Transcript QAPI Defined - Leading Age Wyoming nursing homes, long

Colleen Roylance
Director of Quality and Education
“We are headed into the next
century which will focus on
quality…
….we are leaving one that
has been focused on
productivity.”
Dr. Joseph M. Juran
1904 - 2008
8/30/2013
Culture of Safety and Quality
Pathological
Reactive
Bureaucratic
Proactive
Generative
Systems are
purposefully
designed to see
no evil, hear no
evil and speak no
evil. Actions of
improvement only
come when
necessary to
survival
Actions are driven
by outside forces
and what is
perceived to
create negative
consequences by
regulators or
entities with the
power to create
such
consequences
Actions are very
task oriented with
most existing to
satisfy the rules
and requirements
of a bureaucratic
structure with little
focus on achieving
the larger goal
There is a genuine
interest in
advancing safety
and quality but
leaders struggle
with cohesively
supporting quality
as an equal—
although safety
wins out more and
more frequently
Safety and quality
are equal to other
competing
priorities and is an
integral piece of
day-to-day
operations as
leaders recognize
its importance to
operational,
financial and
reputational
success
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QAPI Defined
A systematic approach to assessing
services and improving them on a
priority basis
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Customer Focus
Employee Empowerment
Leadership Involvement
Data-Informed Practice
Statistical Tools
Prevention Over Correction
What it really boils down to…
 Is this a safe, comfortable place to
receive care?
 Do people feel comfortable speaking
up?
 How do you know?
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Taiichi Ohno
Lean
Joseph Juran
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CQI
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Lean
Six Sigma
Voice of the
Customer
and
Recognize
Waste
Fool Proof
and
Standardize
Value-added actions in
the best sequence,
without interruption
whenever someone
requests them, and
perform them more
and more effectively
Level the
Workload
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Visual
Control and
5S
Establish
Flow: Pull
vs. Push
and one
piece flow
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Quality
Product
Features
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Freedom from
Deficiencies
That Customers Want
At Six Sigma Levels
Design for Six Sigma
Improve to Six Sigma
What is Lean?
Lean is about understanding what is
important to the customer
Lean increases the activities that add value
and decreases or eliminates those that don’t
Lean focuses on eliminating waste in processes
(i.e. the waste of time, supplies, transportation)
Lean is about expanding capacity by reducing
costs and increasing process effectiveness
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Key LEAN
Leverage Points
Key Implementation
Leverage Points
 Eliminate Waste:
Eliminate Inefficiency
 Managers and staff
working side by side to
solve problems when and
where they happen
 Standardize Work:
Eliminate Variation
 Incremental improvement
over and over and over…
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Voice of the Customer
ASK:
“What is the customer paying for?”
The answer tells you what adds value and
you should keep doing OR what doesn’t
add value and you should stop doing.
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3 non-value-adding steps
x 3 minutes per step
x 25 residents
x 3 times per day
675 non-value-adding minutes per day
/ 60 minutes in an hour
11.25 hours per day
x 365 day per year
4,106.25 hours per year
/ 1800 hours in an FTE
2.28 FTEs
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7 Wastes
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Over production
Waiting
Motion
Inventory
 Transportation
 Defects
 Excess processing
7 Wastes: Overproduction
Doing what is unnecessary when it is
unnecessary in an unnecessary amount
Example:
Setting up meal trays for residents only to learn several
residents are gone, thus having to throw out food
Solution:
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Improve communication with direct care and dietary staff
Design form or tear-off for kitchen when resident(s) leave
facility during meal hour (Common on weekends and
during holidays)
7 Wastes: Waiting
Staff: For information, approval, supplies
Customers: For assistance, information, supplies, comfort
Example:
Call light not being addressed and residents waiting for help
Solution:
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Review staffing patterns for timely availability (3 - 5 mins)
Staff awareness of high-risk residents – patient safety
7 Wastes: Motion
Movement that is too fast, slow or
unnecessary
Example:
Not having towels and washcloths in AM for staff to assist
with residents’ personal hygiene before breakfast
Solution:
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Night shift stocks towels and washcloths during last
rounds
Place at resident bedside as appropriate
7 Wastes: Inventory
When anything is retained longer than
necessary
Example:
Outdated supplies or medication
Solution:
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Design system so medication/supplements and supplies
are checked at least monthly
Can be incorporated into night shift duties while stocking
medication carts
7 Wastes: Transportation
Transferring or moving unnecessary
items and the problems created
Example:
Supplies are off-loaded at dock  central supply closet 
floor supply closet  resident’s room
Solution:
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Solicit supplier to off-load stock to central supply closet
Eliminate floor supply closet and stock residents’ rooms
7 Wastes: Defects
Related to costs for inspection of defects
Example:
Inadequate communication among shifts
Solution:
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Improve communication efforts with TeamSTEPPS
handoff tools
Provide extra 15 mins between shifts for rounds and
questions
Utilize standard handoff tool to address resident safety
(i.e., weight loss, food intake, skin, falls, behavior)
7 Wastes: Excess Processing
Unnecessary tasks traditionally accepted
as necessary
Example:
Redundant documentation for pressure ulcers – several
different forms and/or documentation doesn’t match
Solution:
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Standardize documentation/assessment form
Wound/treatment binder
Keep binder accessible and include policies and
standards
Visual Control
 Makes abnormalities and waste obvious
enough for anyone to recognize
 Uses standardized control devices,
information, color coded layout and
signboards
 Successful leadership depends on visibility
of abnormalities
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5S is essential
 Method of workplace organization
 Place for everything; everything in its
place
 Reduces wastes due:
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To clutter
Time to find materials and equipment
Duplication of equipment
Floor space
Inconsistency
5S
 Sort: Separate the necessary from the
unnecessary
 Simplify: Create a place for everything
 Sweep: Control the work area visually and
physically
 Standardize: Document agreements made
 Self-discipline: Follow through and maintain
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Standard Operations
 Standardize the “least waste” way to work
 Provide low variation in the output
 Simplifies training, cross training and
sharing resources
 Provides a foundation for improvement
“Without standard work there can be no improvement.”
–Taiichi Ohno
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Basic Principles for Lean
 Specified Activities
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Outcome
Content
Sequence
Timing
 Clear Connections
Every connection must be direct with an unambiguous yes-or-no
way to send requests and receive responses
 Simple pathways
The pathway for every product and service must be as simple and
direct as possible
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PDSA and A3
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Project Planning
A straightforward project prioritization tool that effectively
ranks projects to ensure the facility is getting the ‘biggest
bang for their buck’.
Projects are mapped on
a spectrum from:
 Implement immediately
 Postpone
 Do not implement
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Project Prioritization Worksheet
Proposed Project
High Risk
High
Volume
High
Cost
High Error Customer Staff
Regulatory
Rate
Satisfaction Satisfaction Requirement
Rank by
Criticality Criticality
Assign a priority rank to each indicator: 1=highest; 2=high; 3=medium; 4=low. Criticality is computed by multiplying the priority value of
each indicator. Projects with the lowest criticality number are ranked highest priority.
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The Power of One
Don’t wait for
more than one
missed
opportunity to
evaluate the
process
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Root Cause Analysis:
Each Time… Every Time
What Happened?
Identify the issue
How Did It Happen?
Classify the cause(s)
Why Did It Happen?
State your findings
How Can We Prevent It
from happening again?
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5 Whys
Problem Statement:
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The patient was late to the OR; it caused a delay. Why?
There was a long wait for a transport bed. Why?
A replacement transport bed had to be found. Why?
The original transport bed’s safety rail was worn and had eventually broken.
Why?
It had not been regularly checked for wear. Why?
The Root Cause: There is no equipment maintenance schedule.
Setting up a proper maintenance schedule helps ensure that patients should never
again be late due to faulty equipment. This reduces delays and improves flow. If you
simply repair the bed or do a one-off safety rail check, the problem may happen
again sometime in the future.
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Establish Root Cause(s)
A cause and effect diagram, also known as a “fishbone” diagram, is a graphic
tool used to explore and display the possible causes of a certain effect.
What Is Failure Mode
and Effect Analysis?
FMEA is a systematic
method of identifying and
preventing problems
before they occur.
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RCA vs. FMEA
Similarities
Differences
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 Process vs. chronological flow
diagram
 Prospective (what if) analysis
 Choose topic for evaluation
 Include detectability and
criticality in evaluation
 Emphasis on testing
intervention
Interdisciplinary Team
Develop Flow Diagram
Focus on systems issues
Actions and outcome measures
developed
 Scoring matrix
(severity/probability)
 Use of cause & effect diagram,
brainstorming
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FMEA: Your Crystal Ball
FMEA Template
1
Step or link in process
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2
List all potential failures
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Potential effect
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5
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7
Severity of Probability of Criticality Rank by
effect failure effect (col. 4x5) Criticality
For More Information:
Colleen Roylance
Director of Quality and Education
(406) 457-5874
[email protected]
This material was developed by Mountain-Pacific Quality Health, the Medicare quality improvement organization for Montana, Wyoming,
Hawaii, Alaska and the Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents
presented do not necessarily reflect CMS policy. 10SOW-MPQHF-WY-IPC-13-10