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					Quality Improvement 101

 Barbara DeBaun, RN, MSN, CIC
Kathleen Carrothers, MPH, CPHQ
        Cynosure Health
         Today’s Objectives
Describe the elements of process design
Explain how to flow chart a process
Describe the Model for Improvement
Demonstrate 2 Performance Improvement
 tools
How Hazardous Is Health Care? (Leape)
4
2001
2003: Duke University Medical Center
2007
               Complexity of Healthcare
•   90,000 people in an ICU every day
•   Five million Americans will receive
    care in an ICU in a year
•   Average LOS in ICU is 4 days
•   Survival rate is 68%
•   Average patient requires 178
    individual actions per day (suctioning,
    medication, wound care, etc.)
•   An error is made 1% of the time
•   Average of 2 errors/day/patient

•   Gawande, A. (2007, December 10). The checklist: If something so
    simple can transform intensive care, what else can it do? The New
    Yorker.
             Why We Come To Work
•   Pick a dot
     – Goals, measure, current performance
•   Move the dot
     – Select intervention, PDSA
•   Share the dot
                                   Share a Story




       Data Drives Decisions

                            The Heart Motivates
                10 Years Ago
Central Line Blood Stream Infections
  were a part of doing business

Ventilator Associated Pneumonia was
  an unfortunate consequence of being sick

Sepsis was defined as shock from infection and
  carried a 50% mortality rate
2012: Zero Tolerance
The Tennis Ball Exercise
                            How To Play
• Break up into groups of 4-5 people
• Select - Timer, Scribe, Leader
• Using your tennis balls, spend 5 minutes designing a process that meets the
  following specifications:
    – Each ball must be touched by each person at least one time
    – The ball cannot be passed to the person directly next to you
    – The balls must be moved from person to person
• Time your process
• The goal is to build a process that meets the design specifications in the
  shortest amount of time
• After 5 minutes we will get the best time from each team
• You will then have another 5 minutes to improve your process
         What Did You Do?

– Formed a team
– Designated roles
– Brainstormed
– Designed a process
– Measured its performance
– Benchmarked its performance
– Analyzed the process design
– Redesigned your process
– Measured your new process, etc.
     Learning PI From Tennis Balls



• Before you can improve a process you need to know
  how it works
• Listen to all members of your team
• Especially those who are closest to the process
• Share improvement ideas
• Try them
More Learning’s
    • If at first you don’t succeed, try,
      try again
    • Look at others who perform the
      process well both within and
      externally
    • Borrow their ideas
    • Keep going
    • It’s the best process not the
      best people
Performance Improvement Tools
        Flowchart     Brainstorming


                             Pareto
       Multi-voting
                            diagram


                 Fishbone
                 diagram
        Facts About Flowcharts
• Used to visually explain a process and the
  interrelationship between process steps
• Allows analysis and better understanding of a
  process
• Great way for a workgroup to better
  understand their environment
• Excellent training documents
Commonly Used Flowchart Shapes
Start or End
                           Start or   Indicates starting or ending
                             End      points of process



                 Task or              Names or describes an
               Procedure
                                      individual task or procedure

                                      Indicates a conditional
                                      branch; a question or a
                Branch                decision; a variation in the
                                      process
                             Start

Yummy Example         Gather ingredients

                    Preheat oven to 325 F

                     Prepare baking pan…

                 Blend water, oil, and eggs in
                       medium bowl

                           Add mix

                     Stir until moistened

                Spoon batter into prepared pan

                        Spread evenly

                    Bake as directed below

                    Cool completely in pan

                        Cut and serve
            Start

    Gather ingredients                              Spoon batter into prepared pan

  Preheat oven to 325 F                                     Spread evenly

   Prepare baking pan…
                                              Bake 45-   Glass               Bake 40-
Blend water, oil, and eggs in                                     Pan
                                                50                             45
      medium bowl                                                type? Metal
                                              minutes                        minutes
          Add mix

                                Add ¼ cup
         Are you at
                           Yes flour and
            high                 add’l 2
         altitude?                                       Cool completely in pan
                               Tbsps. water
               No
                                                             Cut and serve
    Stir until moistened
               Flowcharts


• Identifies parts of the process where data
  can be collected
• Serves as a training tool to understand
  the complete process
           Flowchart Analysis

• What does your process look like?
• What does the desired process look like?
• Compare both charts, looking for areas where
  they are different
• Focus improvement efforts on the differences
  or areas of rework and delays
     Call between MDs office & OR


            Room is booked


     MD’s office faxes paper work


             Complete?          Office called & reminded


             Pt. arrives



     Paperwork checked again


            Complete?            Pt. held in pre-op for
                               MD to complete paperwork

         Pt. taken to OR
24
                Give It a Try
• At your table pick one of the following
  processes to flowchart:
  – Packing for the last trip you took
  – Preparing the last meal you cooked
  – Getting here today
• Determine the start and ending point of the
  process
            Decisions to Make
• Decide on the level of detail
  – Simple macro-flowchart shows only the
    general process flow
  – Detailed flowchart shows all actions and
    decision points
                  Go For It
• Identify the major steps in the process
• Write each step on a post-it note
• Arrange the post-it notes in the desired
  sequence
• Add directional arrows and decision diamonds
  – Keep all yes choices in the same direction
           Flowchart Analysis

• What does your process look like?
• What does the desired process look like?
• Consider flowcharting to compare the ‘real
  world’ with ‘the policy’
• Focus improvement efforts on the differences
  or areas of rework and delays
                 Fishbone
• Also called cause-and-effect diagram
• Can reveal key relationships among various
  variables, and the possible causes provide
  additional insight into process behavior
• Often used in root cause analysis
  – People
  – Processes
  – Equipment
Investigating
Practices to
Prevent CR-BSI
The Model for Improvement


 So You Think You Can Change?
While all changes do not lead to
improvement, all improvement
requires change.
           » Thomas Nolan, The Improvement Guide
Model For Improvement
           What are we trying to
               accomplish?                     AIM

         How will we know that a
                                            MEASURE
        change is an improvement?
     What change can we make that
       will result in improvement?       Selecting Change




               Act       Plan
                                     Small Tests of Change
             Study        Do
     What Are We Trying to Accomplish?



• Developing the
  team’s Aim
  Statement



34
       From Alice in Wonderland

 One day Alice came to a fork in the road
  and saw a Cheshire Cat.
 “Which road do I take?” she asked.
 His response was a question: “Where do
  you want to go?”
 “I don’t know, “ Alice answered.
 “Then,” said the cat, “it doesn’t matter.”


 Lewis Carroll
BIG




BOLD
WHAT?       WHERE?


HOW MUCH?
By WHEN?
Clear and Unambiguous Target
          AIM Statements


• Reduce heart failure mortality rate
  by 40% by September 1, 2012
• Reduce falls with injury on 4 West to
  zero by November 30, 2012
  What Are You Trying to
      Accomplish?


• At your tables, for the next 5-10
  minutes create an AIM
  Statement for a project you are
  working on or planning to start
             Evaluation and Sharing
• Did your AIM statement:
   – Have a clear numerical goal?
   – Have a bold but realistic goal?
   – Clearly articulate what you want
     to achieve and by when?
• Can your AIM statement be
  given in any elevator?
• Would you change your AIM
  statement?
• If so, what would you
  change and why?
How do you know if a
        change
 is an improvement?
Model For Improvement
           What are we trying to
               accomplish?                     AIM

         How will we know that a
                                            MEASURE
        change is an improvement?
     What change can we make that
       will result in improvement?       Selecting Change




               Act       Plan
                                     Small Tests of Change
             Study        Do
             Why Measure?
• How else will you know that the change(s) you
  made resulted in improvement?
Limitations
                      One Voice




                        Sample



Useful, not perfect
Select right measures




      Rapid results



 Adapt interventions
     Types of Measures




49
Process Measures
                   Outcome Measure

                            What
                           you get




              Balance Measures
  MEASURES


Outcome
             Balance
Process
  How Will We Know If A Change
      Is An Improvement?

• At your tables, for the next 5-10 minutes
  decide what measure(s) will help you
  know if you have made an improvement
         Evaluation and Sharing
• Does the measure(s) you
  selected allow you to
  understand if you have
  made a change?

• Would you change your
  measurement plan?

• If so, what would you
  change and why?
Model For Improvement
          What are we trying to
              accomplish?                     AIM

        How will we know that a
                                           MEASURE
       change is an improvement?
    What change can we make that
      will result in improvement?       Selecting Change




              Act       Plan
                                    Small Tests of Change
            Study        Do
                     The PDSA Cycle
                                     Plan                   “What will happen
“What’s next? ”
                             Act     • Objective            if we try
                        • Ready to   • Questions &          something
                      implement?                            different?”
                                       predictions
                  • Try something    • Plan to carry out:
                             else?     Who?When?
                      • Next cycle     How? Where?

                          Study Do
                • Complete data • Carry out plan
                         analysis • Document
                   • Compare to     problems
                      predictions • Begin data
 “Did it work?”    • Summarize      analysis     “Let’s try it!”
What changes can we
       make
that will result in an
  improvement?
              Brainstorm
       Rank

Construct Plan to Test
Time to Brainstorm…
Rules of Brainstorming & Multi-voting

                   • Brainstorm
                      – Each team member gives
                        an idea
                      – No debate of value
                      – Continue until there are no
                        more ideas
                   • Multi-voting
                      – Each team member gets 3-
                        5 votes
                      – Use all on one idea or split
                        them up
Guidelines for Testing Change
Fail Early, Fail Often
What can I do by next
 Tuesday/Thursday?
Work with the
   willing
Aim BIG
          Test   Small
Forget about consensus
Be Innovative
Collect Data
Wide range of conditions
Steal Shamelessly
Why Test?
                     The PDSA Cycle
                                     Plan                   “What will happen
“What’s next? ”
                             Act     • Objective            if we try
                        • Ready to   • Questions &          something
                      implement?                            different?”
                                       predictions
                  • Try something    • Plan to carry out:
                             else?     Who?When?
                      • Next cycle     How? Where?

                          Study Do
                • Complete data • Carry out plan
                         analysis • Document
                   • Compare to     problems
                      predictions • Begin data
 “Did it work?”    • Summarize      analysis     “Let’s try it!”
                 Back to Work

• Over the next 5-10 minutes,
  create 1-2 small tests of
  change you can implement
  by next Tuesday. Describe
  the who, what, how and the
  study approach.
• What do you want to
  happen?
• How will you know if it did?
           Evaluation and Sharing
• Does your test of change:
   – Include a description of
     the test?
   – Indicate who will do what,
     when and where?
   – Describe what you want to
     or think will happen?

• Would you change your test
  of change?

• If so, what would you change
  and why?
    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
                   Common Traps
• Plan Do, Plan Do
• Do Act, Do Act
• No testing, only data collection
• No ramps of tests, random PDSAs
• Undisciplined PDSAs, no
  documentation
• Prediction – what are we going to
  learn
• Beware of Cycles longer than 30 days
    Mistakes Made In Improvement
               Teams
• Failure to state a measurable, specific aim
• Failure to tie measures to aims
• Over-reliance on education and awareness
• Failure to state a population focus
• Failure to abandon a change that does not lead to
  an improvement
• Failure to engage process owners on a team and
  solicit their ideas
• Failure to make data visible to all engaged in the
  process
      Useful Websites
• www.jointcommission.org
• www.healthgrades.com
• www.calhospitalcompare.org
• www.ihi.org
• www.ahrq.gov
• www.apic.org

				
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