Transcript Flowcharts - Cynosure Health Solutions

Quality Improvement 101
Barbara DeBaun, RN, MSN, CIC
Kathleen 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
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
Share a Story
Data Drives Decisions
The Heart Motivates
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
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.
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
Flowchart
Brainstorming
Multi-voting
Pareto
diagram
Fishbone
diagram
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
Start or
End
Start or End
Task or
Procedure
Branch
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
Yummy Example
Gather ingredients
Preheat oven to 325 F
Prepare baking pan…
Blend water, oil, and eggs in
medium bowl
Add mix
Stir until moistened
Spoon batter into prepared pan
Spread evenly
Bake as directed below
Cool completely in pan
Cut and serve
Start
Gather ingredients
Spoon batter into prepared pan
Preheat oven to 325 F
Spread evenly
Prepare baking pan…
Blend water, oil, and eggs in
medium bowl
Bake 4550
minutes
Glass
Bake 40Pan
45
type? Metal
minutes
Add mix
Are you at
high
altitude?
No
Stir until moistened
Add ¼ cup
Yes flour and
add’l 2
Tbsps. water
Cool completely in pan
Cut and serve
Flowcharts
• 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
Call between MDs office & OR
Room is booked
MD’s office faxes paper work
Complete?
Office called & reminded
Pt. arrives
Paperwork checked again
Complete?
Pt. taken to OR
24
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
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
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
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
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
Model For Improvement
What are we trying to
accomplish?
AIM
How will we know that a
change is an improvement?
MEASURE
What change can we make that
will result in improvement?
Act
Selecting Change
Plan
Small Tests of Change
Study
Do
What Are We Trying to Accomplish?
• Developing the
team’s Aim
Statement
34
From Alice 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
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
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?
Model For Improvement
What are we trying to
accomplish?
AIM
How will we know that a
change is an improvement?
MEASURE
What change can we make that
will result in improvement?
Act
Selecting Change
Plan
Small Tests of Change
Study
Do
Why Measure?
• How else will you know that the change(s) you
made resulted in improvement?
Limitations
One Voice
Sample
Useful, not perfect
Select right measures
Rapid results
Adapt interventions
Types of Measures
Outcome
Process
Balance
49
Process Measures
Outcome Measure
What
you get
Balance Measures
MEASURES
Outcome
Balance
Process
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
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?
Model For Improvement
What are we trying to
accomplish?
AIM
How will we know that a
change is an improvement?
MEASURE
What change can we make that
will result in improvement?
Act
Selecting Change
Plan
Small Tests of Change
Study
Do
The PDSA Cycle
“What’s next? ”
Act
• Ready to
implement?
• Try something
else?
• Next cycle
Plan
• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
“What will happen
if we try
something
different?”
Study Do
• Complete data • Carry out plan
analysis • Document
• Compare to
problems
predictions • Begin data
“Let’s try it!”
• Summarize
analysis
“Did it work?”
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 35 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
“What’s next? ”
Act
• Ready to
implement?
• Try something
else?
• Next cycle
Plan
• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
“What will happen
if we try
something
different?”
Study Do
• Complete data • Carry out plan
analysis • Document
• Compare to
problems
predictions • Begin data
“Let’s try it!”
• Summarize
analysis
“Did it work?”
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?
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?
The Value of “Failed” Tests
“I did not fail one
thousand
times; I found one
thousand ways how
not to
make 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
Useful Websites
• www.jointcommission.org
• www.healthgrades.com
• www.calhospitalcompare.org
• www.ihi.org
• www.ahrq.gov
• www.apic.org