Transcript Slide 1

Basics of Quality Improvement:
How to Implement a Quality
Improvement Project (Part 2)
Clemens Steinbock, MBA
Director, National Quality Center
[email protected]
212 417 4730
Funded by HRSA
HIV/AIDS Bureau
Agenda
• 15 min – Tennis Ball Game
• 10 min – Overview of QI Project Steps
• 20 min – Strategies for Successful QI
Projects
• 20 min – Development of an Improvement
Memo for an Upcoming QI Project
• 10 min – Action Planning
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Tennis Ball Game
Funded by HRSA
HIV/AIDS Bureau
Experiential learning
• Work in groups of 6-8
 5-7 people represent key
steps in the verification of
eligibility process
 1 person is the quality
officer and data collector
• Need experience
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Experiential Learning
• Organization
 7 form a circle
representing the steps in
the process
 1 stand aside and
observes/ records data
• Quality Officer
• Equipment
 1 tennis ball representing
the steps in the process
 stop watch or watch with
second hand to
measures time
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Process
• One person throws the ball
to the person across from
him/her in the circle.
• Remember to whom you
threw it.
• The receiver throws it to
another person, again
remembering to whom it is
thrown.
• The last person passes it to
the start person.
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• Rules



Start and stop with same
person
Maintain the same sequence
Don’t drop the ball
Process
The quality officer:
1. Records time from
beginning to end
2. Enforces all rules
•
Start and stop wrong
person

•
Sequence violated

•
Start over
start over
Ball dropped

start over
3. Judgment Call
• Execution done incorrectly
in any other manner

start over
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No where good enough!
Need to cut the time in half!
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St. Elsewhere does it better!
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Debrief our experience
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3 Approaches
• Improvement
 Standardization
 Incremental
Improvement
 Innovation
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Successful QI
Projects
Funded by HRSA
HIV/AIDS Bureau
Framing Questions
• What are key elements for successful
projects to improve HIV care?
• What are your lessons to use teams to
improve HIV care?
• What steps have you taken to initiate a QI
project?
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Teams Outperform Individuals When
 The task is complex
 Creativity is needed
 The path forward is unclear
 More efficient use of resources is required
 Fast learning is necessary
 High commitment is desirable
 The implementation of a plan requires the
commitment of others
 The task or process is cross-functional
Peter Scholtes et al., The Team Handbook.
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Teams Work Best When
• Limited to 5 or 6 members
• Members can meet without
logistical headaches
• Meetings are on target and
succinct
• Meetings have a clear agenda
• Notes are kept and reviewed
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Writing an Improvement Project Memo
Why?
• Clarify and focus the team’s direction and scope of
work
• Create a standard document for communicating what
the project is
• Refocus team efforts if a team gets stuck on a
specific issue
• Educate new team members coming on board during
the project cycle
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Elements of a Memo
•
•
•
•
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Problem statement
Improvement goal
Team leader and team members
Other (resources, authority, frequency of
reporting, ground rules)
Aim Statement for a Broader Improvement Effort
• Aim
The youth clinic will improve care of young adults living with HIV/AIDS by
focusing on education, prevention, and early intervention.
Our goals include:




80% of patients with at least one visit every three months
85% of patient receive adolescent risk reduction education in the last six months
90% of patients have an assessment of sexual activity in the last six months
90% of patients have an assessment of sexual abuse/sexual assault in the last six
months
• Team




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System/ Team Leadership: Primary Care Physician and Nursing Director
Technical Expertise: Senior Physician
Day-to-Day Leadership: Program Manager
Additional team members: Community Health Nurse, Case Manager, Clerical staff
Plan-Do-Study-Act
Funded by HRSA
HIV/AIDS Bureau
In 1601, James Lancaster successfully
conducted an experiment to illustrate the
effectiveness of lemon juice to prevent scurvy.
When did the British Navy adopt this treatment?
1.
2.
3.
4.
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1602
1689
1757
1796
Treatment of Scurvy
• Stephen J. Bown - Scurvy:
How a Surgeon, a Mariner,
and a Gentleman Solved the
Greatest Medical Mystery of
the Age of Sail; St. Martin's
Press, 2004
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




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In 1601 lemon juice, as a protective against scurvy, is
recorded by James Lancaster.
In 1612, Woodall recommended citrus fruit for protection
against scurvy on sea voyages.
In 1753 James Lind published A Treatise on the Scurvy which
portrays his experiment on-board the ship Salisbury in 1747.
From 1772 to 1775 sailors on historic voyages with Captain
James Cook remained free from scurvy.
In 1796 lemon juice was officially introduced in the British
Navy as a prophylactic against scurvy.
In 1865 British Board of Trade adopted the policy for the
merchant marine.
How long did the NIH take to recommend the
treatment of ulcer as suggested by Marshall in
his 1984 Lancet Article?
1.
2.
3.
4.
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2 years
5 years
10 years
20 years
Treatment of Ulcer – Dr. Marshall
Timetable:
1979: Dr. Robin Warren, pathologist at Royal
Perth Hospital, Australia found bacteria in
stomach of patients
1981: Dr. Barry Marshall starts residency
1982: Marshall cultivates bacteria: Helicobacter
pylori, 100% in Duodenal Ulcer and 77% in
Gastric Ulcer
1984: first publication in Lancet; presents
treatment of ulcer with common antibioticum
1994: National Institute of Health recommends
treatment of ulcer as suggested by Dr. Marshall
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How can we accelerate
change and improvements
in HIV programs?
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PDSA Cycle
Act Objective
Plan
What changes
are to be
made?
Next cycle?
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Study Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
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Carry out the plan
Document problems
and unexpected
observations
Begin analysis of
the data
Why Test?
• Increase your confidence that the change will
result in improvement in your organization
• Learn to adapt the change to conditions in the
local environment
• Minimize resistance when you move to
implementation
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PDSA Cycles build on each other…
A P
Changes That
Result in
Improvement
S D
Implementation of
change
Wide-scale tests of
change
A P
S D
Hunches
Theories
Ideas
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Very small scale
test
Follow-up tests
PDSA Cycle to incorporate the use of a new
assessment form
Improve
Quality of HIV
Care
A P
S D
Introduce new
Assessment
Form
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A P
S D
Cycle 1E: Implement and
monitor the standards
Cycle 1D: Revise and test tool
with all providers for one week
Cycle 1C: Present refined tool to all 3
providers and document feedback
Cycle 1B: Revise tool and test with Karl’s
patients next Monday
Cycle 1A: Adapt new form and test with one of Joanne’s patients
Tips for PDSA Cycles
• “What change could you implement by next
Tuesday?”
• Use the “Rule of 1”:
 1 facility
 1 office
 1 provider
 1 patient
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Tips for PDSA Cycles
•
•
•
•
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Volunteers at first
Useful, not perfect, data
Use “huddles” to report
Learn from others (‘Steal shamelessly,
Share senselessly’)
PDSA Example
• What PDSA do you suggest for the following
scenario?
 A clinic wants to initiate a QI project on youth
patients who missed their appointments.
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PDSA Example
• Does your PDSA have the following three
qualities?
 Can you do the PDSA “by next Tuesday”?
 Can you collect just enough data to know that this
change will result in improvement?
 Do you have a hypothesis?
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References
• Moen, Ronald, Thomas Nolan; “Process Improvement” Quality
Progress, 1987, p62
• Langley, Gerald, Kevin Nolan and Thomas Nolan; “The
Foundation of Improvement,” Quality Progress, June 1994, p. 81
• Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and
Lloyd Provost; “The Improvement Guide” San Francisco, CA;
Jossey-Bass, 1996
• Nolan, Kevin; “ASQs Accelerating Change Collaborative Series:
A Challenge for
Industry,” Quality Progress, Jan 1999, p55
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Group Exercise
• Write an Improvement Memo!
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Action Planning
• Use the Action Planning Form and identify
concrete next steps
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Contact Information:
Clemens Steinbock
National Quality Center, New York State Department of Health
[email protected]
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Materials Needed
• Tennis Balls
• Improvement Memo Handout
• Action Planning Handout
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Contact Information
38
National Quality Center
(NQC)
HIVQUAL-US
212-417-4730
NationalQualityCenter.org
[email protected]
212-417-4620
HIVQUAL.org
[email protected]