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Quality Improvement SUPPORTING IMPROVEMENT IN

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Quality Improvement SUPPORTING IMPROVEMENT IN Powered By Docstoc
					Quality Improvement




   Jane Murkin
  Associate Director of Improvement
• Context of healthcare today and its relationship with quality improvement
• Increase understanding and application of improvement science and
  methodologies in relation to improving nutritional care
• Building capacity and capability in quality improvement
• Learning from others - collaboration – a nutritional care network and
  community
• Supporting the spread and dissemination of best practice
• Plan the testing and implementation of ideas and changes
• An exciting opportunity to actively participate in implementation of
  improvements in nutritional care across NHS Scotland
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     CARE IS NOT SAFE –
INSTITUTE OF MEDICINE REPORT



              “Between the care we have
              and the care we could have,
              lies not a gap, but a chasm”
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A MAJOR STUDY OF RELIABILITY IN
AMERICAN HEALTH CARE…

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HOW SAFE ARE CLINICAL SYSTEMS?
               CONVERTING RESEARCH TO CARE
                                      Original research
                        18%
 Negative                                             variable
                    Dickersin, 1987
 results
                                      Submission
                         46%                           0.5 year      Kumar, 1992
                      Koren, 1989

  Negative
                     to apply
           17 years Acceptance 14% of
  results                       0.6 year                             Kumar, 1992
                    knowledge
           research Publication
                                         17:14
                                                                                     Expert
              patient care! 0.3 year
           to 35%                                                    Poyer, 1982     opinion
                Balas, 1995
  Lack of
  numbers                             Bibliographic databases
                    50%                         6. 0 - 13.0 years Antman, 1992
              Poynard, 1985
                                      Reviews, guidelines, textbook
Inconsistent                                          9.3 years
indexing                              Patient Care

  Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
MID STAFFORDSHIRE REPORT
Remember…
Develop the Quality Improvement
 Hub, reflecting a new partnership
 for improvement between NHS
 National Services Scotland (NSS),
 NHS Quality improvement
 Scotland (QIS), NHS Heath
 Scotland, NHS National Education
 for Scotland (NES), and the
 Scottish Government Health
 Directorates Improvement and
 Support Team (IST).

                             Scottish Government, May 2010
The NHS Scotland Quality Improvement Hub works
in partnership by providing a coordinated national
resource to care teams and organisations.

 Providing :
• Implementation support which is flexible and
   responsive
• Education and learning about QI which is
   accessible and relevant
• Measurement of QI which is meaningful
• Facilitating QI networks for NHS staff
                Models for change



– Model for Improvement - Today's focus
– Reliability
– Demand and capacity
– Process mapping / Value stream
– Lean
– Six-sigma
          Changing systems


• Change is difficult and can be threatening
• Change can be time-consuming
• Change involves understanding people,
  systems and processes
• Healthcare systems are often complex
  and fragmented
    What is improvement?



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                     The Quality
                      Pioneers




                     Walter Shewhart
     W. Edwards       (1891 – 1967)    Joseph Juran
      Deming                           (1904 - 2008)
     (1900 - 1993)
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Subject Matter Knowledge: Knowledge basic to the things we do in
life. Professional knowledge.

                                                     Improvement
     Subject Matter
      Knowledge




                                                    Profound
                                                   Knowledge


 Profound Knowledge: The interaction of the theories of systems, variation,
                                                knowledge, and psychology.
(W Edwards Deming)
    The Primary Drivers of
    Improvement
Having the Will (desire) to change the current state to one that is better


                                   Will


                                                          Having the
  Developing                                              capacity to apply
  Ideas that will
  contribute to
                                  QI                      CQI theories,
                                                          tools and
  making                Ideas             Execution       techniques that
  processes and                                           enable the
  outcome better                                          Execution of the
                                                          ideas
The Quality Measurement Journey
     AIM    (Why are you measuring?)
       Concept
        Measure
          Operational Definitions
             Data Collection Plan
                Data Collection
                                         Analysis                                         ACTION



       Source: Lloyd, R. Quality Health Care. Jones and Bartlett Publishers, Inc., 2004: 62-64.

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When you
combine
the 3
questions
with the…

                                                   …the Model
 PDSA cycle,
                                                   for
 you get…
                                                   Improvement.

               The Improvement Guide, API, 2009.
    The basics


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The Improvement Guide, API
Aims create systems
    Aims


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     Developing an Aim Statement
Team name:

Aim statement
(What’s the problem? Why is it important? What are we going to do about it?)


     You should review your Aim Statement frequently to make sure
     it is consistent and that everyone involved with the initiative
     has a common understanding of what is to achieved.




How good?

By when?


32
Example #1 of an Aim Statement




    How good? By When?
      Hope is not a plan!
What do you think of these Aim Statements?


We aim to reduce harm and improve patient safety for all of our
patients.

By June of 2010 we will reduce the incidence of pressure ulcers
in the critical care unit by 50%.

Our patient satisfaction scores are in the bottom 10% of the
national comparative database we use. As directed by senior
management, we need to get the score above the 50th percentile
by the end of the 2st Q of 2010.


We will prevent patients becoming malnourished.

Our most recent data reveal that on the average we only
reconcile the medications of 35% of our discharged inpatients.
We intend to increase this average to 50% by 4/1/10 and to 75%
by 8/31/10.
   34
    Aim Statements

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The Improvement Guide, API
• “The data are wrong”
• “The data are right, but it’s not a problem”
• “The data are right; it is a problem; but it is not
  my problem.”
• “I accept the burden of improvement, but I have
  no idea how to get there!”

           Adapted from D. Berwick and B. Jarman, 2005.
     • Improvement is
       NOT about
       measurement
     • However…

39
Lief Solberg, Gordon Mosser and Sharon McDonald
Journal on Quality Improvement vol. 23, no. 3, (March 1997), 135-147.
“When you have two data
points, it is very likely that one
will be different from the
other.”
                                      W. Edwards Deming

           R Lloyd, Institute for Healthcare
           Improvement
                    80    70
                    70
Cycle Time (min.)




                    60
                    50
                    40               35
                    30
                    20
                    10
                     0
                          Avg     Avg After
                         Before    Change
                         Change
                                                                                                                                100
                                                                                                                                 90




                                                                                                         Cycle Time (min.)
                                                                                                                                 80
Cycle time results for units                                                                                                     70
                                                                                                                                 60
1, 2 and 3                                                                                                                       50
                                                                                                                                 40
                                                                                                                                 30
                                                                                                                                 20                                           Change       Unit 2
                                                                                                                                 10                                            Made
                                                                                                                                  0




                                                                                                                                                                                                                     Oct
                                                                                                                                                                  Mar

                                                                                                                                                                        Apr
                                                                                                                                                      Jan




                                                                                                                                                                                      Jun
                                                                                                                                           date




                                                                                                                                                                                             Jul
                                                                                                                                                            Feb




                                                                                                                                                                                                     Aug

                                                                                                                                                                                                           Sep



                                                                                                                                                                                                                            Nov
                                                                                                                                                                               May




                                                                                                                                                                                                                                   Dec
                                                   Unit 1
                    100
                     90
                                                                                                                                         100
Cycle Time (min.)




                     80
                     70                                                                                                                   90
                                                                                                                     Cycle Time (min.)

                     60                                                                                                                   80
                     50                                                                                                                   70
                                                                                                                                                                                            Unit 3
                     40
                                                                                                                                          60
                     30
                     20                             Change                                                                                50
                     10                              Made                                                                                 40
                      0                                                                                                                   30
                                                                                                                                          20                                  Change
                                                                                       Oct
                                             Mar

                                                   Apr
                                 Jan




                                                               Jun
                          date




                                                                     Jul
                                       Feb




                                                                           Aug

                                                                                 Sep



                                                                                             Nov
                                                         May




                                                                                                   Dec




                                                                                                                                          10                                   Made
                                                                                                                                           0




                                                                                                                                                                                                               Oct
                                                                                                                                                                  Mar

                                                                                                                                                                        Apr
                                                                                                                                                      Jan




                                                                                                                                                                                     Jun
                                                                                                                                               date




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                                                                                                                                                                                                                             Dec
                                                                                       R Lloyd, Institute for Healthcare
                                                                                       Improvement
Sometimes
gathering
data can
bring new
and
surprising
knowledge!
And sometimes you discover that the data you
are analysing do not match your view of reality!
• To plan for improvement
• For testing change
• For tracking compliance
• For determining outcomes
• For monitoring long term progress
• To tell their story
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     MEASUREMENT GUIDELINES

The question - How will we know that a change is
an improvement? - usually requires more than one
measure

• A balanced set of five to eight measures will ensure that the system
  is improved
• Balancing measures are needed to assess whether the system as a
  whole is being improved
The Improvement Guide, API
Why Test Changes?

•   To increase the belief that the change will result in
    improvements in your setting
•   To learn how to adapt the change to conditions in
    your setting
•   To evaluate the costs and “side-effects”
    of changes
•   To minimize resistance when spreading the change
    throughout the organization
                MODEL FOR IMPROVEMENT                           CYCLE:____DATE:____

                           Objective for this PDSA Cycle
               A     P
               S     D
             PLAN:
            QUESTIONS:


            PREDICTIONS:




            PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE




PDSA        PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE




Worksheet   DO:   CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.




            STUDY:    COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.




            ACT:   ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
•
Repeated Use of the Cycle

                                  Changes that
                                    result in
                            A P
                                  Improvement
                            S D




            A P
 Hunches    S D
 Theories
  Ideas
IMPROVEMENT MEASUREMENT
JOURNEY

AIM – Improved nutritional care
Concept – Prevent malnutrition in frail elderly patients
Measure – % compliance with MUST screening tool
Operational Definition – N: total number of opportunities in the
  sample where MUST screening tool was used on admission for
  frail elderly patients divided by D: total number of opportunities
  in the sample multiplied by 100 = % Compliance
Data Collection Plan – monthly
Data Collection – unit submits data for analysis to area/dept
  collating data
Analysis – Run or Control chart
• The data are our patients
• Make sure your data tells the story and the context
• Remind your colleagues its easy to forget!
• Patient stories
• Patient involvement in your improvement work
• Person centeredness
• Experience based design
   WHAT WILL IT TAKE TO IMPROVE QUALITY ?

• Winning the hearts and minds of the staff
• Focusing on improvement not targets
• Leadership
• Integration
• Making it daily work
• Creating infrastructure
• Creating capability and capacity
• Measurement that has meaning
• Understanding context and culture
• Momentum
2/9/2012
"We cant change the human
 condition, but we can change the
 conditions under which humans
 work"

				
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