Practicing the Science of
Improvement:
Studying outcomes and context
in an evaluation of
Releasing Time to Care™ in SK hospitals.
Gary F Teare PhD MSc DVM
Director of Quality Measurement
and Analysis
Health Quality Council
Our Mission
To accelerate improvement in the quality
of healthcare throughout Saskatchewan.
Today’s Presentation
• What is Quality Improvement Science?
How does it apply to health care
Why is it important
• What is Quality Improvement Research?
Challenges and opportunities for studying
improvement innovations
An example in Saskatchewan
Only 56% of adults with
chronic diseases receive
guideline recommended
care
Only 53% of children with
chronic conditions receive
indicated care
1 in 13 hospitalized patients in Canada
experienced 1 or more adverse events in 2000.
300-600 avoidable
deaths per year
in Saskatchewan
Risk of Death
Airline: 1 in 10 million
Health care: 1 in 300
Dimensions of Quality
Safety
Effectiveness
Patient-Centredness
Timeliness
Efficiency
Equity
What is Quality In Health Care?
Quality health care means doing the
right thing at the right time in the
right way for the right person and
having the best possible outcome.
-Agency for Healthcare Research
and Quality
Healthcare Innovation
The Right Thing:
Biotechnology
Pharmacology
Diagnostics
Interventions
WHY?
11,000 new
articles added
per week to on-line
archives
Only ~ 40% of all
biomedical & clinical
journals, world-wide
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An imp
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…it can take 15 to 20 years to
integrate research evidence from
published clinical trials into daily
practice.
• Overuse
• Underuse
• Misuse
Translating Evidence into Practice
Consensus
Established
Basic
Biomedical
Knowledge
DIFFUSION
Clinical
Knowledge
Evidence-based
practices; guidelines
Clinical
Studies
NO
DIFFUSION
Adapted from: Rubenstein LV & Pugh J. (2006)
High
Quality
Care
Change!
Low
Quality
Care
Need focus on
Right way…
…at right time
…for right person
:
n
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o
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t
a
v
o
n
Requires in
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iv
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oD
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D
m
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S
o
o Reliability
n
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t
a
l
s
n
a
r
T
e
g
d
o Knowle
Overcoming 3rd Translational block
DIFFUSION
Established
Basic
Biomedical
Knowledge
Clinical
Studies
High
Quality
Care
Clinical
Knowledge
Evidence-based
practices; guidelines
NO
DIFFUSION
Adapted from: Rubenstein LV & Pugh J. (2006)
QUALITY
IMPROVEMENT
methods and tools
Low
Quality
Care
What is Quality Improvement?
…a range of strategies
and techniques
designed to improve
performance and
quality across systems
We must learn
to see beneath
the events of
every day life
What is the variation in a system over time?
Dynamic View
Static View
St
at
ic
Vi
ew
Every process displays variation:
UCL
time
LCL
• Common cause variation
stable, consistent pattern of variation “chance”,
constant causes
Static View
• Special cause variation
“assignable” cause, pattern changes over time
SPC: a branch of parametric stats
Statistics
Parametric
Enumerative methods of analysis
(static, aggregate)
Ex : t -test
Non-parametric
Analytic methods of analysis
(dynamic, time series)
Ex: SPC control chart
Third Next Available Appt: Clinic Average
Xbar chart
100
90
UCL = 88.22
80
Mean = 61.24
60
8 below centerline
50
2 out of 3 below 2 sigma
2 out of 3 below 2 sigma
40
beyond limits
LCL = 34.26
30
20
Started Working Down Backlog
Goal = 14
2007
Mar 13
Feb 15
Jan 25
Dec 12
Nov 14
O ct 12
Aug 31
Jul 4
Jun 5
M ay 16
Apr 26
Mar 30
Mar 23
Mar 16
M ar 1
10
Feb 22
C a le nda r D a ys
70
Third Next Available Appt: Clinic Average
Xbar chart
100
UCL = 88.22
80
60
2 out of 3 below 2 sigma
40
Mean = 39.34
LCL = 34.26
20
LCL = 16.91
Goal = 14
2007
Apr 10
Mar 13
Feb 15
Jan 25
Dec 12
Nov 14
Oct 12
Aug 31
Jul 4
Jun 5
May 16
Apr 26
Mar 30
Mar 23
Mar 16
Mar 1
Started Working Down Backlog
Feb 22
C a le nda r D a ys
UCL = 61.76
Mean = 61.24
Saskatchewan’s Quality Journey
Measuring and reporting on quality of care.
Working with health system partners to promote
and support quality improvement learning and
initiatives.
Training professionals, academics, and students
to spread QI learning around the province.
Health Services Research @ HQC
www.qualityinsight.ca
QIC Program
CPR School
Lean
Training
TLQIT’s
Organizational
Improvement
Capability
Releasing Time
to Care©
CDMC II
Clinician
Engagement
Accelerating
Excellence
Physician
Engagement
Leadership
Development
Quality as a
Business Strategy
Productive
Leader©
Measurement
Infrastructure
Quality
Insight
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But
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How & why
Research journey towards high-quality health care delivery
Research journey towards high-quality health care delivery
Research journey towards high-quality health care delivery
Research journey towards high-quality health care delivery
QI Research
Dougherty & Conway, JAMA 2008;299(19)
!
!
!
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“Evidence underlying QI Collaboratives is
positive but limited and effects cannot be
predicted with great certainty.”
“Health care improvement is a social
discipline…a form of experiential
learning.”
“…in which effectiveness depends on
ability to change human behaviour – as
much as it is a clinical discipline ”
Davidoff. JAMA 2009.302(23):2580-86.
Are traditional biomedical or
experimental research methods
sufficient …
“Complex social nature of improvement
complicates evaluation process in several
ways.”
Davidoff. JAMA 2009.302(23):2580-86.
Potential approaches…
Mixed methods
Theory driven approaches
Comparative effectiveness trials
Ethnographic techniques
Statistical process control (time series measurement)
Quality Improvement
Research in Saskatchewan
QIC Program
CPR School
Lean
Training
TLQIT’s
Organizational
Improvement
Capability
Releasing Time
to Care©
CDMC II
Clinician
Engagement
Accelerating
Excellence
Physician
Engagement
Leadership
Development
Quality as a
Business Strategy
Productive
Leader©
Measurement
Infrastructure
Quality
Insight
13% of Saskatchewan nurses felt
their team had given poor or fair care
6.4% felt they had given poor or
fair care (2nd highest of all provinces)
32% reported a
patient was injured
in a fall
The state of nursing in Saskatchewan
68% felt too much
work for one person
45% were not given
enough time to do
what was expected
37% reported high
job strain
Traditional Approach
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rses
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The module box set
Releasing Time to Care: The Productive Ward
Based on quality improvement
methodologies pioneered in Japanese
manufacturing in the 1960’s and 70’s
Aim: to improve patient outcomes and
overall job satisfaction
Doing more with the same amount of
resources
Releasing Time to Care: The Productive Ward
“Everything I need to
do my job is
conveniently
located”
‘The paperwork is
‘We have the
easy to understand
information we need to
and quick to
solve
own problems,
I am
notour
interrupted
by
complete’
and
find
out
if
we
were
‘It is people
clear torequesting
everyone
‘’Handovers are
successful”
information
or
looking
who is responsible
for for
concise, timely and
things
what”
provide all the
information I need”
Role Time (e.g. nurse)
Opportunity to increase
safety and reliability of
care
Total
Time
Motion
Admin
Discussion
Source: NHS Institute for Innovation and Improvement
Handovers
Roles
Information
Direct
Care
Time
Releasing Time to Care: The Productive Ward
RTC Module Overview
© Copyright NHS Institute for Innovation and Improvement 2007-2008
Main Storage room:
Before 5Sing
Main Storage room:
After 5Sing
Relocating IV pumps,
blanket warmer &
personal care products to
central location saved
~13 minutes/shift or
158 hours/year or
13 nursing shifts/year
Provincial Rollout
2 cycles of training/year
started May 2010
5 training cycles between
2010 and 2012
Up to 24 units/site /
training cycle
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Typical Results from UK sites
# interruptions reduced from
114 to 64 per shift (per nurse)
Important for safety critical
processes (i.e., Medicine
Administration)
Typical Results from UK sites
Direct care time increased by up to
60% - equivalent of adding more
nurses to ward
Decreases staff sickness rates
Medicine round time reduced by
63% (allowing re-investment of
time into safer care)
Improving Staff Well-being
“For the most part it’s about
empowerment…to actually feel you are
a part of a change and it’s not just people
out there somewhere - that we don’t
know who they are - making the change
for you”
- RN, Regina site
Impact of Releasing Time to Care: The
Productive Ward – Relationship of Outcomes and
Context in a Nurse-led Health Care
Improvement Innovation
CIHR Partnerships for Health System Improvement Grant
SK Partners: SHRF, SUN/Govt, HQC
$2.9 M over 3 years
The Research Team
Decision-Makers (Knowledge User)
Kyla Avis (HQC)
Co-investigators
Bonnie Brossart (HQC)
Dr. Gary Teare (U of S / HQC) [Co-PI]
Paula Blackstien-Hirsch
(The Change Foundation, ON)
Dr. Ross Baker ( U of T) [Co-PI]
Dr. Tanya Verrall (U of S /HQC)
Lawrence LeMoal (SK Union of Nurses)
Dr. Ozlem Sari (U of S / HQC)
Lynn Digney-Davis (SK Ministry of
Health)
Dr. Phil Woods (U of S)
Collaborators
Dr. Anne Sales (U of A)
Dr. Nazmi Sari (U of S)
Janice Seeley (Saskatoon Health
Region)
Dr. Donna Goodridge (U of S)
Pam Molnar (Saskatoon Health Region)
Dr. Liz Quinlan (U of S)
Dr. Marlene Smadu (U of S)
Dr. Jill Maben (King’s College – UK)
Dr. Walter Wodchis (U of S)
Dr. Peter Griffiths (King’s College – UK)
Dr. Keith Willoughby (U of S)
Interactive Research
Elleström et al., 1999
Decision-makers (HQC, SK Nursing Unions / Regulatory
Organizations, Ministry of Health, the Change Foundation)
Researchers (SK, ON, AB,
United Kingdom)
Development of
Research Questions
Implementers/Providers
(SK, ON)
RESEARCH QUESTIONS
Workshop (Meeting, Planning and
Dissemination Grant)
Development of
Research Questions
Decision-makers (HQC, SK Nursing Unions / Regulatory
Organizations, Ministry of Health, the Change Foundation)
Researchers (SK, ON, AB,
United Kingdom)
Implementers/Providers
(SK, ON)
Workshop (Meeting, Planning and
Dissemination Grant)
RESEARCH QUESTIONS
Example: Training Cycle One
Preimplementation
Implementation
PHSI
Funded
Project
Postimplementation
Measurement:
Administrative / routine
data sources for patient
outcome and human
resource measures
Time & activity measures
Survey measurement of
staff well-being and
teamwork
Case studies
Knowledge
translation (KT)
KT Meetings
(Decision-makers,
Researchers, Providers)
1) What are short-term and long-term impacts of
implementing RTC on unit environment?
2) What are contextual factors and mechanisms
associated with impact of implementing RTC
on unit environment?
3) What are impacts of implementing RTC on
patient outcomes?
Data Collection Plan
Research Question 1: Impact on Direct Care Time
Measuring direct and
indirect care time
Self-collected by
nurses
PDA CATEGORIES
Direct Care
Value –
Added
Activities
Necessary
Activities
Non-Value
Added
Activities
Bedside Procedure, Vital Signs, Wound/Skin Care, Incontinence, ADL,
Admit/Discharge, Assessment, Patient Services, Emergency, Bedside
Report, Comm. w/Patient, Comm. w/Family, Teaching Care Processes,
teaching admission, teaching discharge, Give meds
Indirect Care
Chart Review, Report, Prepare meds, Comm. w/ care team, White
board, Prepare meds, Care Conference
Documentation
Admission Paperwork, Daily Assessments, Transcribing Orders,
Writing Care Plan
Meds Paperwork, Teaching, Discharge Paperwork, Other
Documentation
Administration
Paging care giver, Calling ancillary department, teaching
student/resident, accounting for Narcotics and other Meds process at
end of shift, computer data entry, bed control, copy/fax machine,
Admin/training.
Personal
Waste
Lunch, personal break
Look for Person, Look for Equipment, Look for Supplies, Look for
Information, waiting delays.
Other
Other activities
Training Cycle One Evaluation Sites –
Value Added Time
Average Value Added Time -Training Cycle One Evaluation Sites (n=14)
Month
August, 2010
September, 2010
October, 2010
November, 2010
December, 2010
January, 2011
February, 2011
March, 2011
April, 2011
May, 2011
June, 2011
July, 2011
11
12
12
13
13
13
10
11
12
7
10
6
60.80
59.70
61.10
62.70
58.40
60.80
61.80
59.30
61.20
58.50
59.20
60.68
n (sites)=
AVG
August, 2011
Run chart
100
90
80
60
Median line = 60.7
50
40
30
20
10
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Value Added Time (%)
70
Direct Care Time – Ward level
Training Cycle One Units - RTC Direct Care Time for Individual Units (August 2010 - July 2011)
Direct Care Time (%)
32.9
35.6
R un c ha rt
100
90
70
60
10
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33.5
25.5
22.1
31.1
38.5
23.5
30.0
35.4
35.0
R un c h a rt
50
40
30
20
M e di a n l i ne = 3 3 . 5
10
No
Data
March
No
Data
May
No Data June
No Data May
11
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No Data December
No Data A ugust
No Data October
Data March No Data May
No Data No
January
No Data June
80
70
60
S
40
30
20
Direct Care Time (%)
50
S
R un c ha rt
100
90
80
70
60
10
0
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r,
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20
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Yorkton Direct Care Time (Training Cycle One)
33.7
0
be
r,
0
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0
No Data November
No Data February
No Data October
0
10
Month
August,
September,
2010 October,
2010November,
2010 December,
2010 January,
2010 February,
2011 2011
March, 2011
A pril, 2011
June, 2011
July, 2011
Direct Care Time (%)
38.7
32.4 33.9
42.2
37.1
39.6
40.1
41.0
45.7
34.6
R u n c h a rt
100
90
50
40
30
20
10
Women's Health - MJU Direct Care Time (Training Cycle One)
Month July,September,
2010
November,
2010
2010
February, 2011 April, 2011 May, 2011June, 2011 July, 2011
41.5
47.9
35.4
43.0
36.1
Direct Care Time (%)
Direct Care Time (%)
80
70
60
Direct Care Time (%)
80
Me di a n l i ne = 4 1 . 8
37.0
100
90
70
60
No Data February, March , A pril, May
m
be
r,
0
20
1
Month
August,
September,
2010 October,
2010November,
2010December,
2010 January,
2010 February,
2011 2011
March, 2011
April, 2011
June, 2011
July, 2011
Direct Care Time (%)
41.0
80
10
m
be
r,
ug
us
t,
A
ep
te
Fe
S
37.7
70
60
50
40
30
20
O
ct
o
A
S
Direct Care Time (%)
11
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ly
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01
1
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20
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20
1
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be
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48.9
80
50
40
30
20
20
1
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D
Weyburn Direct Care Time (Training Cycle One)
MonthA ugust,S2010
eptember,December,
2010
2010
January, 2011 A pril, 2011 May, 2011June, 2011 July, 2011
Direct Care Time (% )
41.7
be
r,
36.1
be
r,
41.8
R un c ha rt
100
90
be
r,
S urgery - MJU Direct Care Time (Training Cycle One)
41.3
N
ov
em
42.5
0
45.5
No Data June
20
1
36.6
20
m
be
r,
43.5
be
r,
0
0
0
20
1
A
ep
te
ug
us
t,
Ju
ly
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S
44.0
M e di a n l i ne = 4 1 . 5
30
10
0
01
1
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20
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M
a
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2
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0
20
1
be
r,
Ja
n
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em
36.2
0
m
be
r,
20
1
20
1
Direct Care Time (%)
47.2
O
ct
o
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S
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01
1
rc
h,
2
ar
y,
2
M
a
0
20
11
br
u
0
20
1
20
1
be
r,
ua
ry
,
ec
em
Ja
n
0
20
10
ov
em
20
1
be
r,
10
0
No Data February
Month
A ugust,
September,
2010 October,
2010
November,
2010
December,
2010 January,
2010 February,
2011 2011
March, 2011
April, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
34.6
Direct Care Time (%)
Direct Care Time (%)
38.7
0
Direct Care Time (%)
20
Outlook Direct Care Time (Training Cycle One)
41.1
R u n c h a rt
100
90
30
60
50
40
O
ct
o
37.2
M e di a n l i ne = 3 9 . 6
80
70
ep
te
39.6
60
50
40
R un c h a rt
100
90
S
35.8
Moosomin Direct Care Time (Training Cycle One)
80
70
D
ov
em
N
O
ct
o
ug
us
t,
A
Fe
be
r,
20
1
20
10
0
01
1
No Data S eptember
Nipawin Hospital Direct Care Time (Training Cycle One)
34.9
be
r,
0
20
1
10
0
MonthAugust,September,
2010
2010
October, 2010
November, December,
2010
2010
January, 2011June, 2011 July, 2011
Direct Care Time (%)
be
r,
N
20
Ju
ly
,2
e,
20
11
1
y,
20
1
M
a
pr
il,
A
30
No Data June
Ju
n
01
1
2
01
1
rc
h,
2
M
a
br
u
ua
ry
,
ar
y,
2
20
11
0
0
20
1
20
1
be
r,
Ja
n
ec
em
be
r,
N
60
50
40
D
ov
em
be
r,
O
ct
o
01
1
Data May
No DataNo
April
20
10
0
20
1
20
1
m
be
r,
ug
us
t,
A
ep
te
S
m
be
r,
20
1
A
S
20
M e di a n l i ne = 3 1 . 6
Month
August,
S eptember,
2010 October,
2010
November,
2010
December,
2010 January,
2010 February,
2011 2011
March, 2011
April, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
43.4 36.8
42.9 41.8
39.2 39.0
38.2 47.2
42.7 41.8
31.2 41.2
R un c ha rt
100
90
80
70
Direct Care Time (%)
30
0
Direct Care Time (%)
60
50
40
50
40
30
20
10
0
Month
August,
September,
2010 October,
2010
November,
2010
December,
2010 January,
2010 February,
2011 2011
March, 2011
A pril, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (% )
45.0 39.9 52.3 35.3
39.6 39.1
44.0 36.6
36.5 37.6
47.6
R un c ha rt
100
90
No Data June
No Data May
80
70
60
Level 6 Victoria Hospital Direct Care Time (Training Cycle One)
Month
August, 2010
October,
November,
2010 December,
2010
2010
January, 2011
March, 2011
A pril, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
32.1
44.0
48.1
44.7
46.9
42.8
41.0
46.3
49.7
47.0
R u n c h a rt
No Data August
NoAugust
Data September
No Data
Level 5 V ictoria Hospital Direct Care Time (Training Cycle One)
80
70
10
0
O
ct
o
ug
us
t,
Ju
ly
,2
Family Medicine Regina Direct Care Time (Training Cycle One)
Month
A ugust,
S eptember,
2010 October,
2010
November,
2010
December,
2010 January,
2010 February,
2011 2011
March, 2011
April, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
41.1
35.5 39.7 38.3 43.4
46.7 37.2
100
90
50
40
30
20
10
0
01
1
1
11
e,
20
y,
20
1
M
a
Ju
n
01
1
01
1
2
A
20
11
rc
h,
2
M
a
0
0
Ja
n
ec
em
D
N
ua
ry
,
20
1
20
1
be
r,
be
r,
ov
em
O
ct
o
be
r,
0
20
10
0
20
1
20
1
m
be
r,
ug
us
t,
A
ep
te
Me di a n l i ne = 2 8 . 3
R un c h a rt
100
90
80
70
60
10
0
No Data February
S
50
40
30
20
ep
te
10
0
80
70
60
6100 Direct Care Time (Training Cycle One)
Month
August,
S eptember,
2010 October,
2010
November,
2010
December,
2010 January,
2010 February,
2011 2011
March, 2011
April, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
31.1 31.6
35.3 31.0
29.3 34.1
33.7 29.7
35.9 35.2
30.6
R un c ha rt
100
90
Direct Care Time (%)
Direct Care Time (%)
Medi an l i ne = 38. 8
pr
il,
Direct Care Time (%)
80
70
60
50
40
30
20
R un c ha rt
100
90
m
be
r,
R u n c h a rt
100
90
5F Regina Direct Care Time (Training Cycle One)
Month
August,
September,
2010
2010
October,
November,
2010 December,
2010
2010
January,February,
2011
2011
March, 2011
April, 2011
July, 2011
Direct Care Time (% )
30.4
47.8
43.2
45.2
42.3
44.5
37.5
41.4
ep
te
5300 Direct Care Time (Training Cycle One)
Month
A ugust,
September,
2010 October,
2010
November,
2010
December,
2010 January,
2010 February,
2011 2011
March, 2011
April, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
35.3
28.0 29.7 27.0 33.0
23.7 28.8
28.3
28.6 24.2
28.3
O
ct
o
3300 3200 Direct Care Time (Training Cycle One)
Month
A ugust,
September,
2010 October,
2010November,
2010December,
2010 January,
2010
2011
March, 2011
A pril, 2011
May, 2011
June, 2011
July, 2011
Direct Care Time (%)
39.4
42.4
47.9
32.8
41.6
40.3
38.0
33.6
38.2
35.7
Research Question 1: Impact on Staff Well-Being
• Team Climate Survey
• Conditions of Workplace
Effectiveness II
• Maslach Burnout Inventory
CWEQ-II Survey: Baseline measurement from
SK hospital units closely matches published
cross-sectional results
McDonald et al. Critical Care Nursing Quarterly. 2010;33(2):148-62
Maslach Burnout Inventory: Comparison of SK baseline
results to published Canadian nursing sample
(Tertiary Care Hospital in Central Canada)
Leiter MP & Schaufeli W (1996) Anxiety, Stress & Coping, 9(3):229-43.
Research Question 1: Impact on Staff Well-being
• Human Resource Management
System (HRMS database):
Sick time
Overtime
Voluntary staff turnover
Research Question 2: Contextual Factors
• In-depth case studies
Unit staff, leadership
Organizational culture
Key barriers/facilitators
Selecting Units for Case Studies
Focused on
-Module Fidelity
-Leadership
-Direct Care Time
- Rural/Urban
Research Question 3: Patient Outcomes
• Patient experience in
acute care survey
• Average Length of Stay
(efficiency of care)
• Readmission (reliability
of care)
Patient Experience Survey
Website: www.hqc.sk.ca
E-mail: gteare@hqc.sk.ca
My thanks to Dr. Tanya Verrall,
Senior Researcher at HQC for
creating most of the slides used in
this presentation