Introduction to methods for quality improvement

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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
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