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									Can Quality Improvement
Be Improved?
Effective Diagnosis of Performance Gaps
March 12, 2004

Kevin Kennedy, MHS
Donna Thorson, MS
Presentation Objectives
• Define error; understand the “Big 3”
  categories of performance gaps
• Compare & contrast the “Big 3”
• Understand how the “Big 3” affect
  performance gap
In the Beginning…
• All of us have used quality
  improvement (QI) techniques
• How can we go one step further?
• Can QI activities be improved?
• Can Human Factors help?
What Is Human Factors?

The science of designing tools, tasks,
information, and work systems to be
compatible with abilities of human
users; both physical & mental.
Human Factors

• Includes the study of human error
• Airline accidents, car accidents,
• So, what is an error?
Definition of Error

Planned sequence of mental/physical
activities fails to achieve desired
Personal Example
Why an Error?
• Sequence of actions did not achieve
  desired outcome – filling up my tank
  and leaving safely with car/gas pump
  in one piece
• I forgot to remove the nozzle prior to
• What factors contributed to this?
Friends vs. Human Factors

• Friends – How could someone do this?
• HF – What were conditions & situation
  like when getting gas? What are
  characteristics of the task?
Diagnosis of Error
• Filled up my car thousands of times
  before without any problems – routine
• Forgot to execute one step in the
• Distractions contributed to forgetting
  to remove the nozzle
So What?

• When a gap exists, helpful to assess
  why prior to developing interventions
• If we do not understand reasons,
  interventions may not be effective
• Go beyond trial & error
Things to Consider

• Are there different types of errors?
• What are violations?
• How are violations different from
• Who cares?
The “Big 3” Categories of
Performance Gaps?
• Plan is not executed properly
  (execution errors)
• The plan itself was inadequate to
  achieve desired outcome (planning
• Deliberate departure from “safe”
  practice (violations)
What Is a plan?

• Means (includes mental/physical
  activities) to achieve an objective
• Peanut butter & jelly example
• Not having a plan is a plan
The “Big 3” Categories of
Performance Gaps
1. Plan was not executed properly
  (execution errors)
• My gas station story
• Injecting the entire vial of medicine when distracted
• Patient not assessed for pain due to interruptions
• Immunization order given upon admission to be
  given at discharge, forgotten in the interim
The “Big 3” Categories of
Performance Gaps
2. The plan itself was inadequate to
  achieve desired outcome (planning
• Decided to drive to my favorite station 5 miles away
  and ran out of gas
• Not giving immunizations to residents with a cold
• Foot exams given to all patients with diabetes who
  take off shoes & socks
The “Big 3” Categories of
Performance Gaps
3. Violations: deliberate, not necessarily
  reprehensible, deviations from those practices
  deemed necessary (by managers, designers) to
  maintain safe operation
The “Big 3” Categories of
Performance Gaps
3. Violations
• Knowing speed limit is 65 and driving 80, seat belts
• Cutting corners, skipping steps, do not read manual
  before using equipment
• Omit foot exam since patient wearing boots & it will
  take too much time to take them off
• Accept a verbal statement of weight vs. weighing to
  save time

• Act itself is deliberate
• Negative consequences are not
• Certain conditions more likely to
  produce violations
Violation Producing Conditions
                Condition                  Likelihood
Perceived low likelihood of detection         X 10

Inconvenience                                 X7

Apparent authority or status to violate,      X3
disregard or override advice, requests,
procedures or instructions
No disapproving authority figure present      X2

Gender (?)                                   X 1.4
Summary - Violations

• Important to recognize that everyone
  commits violations at some point
• Need to understand why and not just
  blame individual
• Still a systems approach
Errors vs. Violations

• Errors – involve     • Violations – involve
  individual thought     social context
  processes              (procedures, rules)
• Unintentional        • Intentional
• Can be product of    • Can be product of
  system design          system design
What are the “Big 3”
Categories of
Performance Gaps?
• Plan is not executed properly
  (execution errors)
• The plan itself was inadequate to
  achieve desired outcome (planning
• Deliberate departure from “safe”
  practice (violations)
Why Care About the “WHY”?

Different Problems   Different Solutions
Execution Errors
What May Not Work:
  1. Punishment
  2. Rewards
  3. Training or Education of Skilled Operators
Why? Intended to correctly complete task.
Execution Errors
What May Work:
1. Prompts
2. Reminders

3. Memory Aids
Planning Errors
What May Not Work:
  1. Punishment
  2. Rewards
  3. Reminders
Why? They believe they are acting correctly.
Planning Errors
What May Work:
1. Memory Aids

2. Training or Education

3. Creating a process
What May Not Work:
  1. Training and Education
  2. Reminders
  3. Prompts
  4. Memory Aids
  5. Punishment
Why? Violations are a product of consequences and
 positive consequences are strongest.
What May Work:
1. Redesign work to eliminate frustrations
2. Using policies and rules only when
3. Positive feedback for desired behavior
Possible Solutions
• Execution Errors      • Violations
  – Prompts               – Redesign Work
  – Reminders             – Using policies only
                            when necessary
  – Memory Aids
                          – Positive Feedback
• Planning Errors
  – Memory Aids
  – Training/Educatio
  – Process Changes
Group Exercise
• Aim – apply the “Big 3” reasons for
  performance gaps to specific scenarios
• ID a scribe and a reporter
• Choose 1 of the 4 scenarios and list
  potential reasons for gaps in
  performance (10 minutes)
Group Exercise

• After making your list – categorize the
  reasons (plan not executed, wrong
  plan, violation)
• Each table will be asked to report two
  reasons for gap and then their
  classification from the Big 3
Scenario #1

• Patients with diabetes do not always
  get an annual foot exam in the
  outpatient setting.
• Why not?
Scenario #2

• Patients in the hospital who are
  eligible for PPV do not always receive

• Why not?
Scenario #3

• Pressure sores in nursing homes are
  not always treated based on available
• Why not?
Scenario #4

• Care planning & patient teaching for
  post-op orthopedic patients do not
  include instruction for pain
  management during activity/exercise.
• Why not?
The “Big 3” Categories of
Performance Gaps
• Plan is not executed properly
  (execution errors)
• The plan itself was inadequate to
  achieve desired outcome (planning
• Deliberate departure from “safe”
  practice (violations)
 Case Study 1
• Operating Room
• Focused on retention of foreign
• Diagnosed reasons why not all objects
  were discovered before closing
• Interventions implemented focused on
  human factors concepts (planning,
  execution errors)
Case Study 2
• Home health
• Improvement in Pain Interfering with
• Diagnosis – MD not notified
• Solution – Scripted dialogue for
• Results - 24.8% relative improvement
Take Home Ideas
• The “Big 3” provide a useful model to
  understand why performance gaps
  exist – a gap may have multiple
• The “Big 3” are important to consider
  when choosing interventions
• Human Factors concepts supplement
  traditional QI activities

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