Introduction to Quality
Improvement
Author: Nazanin Meshkat MD, FRCPC, MHSc,
Assistant Professor, University of Toronto
Date Created: September 2011
Glo b al H ealth E m e rg e ncy M e dicine Teachi n g M odu le s by G H E M is license d u n de r
a C reativ e C o m m ons A ttrib u tio n -N o n C o m m e rcial -S h areAlike 3.0 Un p or ted License .
“Every system is perfectly designed
to get the results it gets”
Objectives
 To gain an understanding of what quality
improvement is
 To present the Model for Improvement and
PDSA cycle
 To introduce measurement in quality
improvement
 To introduce flowcharts
What is Quality Improvement?
 A formal approach to the analysis of
performance and systematic efforts to
improve it
 Different from Quality Assurance
Quality Improvement versus Quality
Assurance
Quality Improvement
Quality Assurance
What can we do to improve? What went wrong?
Proactive
Reactive
Avoids blame
Often Punitive
Fosters System change
Tries to find who was at fault
Focuses on the entire
system
Focuses on the specific
incident
What is quality?
 Definition of quality depends on
stakeholders
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The client/customer (the patient)
The provider/employer (health care providers)
Management (hospital management)
Payer (Ministry of Health)
6 Pillars of Quality
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Safety
Timely Access
Equitable
Efficacy
Efficient
Patient Centered
“Every system is perfectly designed
to get the results it gets”
 How can you improve a system to achieve
better results in the 6 pillars of quality?
To improve a system…
 You need a good understanding of the system
 You need to understand where it is failing Identify what is wrong
 Make sure it is the step that needs fixing
 Then you can implement a change to the
“system”
What is a system?
 System = any assembly of procedures,
resources and routines to carry out a
specific activity
System
 To understand a system and identify what
is wrong with it
Map it out!
How do you map out a system?
 Use a flow chart/diagram
 Use different perspectives (a doctor’s
perspective is different to a nurse’s or a
porter’s to a patient’s perspective)
Quality Improvement Models
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Model for Improvement = Three questions + PDSA cycle
FADE = Focus, Analyze, Develop, Execute and Evaluate
Six Sigma
CQI = Continuous Quality Improvement
TQI = Total Quality Management
7 step method
Model for Improvement
= Three questions + PDSA cycle
The Three Questions
 The Model for Improvement begins with three
fundamental questions
 1. The Aim: What are we trying to accomplish? (How
good do we want to get and by when?)
 2. The Measures: How will we know a change is an
improvement?
 3. The Changes: What change can we make that will
result in improvement?
PDSA Cycle
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Plan a change
Do the change
Study the results
Act on the results
ACT
STUDY
PLAN
DO
PDSA Cycle
 Enables rapid testing and learning
 Allows for incremental testing
 Instead of spending weeks or months
planning out a comprehensive change,
then putting it into practice only to find that
it is fundamentally flawed
PDSA Cycle
 Can aid you in:
 Developing a change
 Testing a change
 Implementing a change
What are we trying to accomplish?
How will we know that a change is
an improvement?
What change can we make that will
result in improvement?
ACT
STUDY
PLAN
DO
MODEL FOR IMPROVEMENT
Executing the Model for
Improvement
Let’s do an example
The Problem
 Patient’s at Black Lion’s Hospital emergency
department are often in pain
 We want to change that
 Ehm…how do we do that?
Executing the Model for
Improvement
 Form a team
 Three Questions: The
Aim, The Measures, The
changes
 Test changes - PDSA
Cycle
 Implement changes that
work
 Spread the changes to
other areas
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
You need a team
 Why?
 Need different
perspectives
 It’s a lot of work
 Increased buy-in by
staff
 Different levels of
support (e.g.
management)
 To come up with the
right team you have
to have an idea of
what your aim is…
The Aim
What are we trying to accomplish?
The Aim
 A strong, measurable
aim with a clear time
frame will help keep
your project on
course
 It has to be important
to those involved
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
The Aim
 A good aim:

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Is Specific
Is Measurable
Determines a time frame
Addresses who the change is for, and what
has to be achieved
 Is Sustainable
The Aim
 I will become a good runner
 I will run 10 kilometers per week by May
31st
 I will run more often
The Aim
 Back to the Problem: Patients at Black Lion’s
Hospital emergency department are often in pain
 We decide to focus on emergency department
patients with fractures
The Aim
 All emergency department patients with
fractures
 We will provide analgesia to 100% of our
pts with a suspected fracture within 15
minutes of arrival to the emergency
department by the end of December 2011.
Choose your team
Choose your team
 Consider the system that relates to the aim
i.e. what processes will be affected by the
improvement efforts
 Involve members familiar with all different
parts of processes
Back to our example
 All emergency department
patients with fractures
 We will provide analgesia
to 100% of our patients
with a suspected fracture
within 15 minutes of
arrival to the emergency
department by the end of
June 2011.
 What processes will
be affected?
Back to our example
 All emergency department
patients with fractures
 What processes will
be affected?
 We will provide analgesia
to 100% of our patients
with a suspected fracture
within 15 minutes of
arrival to the emergency
department by the end of
June 2011.
 Nursing/Triage
 Pharmacy
 Stocking
 Doctors
 Registration
 ED chief/director/
manager
Choose your team
 Effective teams require three kinds of
expertise
 System leadership
 Clinical -Technical expertise
 Day to day leadership - Project leader
Your team
 Team leader: Medical director of the
emergency department
 Technical expert: Hospital Quality
Management member
 Day to day leader (project leader): an
emergency doctor or nurse
 Additional team members: pharmacist,
person responsible for stocking, charge
nurse, registration clerk
Revisit the Aim
 Once you have chosen your team, review
and modify the aim based on their input
Measurement
How will we know that a change is
an improvement?
Measurement
 Measurement is
critical for testing and
implementing
changes
The Aim
The Measure
The Change
 Different from
measurement for
research
ACT
STUDY
PLAN
DO
Measurement
Measurement for
Research
Measurement for
Improvement
Purpose
To discover new knowledge To bring new knowledge into
daily practice
Tests
One large blind test
Many sequential, observable
tests
Biases
Control for as many biases
as possible
Stabilize the biases from test to
test
Data
Gather as much data as
possible, just in case
Gather just enough data to learn
and complete another cycle
Duration
Can take a long time
Short duration
Measurement
 3 types of measures for quality
improvement
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Outcome measures
Process measures
Balancing measures
(+/- Structure Measures)
Outcome Measure
 = Where are we ultimately trying to go
 Are your changes actually leading to
improvement
Process Measures
 = Are we doing the right things to get
there?
 To affect an outcome you have to improve
your processes
 Are the parts/steps in the system
performing as planned
Balancing Measures
 Tells you if changes designed to improve
one part of the system are causing new
problems in other parts of the system
Structure Measures
 “Physical” measures
 Human resources, equipment, facilities
 Often included in Process Measures
Measurement
 For any improvement project you want to
identify a family of measures
Measurement
 Aim = Decrease sepsis mortality by 20% by
January 2011
Outcome Measure
Process Measure
Balancing Measures
Measurement
 Aim = Decrease sepsis mortality by 20% by
January 2011
Outcome
Measure
Process Measure
Balancing Measures
Mortality rates
-Time it takes to register and triage
-% of patients being appropriately
triaged
-Time from triage to initiation of
resuscitation
-% of patients getting properly fluid
resuscitated
-% of patients getting antibiotics
-Availability of medications and
supplies
-Time to antibiotics
-Delay to getting to hospital
Costs
Neglect of other patients
(e.g. increase in mortality for
another patient population)
(e.g. increase in time to be
seen for other patients)
The Change
What change can we make that will
lead to improvement?
Developing Changes
 Depends what you
are trying to
change
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
Basic techniques
 Critical Thinking
 Flow Chart/Diagram
 Benchmarking
 Compare to best practice
 Using Technology
 Barcodes for medications
 Creative Thinking
 Become a patient for a day
 Using Change Concepts
Basic techniques
 Critical Thinking
 Flow Chart/Diagram
 Benchmarking
 Compare to best practice
 Using Technology
 Barcodes for medications
 Creative Thinking
 Become a patient for a day
 Using Change Concepts
Critical Thinking
 Use a Flow Chart/Diagram
 A flow chart allows to “visualize” the system
you are trying to change
 Allows ALL to see the system the same
way
Flow Chart/Diagram
 It helps to clarify complex processes
 It identifies steps that do not add value to the
internal or external customer, including:
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Delays
Needless storage and transportation
Unnecessary work, duplication, and added expense
Breakdowns in communication
Flow Chart/Diagram
 It helps team members gain a shared
understanding of the process and use this
knowledge to collect data, identify problems,
focus discussions, and identify resources.
 It serves as a basis for designing new
processes.
Flow Chart/Diagram
 High-level flowchart, showing six to 12 steps, gives
a panoramic view of a process
 Detailed flowchart is a close-up view of the process,
typically showing dozens of steps. These flowcharts
make it easy to identify rework loops and complexity
in a process.
Example: High Level Flow Chart
From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart
Example: Detailed Flow Chart
From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart
Change Concepts
 Eliminate Waste - an activity or resource
that does not add value
 Improve Work Flow
 Optimize Inventory - is your work being
held up because items are not properly
organized or available
Change Concepts
 Change the Work Environment (does the work
culture enhance or impede change)
 Manage Time
 Focus on Variation - what aspect of the system
vary and make your outcomes unpredictable
 Focus on Error Proofing (checklist)
Testing Changes: PDSA Cycle
All improvement will require change,
but not all change will result in
improvement.
Testing Changes
 Why test changes (even if they are already
proven elsewhere)?
 To learn how to adapt the change to the
particular conditions in your setting
 To evaluate the costs and side effects
 To minimize resistance when implementing the
change in the organization
 Increase your belief that the change will result
in improvement
PDSA Cycle
 Plan
 Objectives
 Questions and
predictions
 Plan to carry out
the cycle (who,
what, where, when)
 Plan for data
collection
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
PDSA Cycle
 Do
 Carry out the plan
 Document
problems and
unexpected results
 Begin Analysis
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
PDSA Cycle
 Study
 Complete analysis of
the data
 Compare data to
prediction
 Summarize what was
learned
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
PDSA Cycle
 Act
 What changes are to be
made
 Next cycle?
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
Testing Changes
 Much can be learnt
from a failed test
ACT
STUDY
ACT
STUDY
ACT
STUDY
PDSA
DO
PDSA
PDSA
PDSA
DO
PLAN
PLAN
DO
PLAN
PDSA
What happens when you identify
what works?
 Are you done?
How easily is change adopted?
 Process of “Normalization”
 People have a tendency to fall into old
habits
 People have a tendency to resist change
 People may feel threatened by a change
Executing the Model for
Improvement
 Form a team
 Three Questions: The
Aim, The Measures, The
changes
 Test changes - PDSA
Cycle
 Implement changes that
work
 Spread the changes
The Aim
The Measure
The Change
ACT
STUDY
PLAN
DO
Implementation
Implementation
 Usually comes after a series of successful tests
 It requires that staff and leaders build the change
into formal plans, job definitions, training, and
explicit reviews
 The change does not depend on the individuals
doing the work, but on the way the work is
organized - as part of the system.
Implementing Change
 “Hard-wire” the change into the system
Hardwire Change
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Market your change
Train everyone involved
Make changes to job descriptions, policies, procedures, forms
Addressing supply and equipment issues
Assigning day-to-day ownership for the maintenance of the
new process
 Have senior leaders remove any barriers
Social System
 Social System - understand the relationship among the
people who will be adopting the new ideas
 Remember there is an emotional component to change
 Stress of learning and executing something new
 Initial disruption to workflow
 Maybe they feel their job/position is threatened
Social System
 Those who are supportive
 Enlist on your side
 Those who are not supportive
 Don’t try to change their attitude
 Listen to what concerns them, identify barriers
 Those who don’t really care, and will follow when others do
Implementation
PDSA in Pilot PDSA in
Phase
Implementation
Phase
Support Requirements
Low
High
Tolerance for failure
High
Low
Number affected by a test
Low
High
Resistance
Low
Potentially high
Time for each cycle
Short
Longer
Summary
 In this modules we have presented an
introduction to:
 Quality Improvement
 The Model of Improvement
 3 questions (What is your aim, measures,
change) and PDSA cycle
 Types of Measures
 Change and Implementation
References:
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Institute of Healthcare Improvement http://www.ihi.org/Pages/default.aspx
Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical
Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers;
1996;60.
Deming WE. The New Economics for Industry, Government, and Education.2nd ed. Cambridge, MA:
MIT Center for Advanced Engineering Study; 1994. Langley GL, Nolan KM, Nolan TW, Norman CL,
Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass Publishers; 1996:6-7.
Using the Model for Improvement. In: Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL,
Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009:89-108.
Accelerating the pace of improvement: interview with Thomas Nolan. Journal of Quality
Improvement. 1997;23(4).
Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619-622.
Lloyd R. Quality Health Care: A Guide to Developing and Using Indicators. Sudbury, MA: Jones and
Bartlett Publishers; 2004.
Moen R, Nolan T, Provost L. Quality Improvement Through Planned Experimentation. 2nd ed. New
York, NY: McGraw-Hill Companies; 1998.
The Improvement Handbook. Austin, TX: Associates in Process Improvement; 2005.