Practice-based Quality
Improvement
Session 1
PCFDP
October 15, 2010
Sally Kraft, MD, MPH
Stephanie Berkson, MPA
Exercise
1. In a small group, review the performance
data on colorectal cancer screening.
2. Together discuss the following questions:
1. Does the data demonstrate variation in
performance? What are the implications of the
observed variation in performance?
2. What are potential causes of variation?
3. How would you use the data to achieve
improvements in performance rates?
Session Objectives
1. Develop an understanding of health system
levels and how these levels impact
performance and improvement.
2. Develop an understanding of the core
concepts of performance improvement.
3. Develop an understanding of the model of
improvement.
4. Gain experience analyzing variation, using
process maps, brainstorming and creating
affinity diagrams.
Current UW Health Organizational
Performance in WCHQ
Size of the bubble is correlated to the number of
eligible patients at each organization
UW Health
Primary
Care
Clinics
Performance
Health
Colorectal
Cancer
UW UW
Health
Colorectal
Cancer
in Colorectal
Cancer
Screening
ScreeningRates
Rates by
by Clinic
Screening
Clinic
100%
WCHQ Colorectal Cancer Screening Rates
Measurement Period January - December 2008
UW Dane PCP (Clinics over 100 patients)
90%
80%
Screening Rate
70%
UW Overall Rate = 66.8%
60%
50%
40%
30%
20%
10%
0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
UW Clinic
UWHC Clinics
UWMF Clinics
Size of the bubble is correlated to the number of eligible patients at each clinic
5
Physician Screening Rates
At a Single Clinic
*Screening rates based on panel age 50 – 75
6
Levels of improvement
Performance at any level of the healthcare system, may be
influenced by factors at another level in the system
- Berwick. Health Affairs 2002
Patient/Family
Berwick. Health Affairs 2002
Microsystems
Organization
Environment
Quality Improvement:
Improving Performance at the Frontline of Care
Level
A
“True North”
The experience of the patient and their
loved ones
B
Microsystems
Small units of care delivery
C
Organizations
The systems that supports small units of
delivery
D
Environment
Policy, payment, regulation,
accreditation: the factors that shape
behavior, interests and opportunities
Berwick. Health Affairs 2002
Institute of Medicine
Definition of Quality
The degree to which health services for
individuals and populations increases the
likelihood of desired health outcomes and
are consistent with current professional
knowledge.
Chassin and Galvin JAMA 1998: The Urgent Need to Improve Health Care Quality
What is Quality Improvement (QI)?
The combined and unceasing efforts of
everyone – health care professionals, patients
and their families, researchers, payers,
planners, educators – to make changes that
will lead to better:
– patient outcomes
– professional development
– system performance
Practice based QI: focus on improving the quality
of care delivered to a group of patients
receiving care in a practice.
(Presentation by Dr. Batalden IOM Workshop Jan 07)
Institute Of Medicine:
Six Aims for Quality Health Care
1.
2.
3.
4.
5.
6.
Safety
Timely
Effectiveness
Efficiency
Equity
Patient-Centered
STEEEP
Berwick. Health Affairs 2002;21:80-90
Improving Performance by
Understanding Variation
Variation in quality means that every patient is not
receiving the best care every time. Our data
demonstrates:
• UW Health performs poorly compared to other Wisconsin
provider groups on most of the publicly reported measures
• There is significant variation in performance between UW
Health primary care clinics
• There is significant variation between physicians, even
physicians practicing at the same clinic
Variation related to patient factors is appropriate.
Our goal is to decrease inappropriate variation.
Inappropriate variation can be decreased by
standardizing the clinical practices that produce
superior performance (steal best practices from
top performers!)
Which Process is Better?
Which Will be Easier to Improve?
Average
13
Managing Variation is Key to
Improvement
Ideal
Quality/Process
Improvement
Scenario:
1. Assess need to
address variation
within the
process
2. Decrease
variation if
necessary
3. Concentrate
efforts on
improving
average of
improved process
14
How do we understand variation in
Colorectal Cancer screening data?
Start by defining the current process.
Improvement Tool: Process map
Exercise:
1. Define start and end
points of the process
2. Identify all current
steps in the process
Process Map Basics
Definition
Illustration of steps in a process using
symbols and arrows
Purpose
Understand existing processes
Identify non-value added steps
Clarify complex processes
Identify improvement opportunities
Generate alignment and agreement
Train new staff
Patient Arrives at
Clinic
Patient checks in
at Registration
Patient checks in
at Reception
Provider consults
with Patient
Patient checks out
at Reception
Patient Leaves
Clinic
Where are the opportunities for
improvement in this process?
Problem Identification
What do we do that is valuable?
What do we do that isn’t valuable?
Lean Thinking (from Toyota improvement model): Seeing
and eliminating waste, i.e. eliminating anything that
doesn’t add value to the process
Keep
Eliminate
Value-Added
Non Value-Added
An activity that changes the form,
fit, or function of a product or
service; something the customer
would be willing to pay for.
Activities that do not add value to
the final product or service for the
customer. Given a choice,
customer’s won’t pay for it.
Learning from Toyota
“When my grandfather brought Toyota into the
auto business in 1937, he created a set of
principles that has always guided how we
operate. We call it the Toyota Way, & its
pillars are respect for people & continuous
improvement.”
- Akio Toyoda, president Toyota Motor Corporation
But, when customers are overlooked …
Patient-centered = customers first!
(making a U-turn for the better)
“… I am convinced that the only way for Toyota to emerge stronger from
this experience is to adhere more closely to (these core principles)…
… Yet it is clear to me that in recent years we didn't listen as carefully as
we should – or respond as quickly as we must – to our customers' concerns…
… This is why I am taking the company back to basics. Across Toyota, we
are putting our customers, & the values on which our company was founded,
front & center…
… We are listening more closely to our customers' concerns, gathering
information faster, & responding more effectively when there's an issue.”
- Akio Toyoda, president Toyota Motor Corporation
Types of waste
Transportation
Over Production
Waiting
Unnecessary
movement of
materials or patients
from one place to
another
Producing more than is
needed (ordering
unnecessary tests)
Patients waiting for
providers, providers
waiting for patients to be
roomed, waiting for lab, xrays, results etc.
Intellect
Motion
Any failure to fully
utilize the time and
talents of people
(providers escorting
patients through clinic)
Worker motion that
does not add value
(i.e. supplies kept in
central cabinet rather
than room)
Over Processing
Adding more value
than the customer is
paying for
Defects/Rework
Product or service not
meeting customer
requirement (Health ed
materials only in English)
Inventory
any more than the
minimum to get the
job done
What steps does the patient value?
Acute care appointment example
Lead Time Reduction Chart
Non-Value-Added
Value-Added
Patient arrives and checks in (3 mins)
Patient sits in waiting room (10 mins)
Patient is weighed and taken to exam
room (2 mins)
History of current problem described to
nurse/MA (5 mins)
Wait for physician (10 mins)
History of current problem described to
physician (5 mins)
Physician exam, discussion of
treatments, write Rx (10 mins)
Total NVA Time: 25 mins
Total VA Time: 20 mins
Example: Urgent Care Process Map
Identify non-value
added steps then:
WASTE: Patient waits
in room for provider
WASTE: Patient waits
in room for nurse
New Process
• Eliminate
• Combine
WASTE: Patient is
re-roomed
by nurse
• Simplify
Where is the waste in the Colorectal
Cancer screening process?
Exercise:
1. Indentify the value added steps that
deliver satisfaction or value
2. Identify the non-value added steps that
generate costs or waste
QI foundation: Plan-Do-Check-Act
Multiple small improvement projects,
each one building from the earlier project.
“FOCUS” - PDCA
1: Find a process to improve
2: Organize a team
3: Clarify current knowledge
4: Understand causes of problem
5: Select the improvement
Plan – Do – Check – Act
What are the causes of waste in
Colorectal Cancer screening?
Start by Finding a specific process to
improve, then Organize your team.
Improvement Tool: Brainstorming
How do we make sense of our
brainstorming results?
Start by organizing your findings into
themes.
Improvement Tool: Affinity Diagram
How do we choose what to
improve in the process?
After you Clarify the
situation and
Understand the
causes, Select a
process to improve
within your level of
improvement.
Take Home Lessons
• Levels of the health system
• Understand the relationship between the levels and
potential impact on improvement work
• Inappropriate variation is an opportunity for
improvement
• Standardize care processes
• Identify best practices
• Our model for improvement FOCUS PDCA
• Improvement tools
• Process map
• Brainstorming
• Cause and effect diagrams/affinity diagrams
We’ll do a deeper dive into applying
the PDCA cycle in Session 2.
Skills we will practice at the Nov session:
1. Writing a specific aim statement
2. Facilitating an improvement team
3. Collecting improvement data
4. Continuing the momentum to roll uphill