Transcript The Science of Improvement and Creating Reliable Systems
The Science of Improvement:
Creating Reliable Health Systems
Debbie Barnard,MS,CPHQ SHN Project Manager, CPSI
Introduction Current State of Healthcare
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Canadian Experience
• Canadian Adverse Events Study (Hospital settings) (Baker, R. & Norton, P. et al. (2004) – Incidence rate of 7.5% in hospitals (2000) – 70,000 preventable adverse events (est.) – 9,000 - 24,000 preventable AE deaths in Canada (2000) • One in 9 acquire infection in hospital • One in 9 given wrong medication • More deaths occur due to adverse events than from breast cancer, vehicle accidents and HIV 3
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How Hazardous Is Health Care?
(Leape)
100,000 10,000 DANGEROUS (>1/1000) HealthCare REGULATED Driving ULTRA-SAFE (<1/100K) 1,000 Scheduled Airlines 100 10 Mountain Climbing Bungee Jumping Chemical Manufacturing Chartered Flights 1 1 10 100 1,000 10,000 Number of encounters for each fatality 100,000 European Railroads Nuclear Power 1,000,000 10,000,000
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How Hazardous Is Health Care?
(Leape)
100,000 DANGEROUS (>1/1000) HealthCare REGULATED Driving The Goal ULTRA-SAFE (<1/100K) 10,000 1,000 100 10 1 1 Mountain Climbing Bungee Jumping Chemical Manufacturing Chartered Flights Scheduled Airlines European Railroads Nuclear Power 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality
Copyright 2002 Institute for Healthcare Improvement 5
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Seeing Differently
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“The real act of discovery is not in finding new lands, but in seeing with new eyes”.
Marcel Proust (1871-1922) 7
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Nine Box Puzzle
• On your sheet there are nine dots arranged in a set of three rows. Your challenge is to draw four straight lines which go through the middle of all of the dots without taking your pen off the sheet of paper.
• You can start from any position on the paper and draw the lines one after the other without moving your pen from the paper. • Each line must start where the last line finishes. 8
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System of Profound Knowledge
The System has four parts
• Appreciation for a system • Knowledge about variation • Theory of knowledge • Psychology
Source: Horn, Steve, “
Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm
[Accessed October 2007] 9
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Lens of Profound Knowledge
“The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations .”
Theory of Knowledge Appreciation of a system Psychology
Deming, The New Economics , 1993
Understanding Variation Provost, L.; Godlee, F., “Connecting the Science of Improvement to Medical Research” International Forum on Quality and Safety in Health Care [Online Access Oct. 2007] 10
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Deming’s System of Profound Knowledge
APPRECIATION OF A SYSTEM THEORY OF KNOWLEDGE UNDERSTANDING VARIATION Source: Margolis,P & Lannon L; NRSA AHRQ Workshop: Quality and Quality Improvement PSYCHOLOGY 11
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Understanding Systems
APPRECIATION OF A SYSTEM THEORY OF KNOWLEDGE UNDERSTANDING VARIATION PSYCHOLOGY 12
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What is a System?
“A system is a network of interdependent
components that work together to try to accomplish the aim of the system.”
W Edwards Deming, The New Economics, p. 50
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System
Source: Horn, Steve, “
Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm
[Accessed October 2007] 14
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Common View of a System CEO Assistant VP VP Director Director Director Manager RN RN
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Common Conception of a System CEO Assistant VP VP Director Director Director Manager RN
NO!!!! According to Deming
RN
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Slide
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System of Improvement - Five Activities for Leaders
Source: Harries, Bruce: Presentation to SHN Education Resources Committee – January 2007Quality
as a Business Strategy
Associates in Process Improvement (API), Austin Texas copy write 18
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Types of Processes
•
Mainstay processes
- those processes that directly relate to the mission of the organization and add value to the external customers of the organization.
Source:
Quality as a Business Strategy
- Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006 19
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Types of Processes
•
Driver processes
- those processes that "drive" the mainstay of the organization. These processes are usually associated with the need that the organization intends to fulfill
(from the mission statement of the organization).
• Examples: – customer feedback, planning, research, development, budgeting, etc. Source:
Quality as a Business Strategy
- Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006 20
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Types of Processes
•
Support processes
- those processes that are necessary to support the mainstay processes. • Examples for a healthcare organization are IT, HR, Communications, etc. Source:
Quality as a Business Strategy
- Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006 21
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Systems View of SHN Campaign Wednesday Updated: Sunday, January 28, 2007
DRIVERS Purpose of Camgaign
Enabling providers to work with patients on selected topics to reduce preventable harm in Canada Co ordination Partnership and Alliance Planning Funding and Budgets
EXAMPLE
Governance Evaluation Needs Assessment Learning from Teams Feedback
MAINSTAY
Building Relationships (infrastructure) Nodes, Clinical & Campaign Supports
SUPPORT
Maintain and Manage IT Education/ Training Workshops, Conference calls,Website, Getting Started Kits Caring for each other Recognition Future leaders Psychosocial support Support staff Social events Communication Measurement HR Getting people to the right place Clinical supports Nodes/ SIA’s
Harries, Barnard, Hoffman 2006
Purpose of CPSI
Provide national leadership to improve safety in Canada
Purpose of CPSI Secretariat
Provide funding, co-ordination and communication to enable the campaign to reduce harm.
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Understanding Variation
APPRECIATION OF A SYSTEM THEORY OF KNOWLEDGE UNDERSTANDING VARIATION PSYCHOLOGY 23
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“
In God we trust. All others bring data.
” W.E. Deming, Ph.D.
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Measurement Has Two Purposes
• Helps you to know: – Where you are?
– Where you are going?
•
“Without measurement it is impossible to know whether you have improved”
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Types of Measures
Type of measure Outcome measures Process measures Balancing measures Examples Rates Failures Re-admits Mortality, LOS % use order set, guideline, etc % treated in required time % receiving 100% of ‘bundle’ Times, durations Etc Costs Delays Resources % detected by redundant process Etc 26
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Process vs. Outcome Measures
• • •
Outcome = Voice of customer/patient
:
How is the system performing?
What is the result of systems?
How is the health of patients affected?
• •
Process = Voice of workings of the system: Are the parts/steps in the system performing as planned?
Are key changes being implemented?
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Common Terms
•
Variation
- difference in the output of a process (or inputs to a process) over time. Variation consists of common cause variation, special cause variation and structural variation (and some include tampering).
•
Common Cause Variation
- variation resulting from the system. Every system will have some amount of variation of results.
•
Special Cause Variation
- variation resulting from a assignable cause. Special causes should be addressed by finding the special cause and taking action.. Source: Horn, Steve, “
Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm
[Accessed October 2007] 28
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Common Terms
•
Structural Variation
- trends within the data. They often take the form of seasonal variation and growth or decline •
Tampering
- taking action based on the belief that a common cause is a special cause. – Most variation (97% +) is common cause variation Source: Horn, Steve, “
Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm
[Accessed October 2007] 29
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Understanding Variation
Stable Process
control. - one in statistical
Unstable Process
- a process not in statistical control.
Source: Horn, Steve, “
Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm
[Accessed October 2007] 30
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Common Cause Variation
• Variation exists in all aspects of life – People’s Behavior – Weight – Stress – Time required to travel to work – People – “how they learn”, intelligence 31
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Psychology
APPRECIATION OF A SYSTEM THEORY OF KNOWLEDGE UNDERSTANDING VARIATION PSYCHOLOGY 32
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Psychology
• This is Deming’s language for the dynamics of people in the workplace, team performance, learning styles and organizational culture. Deming opines that managers need to know how people interact, their individual needs, their working and learning styles.
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Theory of Knowledge
APPRECIATION OF A SYSTEM THEORY OF KNOWLEDGE UNDERSTANDING VARIATION PSYCHOLOGY 34
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Knowledge for Improvement
Subject Matter Knowledge Profound Knowledge Improvement:
Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement.
Improvement
Provost, L.; Godlee, F., “Connecting the Science of Improvement to Medical Research” International Forum on Quality and Safety in Health Care [Online Access Oct. 2007] 35
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Introduction to PDSA
• Deming argued that inspection at the end of the process is too late and too expensive. Quality results from studying and changing the system, not inspecting the product Measurements used to monitor the processes 36
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Aims
Model for improvement
Measurement Ideas, evidence, hunches, Other people etc.
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 the improvements we seek ?
The three fundamental questions for improvement
The fourth question: how to make changes
Act Plan Study Do Langley, Nolan et al 1996
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Repeated Use of the PDSA Cycle
Model for Improvement 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?
A P S D Changes That Result in Improvement Theories Ideas A P S D Scale Test Follow Very Small up Tests Implementation of Change Wide-Scale Tests of Change
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Why Test
•
Why Not Just Implement then Spread?
Increase degree of belief
Document expectations
Build a common understanding
Source: IHI 39
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Why Test
Evaluate costs and side-effects
Explore theories and predictions
Test ideas under different conditions
Learn and adapt
Source: IHI 40
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We Know That…
• Every system is perfectly designed to get the results it gets. • If we want different results, we must change (transform) the system
Source: Maher,L. and Plsek, P. “Bringing Creativity and Innovation to Health Services” Presented at the Quality Improvement in Healthcare Forum, Prague, April 2006 41
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Reliability in Healthcare
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Why reliability?
• Implementing reliability concepts has been found to reduce defects in care, increase the consistency with which appropriate care is delivered and improve patient outcomes.
( IHI 2004) • “ Reliability means keeping a promise” (Don Berwick) Source: Murkin, J. “Reliability Theory in Action”. www.nhsscotlandevent.com/.../1330%20wed%20alsh%20%20
Reliability
%20Theor y%20in%20Action%20FULL%20SESSION.ppt [Accessed Oct. 2007] 43
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Reliability Rates in Healthcare
A large study in US health care using detailed case notes review concluded that the “defect rate” in the technical quality of American healthcare is approximately 45%
(McGlynn, et al The quality of healthcare delivered to adults in the United States NEJM 2003; 348)
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3 Steps Towards Reliability
1. Prevent failure (a breakdown in operations or functions).
2. Identify and Mitigate failure: Identify failure when it occurs and intercede before harm is caused, or mitigate the harm caused by failures that are not detected and intercepted.
3. Redesign the process based on the critical failures identified.
Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 45
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Reliability Equation
Reliability =
Number of actions that achieve the intended result ÷ Total number of actions taken Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 46
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Reliability What does the system look like?
Less than 10 -1 (<80%, out of control) 10 -1 (80 – 95% success) 10 -2 (95 – 99.5% success) 10 -3 or more (<5 per 1000 failures) Chaotic, ad hoc, no system Intent, vigilance, hard work Design informed by reliability science and human factors Design of ‘High Reliability Organisations’ (Nolan, after Weick) 47
10-1 performance
• Standard tools and techniques used at the 10-1 performance level include: Use of common equipment brands Standard order sheets and guidelines Memory aids such as checklists Feedback mechanisms regarding compliance with standards Awareness-raising and training Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 48
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10-2 performance
• Standard tools and techniques used at the 10-2 performance level include: “Opt-out” – The desired action = flow of work Standardize processes Create redundancies and time lapses Build design aids into the system Make the desired action the default Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 49
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10-2 Performance Principles
• •
Constraints:
constraint.
Constraints restrict or limit the performance of certain actions. For example, computers that signal an alarm when two medications prescribed for the same person should not be taken together serve as a
Affordances:
An affordance provides clear visual or other sensory clues that lead the user to use a product or tool correctly, or perform the correct action. An outward-swinging door with a pushplate but no handle is an example.
Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 50
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10-2 performance
•
Reminders:
Examples include calling patients the day before their appointments to reduce no-shows and late arrivals, and using checklists or alarms to prompt specific actions.
.
•
Differentiation:
To reduce confusion when actions, parts, or numbers are similar, patterns are broken by color coding, sizing parts differently, numbering items in easily distinguishable ways, or separating similar items.
Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 51
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10-3 performance
•
Failure Modes and Effects Analysis (FMEA)
Failure modes (What could go wrong?) Failure modes (Why would the failure happen?) Failure modes (What would be the consequences of each failure?) Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
) 52
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Questions/Comments
Debbie Barnard, MS, CPHQ Project Manager Safer Healthcare Now!
Canadian Patient Safety Institute Suite 1414, 10235 101 Street Edmonton, Alberta T5J3G1 Phone:
780-498-7259
or 1-866-421-6933 Fax: 780-409-8098 Email: [email protected]
Website: www.patientsafetyinstitute.ca
The Canadian Patient Safety Institute would like to acknowledge funding support from Health Canada. The views expressed here do not necessarily represent the views of Health Canada
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