improvement

Evaluation and Sharing• Does the measure(s) you

selected allow you to understand if you have made a change?

• Would you change your measurement plan?

• If so, what would you change and why?

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

AIM

MEASURE

Selecting Change

Small Tests of Change

The PDSA Cycle

Plan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

“What will happen if we try something different?”

“Let’s try it!”“Did it work?”

“What’s next? ”

What changes can we make

that will result in an improvement?

Brainstorm

Rank

Construct Plan to Test

Time to Brainstorm…

Rules of Brainstorming & Multi-voting

• Brainstorm– Each team member gives

an idea– No debate of value– Continue until there are no

more ideas• Multi-voting

– Each team member gets 3-5 votes

– Use all on one idea or split them up

• Brainstorm– Each team member gives

an idea– No debate of value– Continue until there are no

more ideas• Multi-voting

– Each team member gets 3-5 votes

– Use all on one idea or split them up

Guidelines for Testing Change

Fail Early, Fail Often

What can I do by next Tuesday/Thursday?

Work with the willing

Aim BIG

Test Small

Forget about consensus

Be Innovative

Collect Data

Wide range of conditions

Steal Shamelessly

Why Test?

The PDSA Cycle

Plan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

“What will happen if we try something different?”

“Let’s try it!”“Did it work?”

“What’s next? ”

Back to Work

• Over the next 5-10 minutes, create 1-2 small tests of change you can implement by next Tuesday. Describe the who, what, how and the study approach.

• What do you want to happen?

• How will you know if it did?

• Over the next 5-10 minutes, create 1-2 small tests of change you can implement by next Tuesday. Describe the who, what, how and the study approach.

• What do you want to happen?

• How will you know if it did?

Evaluation and Sharing• Does your test of change:

– Include a description of the test?

– Indicate who will do what, when and where?

– Describe what you want to or think will happen?

• Would you change your test of change?

• If so, what would you change and why?

• Does your test of change:– Include a description of

the test?– Indicate who will do what,

when and where?– Describe what you want to

or think will happen?

• Would you change your test of change?

• If so, what would you change and why?

The Value of “Failed” Tests

“I did not fail one thousand

times; I found one thousand ways how

not tomake a light bulb.”

Thomas Edison

Common Traps

• Plan Do, Plan Do

• Do Act, Do Act

• No testing, only data collection

• No ramps of tests, random PDSAs

• Undisciplined PDSAs, no documentation

• Prediction – what are we going to learn

• Beware of Cycles longer than 30 days

Mistakes Made In Improvement Teams

• Failure to state a measurable, specific aim• Failure to tie measures to aims• Over-reliance on education and awareness• Failure to state a population focus• Failure to abandon a change that does not lead to

an improvement• Failure to engage process owners on a team and

solicit their ideas• Failure to make data visible to all engaged in the

process

• Failure to state a measurable, specific aim• Failure to tie measures to aims• Over-reliance on education and awareness• Failure to state a population focus• Failure to abandon a change that does not lead to

an improvement• Failure to engage process owners on a team and

solicit their ideas• Failure to make data visible to all engaged in the

process

Useful Websites• www.jointcommission.org• www.healthgrades.com• www.calhospitalcompare.org• www.ihi.org• www.ahrq.gov• www.apic.org