Performance Improvement:
Making It Simple for the Creative
(Busy) Minds
Norma A. Atienza, BSN, MPA, RN, CIC, CPHQ
October 26, 2011
Quality / Performance Improvement
Definitions:
A planned, systematic, approach to monitor,
analyze and improve performance, thereby
continually improving the quality of patient
care and services provided and the
likelihood of desired patient outcomes.
The continuous study and adaptation of a
healthcare organization’s functions and
processes to increase the probability to
better meet the needs of individuals and
other users of services.
Quality / Performance Improvement
Process
• PI Projects are identified / approved by the governing
body as initiatives that are important to support the
mission and the strategic goals of the organization
• Projects are also identified based on high volume, high
risk and those that affect patient care that potentially
will have negative outcomes.
• Infection Control – looking at processes and outcomes
that supports the goals of the practice aligning to the
strategic goals of the institution.
Why Performance Improvement?
The quest for Quality has become
relentless especially with the advent of
health care reform
Quality initiatives have become more
prominent not only with government
initiatives that set specific benchmarks
to improve patient care but also
among other health care insurers.
Common PI Methodologies or Approaches:
Shewart Cycle / PDCA or PDSA Cycle
PDCA was developed by Walter Shewhart in the 1920s and Edwards
Deming adapted the process and called it PDSA Cycle
– Plan
• Plan change
• Study a process by collecting necessary data
• Evaluate the results
• Formulate a plan for improvement
• Set goals and target
• Determine methods for reaching goals
– Do
• Implement the plan (trial, house-wide)
• Educate / train
– Check or Study
• Gather data and evaluates results of the change
• Determine success of action taken
• Modifications needed
– Act
• Implement the plan changes
• Not successful, abandon the plan and rework the cycle
FOCUS - PDCA Model
Originated with the Hospital Corporation of America now HCA
Healthcare. It assumes that a PI or a QI process is already in place
to improve.
• F = Find a process to improve
– define the process, identify the process
– who will benefit from the improvement
– how the process fits w/in the org priorities
• O = Organize a team that knows the process
– people knowledgeable about and involved in the process
– manageable team size, appropriate members
– method to document team progress (WWW)
• C = Clarify current knowledge of the process
– gather and review current knowledge
– analyze to distinguish between expected and actual performance
• U = Understand variable and causes of variation
– Plan and implement data collection
– Measure using appropriate indicators
• Select = the process improvement
– Identify action to improve
Other Approaches to Performance
Improvement
• Change Acceleration Process (CAP)
– A process that proactively plans for change
acceptance for successful implementation
– Streamlines “traditional QI approaches
– Requires top leadership support to succeed
• Work-Out
– Promotes rapid problem solving via involvement and
accountability
– Flowchart, cost/benefit of solutions
– Test period or pilot
• Lean
– Focused on eliminating waste through detailed
analysis of workflow
Six Sigma Strategy
• Was a strategy developed by Motorola in the mid1980s and implemented successfully in GE and Allied
Signal (manufacturing) as a way to reduce common
cause variation and error rates.
• Driven by statistical analysis of data to identify causes
of unwanted variation and defects
DPMO
Quality Yield
COQ/COPQ
(% quality standards
achieved)
Poor
Cost as % of total
1δ & 2δ
Defects / million
opportunities
700,000/308,537
3δ
(non-competitive)
66,807
93.3%
25-40%
4δ
6210
99.4%
15-25%
5δ
233
99.98%
5-15%
6δ
3.4
99.999%
<1%
Sigma Value
(world Class
Adapted from: Caldwell, Brexler, Gillem. Lean-Six Sigma for Healthcare
High
The DMAIC Approach
D: Define
•
•
•
•
Define the problem
Set the goals
Identify the customers
Who are your team members
M: Measure
• How is the process performed
• Identify the metrics
• What data will be collected
• Methodology in collecting the data
The DMAIC Approach
A: Analyze
• Review data, what have the PI tools revealed
(fishbone, flowchart, etc.)
• Identify or diagnose root cause
• What is the data telling us
I: Improve
• Improve the process
• Identify actions needed to achieve the
performance goal
• Apply WWW process as needed
• Implement actions for improvement
• Review and compare old and new process, what
was changed
The DMAIC Approach
C: Control
• In control only when goal is reached – then
maintain and monitor the improvements Review
data, what have the PI tools revealed (fishbone)
• If not, go back to data analysis. Review
improvement processes in-placed, are they
effective?
• Make changes as needed.
Metrics
• Outcome
• Process
• Person Centered
• Structure
Developing Goals
S – specific
M – measurable
A – attainable
R – relevant
T – time based
C – clearly understood
A – agreed upon
R – re-negotiated
Judy L’s
Examples:
1. To decrease HA CAUTI by 10% by the end of FY2012
from that of 2011.
2. By June 30, 2012, improve Core Measure aggregate
perfect care score to 95%.
3. Reduce department expenses by maintaining no more
than 1.8% (of total Salaries) in overtime expenses each
month as reported in Visionware.
Review of Common
Graphs
and
Charts
Line Graph or Run Chart: provides a
running record of a process overtime
Saint Clare's Hospitals
Falls Data - July 2010 to April 2011
per 1000 Patient Days
4.50
4.02
4.00
3.76
3.50
3.10
2.95
Goal
Ave = 2.70
2.71
2.49
2.50
2.29
2.00
1.48
1.50
1.45
1.00
0.50
Month
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
0.00
Jul
Fall Rate
3.00
2.66
Line Graph
Saint Clare's Hospital
Mortality '10
4.50
RRT '10
4.22
4.00
3.50
3.30
3.00
2.50
2.00
1.85
1.65
1.50
2.27
2.09
1.10
1.00
2.03
1.80
1.44
1.17
0.98
1.11
1.43
1.25
0.50
0.00
Mortality rate continues to decrease in 2010 except for the couple of months. Again if RRT is decreased, mortality rate
increased
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Pie Chart or Circle Graph: used to display
parts of a whole (proportional relationships)
Saint Clare's Hospital
Site of CVAD Insertions
January to Decem ber 2010
26%
31%
Subclavian
Femoral
5%
IJ
Upper arm (PICCs)
38%
Control Chart: a display of normal variations
and “out of control” variations over time
Denville TAT
80
1
70
Individual Value
60
UCL=53.46
50
40
_
X=30.34
30
20
10
LCL=7.23
0
3 5 7 1 3 7 9 1 5 8 1 3 7 9 1 5 7 1 3 5 1 3 7 9 1
1/ 1/ 1 / 1/1 1/1 1 /1 1/1 1/2 1/2 1 /2 2 / 2/ 2/ 2/ 2/1 2/1 2 /1 2/2 2/2 2/2 3/ 3 / 3/ 3/ 3 /1
date1
Bar Chart: comparisons between different
groups
Saint Clare's Hospital
Handwashing Compliance
Hospital-Wide Discipline Specific
100
80
60
40
20
0
Phys
Nsg
NAs
APN
CM/S Anc.
PT/OT
Trans Rad
Resp
Env.
Phleb Other
W
Tech
/ST
port Techs
2009
73.5
96
91
78.6
69.6
88
77.8
80.4
67.7
31.9
66
42.1
83.9
2010
98.4
95
92.9
75
78.9
100
92.5
96.3
73.1
60
92.2
56.1
94
2009
2010
Pareto: offers a comparison of causes of problems
in a process and rank-order (prioritizes).
Determine where to focus improvement
efforts.
250
100
200
80
150
60
100
40
50
20
0
Comments
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Percent
Count
Pareto Chart of Critical Values PowerForm Audit
Realize that change is not always
a process improvement.
Sometimes it’s a process of
invention!
Wendy Kopp Founder of Teach for America
?
Questions