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 • • • • • • 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” • • • • • • A MAJOR STUDY OF RELIABILITY IN AMERICAN HEALTH CARE… • – – – – • • 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? • • • • The Quality Pioneers Walter Shewhart W. Edwards (1891 – 1967) Joseph Juran Deming (1904 - 2008) (1900 - 1993) 20 • • • • 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. 24 When you combine the 3 questions with the… …the Model PDSA cycle, for you get… Improvement. The Improvement Guide, API, 2009. The basics • • • • The Improvement Guide, API Aims create systems Aims • • • • • 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 • • • • 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 Jul Feb Aug Sep Nov May 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 • • • 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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