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Topic 7
Introduction to methods for quality improvement
Learning objective
• the objectives of this topic are to:
– describe the basic principles of quality improvement– introduce students to the methods and tools for improving the
quality of health care
Performance requirement
• know how to use a range of improvement activities and tools
Knowledge requirements
• the science of improvement• the quality improvement model• change concepts• two examples of continuous improvement methods• methods for providing information on clinical care
W Edwards Deming
The science of improvement
• appreciation of a system• understanding of variation • theory of knowledge • psychology
Measurement for research Measurement for learning and process improvement
Purpose To discover new knowledge To bring new knowledge into daily practice
Tests One large "blind" test Many sequential, observable tests
Biases Control for as many biases as possible
Stabilize the biases from test to test
Data Gather as much data as possible, "just in case"
Gather "just enough" data to learn and complete another cycle
Duration Can take long periods of time to obtain results
"Small tests of significant changes" accelerate the rate of improvement
The Institute for Healthcare Improvement (IHI): different measures
Three types of measures
• outcome measures • process measures• balancing measures
The quality improvement model-the PDSA cycle
• What are we trying to accomplish?• How will we know that a change is an improvement?• What changes can we make that will result in an
improvement?
ACT PLAN
What are we trying to accomplish?
How we will know that a change is an improvement?
What change can we make that will result in an improvement?
DOSTUDY
The model for improvement
Langley, Nolan, Nolan, Norman & Provost 1999
ACT PLAN
DOSTUDY
Determines what changes are to be made
Summarizes what was learned
Change or test
Carry out the plan
Langley, Nolan, Nolan Norman & Provost 1999
The PDSA cycle
Change concepts …
… are general ideas, with proven merit and sound scientific or logical foundation that can stimulate specific ideas for changes that lead to improvement.
Nolan & Schall, 1996
9 categories of change
• eliminate waste• improve work flow• optimize inventory• change the work environment• enhance the producer/customer relationship• manage time• manage variation• design systems to avoid mistakes• focus on the product or service
Langley, Nolan, Nolan, Norman & Provost 1999
Two continuous improvement methods
• clinical practice improvement methodology (CPI)• root cause analysis
DP A
S
3
Intervention phase
Diagnostic phase
2
1
Project phase
4
5
Sustaining improvement phase
Impact phase
Project mission Project team
Conceptual flow of process Customer gridData-fishbone-Pareto chart-run charts-SPC charts
2 months
Plan a changeDo it in a small testStudy its effectsAct on the result
2 months
1 month
Annotated run chart SPC charts
DP
AS
DP
AS
D PASD
PA
S
Ongoing monitoring Outcome
Future plans
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
SPC – statistical process control
The improvement process
Identify appropriate interventionsImplement changes identified in the diagnostic phase Undertake one or more PDSA cycles
Interventions phase
Decide on interventions
Undertake one or more PDSA cycles
Interventions phase
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
ACTWhat
changes can be made for the next cycle (adapt change, another test, implementation cycle?)
•
PLAN• Objective
• Prediction
• Plan for change (who, what, when, where)
• Plan for data collection (who, what, when, where)
• Carry out the change
• Document observations
• Record data
DOComplete analysis of data
Compare results to predictions
Summarize knowledge gained
•
•
•
STUDY
How to use the PDSA Cycle
• use plan-do-study-act cycles to conduct small-scale tests of change in real settings– plan a change– do it in a small test– study its effects– act on what learned
• team uses and links small PDSA cycles until ready for broad implementation
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
PDSA Cycles – single test Changes
that result in improvement
Hunches, theories and ideas
A
S D
P
AS
DP
AS
DP
A
SD
P
PDSA cycle - single test
PDSA Cycles – multiple tests
A
S D
P A
S D
P A
S D
P
P
D A
S
P
D A
S
P
D A
S
D
P A
S D
P A
S D
P A
S
Test 1 Test 3Test 2
PDSA cycle – multiple tests
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
1. Measure impact of changes/interventions2. Record the results 3. Revise the interventions4. Monitor impact
Impact and implementation phase
Implement the changes
Measure impact • Annotated run chart
• SPC charts
• Other graphs
Impact and implementation phase
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
1. Once an intervention has been introduced, the intervention and any improvements need to be sustained
2. This may involve:• standardization of existing
systems and processes• documentation of policies,
procedures, protocols and guidelines
• measurement and review of interventions to ensure that change becomes past of “standard” practice
• training and education of staff
Sustaining improvement
phase
Sustain the gains
•
standardization
• documentation
• measurement
• training
Sustaining the improvement phase
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Root cause analysis
• a multidisciplinary team• the root cause analysis effort is directed towards finding
out what happened• establishing the contributing factors of root causes
Performance requirements
Know how to use a range of improvement activities and tools
• flowcharts• cause and effect diagrams (Ishikawa/fishbone)• Pareto charts• run charts
0
2
4
6
8
10
12
14
LOS days
Hospital NSW Health Kehlet et.al
At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.
Evidence for there being a problem worth solving
Flow chart of processFlow chart of process
Something amiss
Referral to Hospital
Visit to general practitioner
Referral to surgeon
Investigations
Hospital admission
Admissions office
Operating theatre
Admitted to hospital
Preoperative clinic
Post anaesthetic care
Allied health
Surgical ward
Surgical team
Discharge plannerPre-op wardPain team
Home
Community health/Peripheral hospital
Return to life
Accelerated Recovery Colectomy Surgery (ARCS)Jenni Prince Jenni Prince Area CNC Pain ManagementArea CNC Pain ManagementNorth Coast Area Health ServiceNorth Coast Area Health ServiceNCHI Sydney AustraliaNCHI Sydney Australia
Multidisciplinary meeting to:
-ask opinion
-brainstorm process of care
-how to improve the process
-who to include in the process of change
-how to communicate progress
standardization
Evidence-based practice
team approach
Customer and expectations list
• surgical ward staff• post-op anaesthetic care staff• physiotherapy dept
• dietitian• peri-operative unit staff• private hospital staff• pain team• anaesthetists• surgeons• intensivist
Cause and effect diagram
Social issues
Staff attitudes Complications
Procedure Patient perception Post discharge support
Prolonged LOS
surgery
mobilization
nutrition
nil by mouth
LOS
mobilization
pain control
nutrition
expect long LOS
home support
often weak
poor understanding of procedure
little knowledge of support services
pain controllocus of control
family support
poor pain control
wound complications
weak/malnourished
community health
general practitioner
infection
family
colon care nurse
Accelerated Recovery Colectomy Surgery (ARCS)Jenni Prince Jenni Prince Area CNC Pain ManagementArea CNC Pain ManagementNorth Coast Area Health ServiceNorth Coast Area Health ServiceNCHI Sydney AustraliaNCHI Sydney Australia
45
34
28
18
16
8
38
0
5
10
15
20
25
30
35
40
45
poor patie
nt knowledge
non-standardized pain control
imbedded staff a
ttitudes
poorly coordinated discharge
slow to m
obilize
undernourished patients etc
24
57
42
7667
80
100
Pareto chart
surgical incisionsurgical incision trial of transverse incisiontrial of transverse incision pain control pain control wound infusion for transverse wound infusion for transverse incisionsincisions
thenthen
• patient information booklet• surgeon pathway• anaesthetic pathway• ARCS clinical pathway - surgical technique- surgical technique
- pain control- pain control- - bowel prep/care- nutrition- nutrition- mobilization- mobilization
1 1 surgeosurgeon10 n10 patientpatientss
1 1 surgeosurgeon1-6 n1-6 patientpatientss
PDSA cycles - implementation
Average LOS (days) per month
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10 11 12
month
day
sRun chart
Made change here
Strategies for sustaining improvement
• document and report each patient LOS• measure and calculate monthly average LOS• place run chart in operating theatre, update run chart
monthly• bimonthly team meetings to report positives and
negatives• continuously refine the clinical pathways • report outcomes to clinical governance unit • Spread - all surgeons
- left hemicolectomy- all colectomy surgery- throughout North Coast Area Health
Service