122
An Introduction to Quality Improvement
Day 1
6th November 2014
Welcome
• Tom Downes
- Clinical Lead for Quality Improvement
• Nicola Platts
- Improvement Facilitator
@sheffielddoc
@nicola_platts
Aims / Objectives
To teach some of the basics
of Quality Improvement…
Agenda – Day 1 - Morning • 09.30 Welcome & Feedback on Self Assessment ( 20 mins )
• 09.50 Patient Story (10 mins)
• 10.00 Complexity (20 mins)
• 10.20 Patient Story Part 2 (10 mins)
• 10.30 The Structure of Improvement (20 mins)
• 10.50 Pull the Lever (10 mins)
• 11.00 Coffee (20 mins)
• 11.20 Systems Thinking & Activity (20 mins)
• 11.40 Microsystems and ownership (20mins)
• 12.00 The 5Ps (10 mins)
• 12.10 Themes and Global Aims (20 minutes)
• 12.30 Lunch
Agenda – Day 1 - Afternoon
• 13.10 Process mapping (60 mins)
• 14.10 Theory of Constraints (10 mins)
• 14.20 The Model for Improvement (10 mins )
• 14.30 Specific Aims Activity (10 mins)
• 14.40 Coffee
• 14.50 M & M Challenge (30 mins)
• 15.20 Measurement (10 mins)
• 15.30 Weight Loss Activity (30 mins)
• 16.00 Evaluation
• 16.10 Close
Key Elements Required for Improvement
Will to do what it takes to change to a new system
Ideas on which to base the design of the new system
Execution of the ideas
A patient story
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Surg
ery
IV
antibio
tics
Dis
charg
e
Pain
ful hand
Ora
l antibio
tics
COMPLEXITY
Ford Mustang
1968 2015
Royal Hallamshire Hospital
1968 2015
Age-standardised five-year relative survival rate,
female breast cancer, England and Wales, 1971-2009
0
10
20
30
40
50
60
70
80
90
100
1971-1975
1976-1980
1981-1985
1986-1990
1991-1995
1996-1999
2001-2006*
2007-2009*
% s
urv
ival
Period of diagnosis
* England only
Chance of Successful Outcome
Time
Surgery Post-Op
Potential
Actual: Great
Actual: Poor
Health care: Good News / Bad News
A patient story
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Surg
ery
IV
antibio
tics
Dis
charg
e
Pain
ful hand
Ora
l antibio
tics
Wound e
xam
ined
Wound r
edre
ssed
Antibio
tics late
Antibio
tics late
3 h
ours
to a
ccess
Second o
pera
tion
Sta
ph / S
trep m
op
Calls
unansw
ere
d
No a
ntibio
tics
No a
nitbio
tics
Work
aro
und a
dm
issio
n
Within 2 weeks two adults died of
identical strain of streptococcal
infection
Successful outcome: • due to fantastic individuals • despite the system If ‘ideal’ systematic had been care delivered: • Would patient satisfaction have been higher? • Would length of stay have been shorter? • Would second operation have been
necessary? • Were the two deaths avoidable?
QUALITY IMPROVEMENT? What is
High Quality care is care that is:
• Safe – no needless deaths
• Effective – no needless pain or suffering
• Patient-Centered – no helplessness in those
served or serving
• Timely – no unwanted waiting
• Efficient – no waste
• Equitable – for all
Quality: The IOM’s Six Aims
Improvement
The combination of a ‘change’
combined with a ‘method’ to
attain a superior outcome
Model I: Bad Apples
The
Problem
Quality
Frequency
The Simple, Wrong Answer
Blame
Somebody
The Cycle of Fear
Increase
Fear
Micromanage Kill the
Messenger
Filter the
Information
Model 2: Positive deviance
Quality
Frequency
Model 2: Continuous Improvement
“Every Defect is a Treasure”
Quality
F
req
ue
nc
y
Quality Improvement -
The structure
Assessment - 5Ps
Diagnosis - Change Ideas
Treatment
- PDSA
SDSA
‘Standardise’
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
SYSTEMS THINKING
• Step 1 – Everyone stand up
• Step 2 – Without speaking; pick two people but
don’t say who they are or point at them (Keep it a
secret)
• Step 3 - Move to be equidistant between both of
the people
Understanding Systems
• What is a “system”?
• How do we define a “system”?
A collection of parts and processes organised
around a purpose.
Processes?
• How is a process different from a “system”?
• Can we brainstorm a series of processes which
make up the “systems” we might encounter in our
improvement work?
Elements of a Process
33
Suppliers Outcomes
Thing being passed along
Inputs Outputs
Sequence of steps
MICROSYSTEMS: AN OVERVIEW
Microsystems
• 1992 – Quinn – ‘Intelligent Enterprise’
• Studied the ‘best of the best’
• They are organised around the frontline
interface with the customer
• ‘Smallest replicable unit’
Microsystems
• Nelson, Batalden, Godfrey 2000 – 2007
• Looked at the characteristics of high
performing clinical microsystems
• Formulated a curriculum to develop high
performing microsystems
High Performing Clinical Microsystems
Information
&
Information
Technology
Staff • Staff focus
• Education &
Training
• Interdependence
of care team
Patients • Patient Focus
• Community &
Market Focus
Performance • Performance
results
• Process
improvement
Leadership • Leadership
• Organizational
support
38
What is a Clinical Microsystem?
• ‘The Place where Patients, Families and
Clinical Teams meet’
• The essential frontline building blocks of any
healthcare system. It is where the quality
is delivered.
It’s where everything happens with, for and
to the patient and family
Clinical Microsystem Outputs Inputs
Pharmacy
People with Healthcare Needs Met
People with Healthcare
Needs
X ray IT Supplies Medical
Records
Supporting Microsystems
Supporting Microsystems
Have Many Roles:
Within their own microsystem
and as members of other
microsystems
41
Chest
Medicine
STH
• Some of you have a red card
• Read out in turn
• Is this a Microsystem?
Is this a
Microsystem?
“The principal task of the mesosystem is
to enable the work of the microsystems
for the population(s) of patients served.”
Paul Batalden
THE MICROSYSTEMS
APPROACH TO IMPROVEMENT
- ‘OWNERSHIP’ VS. ‘BUY IN’
These are not the same thing
Why?
‘Ownership’
• Is where you share the ownership of an
idea, a decision, an action plan.
• You have participated in it’s development,
you have chosen it of your own accord and
you endorse it.
• You understand it and believe in it and are
willing to implement it
‘Buy In’
‘Buy – In’ is the opposite
• Someone else has done the development,
the thinking
• They are now telling you or convincing you
to implement their ideas
REDESIGN FROM
THE INSIDE - OUT
Microsystems is about
ownership
Team Coaching
Improvement
Science
Microsystem
Improving Microsystems - Elements
QI
18
Quality Improvement -
The structure
Assessment - 5Ps
Diagnose – Change Ideas
Treat
PDSA
SDSA
‘Standardise’
Define Themes
Just like a patient…
To improve a patient’s health status
A clinician:
• Assesses
• Diagnoses
• Treats
• Follows-up
based on biomedical science,
patient preferences,
and their outcomes.
Assessing the system • We need data to understand the system
Purpose
5 Ps
Know Your Patients
• What conditions do they present with?
• What are the demographics? Where
do they travel from?
• What do they think about the service?
• What do they think we can do better?
• What is like in daily to life to have the
condition(s) you treat?
Use Trust Information, Recent surveys,
Talk to patients!
Know Your Professionals
• Who works here?
• How many of each role?
• What do staff think about the service?
-What do they love about their microsystem?
-What drives them nuts?
Involve staff by asking them what they think
Know Your Processes
• What are our key processes that patients go
through in the department?
• How do we get patients into the microsystem?
• How long do things take?
• What help do they depend on from other
support/clinical microsystems?
Create a high level process map (7-12 boxes)
Know Your Patterns
• How is the microsystem performing?
• What are the metrics that matter in this
microsystem? The outcome measures?
• What are the trends over time?
• What are we proud of? What needs improving?
• What data are we tracking? What data is
missing?
- Referrals, DNA, Follow-up queue, Wait for
appointment, 18 Weeks
A Real 5Ps Story – Cystic Fibrosis Unit
Pre Phase – The Work Before the Work
• March 2011
• Met clinical leaders – ‘challenging’ team dynamics
• Lots of time invested in discussing the approach
with the Doctors, manager and senior nurses
• Sought support from Clinical Director
• Agreed expectations, set a regular weekly
meeting, communication plan, who would be
involved, Patient representation
• Coach – visit
Initial Meeting - April 2011
• Introduced what quality improvement is
• Introduced effective meeting skills and roles
• Set up the ground rules
59
2
Service Improvement
There’s so much talk about
the system. And so little
understanding
Robert Pirsig
Zen and the Art of Motorcycle Maintenance
3
Service Improvement
Ground Rules
You are all equal•System, NOT individuals•Treat others as you would expect to be treated
•All contributions are valuable•Please don’t interrupt•Don’t say it can’t be done!•If you oppose, you must propose•No meddling•Please have fun
Patients -
Hello to
Brandon
60
The 5Ps develop.....
Purpose
• What is the purpose of the microsystem?
• Lots of debate!
‘To enable people with CF to live
as normal a life as possible’
Remember that the aim of the 5Ps is.......
To understand the system well
enough to generate your first
for improvement
How to create the 5Ps - tips
5Ps review – May 2011
• Meeting dedicated to reviewing the 5Ps
• Team stuck post its – where they saw
something to improve for Brandon
• Grouped these to form ‘Themes’
How to create the 5Ps - tips
• Don’t spend too long in this phase!
• Some Ps can be done in weekly meetings
(Purpose, Processes)
• MCA has useful templates
• Doesn’t have to be pretty
• Use as much existing data, resources and
information support as is available (ecat,
surveys, reports, datix, information services
etc.)
Remember that the aim of the 5Ps is.......
To understand the system well
enough to generate your first
for improvement
How to create the 5Ps - tips
Diagnosis – Selecting a theme
Can be tested without
permission from others
Most important for our
patients
No cost High impact for low effort
Must do –strategic importance.
Global Aim Statement
• Clarifies and connects the improvement theme to
your work
• The starting point
• Sets the scope
• Increasing clarity of focus
CF Clinic Global Aim
•We aim to improve the efficiency and quality of
the service of the CF outpatient clinic for staff and
patients. The process begins with first contact
with the patient and ends with them arriving back
to their home after the visit. By working on the
process we expect; the DNA rate to improve, for
there to be less waiting for patients, improved
efficiency for patients and staff and to achieve a
greater standard of our quality markers. It is
important to work on this to improve the clinic
experience for patients, meet CF trust standards,
and to provide an area of clinical excellence.
69
Template for writing a global aim
Write a Theme for Improvement: _________________________________________
Global Aim Statement Create an aim statement that will help keep your focus clear and your work productive:
We aim to improve: _________________________________________________________________ (Name the process)
In: _______________________________________________________________________________ (Clinical location in which process is embedded)
The process begins with: _____________________________________________________________ (Name where the process begins)
The process ends with: _______________________________________________________________ (Name the ending point of the process)
By working on the process, we expect: __________________________________________________ (List benefits)
It is important to work on this now because: ______________________________________________ (List imperatives)
Create Flowchart
PROCESS MAPPING
PROCESS
Processes
“Every system is perfectly
designed to get
the results it gets”
Paul B. Batalden
Process Mapping
• Simple exercise.
• Picture of the sequence of steps in the process.
• Opportunity to bring multidisciplinary teams together.
• Identify what actually happens now in a process.
• Overview of how complicated the process can be for
patients.
High Level Example – Renal OPD
Referral Grading Admin—New Appointment
Prep clinic, Notes
Reception New and Fol-
low Up
Specimen Room
Dr or SPR or MDT Review
Dietician Re-view (Some
Patients)
Bloods Reception, Book Follow
Up
Visit Phar-macy for
Meds
Iron Clinic
Referral Grading Admin—New Appointment
Prep clinic, Notes
Reception New and Fol-
low Up
Specimen Room
Dr or SPR or MDT Review
Dietician Re-view (Some
Patients)
Bloods Reception, Book Follow
Up
Visit Phar-macy for
Meds
Iron Clinic
Analyse the process
• Number of steps
• Order
• Transfer of ‘object’ from one person to
another (loss and probability of error)
• Delays
• Added Value
• Bottlenecks
Added ‘value’
Produce a process map
for making a paper airplane
Referral Grading Admin—New Appointment
Prep clinic, Notes
Reception New and Fol-
low Up
Specimen Room
Dr or SPR or MDT Review
Dietician Re-view (Some
Patients)
Bloods Reception, Book Follow
Up
Visit Phar-macy for
Meds
Iron Clinic
Referral Grading Admin—New Appointment
Prep clinic, Notes
Reception New and Fol-
low Up
Specimen Room
Dr or SPR or MDT Review
Dietician Re-view (Some
Patients)
Bloods Reception, Book Follow
Up
Visit Phar-macy for
Meds
Iron Clinic
500 grains/30 secs
270 grains/30 secs
170 grains/30 secs
270 grains /30 secs
Bottlenecks
500/30 secs
270/30 secs
170/30 secs
270/30 secs
InputOutput
Using Process
Maps to generate
change ideas
Regional anaesthetic
used.
Consultant transports patient back to
the ward and discusses surgery.
Time in recovery
not required.
Consultant returns
patient to TAU and
consents the next
available patient
Member of theatre
team collects patient
directly from TAU
THE MODEL FOR
IMPROVEMENT
The Model for Improvement
• A framework for testing ideas
• Fundamental questions come first –
Aim – What are we trying to accomplish?
Measures – How will we know the change is an
improvement
Changes – What changes can we make that will
result in an improvement?
Plan
•Objective
•Questions and
predictions (Why)
•The plan – who what
where when
Do
•Do the Plan
•Document problems,
observations
•Begin analysis
of the data
Study
•Complete analysis of
data
•Compare data to
predictions
•Summarise the
learning
Act
•What changes
are to made now?
•What is the next
cycle
PDSA
PDSA - experimentation • Always start with a specific aim - What are we trying to accomplish?
• How will know if this is an improvement? – Data.
• Small tests of change over a short time
• Debrief frequently
• Communicate results
• Repeated Cycles
• When we meet our aim? –
SDSA = Standardise
SDSA
1
3
2
P
DS
A
P
DS
A
P
DS
A
P
DS
A
P
DS
A
P
DS
A
4
5
6
Flowchart – A detailed process map
• Took three sessions
• Everybody understood the process by the end!
• Generated lots of change ideas – Car Park
Specific Aim – June 2011
• After reviewing the 5Ps and the Flowchart the
team chose to reduce Patient waiting as their first
Specific Aim
‘We aim to reduce average total patient waiting time
within the 2 CF outpatient clinics by 50% from our
baseline measure of 40 minutes by the end of
October 2011’
90 90
Service Improvement
Why are Patients waiting in
the CF clinic?
Late & early arrivals Communication
Treatments Finding Things
Scheduling
Interruptions
Mismatch of arrivals and
resources
Don’t know how long
things take – cycle times
Non standardised –
variation in content
Waiting for other
professionals to finish
Culture – it’s accepted
See early patients
early (sometimes)
See patients even if
late
Patients don’t have
own transport
Hospital transport is
late Reliant on others for
lifts
Fax machine doesn’t
work properly
Dictation delays clinic,
always get out of sync
Trials
PEG changes,
not planned
into timings
Going to find
nebuliser from the
ward
Notes
Scales
X ray
Going to the Pharmacy if
patient too unwell
Pharmacy
Taking patient off for a
ward tour
Answering the doorbell
Telephone Calls
Calls from the ward
Lots of paperwork -
delays the clinic
Change Ideas
• Review of Fishbone and Process map
• Brainstormed ideas to reduce waiting – top 4
91
Reschedule
the clinics
Standardise
the
paperwork
New Clinic
Whiteboard
Get
everything
we need
PDSA - Plan
1.15 1.30 2.00 2.30 3.00 3.30 4.00 4.30 5.00
Patient 1L L L W N D D D D Dr Dr Dr Dr O O O
Patient 2L L L W N D D D D Dr Dr Dr Dr O O O
Patient 3L L L W N D D D D Dr Dr Dr Dr O O O
Patient 4L L L W N D D D D Dr Dr Dr Dr O O O
Patient 5L L L W N D D D D Dr Dr Dr Dr O O O
Patient 6L L L W N D D D D Dr Dr Dr Dr O O O
Patient 7L L L W N D D D D Dr Dr Dr Dr O O O
Patient 8L L L W N D D D D Dr Dr Dr Dr O O O
Patient 9L L L W N D D D D Dr Dr Dr Dr O O O
Patient 10L L L W N D D D D Dr Dr Dr Dr O O O
Patient 11L L L W N D D D D Dr Dr Dr Dr O O O
Patient 12L L L W N D D D D Dr Dr Dr Dr O O O
Patient 13L L L W N D D D D Dr Dr Dr Dr O O O
Patient 14L L L W N D D D D Dr Dr Dr Dr O O O
Patient 15L L L W N D D D D Dr Dr Dr Dr O O O
Patient 16L L L W N D D D D Dr Dr Dr Dr O O O
Patient 17L L L W N D D D D Dr Dr Dr Dr O O O
Patient 18L L L W N D D D D Dr Dr Dr Dr O O O
PDSA – Do & Study
CF - Themes, Aims and PDSA Cycles
1
ThemesCapacity &
DemandAdherence
Clinic
Process &
Flow
5Ps
Global Aim Global Aim Global Aim
Specific Aim 1
Reduce Waiting
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Specific Aim 2
Reduce DNA
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Specific Aim 1
Increase nurse
led activity
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Specific Aim 2
Reduce
Variation in
follow up
frequency
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Specific Aim
Shorten Annual
Review
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Specific Aim 1
Increase use of
iNebs
Specific Aim 2
Increase use of
MI
Flowchart FlowchartFlowchart
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Global Aim
1
2
3
SDS
A
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Always start with a Specific Aim…
An aim should be ‘impossible’ within our current
system – meaning we will need to completely
transform how we work in order to accomplish
what we set out to do
PROCESS
Key Components of an AIM
• ambitious
• measureable
• operationally specific
• time-limited
Transformative
“The greatest danger for most of us is not that our aim is
too high and that we miss it, but that it is too low and we
reach it”. Michaelangelo
Setting an Aim
• What are we trying to accomplish?
•Having a clear understanding of your Aim is critical
-Key points:
How Much?
By When?
Global Aim
Specific Aim
Change Idea
Conceptual Definition
Measurement
Plan
‘The How’
Operational
Definition
“The Big Picture”
“The Component Parts”
“How you will do it”
The Measure (Abstract Idea)
The Measure
(“Specify and Quantify”)
The “How, What, Where, When and
Who”
Workbook Page 156
AIM STATEMENT
• Less is not a number, soon is not a time
• We aim to reduce catheter associated UTIs among patients on Ward A1 by 50% by September 2013
What is a catheter associated UTI?
Is it bacteria in urine?
Or above plus fever or abdo tenderness or pyuria?
Or confusion?
Or above with other sources of infection excluded?
Where, by whom, when – rigorous specificity
Example Specific Aims
• We aim to achieve 50% of all daily TTOs are
written, checked and delivered to Pharmacy by
10am from the four Brearley Respiratory wards by
1st September 2012. Our current baseline
measure is 15% by 10am.
• We will decrease waiting times in Clinic DT247J
by 75% compared to our baseline measure by
March 2012
What is a specific aim from your global aim?
THE M&M CHALLENGE
The M&M Challenge
• Aim – to be left with one M&M at the end
• Measure – number of M&Ms left
Operational definitions:
•DO NOT EAT THE M&Ms
•Remove one to start
•Jump over one at a time and remove it
MEASUREMENT FOR
IMPROVEMENT
Measurement for Improvement
Improvement
Research Assurance
/Judgement
Sampling Water Content
TIME
Measurement for Research
•eg Peak flow of patients receiving active inhaler and placebo inhaler
• One large test / blinded / controlled
• Number of patients calculated to give power to results (usually p<0.05 or 5%)
• Inclusion and exclusion criteria to control for bias as far as possible
Measurement for Assurance
•eg HSMR
• All data included (100% of hospital admissions)
• No statistical testing
• Adjust to reduce bias
• Used by CQC and DH to monitor for poorly performing hospitals (bad apples)
Measurement for Improvement
•eg patient waiting time in clinic
• Sequential measurements
• ‘Just enough’ repeated small samples
• Accept consistent bias
• Test data using time series analytical statistics (SPC or run charts)
The Three Faces of Performance Measurement
Aspect Improvement Assurance Research
Aim Improvement of care
(optimise application of
knowledge)
Comparison, choice,
reassurance, spur for
change
Generate new knowledge
Methods:
•Test Observability
Test observable
No test, evaluate current
performance
Test blinded or controlled
• Bias Accept consistent bias Measure and adjust to
reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small
sequential samples
Obtain 100% of available,
relevant data
“Just in case” data
• Testing Strategy Sequential tests No tests One large test
• Determining if a change is an improvement
Time Series Data
(Run charts or Shewhart
control charts)
No change focus Hypothesis, statistical
tests (t-test, F-test, chi
square), p-values
Three Types of Measures for Improvement
• Outcome Measures
• Process Measures
• Balance Measures
Outcome Measures
• Outcome Measures:
• What is the outcome or result?
• How is the overall system performing? (Voice of the customer)
• What might some examples of outcome measures be?
Process Measures
• Process Measures:
• What is the system telling you about how well it is working?
• Are the parts/steps in the system performing as planned? (Voice of the system)
• What might some examples of process measures be?
Balance Measures
• Balance Measures:
• Unrelated Processes which might be affected by the changes we make
• What happened to the system as we improved the outcome and process measures?
• What might some examples of balance measures be?
Weight loss and developing
measures exercise Background: A friend has come to you and asked you to help develop measures for a group she is working with
Aim: The aim of the improvement project is for participants to lose weight. They need regular feedback to keep them on task
Develop a Family of 4 to 6 measures that could be reported each week for the project:
• Outcome Measures – 1-2 measures
• Process Measures – 2 measures
• Balance Measures – 1 or 2 measures
Agenda – Day 1 - Morning • 09.30 Welcome & Feedback on Self Assessment ( 20 mins )
• 09.50 Patient Story (10 mins)
• 10.00 Complexity (20 mins)
• 10.20 Patient Story Part 2 (10 mins)
• 10.30 The Structure of Improvement (20 mins)
• 10.50 Pull the Lever (10 mins)
• 11.00 Coffee (20 mins)
• 11.20 Systems Thinking & Activity (20 mins)
• 11.40 Microsystems and ownership (20mins)
• 12.00 The 5Ps (10 mins)
• 12.10 Themes and Global Aims (20 minutes)
• 12.30 Lunch
Agenda – Day 1 - Afternoon
• 13.10 Process mapping (60 mins)
• 14.10 Theory of Constraints (10 mins)
• 14.20 The Model for Improvement (10 mins )
• 14.30 Specific Aims Activity (10 mins)
• 14.40 Coffee
• 14.50 M & M Challenge (30 mins)
• 15.20 Measurement (10 mins)
• 15.30 Weight Loss Activity (30 mins)
• 16.00 Evaluation
• 16.10 Close
