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QI: “Just Do It!”. Emergency Medicine Residents July 31st, 2003 Jamie Jones, QI Consultant, QIHI Dr. Sarah McPherson, PGY-5. Quality & Change. About process NOT performance New way of practicing care NOT top down change Its about redesigning the system we work in NOT working harder.

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QI: “Just Do It!”

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Qi just do it

QI: “Just Do It!”

Emergency Medicine Residents

July 31st, 2003

Jamie Jones, QI Consultant, QIHI

Dr. Sarah McPherson, PGY-5

Quality change

Quality & Change

  • About process NOT performance

  • New way of practicing care NOT top down change

  • Its about redesigning the system we work in NOT working harder

My qi experience

My QI Experience

  • Is it important to teach residents HQI?

  • What is the best way to teach residents HQI?

  • Does the Emergency Medicine program adequately teach HQI?

  • If not, how could we do a better job at teaching HQI skills?

The answers to my questions

The Answers to My Questions

1. Do Residents need to learn HQI?

Absolutely YES….

  • Knowledge of QI principles and skills is not innate.

  • Residents need to know how to make their workplaces and the care they provide to patients better.

  • Residents are part of the frontline staff and are therefore uniquely able to identify potential areas for improvement in the healthcare system.

Qi just do it

2. What is the best way to teach residents QI?

  • Many different approaches

  • After reviewing the literature and discussing with other residents and medical staff, I think that..

Qi just do it

  • Theory should be taught and then practiced

  • Every resident should be involved in a yearly, small scope project to utilize skills firsthand

  • The format should be encouraged to be group based to minimize excess workloads and to teach teamwork skills

  • Dedicated time should be given to the teaching of QI

  • Regular evaluation of QI education

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3. Do the Emergency residency programs

adequately teach QI?


  • In the last 4 years we have had a 1 day QI workshop and 1 core rounds session (2 hrs) addressing QA/QI theory

  • Few QI projects have involved residents; even fewer have been initiated by residents

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4. How could we do a better job at teaching HQI?

I propose that we should start a structured program for HQI so that all residents get to be involved….

What are the goals of our proposal

What are the Goals of our Proposal?

  • To challenge residents to regularly ask the following questions:

    • Why do we do what we do?

    • How do we know that what we are currently doing works well?

    • How do we identify specific parts of a process that require improvement?

    • How can we change to do our work better?

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  • To develop a system where residents, attending physicians, and other members of the health care team can work together on clinical and educational improvements

  • To continually improve care delivered by residents

  • To teach residents the principles and clinical skills of HQI and the improvement model (PDSA)

Qi in ed residency program

QI in ED Residency Program

  • Schedule and Content:

    3 Scheduled QI Days each year:

    • July 31st - Setting the context for QI in Emergency Residency programs

    • Mid-September ‘03 - Moving forward with measurement

    • Mid-January ‘04 - Successes & Holding the Gains

Qi just do it

  • Schedule and Content:

    • July 31 ‘03

      • Major principles of QI

        • team based philosophy

        • culture of change

        • The Improvement Model

      • Brainstorm ideas and develop resident projects

Qi just do it

  • Schedule and content:

    • Mid-September ‘03

      • PDSA Cycles

        • moving forward with testing

        • measurement & graphing

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  • Schedule and content:

    • Mid-January ‘04

      • Share Successes

      • How will we hold the gains?

      • How will we spread successes?

What the iom said

What the IOM said…..

  • Trying harder will not work anymore

  • Only redesign of our health care systems

    • Crossing the Quality Chasm, May 2001

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What is Best Care?

S - Safe

T - Timely

E - Efficient

E - Effective

E - Equitable

P - Patient Centered

It’s a STEEEP Climb to Quality!

Adopted from D. Ballard, Baylor Healthcare Organization

Qi just do it

Calgary Health Region Goal:

“To become a national leader in the delivery and measurement of quality health care.”

Qi just do it


  • Does not “own” quality

  • A support service to provide consultation & information for decision-making

Individual clinical departments/programs are ultimately responsible and accountable for quality of care.

Integrative process for qi projects

Integrative Process for QI Projects


Quality Council



  • Quality Issues/

  • Problems

  • Front Line Staff

  • Management

  • Executive




Quality Councils




  • Clinical Enhancement Team

  • Clinical Enhancement Physician

  • QI Consultant

  • QI Data Coordinator

  • Health Record Analyst

  • Data/Systems Analyst

QIHI Resources

Qi methodology

QI Methodology

Healthcare Quality Improvement

Practical 11 step problem solving process

The Improvement Model

Plan - Do - Study - Act

Methodologies require

QI teams

Tools & techniques

Qi principles

QI Principles

  • Empower front line employees

  • Focus on process

  • Structured problem solving

  • Patient focused

  • Decisions based on data

More qi principles

More QI Principles

  • Reliance on tools

  • Emphasis on visual presentation

  • Promote innovation, learning and reasonable risk taking

  • Cycle for learning and improvement

Qi just do it





“Trial and Learn”

Plan - Do - Study - Act

measuring results and acting on them

Re-evaluate and Continuous Improvement

“act, capture the gain and start all over”

A few required understandings

A Few Required Understandings...

  • Does baseline data support there is a “problem”?

  • What are we hereafter?

    • Does everyone on team understand the aim?

  • Do we understand our process?

  • Does data support there is a problem

    Does data support there is a “problem”?

    Background data

    Background Data

    • Important to have issue supported with data

      • Greater confidence

      • Understand issue

      • Greater degree of ‘belief’

    Background data1

    Background Data

    • Collect data

      -Many ways to gather

      • surveys

      • new performance data

      • existing data

      • qualitative & quantitative

    Background data2

    Background Data

    • Organize data

    • Display data

      • graphical display of data is key to sharing the message

        • ‘a picture is worth a thousand words’

          • e.g. histograms, run charts, Pareto charts

    Data drives decisions

    Data Drives Decisions

    • Measurement is for learning NOT for judgement

    • Research: Just in case measurement

    • QI: Just enough measurement

    • “Measures tell a story;

    • Goals give a reference point”

    Data cont d

    DATA Cont’d

    • Measurement helps teams:

      • manage, learn & improve work processes

      • communicate & understand the current process & the changes in process

        “But, I’m not a statistician…!”

    That s ok it s easier than it looks

    That’s ok - it’s easier than it looks!

    • Random sampling

    • Pen & paper are fine - don’t wait for information system

    • Use qualitative data, rather than waiting for quantitative

    • Collect useful data, not perfect data

    • Plot your data over time “Run Charts”

    Ekg turnaround time

    EKG Turnaround Time

    West Roxbury Center

    (1/22/89 - 2/3/89)

    32 data points

    916 1 4

    15 813 1

    13 161417

    7 220 2

    2 218 3

    17 21420

    1 1 2 7

    1 215 2

    Dr. Peter Norton

    Average = 8.3 days

    Run chart of ekg turnaround times

    Run chart of EKG Turnaround Times



    Dr. Peter Norton

    Annotated run charts

    Annotated Run Charts

    • Run charts:

      • simplify the data

      • focus attention on trends & ranges

      • are attention getting

      • help us evaluate the effect of change activities

    Annotated run chart

    Change 1


    Change 2





    (e.g., Infection Rate)

    Time Order (e.g., Month)

    Annotated Run Chart

    • Plot small samples frequently over time

    What are we hereafter

    What are we hereafter?

    Does everyone on the team understand the aim?

    Issue statement

    Issue Statement

    • Why is an Issue Statement important?

      • To focus the project on the biggest issues

      • To ensure all team members are “on the same page”

      • To avoid “ Scope Creep”

      • To begin thinking about measurement

    Issue statement1

    Issue Statement

    • Three components of an Issue Statement

      • Direction

        • Increase, improve, decrease, remove

      • Measure

        • # of days, weeks, hours

        • Cost, wait times, errors, availability

      • Process

        • admission process

        • patient teaching

    Issue statement2

    Issue Statement

    Reasons for Measurement

    • Before/after measures are important to quantify improvement

    • What gets measured tends to get results

    Issue statement3

    Issue Statement

    • Examples

      • Decrease the number of patient complaints about length of stay in ED waiting rooms.

      • Increase, by 25%, the number of patients expressing satisfaction with care experience.

      • Reduce lab turn around times by 50%.

    Paramedic downtime estimated at 500 000 source calgary herald 01 24 03

    Paramedic downtime estimated at $500,000Source: Calgary Herald 01/24/03

    • Calgary taxpayers spent at least $500,000 paying paramedics to wait in line to drop patients off at Calgary hospitals

    • “we are very concerned about the number of hours ambulances are tied up in emergency rooms”

    Ems official demands province provide cure courtesy calgary sun 01 04 03

    EMS Official Demands Province Provide CureCourtesy: Calgary Sun 01/04/03

    • “it’s just that the health region needs capacity and EMS needs funding”

    • “I think the province is dragging their feet and there’s a need to address this politically”

    • “we need to look at more efficient ways of using existing resources

    Ambulance delay lingers courtesy calgary sun 02 21 03

    Ambulance Delay LingersCourtesy: Calgary Sun 02/21/03

    • Ambulances are waiting more than one-third longer at hospital emergency wards

    • “the concern we have is we have fewer ambulances available and spread across a larger area --- it will take us longer to reach people and we don’t want it to happen”

    Frustration shared by patients and staff courtesy calgary herald 02 08 03

    Frustration Shared byPatients and StaffCourtesy: Calgary Herald 02/08/03

    • “I’m not sure there’s always evidence the patient is compromised (by a long wait), but it certainly is extremely uncomfortable to be in pain for too long or to be worried and anxious for too long”

    Issue statement4

    Issue Statement

    • Exercise:

      • At each table, work as a group to develop an issue statement for the following ‘problem’:

        EMS has long wait-times in ED hallways

    Issue statement5

    Issue Statement

    • Goals:

      • Reduce turnaround time for paramedic units from ‘arrival at ED triage to being available for next call’; without negatively impacting ED waiting room patients while maintaining safe, effective & high quality patient care.

    Understanding work as a process

    Understanding Work as a Process

    Hqi focus on process

    HQI - Focus on Process

    • Consider Juran and Demings 85/15 rule:

      • At least 85% of problems can be dealt with by improving systems; only 15% are the direct result of people.

    Diagram the process

    Allows you to analyze how a process functions (or doesn’t!)

    Most processes were never designed – they just developed

    40 – 60% of everything that is done in a large complex process is non-value adding

    How can you possibly improve something unless you know how it works?

    Diagram the Process

    Diagram the process1


    tool used to diagram the process

    macro or micro


    Micro Flowchart

    PROF Bed Flow (ED - Unit 72 - OR)

    Macro Flowchart

    ED Consultant Process

    Diagram the Process

    Qi just do it



    Find a bed

    Arrange transfer


    1. FMC ED doc: decision to admit

    2. FMC ED doc: checks PLC census

    3. FMC ED doc: pages PLC Hospitalist

    4. PLC Hospitalist: calls FMC ED doc

    5. PLC Hospitalist: calls PLC Admitting

    (bed assigned immediately1)

    6. PLC Hospitalist: calls FMC ED doc to

    accept transfer

    7. PLC Admitting: calls & faxes FMC ED

    UC to advise bed information

    8. FMC ED doc informs FMC ED UC

    1. PLC Hospitalist: calls ‘report’ to

    inpatient unit 2

    2. PLC Hospitalist: books Patient


    3. FMC ED UC: puts PLC fax on pt chart

    4. FMC ED doc: writes order

    5. FMC ED RN/UC: completes transfer


    6. ED RN: completes Admission Sheet

    7. ED RN: gives Admission Sheet to ED UC

    8. ED UC: enters into Log Book

    9. Admission Sheet to FMC Admitting

    10. FMC Admitting: calls PLC Admitting

    11. PLC Hospitalist: informs PLC Admitting

    12. PLC Admitting: assigns bed

    13. PLC Admitting: calls FMC Admitting

    14. FMC Admitting: advises ED UC

    15. ED UC: advises RN

    16. ED RN: phones report to PLC unit

    1. Pt. Transport: dispatches vehicle

    2. Pt. Transport: arrives FMC

    3. Pt. Transport: collects chart/patient

    4. Pt. Transport: receives report

    5. Pt. Transport: transports patient

    6. Pt Transport: arrives PLC Admt’g

    7. PLC Admitting: registers patient

    8. Pt. Transport: transport to unit

    9. Pt. Transport: check-in with UC

    10. Pt. Transport: report to RN

    11. PLC UC: pages Hospitalist


    red indicates new steps

    indicates eliminated steps

    Qi just do it

    Family Medicine - Results

    Qi just do it

    Macro Flowchart – ED Consult Process

    Triage Delays

    • Order of diagnostics

    • waiting diagnostic results

    • RN busy (can’t get tests done)

    • UC busy/UC forgets to page

    • Waits to page consultant (nights)

    • MD delay in re-assessing patient after diagnostic results are back


    • More diagnostics ordered

    • level of experience of responding consultant

    • Is it appropriate service?

    • ordering of further tests prior to admit so don’t have to wait for tests on ward

    • transfers care to another service

    • many ED patients to assess

    • returns to OR/Clinic/Unit to d/c patients

    Diagram the process2

    Diagram the Process

    • Reasons to flowchart

      • Develop common understanding of process

      • Get a complete picture

    • Easily identify issues in the process

      • duplication of effort

      • sources of delays

      • non value adding activities

    • Redesign the process

    • Communicate changes to the process

    Diagram the process3

    Diagram the Process

    • Analysis of Flowchart / Process Redesign

      • Can it be standardized?

      • Does every step or activity add value?

      • Is there duplication of work?

      • Is it possible to simplify?

    Exercise diagram the process

    Exercise - Diagram the Process

    • In your group, create a flowchart of:

      EMS arriving at triage through to treatment space & transfer of care to RN

    • Suggestions:

      • use a post-it note for each step

      • find a large space on which to work

    The improvement model pdsa

    The Improvement Model“PDSA”

    Qi just do it





    “Trial and Learn”

    Plan - Do - Study - Act

    measuring results and acting on them

    Re-evaluate and Continuous Improvement

    “act, capture the gain and start all over”

    Qi just do it

    What are we trying to accomplish?

    How will we know that a change is an improvement?

    What changes can we make that will result in improvement?

    Act Plan

    Study Do

    Improvement Model


    Framework for

    “Trial & Learning”

    Qi just do it





    The model consists of two parts:

    3 questions & a cycle for learning and improvement

    • What are we trying to accomplish?

    • How will we know that a change is an improvement?

    • What changes can we make that will result in I improvement?

    Improvement cycle pdsa

    • Plan:

    • State objectives

    • Make predictions

    • Make conditions explicit

    • Develop plan

    • Act:

    • Adopt, adapt or abandon?

    • Build knowledge sequentially

    • Study:

    • Complete analysis

    • Compare data to prediction

    • What did you learn?

    • Do:

    • Carry out the test

    • Document problems, observations.

    • Begin analysis

    Improvement Cycle“PDSA”

    Qi just do it

    Improvement Model


    • Facilitates the use of teams to make improvements

    • Provides a framework for the use of effective measurement and use of improvement tools

    • Encourages planning to be based on evidence-based theory

    • Emphasizes and encourages learning (trial and learn)

    • Empowers people to take action

    • Creates the will for improvement

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    Rapid and repeated use of the cycle helps

    teams build knowledge sequentially

    • Breakthrough

    • P

    • P

    • D

    • D


    • A

    • A

    • S

    • S

    • P

    • P

    • D

    • D

    • A

    • A

    • S

    • S

    • P

    • P

    • D

    • D

    • A

    • A

    • S

    • S

    • P

    • P

    • D

    • D

    • Learning and improvement

    • Learning and improvement

    • Theories,

    • Theories,

    • A

    • A

    • S

    • S

    • hunches,

    • hunches,

    • & best practices

    • & best practices

    Use the pdsa cycle for





    Use the PDSA Cycle for

    • Testing or adapting a change idea

    • Implementing a change

    • Spreading the changes to the rest of your system

    Qi just do it

    Hip Fracture ProjectOrthopedics and ED

    • Purpose of Project:

    • Reduce (ALOS) in ED for all hip fracture patients by 50%

    • Fracture hip patients receive surgery within 24 - 48 hours

    • Scope & Boundaries:

    • All hip fracture patients at FMC site.

    • Improvement Objectives:

    • Optimize time to surgery to ensure patients receive high quality care with positive outcomes

    • Address co-morbidity factors prior to discharge.

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    PDSA Cycle 1

    Act:: Implement checklist to ensure streamline care of hip # pts.

    Study: Chart review of all # hip patients in ED. Does checklist decrease LOS in ED?

    Do: - Use Guidelines to develop a checklist for hip # pts in ED

    Plan: Test feasibility of utilizing guidelines in ED

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    PDSA 1 Learning's:

    • Hip fracture checklist streamlines care =

       LOS in ED.

    • Improved communication between ED and Orthopedics

    • awareness of flow (ED to OR)

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    PDSA Cycle 2

    Act: Continue with PROF (Pre-Operative Fracture) bed until November 30, 2002

    Study: Findings -  ALOS in ED & time to OR

    Do: - Create a designated bed for hip fractures on unit 72

    - Work with anesthesiology to assist with surgical clearance

    Plan: Test feasibility of having a designated PROF bed.

    Can anesthesiology assist with surgical clearance in timely manner?

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    PDSA 2 Learning’s:

    • A designated bed (PROF) for hip #’s enhances flow of patients from ED to OR

    • Right staff is caring for the right patient in the right bed

    • Pre-op delays are reduced

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    PDSA Cycle 3

    Act: Refine the flowchart =  communication amongst care providers

    Study: Chart & bed utilization review (ALOS in ED; Time to O.R.; ALOS as inpatient; patient outcomes)

    Do: Follow all hip fracture patients admitted to the FMC

    Plan: Work on effectiveness & efficiency of flow for hip # across continuum of care

    Qi just do it

    Hip Fracture ProjectOrthopedics and ED

    • Progress to date:

    • ALOS in ED:

    • ALOS in ED:

      • 13 hours  < 5 hours

    • Time from admit to O.R:

    • 5-7 days  17 - 24 hours

    • Inpatient ALOS:

    • 21 days  12 days

    • Direct admits bypassing ED

    Success obtained through re-allocation of current resources

    Emergency triage project





    Emergency Triage Project

    • Challenge:“at-risk” patient population in triage line-ups and waiting rooms  triage practices targeted for QI

    • 11 step HQI methodology  PDSA

    • “Trial and Learn” for change ideas:

    • sequential building of knowledge

       breakthrough results

    Redis snapshot over capacity

    REDIS Snapshot “Over Capacity”

    Site core teams fmc rgh plc

    Site Core Teams(FMC, RGH, PLC)

    Ideas to Test:

    • Rapid assessment of line-up by RN

    • Promote information/security in waiting room

    • Consistent communication

    • Re-allocate resources

    •  D.I. patients at triage desk

    •  ED patients presenting x 2 at triage

    Criteria for a good action plan

    Criteria for a Good Action Plan

    • SMART Plan

      • specific

      • measurable

      • action oriented

      • responsibilities defined

      • time lined

    Rapid triage assessment

    Rapid Triage Assessment

    • Test cycles:

      • nurse educator to assist assessing line-up

      • “post-it” notes

      • > 5 patients in line-up or PRN

      • one day/one nurse  spread

      • dedicated chair for “sicker” patients

      • re-allocate staff

    Re evaluate and continuous improvement

    Re-evaluate and Continuous Improvement




    “act, capture the gain

    and start all over”



    Exercise create a plan for a pdsa cycle

    Exercise : Create a “Plan” for a PDSA Cycle

    • What is the objective of this cycle?

    • What change are you testing?

    • What is your prediction?

    • Details of the plan

      • Who ?

      • What ?

      • Where ?

      • When?

      • How?

    Anyone who has never made a mistake has never tried anything new

    “Anyone who has never made a mistake has never tried anything new”

    Albert Einstein

    Create a pdsa cycle for ems delays

    Create a PDSA Cycle for EMS Delays

    Go forth and work

    Go forth and work…….

    Qi just do it


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