QI, in a nutshell

Georgia McIntosh, MD And Quality and Safety Educator’s Academy, Society of Hospital Medicine

6 Steps to QI

1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

6 Steps to QI

1. Understand the problem

2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

Process Modeling Tools

    Cause and Effect Diagram or Fishbone diagram Standard Flow diagram Deployment Flowchart or Swim-lane Diagram Mind Map

Process Modeling Tools

 Cause and effect diagram ( “fishbone or ishikawa”)  Process Map

Process Modeling Tools

Mind Map

Process Modeling Tools

Deployment Flowchart or Swim lane Diagram

Error Reduction Strategies Strong actions Intermediate Actions Weak Actions

6 Steps to QI

1. Understand the problem

2. Identify areas for change/improvement

3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

Donabedian’s Topology of Quality Measures

Structure

How was care delivered to the patient

Process

patient What was done to the

Outcome

What happened to the patient

Balancing

Unintended, undesirable consequences

Structure, Process or Outcome?

      30 day mortality after CABG Bone densitometry ordered in women over 65 Computerized order entry ACE or ARB for CHF pts with low EF Last BP of < 140/90 in pts with HTN Physician boarded in critical care medicine responding to codes at all times

6 Steps to QI

1. Understand the problem 2. Identify areas for change/improvement

3. Explicitly state your goals

4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

Aim Statement

“VCUHS will be the safest hospital in the United States.”

Aim Statement

VCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients, team members and visitors.”

Aim Statement

VCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients, team members and visitors.”

   For whom?

How good?

By when?

6 Steps to QI

1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals

4. How will you measure progress

5. Create effective, reliable improvements 6. Build upon success and sustain the process

Measurement Payers Demanding Increased Accountability

Voluntary reporting to payer Pay for reporting to payer Public reporting Pay for performance

6 Steps to QI

1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress

5. Create effective, reliable improvements

6. Build upon success and sustain the process

6 Steps to QI

1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements

6. Build upon success and sustain the process

Quality and Safety Concept Map Quality Safety

QI project Work Measures K Adverse events Near Misses Swiss Cheese Model Root Cause Analysis S Change A Error Reporting Safety Culture

1.

a.

b.

c.

d.

e.

Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby?

LEAN Six Sigma Cause-and-effect diagramming Swim lane diagramming Failure mode and effects analysis

1.

a.

b.

c.

d.

e.

Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby?

LEAN

Six Sigma Cause-and-effect diagramming Swim lane diagramming Failure mode and effects analysis

LEAN

   Developed by Toyota Aim to eliminate waste in the system Most common waste is patient wait time

Six Sigma

    Invented by Motorola Designed to remove defects and variations from a system Six sigma means 6 standard deveiations from the mean which represents 3.4 defects per 1 million opportunities Utilizes DMAIC methodology  Design, Measure, Analyze, Improve, Control

Cause and effect diagramming

   AKA Fishbone diagram Uncovers the factors that influence an outcome Hypothesis-generating tool

Deployment Flowchart or Swim-lane Diagram

Failure mode and effects analysis

 Tool for classifying errors by severity and likelihood of recurrence for use in prioritizing quality initiatives

Failure Mode and Effects Analysis

 systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.

2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect?

1.

Online education module on heparin dosing 2.

3.

Distribution of a heparin dosing pocket card A heparin order set 4.

5.

A new institutional policy on heparin dosing A physician education conference on heparin dosing

2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect?

1.

Online education module on heparin dosing 2.

Distribution of a heparin dosing pocket card

3.

4.

5.

A heparin order set

A new institutional policy on heparin dosing A physician education conference on heparin dosing

Error Reduction Strategies Strong actions Intermediate Actions Weak Actions

How do you prevent customers from leaving behind their ATM cards?

Strong Action Swipe card only Intermediate Action- Beeping Weak Action- signs