QI Theory Quality Improvement in the Hospital Goals for

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					              QI Theory:
  Quality Improvement in the Hospital
            Goals for this Primer
• Understand fundamental concepts in
  quality improvement
• Identify the environment and key steps for
  a successful quality improvement project
• Become familiar with several quality
  improvement tools and their use
         Quality Improvement:
    Bridging the Implementation Gap
Progress


           How good is American healthcare?




                              Patient care


                  Time
         Quality Improvement:
    Bridging the Implementation Gap
Progress


           We get it right 54% of the time.
           -Brent James, MD, MStat
            Executive Director, Intermountain Health Care




                                        Patient care


                      Time
         Quality Improvement:
    Bridging the Implementation Gap

           Scientific
           understanding
                                          Implementation
Progress



                                               Gap


                           Patient care


              Time
 Hospitalists and Quality Improvement

• Complex process problems need multidisciplinary
  solutions
• We are at the frontlines seeing system failures,
  process errors, and performance gaps with our
  own eyes -- which is our competitive advantage
• Improved quality delivers:
   better patient care…
   at lower costs…
   with potentially higher reimbursements (pay-for-
    performance)…
  And it can make our jobs more interesting, fun, and
    rewarding.
          Section I:
Quality Improvement and Change
    in the Hospital Atmosphere
               Definition of Quality

• Meeting the needs and exceeding the
  expectations of those we serve

• Delivering all and only the care that the patient
  and family needs
          “Definition” of Improvement

It is NOT…
 yelling at people to work harder, faster, or safer
 creating order sets or protocols and then failing to
  monitor their use or effect
 traditional Quality Assurance
 research (but they can co-exist nicely)
             Principle #1:
     Improvement Requires Change


Every system is perfectly designed to achieve
       exactly the results it gets

To improve the system, change the system…
            Principle #2:
            Less is More


    You cannot destroy productivity

When changing the system, keep it simple
   Illustrating Principle #2: Less Is More
     Probability of Performing Perfectly

No.      Probability of Success, Each Element
Elements 0.95       0.99       0.999     0.999999

1         0.95      0.99      0.999     0.999999
25        0.28      0.78      0.98      0.998
50        0.08      0.61      0.95      0.995
100       0.006     0.37      0.90      0.99
  Understanding Change in the Hospital
              Atmosphere


• Change = not just doing something different, but
  engineering something different
      • at least one step in at least one process


• Hospital Atmosphere = hospitals tend to be viscous,
  complex systems with default levels of performance
      • change engineered to improve performance can be a foreign
        concept - or even overtly resisted
        Understanding Change in the Hospital
                   Atmosphere
      A Common Strategy Which Commonly Fails:
•   Experts design a comprehensive protocol using EBM
    over several months
•   Protocol is presented as a finished, stand alone
    product
•   Customization of protocol is discouraged
•   Compliance depends on vigilance and hard work
•   Monitoring for success or failure is the exception to
    the rule (with failures coming to light after patients
    are harmed)
•   Flawed implementation leads to repetitive efforts
    down the road
         Understanding Change in the Hospital
                    Atmosphere
     High-Reliability Strategies Commonly Succeed:
•   Build a “decision aide” or reminder into the system
•   Make the desired action the default action (not doing
    the desired action requires opting out)
•   Build redundancy into responsibilities (e.g. if one
    person in the chain overlooks it, someone else will
    catch it)
•   Schedule steps to occur at known intervals or events
•   Standardize a process so that deviation feels weird
•   Take advantage of work habits or reliable patterns of
    behavior     Build at least one - if not more - of these high-
                   reliability strategies into any changed process.
Understanding Change in the Hospital
            Atmosphere


 Change engineered to drive improvement depends on…
    • Workplace Culture: personnel must be receptive to change
    • Awareness: administrative and medical staffs must care
      about performance and support its improvement through
      change
    • Evidence: local experts must identify which research to
      translate into practice
    • Experience: a skilled team must choose, implement, and
      follow up changes to ensure:
        1) improvement efforts are ongoing and yielding better
          performance
        2) productivity is preserved
               An Atmosphere for Change

         AWARENESS                                EXPERIENCE
OF THE LOCAL PERFORMANCE GAP                WITH SIMILAR IMPROVEMENT
             Patient                                EFFORTS
         Medical Staff                       Hospitalist Quality Officer
      Administrative Support               Multidisciplinary Team Members
                                        Success Stories From Other Institutions




          EVIDENCE                        WORKPLACE CULTURE
 TO TRANSLATE INTO PRACTICE                 READY TO ACCEPT CHANGE
        “Bedside” Teaching                            Task Load
    Didactic Teaching Sessions                 Culture of Improvement
Local Expertise in Disease Literature      Culture of Negative Expectations
                 An Atmosphere for Change

              AWARENESS                       Patient
                                             At mercy and increasingly aware of
    OF THE LOCAL PERFORMANCE GAP                underperforming status quo
                   Patient                   Now can access a new resource promoting
               Medical Staff                    transparency in hospital performance:
           Hospital Administration              www.hospitalcompare.hhs.gov




 Hospital Administration                     Medical Staff
Understands status quo is unacceptable      Has professional responsibility to improve
   (IOM, Leapfrog, NQF, JCAHO)               Knows all too well where system fails
Sees fiscal health tied to performance      Recognizes that professional livelihood will
   against national benchmarks, ability to      depend on paying attention to outcomes:
   reduce costs & LOS, improve margins,                Pay-for-Performance
   and competitive reputation in the
   community
                   An Atmosphere for Change

   Hospitalist Team Facilitator                            EXPERIENCE
   Technical expert on Quality Improvement
      theory and tools                           WITH SIMILAR IMPROVEMENT EFFORTS
   Owns the team process, enforces ground             Hospitalist Team Facilitator
      rules, helps judge feasibility                 Multidisciplinary Team Members
   Teaches the team while doing                   Successful Strategies Used By Others


Successful Strategies Used By Others         Multidisciplinary Team Members           
Learn from mistakes of others                Chosen for hands-on, fundamental
Adapt successes of others (tools and            knowledge of key processes
   methods): steal shamelessly                Inclusive, open, & consensus seeking
Get specific advice in ‟Ask the Expert‟      Impact not only the change(s) but the
   forums or other consortiums that collect      implementation
   and share experience
                An Atmosphere for Change

“Bedside” Teaching                          Didactic Teaching Sessions
To an audience of residents or students    To an audience of peers, administrators,
To build cadre of “experts” (and to help      nurses, or support staff
   meet ACGME requirements)                 To boost awareness, knowledge,
Download teaching pearls from SHM             enthusiasm, and support
   resource rooms                           Download slide sets from SHM resource
                                               rooms


                                           
                                            Local Expertise in Disease Literature
          EVIDENCE                          Decide what changes to make based on
  TO TRANSLATE INTO PRACTICE                   the level of evidence
        “Bedside” Teaching                  Establishes team‟s credibility
    Didactic Teaching Sessions              Extends team‟s authority when local sub-
Local Expertise in Disease Literature          specialists or experts participate in
                                               selecting and implementing change
                                            
                    An Atmosphere for Change

   Task Load                                     Culture of Improvement
   Be sensitive about piling new tasks onto     Extend it, one person and one project at a
      over-tasked personnel                         time
   Use the input of personnel who will be       Advertise successes
      responsibile for implementing              Use or adapt this online „cultural survey:‟
   Make it easy and desirable to do the right       http://www.patientsafetygroup.org/program/step1c.cfm

      thing                                                                                            



Culture of Negative Expectations
Overcome it, one person and one project            WORKPLACE CULTURE
   at a time                                          READY TO ACCEPT CHANGE
Attach pride to balance between                               Task Load
   performance successes and failures
                                                      Culture of Improvement vs.
Consider using a „cultural survey‟ to
   identify problems and address them               Culture of Negative Expectations
   through proper channels             
       Section II:

The Multidisciplinary Team
The Driving Force for Change


     THE MULTIDISCIPLINARY TEAM


Leverages frontline expertise and experience.
    Impacts not only the change/interventions,
          but also the implementation
        The Driving Force for Change:
         The Multidisciplinary Team
A team is not the same as a committee…
Committee
• individuals bring representation
• productive capacity = single most able member
Team
• individuals bring fundamental knowledge
• productive capacity = synergistic (more than the sum of all
  individual team members together)
        The Driving Force for Change:
         The Multidisciplinary Team
Features of a good team…
• Safe (no ad hominem attacks)
• Inclusive (values all potential contributors including
              diverse views; not a clique)
• Open (considers all ideas fairly)
• Consensus seeking
         The Driving Force for Change:
          The Multidisciplinary Team
Consensus…
• definition: finding a solution acceptable enough
  that all members can support it; no member
  opposes it

• It is not:
    A unanimous vote (consensus may not represent
     everyone‟s first priorities)
    A majority vote (in a majority vote, only the majority
     gets something they are happy with; people in the
     minority may get something they don‟t want at all,
     which is not what consensus is all about)
    Everyone totally satisfied
       The Driving Force for Change:
        The Multidisciplinary Team
Three types of team members…
1) Team Leader
2) Team Facilitator
3) Process Owners (members with operational, hands-on
  fundamental knowledge of the process)
       The Driving Force for Change:
        The Multidisciplinary Team
Team Leader…
• schedules and chairs team meetings
• sets the agenda (printed at each meeting)
• records team activities (working documents in
  binder)
• reports to management (Steering Team)
• often a member of Steering Team
          The Driving Force for Change:
           The Multidisciplinary Team
Team Facilitator…
•   owns the team process (enforces ground rules)
•   technical expert on QI theory and tools
•   assists Team Leader
•   teaches while doing, within team
        The Driving Force for Change:
         The Multidisciplinary Team
Process Owners…
• chosen for fundamental knowledge
• will help implement
• should become leaders (so choose wisely)
            The Driving Force for Change:
             The Multidisciplinary Team
Team Ground Rules…
• All team members and opinions are equal
• Team members will speak freely and in turn
      We will listen attentively to others
      Each must be heard
      No one may dominate
• Problems will be discussed, analyzed, or attacked (not people)
• All agreements are kept unless renegotiated
• Once we agree, we will speak with "One Voice" (especially after leaving the meeting)
• Honesty before cohesiveness
• Consensus vs. democracy: each gets his say, not his way
• Silence equals agreement
• Members will attend regularly
• Meetings will start and end on time
A Brief Digression into Quality
     Improvement Theory
                       Defining an Approach to Change
       Will the team target „all‟ patients in the
       inpatient bell curve, or just a sub-group
       considered „at-risk‟ (depicted in the
       outlying tail)? Is the quality of inpatient
       care which is not in the tail somehow
       „acceptable?‟



                       Before
Bell Curve:
Inpatient Population


       Tail




      worse
                       Defining an Approach to Change
  If the team can identify and define an inpatient sub-group
  „at-risk,‟ then improvement efforts could conceivably
  focus just on these „at-risk‟ patients - this is similar to           After
  traditional Quality Assurance. Note that even if tail
  events are eliminated, the quality of care for the rest of
  the inpatient population (depicted by the unchanged
  position and shape of the bell curve) does not improve at
  all. While the mean does move toward better care, this is
  due only to eliminating statistical outliers.

                       Before
Bell Curve:                                                     worse   Quality
Inpatient Population


       Tail




      worse
                       Defining an Approach to Change
  If the team identifies a performance gap applicable to a
  wider patient population, the team may design changes in
                                                                         After
  processes with the potential for dramatic effect:
  improvement and standardization in processes reduces
  variation (narrows the curve) and raises quality of care for
  all (shifts entire curve toward better care). This radical
  change is what defines Quality Improvement.

                       Before
Bell Curve:                                                      worse   Quality
Inpatient Population


       Tail



                                                                              better
      worse


                                                                 worse   Quality
        Section III:
Tools for Engineering Change
             Engineering Change

• Hospitals have two dynamic levels impacting
  performance:
 1) Processes
     • tasks performed in series or in parallel, impacting patient care
       and potentially patient outcomes
 2) Personnel
     • skilled people with hearts and minds, with variable levels of
       attention, time, and expertise
               Engineering Change:
   What Variables Impact Quality Outcomes of Care?


 Structure         Processes           Outcomes of Care

  Inputs             Steps                 Outputs

•Patients         •Inventory Methods    •Physiologic
•Equipment        •Coordination          parameters
•Supplies         •Physician orders     •Functional status
•Training         •Nursing Care         •Satisfaction
•Environment      •Ancillary staff      •Cost
                  •Housekeeping
                  •Transport
            Engineering Change:
What Variables Impact Quality Outcomes of Care?
The two most dynamic levels impacting performance

                  Processes

                     Steps

                 •Inventory Methods
                 •Coordination
                 •Physician orders
                 •Nursing Care
                 •Ancillary staff
                 •Housekeeping Personnel
                 •Transport
            Engineering Change

• Processes
   all those affecting relevant aspects of patient
    care
     • clinical decision making, order writing, admission
       intake, medication delivery, direct patient care,
       discharge planning, PCP communication,
       discharge follow-up, etc
           Engineering Change

• Personnel
   anybody who touches the patient or a relevant
    process in the system
    • departments, physicians, clerks, pharmacy,
      nursing, RT, PT/OT/ST, care technicians,
      phlebotomist, patient transport, administration
          Engineering Change:
The Multidisicplinary Team Asks “What?”
• What?
   is the right thing to do?
   will make the system more effective?
          Engineering Change:
     The Multidisicplinary Team Asks
                “Where?”
• Where?
   are the processes to improve?
     • Brainstorming
     • Multivoting & nominal group technique
     • Affinity grouping
   do we start? (dissect and understand the processes)
     •   Cause and effect diagrams (Ishikawa or ‘fishbone’ diagrams)
     •   Tally sheets
     •   Pareto charts
     •   Flow (conceptual flow, decision flow) charts
     •   Run charts
     •   SPC charts
     •   Scatter charts
        Tools for Engineering Change:
          Cause-and-Effect Diagram
• sometimes also called a „fishbone‟ or Ishikawa diagram
• graphically displays list of possible factors, focused on
  one topic or objective
• used to quickly organize and categorize ideas during a
  brainstorming session, often as an interactive part of the
  session itself (the added organization can help produce
  balanced ideas during a brainstorming session)
                 Tools for Engineering Change:
                   Cause-and-Effect Diagram
                                Example: Adverse Drug Events (ADE)
                    Drug
                                                   Nurse
                                                                                    Ordering                   Physician
                 Administration
                                                    Physician                        Errors                     Pharmacy
                    Errors
                                                     Pharmacist                                                  Nurse/Clerk
                        Rate                                                                Transcribing
                                       Dilution
                                                                                 Spelling
                               Route
                                                                                                Dosage
                                                                                                                                 Place outcome here
                                            Time                                                    Route

                                   Nurse                                              Scheduling
                                                                                                              Order Missed
                                                     Wrong
                                                     Drug
                                           Dose

                                                                       Age
                                                                             Weight
                                                                                                              Unforeseen                   ADE
       Psychiatric                                              Gender                                                       Expected
                                                                                                           Drug/Drug
                                                                         Renal
                     Cognitive                         Electrolyte
                                                                                                   Drug/Food           Pharmacokinetics
                                                                    Past Allergic
Compliance                                            Hepatic         Reaction
                                                                                                Drug/Lab
                                                                Absorption                                     Pharmacodyamics
                                                     Race


       Patient                                        Physiologic                                  Pharmocologic
       Errors                                           Factors                                       Factors                   Pharmacist
                                                                                                                                 Patient
                                                             Patient                                                               Physician
                                                                                                                                     Dietician
              Tools for Engineering Change:
                       Pareto Chart
• graphical display of the relative weights or frequencies of competing
  events, choices, or options
• a bar chart, sorted from greatest to smallest, that summarizes the
  relative frequencies of events, choices, or options within a class
• often includes a cumulative total line
• used to focus within a broad category containing many choices, based
  on factual or opinion-based information
• can combine factors that contribute to each item's practical
  significance
                    Tools for Engineering Change:
                             Pareto Chart
                    Causes Contributing to Adverse Drug Events
           100


               90


               80


               70


               60
Contributing
  Percent




               50


               40


               30


               20


               10


                0
                                     Causes
                                       Causes
       Tools for Engineering Change:
        Sketching Processes or Flow


• Macro Process Maps
• Decision Flow Diagrams
                    Tools for Engineering Change:
   The patient is        Macro Process Map
  admitted to the
     hospital
                        Example: Heart Failure Core Measures 2-3
    The patient is
clinically identified
   as having heart
       failure

                                                    The patient is         The patient is
                                                 prescribed an ACEI     prescribed an ACEI
The ejection fraction                                in hospital            at discharge
    is evaluated
                         The ejection fraction
                                < 40%
The ejection fraction
is documented in the
                                                                        The contraindication
       chart                                      The patient is not
                                                                           for an ACEI is
                                                 prescribed an ACEI
                                                                         documented in the
                                                     in hospital
                                                                                chart
                         The ejection fraction
                                > 39%

                                                      The patient is
                                                   excluded from the
                                                    target population
                         Tools for Engineering Change:
                            Decision Flow Diagram
   Deep Post-Op                        UTI              Pneumonia                Bacteremia           Other
  Wound Infection

               Contributing layer dissected:                          Contributing layer dissected:
                       Prevention              Prevention               Prophylactic Antibiotics


                                                  Patient                           Prophylaxis
            Prevention                          Preparation
                                                                                        Patient
                                                                                       Selection
                                               Prophylactic
                                                Antibiotics
            Detection                                                                  Antibiotic
                                                                                       Selection
                                                                                         - Duration
                                                  Surgery
                                               - Sterile Technique
                                               - Operative Findings
            Treatment
                                                                                      Delivery
                                                                                          - Timing
For iatrogenic infections, any                  Post-Op
given type of infection can be                 Wound Care                 Calling out the contributing layers
dissected into the hierarchy of                                           helps the team think through the steps
     contributing layers.                                                 ripest for change.
           Tools for Engineering Change:
                     Run Charts
• Our brains understand graphics better than tables
• Tabular information doesn‟t convey trends over time very
  well
• Keep it simple
• In center of horizontal axis place: baseline mean
  performance
• In center of vertical axis place: implementation point
• Can add upper and lower control limits, but usually not
  needed
                        Tools for Engineering Change:
                                  Run Charts
                                           Percent Sliding Scale Insulin Only

          80

          70

          60

          50                                                         10/20/03
Percent




                                                                 New Order Set

          40

          30                                                                       01/20/04
                                                                                  CPOE - TH
          20

          10

              0
                                                   03




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                           Tools for Engineering Change:
                                     Run Charts
                                Percent with Frank Hypoglycemic Events

          16

          14

          12

          10
Percent




              8
                                                    10/20/03
                                                  New Order Set
              6
                                     March 2003
              4                      Team Forms                    CPOE
                                                                  TH - 1/04
                                                                  HC - 8/04
              2

              0
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                           Tools for Engineering Change:
                                     Run Charts
                               Percent with Optimal/Acceptable Glucose Readings

          100
          90
          80
          70
          60
Percent




                                                     10/20/03
          50                                       New Order Set
                                                                              CPOE
                                  March 2003
                                  Team Forms                                 TH - 1/04
          40                                                                 HC - 8/04

          30
          20
          10
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          Engineering Change:
The Multidisicplinary Team Asks “How?”
• How?
   can you make it easy to do the right thing?
     • You cannot destroy productivity
         – Changes must maintain, or enhance, workplace efficiency or balance

     • You must devote as much attention to fitting changes into clinical
       work flow as you do to the evidence-based guideline
         – Changes must be blended into the flow of clinical care
         – Important variables to consider: staffing, training, supplies, physical
           layout, information flow, and educational materials
          Engineering Change

 Improve incrementally. Learn through action.

            Plan Do Study Act
     PDSA PDSA  PDSA  PDSA PDSA  PDSA



        Test your changes. Assess their effect.
Then re-work the changes and do it again…and again…
            Engineering Change:
                    PDSA
      (the Benefits of Repeated Cycles)

• Increases belief that change will result in
  improvement
• Allows opportunities for “failures” without
  impacting performance
• Provides documentation of improvement
• Adapts to meet changing environment
• Evaluates costs and side-effects of the change
• Minimizes resistance upon implementation
          Engineering Change:
                        PDSA
• Overview:
   scientific method for action-oriented learning:
    shorthand for testing a change in the real world setting
   test a change by: planning it, trying it, measuring its
    results… and then trying to do it better the next time
   multiple rounds of changes – some failures and some
    successes - should lead to improved aggregate
    outcome
           Engineering Change:
                        PDSA
• Principles for Success:
   start new changes on the smallest possible scale, e.g.
    one patient, one nurse, one doctor
   run just as many PDSA cycles as necessary to gain
    confidence in your change – then expand
   expand incrementally to more patients
   expand to involve more nurses, more doctors, more
    departments
   balance changes within system to ensure other
    processes not adversely stressed
            What do we want to achieve?



            What changes will drive our progress?



            How will we measure our progress?



           How should we modify our latest changes?




modified from: The Foundation of Improvement by Thomas W. Nolan et. al
   Engineering Change

    What do we want to achieve?
    Set an outcome aim.
    (It should be ambitious, must be measurable and must
    specify a time-period and a definite population in your
    hospital.)


     List the outcome aim again, then:
     –   ask “why” three times,                          “Function
     –   ask “how” three times,
     –   look at the new aim statements, and
                                                         Expansion”
     –   pick the best one



modified from: The Foundation of Improvement by Thomas W. Nolan et. al
   Engineering Change


 What changes will drive our progress ?
 Select change(s) to your system, the one(s) most likely to
 improve outcomes.
 (Recognize that not all changes improve outcomes or offer
 balance.)




modified from: The Foundation of Improvement by Thomas W. Nolan et. al
     Engineering Change
                                Principles of Measurement:
                                Seek usefulness, not perfection.
                                Integrate measurement into the daily routine.
                                Use qualitative and quantitative data.
                                Use sampling.
                                Plot data over time.


       How will we measure our progress?
       Define what you will measure quantitatively.
       (Collect data, chart measures regularly over specified
       time-period, and chart against benchmarks & goal lines.)
                                Three Types of Measures:
                                1) Outcomes
                                2) Process
                                3) Balancing measures
                                      (Use a balanced set of measures for all
                                      improvement efforts.)
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Engineering Change




 How should we modify our latest changes?
 Test your changes.
 (Run PDSA cycles to learn from the work setting.)

modified from: The Foundation of Improvement by Thomas W. Nolan et. al
                         Engineering Change:
                                  Hints for Success
•   Empower nursing
•   Expedite order set and protocol passage through appropriate medical staff committees
•   Better to implement an imperfect, compromise change than no change at all
•   Pilot newest changes on smallest scale
•   Provide hot line or support for difficult implementation situations
•   Use your new system as a shared baseline, with clinicians free to vary based on individual patient
    needs
•   Follow metrics continuously as you implement
•   Feed metrics back into subsequent PDSA cycles
•   Measure, learn, and over time eliminate variation arising from professionals; retain variation arising
    from patients
•   Keep big picture in mind
•   Negotiate „speed bumps‟
          Time delays in getting data
          Incomplete buy-in
          Go around obstacles instead of through them (can always go back to them later)
          Some who disagree with you may be correct
          Make changes painless as possible: make it easy to do the right thing
              QI Theory:
  Quality Improvement in the Hospital

• Suggested next steps:
   1) Share this primer in QI Theory with other hospitalists in
     your group
   2) Identify an important QI project at your hospital
   3) Lead the QI project using all available resources
   4) Learn from your experience and be among the first to
     mentor other hospitalists

   Use SHM‟s topic-specific resource rooms to ask questions,
     share experiences & tools, review the literature, and to
     download presentations to help you educate others.
             Acknowledgments
• Brent James, MD, MStat (Intermountain Health Care's Institute for
  Health Care Delivery Research): concepts, content, figures
• Thomas Nolan, PhD (Institute for Healthcare Improvement): concepts,
  content, figures
• Greg Maynard, MD, MSc (University of California, San Diego):
  editorial composition and review
• Jason Stein, MD (Emory University School of Medicine): editorial
  composition