Developing a Provider Culture of
Dynamic Quality Improvement
My Practice is Perfect
So Why Are Some Of My Patients Unhappy and Unhealthy
Quality Health Care
“Problems in health care quality are serious and
extensive; they occur in all delivery systems and
financing mechanisms. Americans bear a great
burden of harm because of these problems, a burden
that is measured in lost lives, reduced functioning,
and wasted resources. Collectively, these problems
call for urgent action.”
Institute of Medicine, Committee on Quality of Health Care in America. Crossing
the Quality Chasm. A New Health System for the 21st Century.
Washington, DC: National Academy Press; 2001
Quality Health Care
“The Institute of Medicine outlines 6 aims for improving our nation’s
health care system by stating that all health care should be
safe,
effective,
patient-centered,
efficient,
equitable, and
timely. “
Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A
New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
Quality Health Care
The quality of health care is
defined as the degree to which
health services for
individuals and populations
increase the likelihood of
desired health outcomes and
are consistent with current
professional knowledge.
Donald Berwick
How Do We Define Health Care
Three Domains of Health Care
1. Structural
2. Processes
3. Outcomes
How Do We Define Health Care
Three Domains of Health Care
1. Structural – tools available
for care
2. Processes – activities we do
3. Outcomes - results
How Do We Define Health Care
Indicators
Indicators are the metrics we use to
measure the element of the three
domains.
As medical professionals, we are used to
working with these. Vital signs are a
outcome metric we use all the time.
Types of Quality Problems
1. Overuse – risk of potential harm exceeds the
possible benefit
2. Underuse – opportunity for likely favorable
outcome missed
3. Misuse - appropriate service causes a preventable
complication and full potential benefit not acheived
Six Health Care Improvement Dimensions
1. Safe - Avoiding injuries to patients from the care
2. Effective - Providing services based on scientific knowledge
3. Patient-centered - respectful of and responsive to individual
4. Timely - reducing delays
5. Efficient - avoiding waste
6. Equitable – patient doesn’t impact the quality of service offered
Institute of Medicine, Committee on Quality Health Care in America.
Crossing the Quality Chasm. A New Health System for the 21st Century.
Washington, DC: National Academy Press; 2001.
I Wish My Practice Was This Simple
A Better Model of My Practice
Health Status
Gender
Direct Effects of Practice
Variables on Patient Outcome
Care
Coordination
Family
Age
Communication
A Better Model of My Practice
Health Status
RHS
Numerous Direct and Indirect
Effects of Practice Variables on
Patient Outcome
RCC
Care
Coordination
RF
Family
RP
Age
RA
Communication
R=Residual Error
RC
Blalock HM, Causal Models in
the Social Sciences, Aldine
Publishing Co., 1999.
Building Blocks of Quality Improvement
Focus on PROCESS
Both internal and
external CUSTOMER
driven
Use objective DATA to make
decisions
Building a Team for Quality Improvement
•
Multidisciplinary Team
MD
Nursing
Lab
IT
Billing
•
•
•
Office Staff
Medical Records
Management
Clear involvement of leadership
Variable sponsorship
Efficient communication
Meet regularly
Foster “No Bad Suggestion” culture
Quality Improvement Model
The Model for Improvement,
as seen on the Institute for
Healthcare Improvement’s
website (IHI.org), was
developed by Associates in
Process Improvement
[Langley, Nolan, Nolan,
Norman, Provost. The
Improvement Guide. San
Francisco: Jossey-Bass
Publishers; 1996].
Quality Improvement Model
The Model for Improvement,
as seen on the Institute for
Healthcare Improvement’s
website (IHI.org), was
developed by Associates in
Process Improvement
[Langley, Nolan, Nolan,
Norman, Provost. The
Improvement Guide. San
Francisco: Jossey-Bass
Publishers; 1996].
What Are We Trying To Accomplish?
AIM
Use quality indicators to make a list of problems
faced by your practice or opportunities for
change.
Prioritize the problems or opportunities for
change
Make goal improvement unambiguous and
achievable
Be clear on boundaries
What Change Can We Make That Will
Result in Improvement?
Change Concepts
Eliminate waste
Improve work flow
Optimize inventory – Vaccines
Change the work environment
Improve provider/customer experience
Improve time efficiencies
Decrease variation in the process
Mistake proofing
Improve product or service
Langley G et al. The Improvement Guide.
Josey-Bass Publishers, San Francisco, 1996; xxi, p295.
What Are We Trying To Accomplish?
AIM
Use quality indicators to make a list of problems
faced by your practice or opportunities for
change.
Prioritize the problems or opportunities for
change
Make goal improvement unambiguous and
achievable
Be clear on boundaries
What Are We Trying To Accomplish?
AIM
FOCUS on
what is important to your organization
not what is sexy
STEAL shamelessly
What Are We Trying To Accomplish?
AIM
Avoid AIM drift
Be ready to refocus – always learn from
current data set
Pilot, try a panel of strategy and spread
What Are We Trying To Accomplish?
AIM
HOW GOOD?
BY WHEN?
What Are We Trying To Accomplish?
AIM
HOW GOOD?
BY WHEN?
Highland Pediatrics will decrease mean
registration to physician time by 20%
in 18 months.
What Are We Trying To Accomplish?
AIM
HOW GOOD?
BY WHEN?
Highland Pediatrics will offer 3 possible
well care visits times within 48 hours
of parental request within the next 6
months.
What Are We Trying To Accomplish?
AIM
HOW GOOD?
BY WHEN?
Highland Patients will decrease ER or
hospital admissions in known Asthma
patients by 15% in 12 months.
What Are We Trying To Accomplish?
AIM
HOW GOOD?
BY WHEN?
Highland Pediatrics babies will have
completed maternal Edinburgh screens
on the chart for the one and four
months visits for 90% of patients in 12
months.
Quality Improvement Model
The Model for Improvement,
as seen on the Institute for
Healthcare Improvement’s
website (IHI.org), was
developed by Associates in
Process Improvement
[Langley, Nolan, Nolan,
Norman, Provost. The
Improvement Guide. San
Francisco: Jossey-Bass
Publishers; 1996].
How will we know a change is an
improvement?
Know that progression is vital
BUT can be painful
How will we know a change is an
improvement?
Challenges
Adds work
Threatening – I plead the 5th
Difficultly with accuracy and consistency
Using the data to take action
Manual vs Automated
Management’s reality conflicts with data
Measured elements chosen inappropriately
Lack of training in data collection and analysis
How will we know a change is an
improvement?
Opportunity
Healthier and more effective decision
making process
Progress (or lack of) can be followed
Build a defined platform for improvement and areas of opportunity
Build confidence in understanding of operations
Everyone is talking a similar language
Easier to see trends – move to proactive instead of reactive
Focus on important items
Data sells ideas and limits the power of dramatic anecdote
How will we know a change is an
improvement?
Rules
QI is for learning how well what you do correlates with what you
want to do
QI is not to build a case to punish someone
“All measures have limits, but limitations do not negate value.”
Use a “balanced set of measures”
Focus on a VITAL FEW forget the common many
Data plotted over time
How will we know a change is an
improvement?
Steps
AIM Statement
Concept
Measures
Operational Definition
Data Collection
Analysis
Test Change
How will we know a change is an
improvement?
Operational Definition
Clear and not ambiguous
Measurement methods
Measurement equipment
Identifies criteria
Specific measures
Ends with numerator/
denominator
How will we know a change is an
improvement?
Run Chart
Measure over time
Common and Special Causes
Dr Coffman - Edinburgh Screening
1.20
1.00
0.80
one month
four month
0.60
Balance
0.40
0.20
0.00
Q2/11
Q3/11
Q4/11
Q1/12
Q2/12
Q3/12
Q4/12
Q1/13
Quality Improvement Model
The Model for Improvement,
as seen on the Institute for
Healthcare Improvement’s
website (IHI.org), was
developed by Associates in
Process Improvement
[Langley, Nolan, Nolan,
Norman, Provost. The
Improvement Guide. San
Francisco: Jossey-Bass
Publishers; 1996].
What Change Can We Make That Will
Result in Improvement?
“All improvement will result in change. All change will not
result in improvement”
“Every system is perfectly designed to get the precise results that
it gets”
What Change Can We Make That Will
Result in Improvement?
Do a detailed analysis of your area of concern
Review the current Evidence-Based Medicine
Review Benchmarks (ie, learning from superior performers in
the area chosen for improvement)
Advice from experts or others who have attempted
improvement in similar topics
Brainstorming, critical thinking, and hunches about the current
system of care
Don’t reinvent the wheel
What Change Can We Make That Will
Result in Improvement?
Change Concepts
Eliminate waste
Improve work flow
Optimize inventory – Vaccines
Change the work environment
Improve provider/customer experience
Improve time efficiencies
Decrease variation in the process
Mistake proofing
Improve product or service
Langley G et al. The Improvement Guide.
Josey-Bass Publishers, San Francisco, 1996; xxi, p295.
Quality Improvement Model
The Model for Improvement,
as seen on the Institute for
Healthcare Improvement’s
website (IHI.org), was
developed by Associates in
Process Improvement
[Langley, Nolan, Nolan,
Norman, Provost. The
Improvement Guide. San
Francisco: Jossey-Bass
Publishers; 1996].
How To Use a PDSA Cycle
Plan
Describe the change to be tested.
What do you predict will happen?
When will you conduct the test?
Who will be involved?
Who needs to know about the test?
How will you conduct the test?
Do
Conduct the test.
Document what happened.
Study
Discuss the results of the test.
How do your results compare with your
predictions?
What did you learn?
Act
Based on the results of the test adopt,
adapt, or abort the change.
Overview on Testing Change
Must have a THEORY and a PREDICTION
Test on small scale and collect data over time
Build on your understanding with multiple PDSA cycles for
each change idea
Look at change over a wide range on circumstances as you
sequence through your PDSA cycles
How will we know a change is an
improvement?
Change Concept
Theory and Prediction
Testing Change Concept
Test over a spectrum
of conditions
Applying Change
Concept
Become routine
operation
Universalization
How will we know a change is an
improvement?
AIM: Improve infant
care of depressed
mothers by better
screening mothers at
one and four month
visits
Having moms fill
out Edinburgh
Screening Tool will
help identify
mothers at risk for
severe post partum
depression
Data
Cycle 1: MD gives mom
Edinburgh Screening Tool
to complete during exam
to 3 moms
15% have EST
Cycle 2: MD gives screen
to all moms for a month
Cycle 3: RN introduces
screen during rooming,
MD grades
Cycle 4: All staff oriented
to use of Edinburgh
Screen Tool
90% have EST
How will we know a change is an
improvement?
Change Concept
Theory and Prediction
Testing Change Concept
Test over a spectrum
of conditions
Applying Change
Concept
Become routine
operation
Universalization
PDSA Cycle
Why did you succeed?
Why did you fail?
What further changes do
you now need to make
in order to succeed?
Were there unintended
consequences or harm
created by your change
attempts?
Concept Triangle
Change ConceptI want to minimize my
vaccine inventory
Concept Triangle
IdeaOnly order to replace
what we have used
that month
Change ConceptI want to minimize my
vaccine inventory
Concept Triangle
Idea ConceptNot overstock by
over ordering
IdeaOnly order to replace
what we have used
that month
Change ConceptI want to minimize my
vaccine inventory
Concept Triangle
Another way to do that idea
conceptIdea ConceptNot overstock by
over ordering
IdeaOnly order to replace
what we have used
that month
Track our use from last
year and purchase
potential deficient
compared to current stock
Change ConceptI want to minimize my
vaccine inventory
Concept Triangle
Another way to do that idea
conceptIdea ConceptNot overstock by
over ordering
IdeaOnly order to replace
what we have used
that month
Track our use from last
year and purchase
potential deficient
compared to current stock
Change ConceptI want to minimize my
vaccine inventory
Summary
My Mind Set
Think like your customer for the problem at hand
Focus on processes – How you do what you do
Use DATA
My Map and Compass
My AIM – What am I trying to accomplish
How do I know a change is an improvement?
What change can I make that will result in improvement?
My Transportation
Start SMALL and end with ALL
Build your understanding of your processes through sequential testing
Test, Implement, Spread
References
Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med1998;128(8):651-656.
Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care
Quality. JAMA. 1998;280(11): 1000-1005.
Clemmer TP, Spuhler VJ, Berwick DM, Nolan TW. Cooperation: the foundation of improvement.Ann Intern Med. 1998;128(12):1004-1009.
Council on Medical Service. Quality of care. JAMA.1986;256(8):1032-1034.
Donabedian A. The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI: Health Administration Press, 1980. Explorations in
Quality Assessment and Monitoring; vol 1.
Horbar JD. The Vermont Oxford Network: evidence-based quality improvement for neonatology.Pediatrics. 1999;103(1)(suppl E):350-359.
Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century.
Washington, DC: National Academy Press; 2001.
Langley GJ, Nolan KM, Nolan TW, Normal CL, Provost LP. The Improvement Guide. A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass Publishers; 1996. E):203-214.
Lloyd R. An Introduction to the Model for Improvement. The Institute for Healthcare Improvement . 2007-06-29
Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med.
2007;357(15):1515-1523.
Perla RJ, Provost LP, Murray SK. Sampling considerations in health care improvement. Quality Management in Health Care. 2013
Jan/Mar;22(1):36-47.
Plsek PE. Quality improvement methods in clinical medicine. Pediatrics. 1999;103(1)(suppl