Topic 7 Introduction to methods for quality improvement LEARNING OBJECTIVE • the objectives of this topic are to: – describe the basic principles of quality improvement – introduce students to the methods and tools for improving the quality of health care PERFORMANCE REQUIREMENT • know how to use a range of improvement activities and tools KNOWLEDGE REQUIREMENTS • the science of improvement • the quality improvement model • change concepts • two examples of continuous improvement methods • methods for providing information on clinical care THE SCIENCE OF IMPROVEMENT • appreciation of a system • understanding of variation • theory of knowledge • psychology W Edwards Deming THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI): DIFFERENT MEASURES Measurement for research Measurement for learning and process 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 long periods of time to obtain results "Small tests of significant changes" accelerate the rate of improvement THREE TYPES OF MEASURES • outcome measures • process measures • balancing measures THE MODEL FOR IMPROVEMENT What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement? ACT PLAN STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999 THE PDSA CYCLE Determines what changes are to be made ACT STUDY Summarizes what was learned Langley, Nolan, Nolan, Norman & Provost 1999 Change or test PLAN DO Carry out the plan CHANGE CONCEPTS … … are general ideas, with proven merit and sound scientific or logical foundation that can stimulate specific ideas for changes that lead to improvement. Nolan & Schall, 1996 9 CATEGORIES OF CHANGE • eliminate waste • improve work flow • optimize inventory • change the work environment • enhance the producer/customer relationship • manage time • manage variation • design systems to avoid mistakes • focus on the product or service Langley, Nolan, Nolan, Norman & Provost 1999 TWO CONTINUOUS IMPROVEMENT METHODS • clinical practice improvement methodology (CPI) • root cause analysis THE IMPROVEMENT PROCESS Project mission Project team Ongoing monitoring Outcome Future plans Project phase 1 month Annotated run chart SPC charts 2 months Sustaining improvement phase 1 5 Impact phase 2 Diagnosti c phase 4 Conceptual flow of process Customer grid Data -fishbone -Pareto chart -run charts -SPC charts 3 A S P D Intervention phase S A D P 2 months D S P A A A S P D S P D Plan a change Do it in a small test Study its effects Act on the result Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) SPC – statistical process control INTERVENTIONS PHASE Identify appropriate interventions Implement changes identified in the diagnostic phase Undertake one or more PDSA cycles Interventions phase Decide on interventions Undertake one or more PDSA cycles Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) HOW TO USE THE PDSA CYCLE • use plan-do-study-act cycles to conduct small-scale tests of change in real settings – – – – • plan a change do it in a small test study its effects act on what learned team uses and links small PDSA cycles until ready for broad implementation ACT • What changes can be made for the next cycle (adapt change, another test, implementation cycle?) STUDY • Complete analysis of data • Compare results to predictions PLAN • Objective • Prediction • Plan for change (who, what, when, where) • Plan for data collection (who, what, when, where) DO • Carry out the change • Document observations • Record data • Summarize knowledge gained Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) PDSA CYCLE - SINGLE TEST PDSA Cycles – single test S D A A P S P A D S P A Changes that result in improvement P D S D Hunches, theories and ideas Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) PDSA CYCLE – MULTIPLE TESTS D S D S D S P A P A P A S D S A D P A P S D S A D P A P A P A P S D S D Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) IMPACT AND IMPLEMENTATION PHASE 1. Measure impact of changes/interventions 2. Record the results 3. Revise the interventions Impact and implementation phase Measure impact • Annotated run chart • SPC charts • Other graphs Implement the changes ROOT CAUSE ANALYSIS • a multidisciplinary team • the root cause analysis effort is directed towards finding out what happened • establishing the contributing factors of root causes PERFORMANCE REQUIREMENTS Know how to use a range of improvement activities and tools • flowcharts • cause and effect diagrams (Ishikawa/fishbone) • Pareto charts • run charts EVIDENCE FOR THERE BEING A PROBLEM WORTH SOLVING At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales. FLOW CHART OF PROCESS Something amiss Visit to general practitioner Post anaesthetic care Investigations Operating theatre Referral to surgeon Pre-op ward Surgical ward Allied health Surgical ward Pain team Surgical ward Referral to Hospital Admitted to hospital Hospital admission Preoperative clinic Community health/ Peripheral hospital Return to life Admissions office Home Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince , Area CNC Pain Management, North Coast Area Health Service, NCHI Sydney Australia CUSTOMER AND EXPECTATIONS LIST • surgical ward staff Multidisciplinary meeting to: • post-op anaesthetic care staff - ask opinion • physiotherapy dept - brainstorm process of care • dietitian - how to improve the process • peri-operative unit staff - • private hospital staff who to include in the process of change • pain team - how to communicate progress • anaesthetists • surgeons Evidence-based practice • intensivist team approach Standardization CAUSE AND EFFECT DIAGRAM Social issues Staff attitudes poor pain control LOS home support mobilization often weak family support Complications pain control nutrition nutrition wound complications weak/malnourished infection Prolonged LOS expect long LOS general practitioner poor understanding mobilization community health of procedure nil by mouth little knowledge of family surgery support services colon care nurse pain control locus of control Procedure Patient perception Post discharge support Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince , Area CNC Pain Management, North Coast Area Health Service, NCHI Sydney Australia PARETO CHART PDSA CYCLES - IMPLEMENTATION • surgical incision trial of transverse incision 1 surgeon • pain control wound infusion for transverse incisions 10 patients - patient information booklet – surgeon pathway – anaesthetic pathway – ARCS clinical pathway – – – – – surgical technique pain control bowel prep/care Nutrition mobilizatioN 1 surgeon 1-6 patients RUN CHART STRATEGIES FOR SUSTAINING IMPROVEMENT • document and report each patient LOS • measure and calculate monthly average LOS • place run chart in operating theatre, update run chart monthly • bimonthly team meetings to report positives and negatives • continuously refine the clinical pathways • report outcomes to clinical governance unit • Spread – all surgeons – left hemicolectomy – all colectomy surgery – throughout North Coast Area Health Service