Transcript Slide 1

Topic 7
Introduction to methods for
quality improvement
Learning objective
• the objectives of this topic are to:
– describe the basic principles of quality improvement
– introduce students to the methods and tools for improving the
quality of health care
Performance requirement
• know how to use a range of improvement activities
and tools
Knowledge requirements
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the science of improvement
the quality improvement model
change concepts
two examples of continuous improvement methods
methods for providing information on clinical care
The science of improvement
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appreciation of a system
understanding of variation
theory of knowledge
psychology
W Edwards Deming
The Institute for Healthcare
Improvement (IHI): different measures
Measurement for research
Measurement for learning
and process 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 as
possible
Stabilize the biases from test to
test
Data
Gather as much data as possible,
"just in case"
Gather "just enough" data to
learn and complete another
cycle
Duration
Can take long periods of time to
obtain results
"Small tests of significant
changes" accelerate the rate of
improvement
Three types of measures
• outcome measures
• process measures
• balancing measures
The quality improvement model-the
PDSA cycle
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an
improvement?
The model for improvement
What are we trying to accomplish?
How we will know that a change is an improvement?
What change can we make that will result in an improvement?
ACT
STUDY
PLAN
DO
Langley, Nolan, Nolan, Norman & Provost 1999
The PDSA cycle
Determines what
changes are to be made
Change or test
ACT
PLAN
STUDY
DO
Summarizes what
was learned
Carry out the plan
Langley, Nolan, Nolan Norman & Provost 1999
Change concepts …
… are general ideas, with proven merit
and sound scientific or logical foundation
that can stimulate specific ideas for
changes that lead to improvement.
Nolan & Schall, 1996
9 categories of change
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eliminate waste
improve work flow
optimize inventory
change the work environment
enhance the producer/customer relationship
manage time
manage variation
design systems to avoid mistakes
focus on the product or service
Langley, Nolan, Nolan, Norman & Provost 1999
Two continuous improvement
methods
• clinical practice improvement methodology (CPI)
• root cause analysis
The improvement process
Project mission
Project team
Ongoing monitoring
Outcome
Future plans
Project
phase
Sustaining
improvement
phase
1
5
1 month
Annotated
run chart
SPC charts
Impact
phase
4
3
S
2 months
2 Diagnostic
phase
Conceptual flow of
process
Customer grid
Data
-fishbone
-Pareto chart
-run charts
-SPC charts
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D
Intervention
phase
P
S A
D P
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P
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D S
P A
P
2 months
Plan a change
Do it in a small test
Study its effects
Act on the result
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
SPC – statistical process control
Interventions phase
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Identify appropriate interventions
Implement changes identified in the diagnostic phase
Undertake one or more PDSA cycles
Interventions phase
Decide on interventions
Undertake one or more PDSA
cycles
How to use the PDSA Cycle
• use plan-do-study-act cycles
to conduct small-scale tests
of change in real settings
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plan a change
do it in a small test
study its effects
act on what learned
• team uses and links small
PDSA cycles until ready for
broad implementation
ACT
• What changes
can be made for
the next cycle
(adapt change,
another test,
implementation
cycle?)
STUDY
• Complete analysis
of data
• Compare results
to predictions
PLAN
• Objective
• Prediction
• Plan for change (who,
what, when, where)
• Plan for data collection
(who, what, when, where)
DO
• Carry out the change
• Document observations
• Record data
• Summarize
knowledge gained
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
PDSA cycle - single test
PDSA Cycles – single test
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A
A
P
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D
S
D
P
A
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P
A
Changes that
result in
improvement
P
D
Hunches,
theories
and ideas
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
PDSA cycle – multiple tests
D
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D
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P
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P
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P
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A
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P
P
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P
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P
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P
S
D
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Test 1
Test 2
A
Test 3
PDSA Cycles – multiple tests
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Impact and implementation phase
1.
2.
3.
4.
Measure impact of changes/interventions
Record the results
Revise the interventions
Monitor impact
Impact and implementation phase
• Annotated run chart
Measure impact
• SPC charts
• Other graphs
Implement the changes
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Sustaining the improvement phase
1.
2.
Once an intervention has been
introduced, the intervention and any
improvements need to be sustained
This may involve:
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standardization of existing
systems and processes
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documentation of policies,
procedures, protocols and
guidelines
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measurement and review of
interventions to ensure that
change becomes past of
“standard” practice
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training and education of staff
Sustaining
improvement phase
• standardization
Sustain the gains
• documentation
• measurement
• training
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Root cause analysis
• a multidisciplinary team
• the root cause analysis effort is directed towards finding
out what happened
• establishing the contributing factors of root causes
Performance requirements
Know how to use a range of improvement activities and tools
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flowcharts
cause and effect diagrams (Ishikawa/fishbone)
Pareto charts
run charts
Evidence for there being
a problem worth solving
14
12
10
LOS days
8
6
4
2
0
Hospital
NSW Health
Kehlet et.al
At the same time LBH executives and staff expressed a desire to improve LOS.
NSW – New South Wales.
Flow chart of process
Accelerated Recovery Colectomy Surgery (ARCS)
Jenni Prince
Area CNC Pain Management
North Coast Area Health Service
NCHI Sydney Australia
Something amiss
Visit to general
practitioner
Investigations
Referral to surgeon
Referral to Hospital
Hospital admission
Return to life
Post anaesthetic care
Operating theatre
Surgical ward
Allied health
Surgical team
Pain team
Pre-op ward
Admitted to hospital
Discharge planner
Community health/
Peripheral hospital
Preoperative clinic
Admissions office
Home
Customer and expectations list
• surgical ward staff
• post-op anaesthetic care staff
• physiotherapy dept
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dietitian
peri-operative unit staff
private hospital staff
pain team
anaesthetists
surgeons
intensivist
Multidisciplinary meeting to:
-ask opinion
-brainstorm process of care
-how to improve the process
-who to include in the process
of change
-how to communicate progress
standardization
Evidence-based
practice
team approach
Accelerated Recovery Colectomy Surgery (ARCS)
Jenni Prince
Area CNC Pain Management
North Coast Area Health Service
NCHI Sydney Australia
Cause and effect diagram
Social issues
Staff attitudes
Complications
LOS
mobilization
pain control
home support
often weak
family support
poor pain control
wound complications
weak/malnourished
nutrition
infection
Prolonged
LOS
nutrition
mobilization
nil by mouth
surgery
pain control
Procedure
expect long LOS
poor understanding
of procedure
little knowledge of
support services
locus of control
Patient perception
general practitioner
community health
family
colon care nurse
Post discharge support
Pareto chart
45
100
40
35
45
80
30
57
25
20
38
34
28
42
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18
10
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76
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PDSA cycles - implementation
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surgical incision
pain control
trial of transverse incision
wound infusion for transverse incisions
1
surgeon
10
patients
then
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patient information booklet
surgeon pathway
anaesthetic pathway
ARCS clinical pathway
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surgical technique
pain control
bowel prep/care
nutrition
mobilization
1
surgeon
1-6
patients
Run chart
Average LOS (days) per month
60
50
Made change here
days
40
30
20
10
0
1
2
3
4
5
6
m onth
7
8
9
10
11
12
Strategies for sustaining
improvement
• document and report each patient LOS
• measure and calculate monthly average LOS
• place run chart in operating theatre, update run chart
monthly
• bimonthly team meetings to report positives and
negatives
• continuously refine the clinical pathways
• report outcomes to clinical governance unit
• Spread
- all surgeons
- left hemicolectomy
- all colectomy surgery
- throughout North Coast Area Health Service