Transcript Quality Improvement Methods Greg Randolph, MD, MPH Healthcare Quality Defined ”The degree to which health services for individuals and populations increase the likelihood of desired.

Quality Improvement
Methods
Greg Randolph, MD, MPH
Healthcare Quality Defined
”The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and
are consistent with current professional
knowledge.”
--Institute of Medicine, 2001
Exercise
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In pairs, define Quality
Improvement (3 minutes)
Be prepared to share (2 minutes)
UNC Pediatrics Residency QI
Program
“A systematic approach of measuring and
identifying gaps between actual and desired
quality of care and applying tools and
improvement methods (e.g., PDSA cycles) to
make changes to the system that result in
measurable improvements (i.e., closing the gap)”
Quality Improvement Focus
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Patient-centered - care that is responsive to patient
preferences, needs, values
Effective - providing services based on scientific
knowledge to all who could benefit and refraining from
providing to those not likely to benefit
Equitable - providing care that does not vary in quality
because of personal characteristics
Timely - reducing waits and delays for care
Efficient - avoiding waste
Safe - avoiding injuries to patients from care
--Institute of Medicine, 2001
Fundamental Questions for
Improvement

What are we trying to accomplish?
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How will we know that a change is an
improvement?
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What changes can we make that will
result in an improvement?
Model for Improvement
What are we trying to accomplish?
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Aim
How will we know that
changes are an improvement?
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Measures
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Ideas/Change
Concepts
What changes can we
make that will result in
an improvement?
Model for Improvement
AIM:
What are we trying to
accomplish?
MEASURES: How will we know that changes are an
improvement?
IDEAS:
What changes can we make that will
result in an improvement?
What is an Aim Statement?
Aim:
A written statement of the
accomplishments expected from
improvement effort
Key components:
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A general description of aim - should answer, “what are we trying to
accomplish?”
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Rationale/importance
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Some guidance for carrying out the work
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Specify target population and time period
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Measurable goals
Goals Should Be:
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Measurable
Numeric
 Preferably absolute rather than relative
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A stretch, not business as usual
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Achievable, not impossible
Exercise



In pairs, critique aim statement –
are key components present (3
minutes)
Then pick a problem and write
your own (5 minutes)
Be prepared to share (2 minutes)
Model for Improvement
AIM:
What are we trying to accomplish?
MEASURES:
IDEAS:
How will we know that
changes are an
improvement?
What changes can we make
that will result in an improvement?
Project Measures
Goal
Project Measures
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The question: How will we know that a change is an improvement?
- usually requires more than one measure.
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A balanced set of measures helps assure that the system is
improved:
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Related to aim’s measurable goals
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Easy to collect
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Show improvement quickly and include outcomes
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Can display them graphically over time
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Run charts
Balancing Measures
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Are we improving parts of our system at the
expense of others?
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Usually not one of goals
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Great source is to listen to skeptics… “Yes,
but…”
Example of Measure Set
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The delay for routine appointments
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% of patient visits with the patient’s primary clinician
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Practice average cycle times
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% of patients rating the overall visit as excellent
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% of visits that are “no show/missed”
Usual Display of Measures
100
90
80
70
60
50
40
30
20
10
0
Before
After
Imm Rate
QI Measures: Annotated Run Charts
Clinician education
Reduced
appt
delays
Practice wide guidelines
Reminder system
Model for Improvement
AIM:
What are we trying to
accomplish?
MEASURES: How will we know that change is
an improvement?
IDEAS:
What changes can we make
that will result in an
improvement?
“PDSA Cycles”
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PDSA Cycles help teams adapt good ideas to
their specific situation:
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Force us to think small
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Force us to be methodical, make predictions
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Allow rapid adaptation and implementation of
changes in busy healthcare settings
The PDSA Cycle
Act
• What changes
are to be made?
• Next cycle?
Study
• Complete the
analysis of the data
• Compare data to
predictions
• Summarize what
was learned
Plan
• Objective
• Questions and
predictions
• Plan to carry out the
cycle (who, what,
where, when)
Do
• Carry out the plan
• Document problems
and unexpected
observations
Example PDSA Cycle
Act
Changes to be
made: Test 2 more
days- Dr. R on time;
nurse to bring
charts for
prescheduled
Study
4 unused visits
identified; took 15
minutes due to late
arrivals; charts
would be helpful
Plan
Objective: Test huddles
Questions: Will they
uncover capacity?
Prediction: Yes
Plan: Dr. R care team,
huddle 5 mins in AM for 2
days at schedule
Do
Mon and Tues - document
problems,
Unexpected observations;
count uncovered
capacity
Key Points for PDSA Cycles
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Do initial cycles on smallest scale possible
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Think baby steps…a “cycle of one” usually best
“Failed” cycles are good learning opportunities when small
Successful tests
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As move to implementation, test under as many conditions as possible
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Special situations (e.g., busy days)
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Factors that could lead to breakdowns (e.g., different staff or physicians
involved)
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Things “naysayers” worry about (e.g., “It will not work when Dr. Noonan is not
here”)
Questions?