Introduct

ion to Qua
Improvem lity
ent
T h an in
ad
Ahm
 Objectives
0 To gain an understanding of what quality
improvement is
0 To present the Model for Improvement and PDSA
cycle
0 To introduce measurement in quality improvement
0 To introduce flowcharts
 What is Quality
Improvement?

0 A formal approach to the analysis of performance and

systematic efforts to improve it
0 Different from Quality Assurance
 Quality Improvement versus
Quality Assurance
Quality Improvement Quality Assurance
What can we do to improve? What went wrong?

Proactive Reactive
Avoids blame Often Punitive
Fosters System change Tries to find who was at fault

Focuses on the entire Focuses on the specific

system incident
 What is quality?
0 Definition of quality depends on stakeholders
0 The client/customer (the patient)
0 The provider/employer (health care providers)
0 Management (hospital management)
0 Payer (Ministry of Health)
 6 Pillars of Quality
0 Safety
0 Timely Access
0 Equitable
0 Efficacy
0 Efficient
0 Patient Centered
 “Every system is perfectly
designed to get the results it
gets”
0 How can you improve a system to achieve better results
in the 6 pillars of quality?
 To improve a system…
0 You need a good understanding of the system

0 You need to understand where it is failing -

Identify what is wrong
0 Make sure it is the step that needs fixing

0 Then you can implement a change to the “system”

 What is a system?
0 System = any assembly of procedures, resources and
routines to carry out a specific activity
 System
0 To understand a system and identify what is wrong
with it Map it out!
 How do you map out a
system?
0 Use a flow chart/diagram

0 Use different perspectives (a doctor’s perspective is

different to a nurse’s or a porter’s to a patient’s
perspective)
Quality Improvement Models
0 Model for Improvement = Three questions + PDSA cycle
0 FADE = Focus, Analyze, Develop, Execute and Evaluate
0 Six Sigma
0 CQI = Continuous Quality Improvement
0 TQI = Total Quality Management
0 7 step method
 Model for Improvement
= Three questions + PDSA cycle
 The Three Questions
0 The Model for Improvement begins with three
fundamental questions

0 1. The Aim: What are we trying to accomplish? (How

good do we want to get and by when?)
0 2. The Measures:
Measures How will we know a change is an
improvement?
0 3. The Changes: What change can we make that will
result in improvement?
 PDSA Cycle
0 Plan a change
0 Do the change
ACT PLAN
0 Study the results
0 Act on the results

STUDY DO
 PDSA Cycle
0 Enables rapid testing and learning
0 Allows for incremental testing
0 Instead of spending weeks or months planning out a
comprehensive change, then putting it into practice
only to find that it is fundamentally flawed
 PDSA Cycle
0 Can aid you in:
0 Developing a change
0 Testing a change
0 Implementing a change
What are we trying to accomplish?

How will we know that a change is

an improvement?

What change can we make that will

result in improvement?

ACT PLAN

STUDY DO

MODEL FOR IMPROVEMENT

 Executing the Model for
ple

doa
n e xam
Improvement
’s
Let
 The Problem
0 Patient’s at XY - Hospital emergency department
are often in pain

0 We want to change that

0 So…how do we do that?
 Executing the Model for
Improvement
0 Form a team
0 Three Questions: The Aim,
The Aim
The Measures, The changes
0 Test changes - PDSA Cycle The Measure
0 Implement changes that
The Change
work
0 Spread the changes to other
ACT PLAN
areas
STUDY DO
 You need a team
0 Why? 0 To come up with the
0 Need different right team you have to
perspectives have an idea of what
0 It’s a lot of work your aim is…
0 Increased buy-in by staff
0 Different levels of support
(e.g. management)
 The Aim
What are we trying to accomplish?
 The Aim
0 A strong, measurable
aim with a clear time The Aim
frame will help keep
your project on course The Measure

The Change
0 It has to be important to
those involved ACT PLAN

STUDY DO
 The Aim
0 A good aim:
0 Is Specific
0 Is Measurable
0 Determines a time frame
0 Addresses who the change is for, and what has to be
achieved
0 Is Sustainable
 The Aim

0 I will become a good runner

0 I will run 10 kilometers per week by May 31st

0 I will run more often

Which one of the above is a good aim?

 The Aim
0 Back to the Problem: Patients at XY - Hospital
emergency department are often in pain

0 We decide to focus on emergency department

patients with fractures
 The Aim
0 All emergency department patients with fractures

0 We will provide analgesia to 100% of our pts with a

suspected fracture within 15 minutes of arrival to the
emergency department by the end of December 2013.
Choose your team
 Choose your team
0 Consider the system that relates to the aim i.e. what
processes will be affected by the improvement efforts

0 Involve members familiar with all different parts of

processes
 Back to our example
0 All emergency department 0 What processes will be
patients with fractures affected?
0 We will provide analgesia to
100% of our patients with a
suspected fracture within 15
minutes of arrival to the
emergency department by
the end of June 2011.
 Back to our example
0 All emergency department 0 What processes will be
patients with fractures affected?
0 Nursing/Triage
0 We will provide analgesia to 0 Pharmacy
100% of our patients with a 0 Stocking
suspected fracture within 15
minutes of arrival to the 0 Doctors
emergency department by 0 Registration
the end of June 2011. 0 ED chief/director/
manager
 Choose your team
0 Effective teams require three kinds of expertise
0 System leadership for authority
0 Clinical -Technical expertise
0 Day to day leadership - Project leader
 Your team
0 Team leader: Medical director of the emergency
department
0 Technical expert: Hospital Quality Management
member
0 Day to day leader (project leader): an emergency
doctor or nurse
0 Additional team members: pharmacist, person
responsible for stocking, charge nurse, registration
clerk
 Revisit the Aim
0 Once you have chosen your team, review and modify
the aim based on their input
Measurement
How will we know that a change is an
improvement?
 Measurement
0 Measurement is critical
for testing and The Aim
implementing changes
The Measure

0 Different from The Change

measurement for
research ACT PLAN

STUDY DO
 Measurement
Measurement for Measurement for
Research Improvement
Purpose To discover new knowledge To bring new knowledge into
daily practice
Tests One large blind test Many sequential, observable
tests
Biases Control for as many biases Stabilize the biases from test to
as possible test
Data Gather as much data as Gather just enough data to learn
possible, just in case and complete another cycle
Duration Can take a long time Short duration
 Measurement
0 3 types of measures for quality improvement
0 Outcome measures
0 Process measures
0 Balancing measures
0 (+/- Structure Measures)
 Outcome Measure
0 = Where are we ultimately trying to go
0 Are your changes actually leading to improvement
 Process Measures
0 = Are we doing the right things to get there?
0 To affect an outcome you have to improve your
processes
0 Are the parts/steps in the system performing as
planned
 Balancing Measures
0 Tells you if changes designed to improve one part of
the system are causing new problems in other parts of
the system

Examples for our case scenario: Complications from

analgesics (allergic reactions, hypotension,
infections at IM injection sites); increased times to
nursing assessments for all other patients other
than those with fractures
 The Change
What change can we make that will lead to
improvement?
 Developing Changes
0 Depends what you are
trying to change The Aim

The Measure

The Change

ACT PLAN

STUDY DO
 Basic Techniques
0 Critical Thinking
0 Flow Chart/Diagram
0 Benchmarking
0 Compare to best practice
0 Using Technology
0 Barcodes for medications
0 Creative Thinking
0 Become a patient for a day
0 Using Change Concepts
 Critical Thinking
0 Use a Flow Chart/Diagram

0 A flow chart allows to “visualize” the system you are

trying to change

0 Allows ALL to see the system the same way

 Flow Chart/Diagram
0 It helps to clarify complex processes

0 It identifies steps that do not add value to the

internal or external customer, including:
0 Delays
0 Needless storage and transportation
0 Unnecessary work, duplication, and added expense
0 Breakdowns in communication
 Flow Chart/Diagram
0 It helps team members gain a shared
understanding of the process and use this
knowledge to collect data, identify problems,
focus discussions, and identify resources.

0 It serves as a basis for designing new

processes.
 Flow Chart/Diagram
0 High-level flowchart, showing six to 12 steps, gives a
panoramic view of a process

0 Detailed flowchart is a close-up view of the process,

typically showing dozens of steps. These flowcharts
make it easy to identify rework loops and complexity
in a process.
Example: High Level Flow
Chart
Example: Detailed Flow Chart
 7Change Concepts
0 Eliminate Waste - an activity or resource that does
not add value

0 Improve Work Flow

0 Optimize Inventory - is your work being held up

because items are not properly organized or available
 Change Concepts
0 Change the Work Environment (does the work
culture enhance or impede change)

0 Manage Time

0 Focus on Variation - what aspect of the system

vary and make your outcomes unpredictable

0 Focus on Error Proofing (checklist)

 Testing Chang
es:
PDSA Cycle

All improvem
ent will requ
change wil ire change,
l result in i but not all
mproveme
n t.
 Testing Changes
0 Why test changes (even if they are already proven
elsewhere)?
0 To learn how to adapt the change to the particular
conditions in your setting
0 To evaluate the costs and side effects
0 To minimize resistance when implementing the change
in the organization
0 Increase your belief that the change will result in
improvement

To test your change use the PDSA cycle

 PDSA Cycle
0 Plan
The Aim
0 Objectives
0 Questions and predictions The Measure
0 Plan to carry out the cycle
The Change
(who, what, where, when)
0 Plan for data collection
ACT PLAN

STUDY DO
 PDSA Cycle
0 Do The Aim
0 Carry out the plan
The Measure
0 Document problems and
unexpected results The Change
0 Begin Analysis
ACT PLAN

STUDY DO
 PDSA Cycle
0 Study
0 Complete analysis of the The Aim

data
The Measure
0 Compare data to prediction
0 Summarize what was The Change
learned
ACT PLAN

STUDY DO
 PDSA Cycle
0 Act
0 What changes are to be The Aim

made
The Measure
0 Next cycle?
The Change

ACT PLAN

STUDY DO
 Testing Changes
0 Much can be learnt
from a failed test

ACT PLAN

STUDY DO
ACT PLAN PDSA
PDSA
STUDY DO

ACT PLAN PDSA

STUDY DO PDSA

PDSA
 What happens when you
identify what works?
0 Are you done?

0 Once you identify what works, change has to be

SUSTAINED. Implementing a change is the hardest
part.
 How easily is change
adopted?
0 Process of “Normalization”

0 People have a tendency to fall into old habits

0 People have a tendency to resist change

0 People may feel threatened by a change

 Executing the Model for
0 Form a team
Improvement
0 Three Questions: The Aim,
The Measures, The changes The Aim
0 Test changes - PDSA Cycle
The Measure
0 Implement changes that
work The Change
0 Spread the changes

ACT PLAN

STUDY DO
Implementation
 Implementation
0 Usually comes after a series of successful tests

0 It requires that staff and leaders build the change

into formal plans, job definitions, training,
and explicit reviews

0 The change does not depend on the individuals

doing the work, but on the way the work is
organized - as part of the system.
 Implementing Change
0 “Hard-wire” the change into the system

Remember
The implementation phase is the most common
area where process improvements fails.
 Hardwire Change

0 Market your change

0 Train everyone involved
0 Make changes to job descriptions, policies, procedures, forms
0 Addressing supply and equipment issues
0 Assigning day-to-day ownership for the maintenance of the
new process
0 Have senior leaders remove any barriers
 Social System
0 Social System - understand the relationship among the
people who will be adopting the new ideas

0 Remember there is an emotional component to change

0 Stress of learning and executing something new
0 Initial disruption to workflow
0 Maybe they feel their job/position is threatened
 Social System
0 Those who are supportive
0 Enlist on your side

0 Those who are not supportive

0 Don’t try to change their attitude
0 Listen to what concerns them, identify barriers

0 Those who don’t really care, and will follow when others
do
 Summary
0 In this modules we have presented an introduction to:
0 Quality Improvement
0 The Model of Improvement
0 3 questions (What is your aim, measures, change) and PDSA
cycle
0 Types of Measures
0 Change and Implementation
Thank You