QI, in a nutshellGeorgia McIntosh, MDAndQuality and Safety Educator’s Academy, Society of Hospital Medicine

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

Process Modeling Tools Cause and Effect Diagram or Fishbone

diagram Standard Flow diagram Deployment Flowchart or Swim-lane

Diagram Mind Map

Process Modeling Tools Cause and effect

diagram ( “fishbone or ishikawa”)

Process Map

Process Modeling ToolsMind Map

Process Modeling ToolsDeployment Flowchart or Swim-lane Diagram

Error Reduction StrategiesStrong actions

Intermediate Actions

Weak Actions

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

Donabedian’s Topology of Quality Measures

Structure How was care delivered to the patient Process What was done to the patient Outcome What happened to the patient Balancing Unintended, undesirable consequences

Structure, Process or Outcome? 30 day mortality after CABG Bone densitometry ordered in women

over 65 Computerized order entry ACE or ARB for CHF pts with low EF Last BP of < 140/90 in pts with HTN Physician boarded in critical care

medicine responding to codes at all times

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

Aim Statement

“VCUHS will be the safest hospital in the United

States.”

Aim StatementVCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients,

team members and visitors.”

Aim StatementVCUHS’ mission is “to become America’s

safest health system with the goal of zero events of preventable harm to

patients, team members and visitors.”

For whom? How good? By when?

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

MeasurementPayers Demanding Increased Accountability

Voluntary reporting to payer

Pay for reporting to payer

Public reporting

Pay for performance

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

6 Steps to QI1. Understand the problem2. Identify areas for change/improvement3. Explicitly state your goals4. How will you measure progress5. Create effective, reliable improvements6. Build upon success and sustain the process

Quality and Safety Concept Map

Swiss Cheese Model

Root Cause Analysis

Safety CultureError Reporting

Measures

Safety

Quality

QI project Work

Change

Adverse eventsNear Misses

K

S

A

1. Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby?

a. LEANb. Six Sigmac. Cause-and-effect diagrammingd. Swim lane diagramminge. Failure mode and effects analysis

1. Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby?

a. LEANb. Six Sigmac. Cause-and-effect diagrammingd. Swim lane diagramminge. Failure mode and effects analysis

LEAN Developed by Toyota Aim to eliminate waste in the system Most common waste is patient wait time

Six Sigma Invented by Motorola Designed to remove defects and

variations from a system Six sigma means 6 standard deveiations

from the mean which represents 3.4 defects per 1 million opportunities

Utilizes DMAIC methodology Design, Measure, Analyze, Improve,

Control

Cause and effect diagramming AKA Fishbone diagram Uncovers the factors that influence an

outcome Hypothesis-generating tool

Deployment Flowchart or Swim-lane Diagram

Failure mode and effects analysis Tool for classifying errors by severity

and likelihood of recurrence for use in prioritizing quality initiatives

Failure Mode and Effects Analysis systematic, proactive method for

evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.

2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect?1. Online education module on heparin dosing2. Distribution of a heparin dosing pocket card3. A heparin order set4. A new institutional policy on heparin dosing5. A physician education conference on heparin

dosing

2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect?1. Online education module on heparin dosing2. Distribution of a heparin dosing pocket card3. A heparin order set4. A new institutional policy on heparin dosing5. A physician education conference on heparin

dosing

Error Reduction Strategies

Strong actions

Intermediate Actions

Weak Actions

How do you prevent customers from leaving behind their ATM cards?

Strong Action- Swipe card only

Intermediate Action- Beeping

Weak Action- signs