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QI Theory: Quality Improvement in the Hospital Goals for this Primer. Understand fundamental concepts in quality improvement Identify the environment and key steps for a successful quality improvement project Become familiar with several quality improvement tools and their use . Progress.

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qi theory quality improvement in the hospital goals for this primer
QI Theory:Quality Improvement in the HospitalGoals for this Primer
  • Understand fundamental concepts in quality improvement
  • Identify the environment and key steps for a successful quality improvement project
  • Become familiar with several quality improvement tools and their use
slide2

Progress

Patient care

Time

Quality Improvement: Bridging the Implementation Gap

How good is American healthcare?

slide3

Progress

Patient care

Time

Quality Improvement: Bridging the Implementation Gap

We get it right 54% of the time.

-Brent James, MD, MStat

Executive Director, Intermountain Health Care

slide4

Scientific understanding

Implementation Gap

Progress

Patient care

Time

Quality Improvement: Bridging the Implementation Gap

hospitalists and quality improvement
Hospitalists and Quality Improvement
  • Complex process problems need multidisciplinary solutions
  • We are at the frontlines seeing system failures, process errors, and performance gaps with our own eyes -- which is our competitive advantage
  • Improved quality delivers:
    • better patient care…
    • at lower costs…
    • with potentially higher reimbursements (pay-for-performance)…

And it can make our jobs more interesting, fun, and rewarding.

section i

Section I:

Quality Improvement and Change

in the Hospital Atmosphere

definition of quality
Definition of Quality
  • Meeting the needs and exceeding the expectations of those we serve
  • Delivering all and only the care that the patient and family needs
definition of improvement
“Definition” of Improvement

It is NOT…

  • yelling at people to work harder, faster, or safer
  • creating order sets or protocols and then failing to monitor their use or effect
  • traditional Quality Assurance
  • research (but they can co-exist nicely)
principle 1 improvement requires change
Principle #1:Improvement Requires Change

Every system is perfectly designed to achieve exactly the results it gets

To improve the system, change the system…

principle 2 less is more
Principle #2:Less is More

You cannot destroy productivity

When changing the system, keep it simple

understanding change in the hospital atmosphere
Understanding Change in the Hospital Atmosphere
  • Change = not just doing something different, but engineering something different
      • at least one step in at least one process
  • Hospital Atmosphere = hospitals tend to be viscous, complex systems with default levels of performance
      • change engineered to improve performance can be a foreign concept - or even overtly resisted
understanding change in the hospital atmosphere13
Understanding Change in the Hospital Atmosphere

A Common Strategy Which Commonly Fails:

  • Experts design a comprehensive protocol using EBM over several months
  • Protocol is presented as a finished, stand alone product
  • Customization of protocol is discouraged
  • Compliance depends on vigilance and hard work
  • Monitoring for success or failure is the exception to the rule (with failures coming to light after patients are harmed)
  • Flawed implementation leads to repetitive efforts down the road
understanding change in the hospital atmosphere14
Understanding Change in the Hospital Atmosphere

High-Reliability Strategies Commonly Succeed:

  • Build a “decision aide” or reminder into the system
  • Make the desired action the default action (not doing the desired action requires opting out)
  • Build redundancy into responsibilities (e.g. if one person in the chain overlooks it, someone else will catch it)
  • Schedule steps to occur at known intervals or events
  • Standardize a process so that deviation feels weird
  • Take advantage of work habits or reliable patterns of behavior

Build at least one - if not more - of these high-reliability strategies into any changed process.

understanding change in the hospital atmosphere15
Understanding Change in the Hospital Atmosphere

Change engineered to drive improvement depends on…

  • Workplace Culture: personnel must be receptive to change
  • Awareness: administrative and medical staffs must care about performance and support its improvement through change
  • Evidence: local experts must identify which research to translate into practice
  • Experience: a skilled team must choose, implement, and follow up changes to ensure:

1) improvement efforts are ongoing and yielding better performance

2) productivity is preserved

an atmosphere for change17
An Atmosphere for Change

AWARENESS

OFTHE LOCAL PERFORMANCE GAP

Patient

Medical Staff

Hospital Administration

 Patient

At mercy and increasingly aware of underperforming status quo

Now can access a new resource promoting transparency in hospital performance: www.hospitalcompare.hhs.gov

 Hospital Administration

Understands status quo is unacceptable (IOM, Leapfrog, NQF, JCAHO)

Sees fiscal health tied to performance against national benchmarks, ability to reduce costs & LOS, improve margins, and competitive reputation in the community

 Medical Staff

Has professional responsibility to improve

Knows all too well where system fails

Recognizes that professional livelihood will depend on paying attention to outcomes:

Pay-for-Performance

an atmosphere for change18
An Atmosphere for Change

EXPERIENCE

WITHSIMILAR IMPROVEMENTEFFORTS

Hospitalist Team Facilitator

Multidisciplinary Team Members

Successful Strategies Used By Others

Hospitalist Team Facilitator

Technical expert on Quality Improvement theory and tools

Owns the team process, enforces ground rules, helps judge feasibility

Teaches the team while doing

Multidisciplinary Team Members

Chosen for hands-on, fundamental knowledge of key processes

Inclusive, open, & consensus seeking

Impact not only the change(s) but the implementation

Successful Strategies Used By Others

Learn from mistakes of others

Adapt successes of others (tools and methods): steal shamelessly

Get specific advice in ’Ask the Expert’ forums or other consortiums that collect and share experience

an atmosphere for change19
An Atmosphere for Change

EVIDENCE

TO TRANSLATE INTO PRACTICE

“Bedside” Teaching

Didactic Teaching Sessions

Local Expertise in Disease Literature

“Bedside” Teaching

To an audience of residents or students

To build cadre of “experts” (and to help meet ACGME requirements)

Download teaching pearls from SHM resource rooms

Local Expertise in Disease Literature

Decide what changes to make based on the level of evidence

Establishes team’s credibility

Extends team’s authority when local sub-specialists or experts participate in selecting and implementing change

Didactic Teaching Sessions

To an audience of peers, administrators, nurses, or support staff

To boost awareness, knowledge, enthusiasm, and support

Download slide sets from SHM resource rooms

an atmosphere for change20
An Atmosphere for Change

WORKPLACE CULTURE

READY TO ACCEPT CHANGE

Task Load

Culture of Improvement vs.

Culture of Negative Expectations

Task Load

Be sensitive about piling new tasks onto over-tasked personnel

Use the input of personnel who will be responsibile for implementing

Make it easy and desirable to do the right thing 

Culture of Negative Expectations

Overcome it, one person and one project at a time

Attach pride to balance between performance successes and failures

Consider using a ‘cultural survey’ to identify problems and address them through proper channels 

Culture of Improvement

Extend it, one person and one project at a time

Advertise successes

Use or adapt this online ‘cultural survey:’ http://www.patientsafetygroup.org/program/step1c.cfm

section ii

Section II:

The Multidisciplinary Team

the driving force for change
The Driving Force for Change

THEMULTIDISCIPLINARYTEAM

Leverages frontline expertise and experience.

Impacts not only the change/interventions,

but also the implementation

the driving force for change the multidisciplinary team
The Driving Force for Change: The Multidisciplinary Team

A team is not the same as a committee…

Committee

  • individuals bring representation
  • productive capacity = single most able member

Team

  • individuals bring fundamental knowledge
  • productive capacity = synergistic (more than the sum of all individual team members together)
the driving force for change the multidisciplinary team24
The Driving Force for Change: The Multidisciplinary Team

Features of a good team…

  • Safe (no ad hominem attacks)
  • Inclusive (values all potential contributors including diverse views; not a clique)
  • Open (considers all ideas fairly)
  • Consensus seeking
the driving force for change the multidisciplinary team25
The Driving Force for Change: The Multidisciplinary Team

Consensus…

  • definition: finding a solution acceptable enough that all members can support it; no member opposes it
  • It is not:
    • A unanimous vote (consensus may not represent everyone’s first priorities)
    • A majority vote (in a majority vote, only the majority gets something they are happy with; people in the minority may get something they don’t want at all, which is not what consensus is all about)
    • Everyone totally satisfied
the driving force for change the multidisciplinary team26
The Driving Force for Change: The Multidisciplinary Team

Three types of team members…

1) Team Leader

2) Team Facilitator

3) Process Owners (members with operational, hands-on fundamental knowledge of the process)

the driving force for change the multidisciplinary team27
The Driving Force for Change: The Multidisciplinary Team

Team Leader…

  • schedules and chairs team meetings
  • sets the agenda (printed at each meeting)
  • records team activities (working documents in binder)
  • reports to management (Steering Team)
  • often a member of Steering Team
the driving force for change the multidisciplinary team28
The Driving Force for Change: The Multidisciplinary Team

Team Facilitator…

  • owns the team process (enforces ground rules)
  • technical expert on QI theory and tools
  • assists Team Leader
  • teaches while doing, within team
the driving force for change the multidisciplinary team29
The Driving Force for Change: The Multidisciplinary Team

Process Owners…

  • chosen for fundamental knowledge
  • will help implement
  • should become leaders (so choose wisely)
the driving force for change the multidisciplinary team30
The Driving Force for Change: The Multidisciplinary Team

Team Ground Rules…

  • All team members and opinions are equal
  • Team members will speak freely and in turn
    • We will listen attentively to others
    • Each must be heard
    • No one may dominate
  • Problems will be discussed, analyzed, or attacked (not people)
  • All agreements are kept unless renegotiated
  • Once we agree, we will speak with "One Voice" (especially after leaving the meeting)
  • Honesty before cohesiveness
  • Consensus vs. democracy: each gets his say, not his way
  • Silence equals agreement
  • Members will attend regularly
  • Meetings will start and end on time
slide32

Will the team target ‘all’ patients in the inpatient bell curve, or just a sub-group considered ‘at-risk’ (depicted in the outlying tail)? Is the quality of inpatient care which is not in the tail somehow ‘acceptable?’

After

Defining an Approach to Change

Before

Quality Assurance

Bell Curve:

Inpatient Population

Tail

worse

better

Quality

slide33

If the team can identify and define an inpatient sub-group ‘at-risk,’ then improvement efforts could conceivably focus just on these ‘at-risk’ patients - this is similar to traditional Quality Assurance. Note that even if tail events are eliminated, the quality of care for the rest of the inpatient population (depicted by the unchanged position and shape of the bell curve) does not improve at all. While the mean does move toward better care, this is due only to eliminating statistical outliers.

After

After

Defining an Approach to Change

Before

Quality Assurance

Quality

Bell Curve:

Inpatient Population

worse

better

Quality

Tail

worse

better

Quality

slide34

If the team identifies a performance gap applicable to a wider patient population, the team may design changes in processes with the potential for dramatic effect: improvement and standardization in processes reduces variation (narrows the curve) and raises quality of care for all (shifts entire curve toward better care). This radical change is what defines Quality Improvement.

After

After

Defining an Approach to Change

Before

Quality Assurance

Quality

Bell Curve:

Inpatient Population

worse

better

Quality

Tail

Quality Improvement

better

worse

better

Quality

Quality

worse

better

Quality

section iii

Section III:

Tools for Engineering Change

engineering change
Engineering Change
  • Hospitals have two dynamic levels impacting performance:

1) Processes

      • tasks performed in series or in parallel, impacting patient care and potentially patient outcomes

2) Personnel

      • skilled people with hearts and minds, with variable levels of attention, time, and expertise
engineering change what variables impact quality outcomes of care
Engineering Change: What Variables Impact Quality Outcomes of Care?

Structure

Processes

Outcomes of Care

Outputs

Inputs

Steps

  • Inventory Methods
  • Coordination
  • Physician orders
  • Nursing Care
  • Ancillary staff
  • Housekeeping
  • Transport
  • Physiologic
  • parameters
  • Functional status
  • Satisfaction
  • Cost
  • Patients
  • Equipment
  • Supplies
  • Training
  • Environment
engineering change what variables impact quality outcomes of care38

Personnel

Engineering Change: What Variables Impact Quality Outcomes of Care?

The two most dynamic levels impacting performance

Processes

Steps

  • Inventory Methods
  • Coordination
  • Physician orders
  • Nursing Care
  • Ancillary staff
  • Housekeeping
  • Transport
engineering change39
Engineering Change
  • Processes
    • all those affecting relevant aspects of patient care
      • clinical decision making, order writing, admission intake, medication delivery, direct patient care, discharge planning, PCP communication, discharge follow-up, etc
engineering change40
Engineering Change
  • Personnel
    • anybody who touches the patient or a relevant process in the system
      • departments, physicians, clerks, pharmacy, nursing, RT, PT/OT/ST, care technicians, phlebotomist, patient transport, administration
engineering change the multidisicplinary team asks what
Engineering Change: The Multidisicplinary Team Asks “What?”
  • What?
    • is the right thing to do?
    • will make the system more effective?
engineering change the multidisicplinary team asks where
Engineering Change: The Multidisicplinary Team Asks “Where?”
  • Where?
    • are the processes to improve?
      • Brainstorming
      • Multivoting & nominal group technique
      • Affinity grouping
    • do we start? (dissect and understand the processes)
      • Cause and effect diagrams (Ishikawa or ‘fishbone’ diagrams)
      • Tally sheets
      • Pareto charts
      • Flow (conceptual flow, decision flow) charts
      • Run charts
      • SPC charts
      • Scatter charts
tools for engineering change cause and effect diagram
Tools for Engineering Change: Cause-and-Effect Diagram
  • sometimes also called a ‘fishbone’ or Ishikawa diagram
  • graphically displays list of possible factors, focused on one topic or objective
  • used to quickly organize and categorize ideas during a brainstorming session, often as an interactive part of the session itself (the added organization can help produce balanced ideas during a brainstorming session)
slide44

Tools for Engineering Change: Cause-and-Effect Diagram

Example: Adverse Drug Events (ADE)

Drug Administration

Errors

Ordering Errors

Physician

Nurse

Pharmacy

Physician

Nurse/Clerk

Pharmacist

Transcribing

Rate

Dilution

Place outcome here

Spelling

Dosage

Route

Time

Route

Scheduling

Nurse

Order Missed

Wrong Drug

Dose

ADE

Age

Unforeseen

Weight

Psychiatric

Gender

Expected

Drug/Drug

Renal

Electrolyte

Cognitive

Pharmacokinetics

Drug/Food

Past Allergic Reaction

Compliance

Hepatic

Drug/Lab

Pharmacodyamics

Absorption

Race

Patient Errors

Physiologic

Factors

Pharmocologic

Factors

Pharmacist

Patient

Physician

Patient

Dietician

slide45

Tools for Engineering Change: Pareto Chart

  • graphical display of the relative weights or frequencies of competing events, choices, or options
  • a bar chart, sorted from greatest to smallest, that summarizes the relative frequencies of events, choices, or options within a class
  • often includes a cumulative total line
  • used to focus within a broad category containing many choices, based on factual or opinion-based information
  • can combine factors that contribute to each item's practical significance
slide46

100

90

80

70

60

50

Percent

40

30

20

10

0

Causes

Tools for Engineering Change: Pareto Chart

Causes Contributing to Adverse Drug Events

Contributing

Causes

tools for engineering change sketching processes or flow
Tools for Engineering Change: Sketching Processes or Flow
  • Macro Process Maps
  • Decision Flow Diagrams
slide48

Tools for Engineering Change: Macro Process Map

Example: Heart Failure Core Measures 2-3

slide49

Tools for Engineering Change: Decision Flow Diagram

Contributing layer dissected: Prevention

Contributing layer dissected:

Prophylactic Antibiotics

For iatrogenic infections, any given type of infection can be dissected into the hierarchy of contributing layers.

Calling out the contributing layers helps the team think through the steps ripest for change.

slide50

Tools for Engineering Change: Run Charts

  • Our brains understand graphics better than tables
  • Tabular information doesn’t convey trends over time very well
  • Keep it simple
  • In center of horizontal axis place: baseline mean performance
  • In center of vertical axis place: implementation point
  • Can add upper and lower control limits, but usually not needed
engineering change the multidisicplinary team asks how
Engineering Change: The Multidisicplinary Team Asks “How?”
  • How?
    • can you make it easy to do the right thing?
      • You cannot destroy productivity
        • Changes must maintain, or enhance, workplace efficiency or balance
      • You must devote as much attention to fitting changes into clinical work flow as you do to the evidence-based guideline
        • Changes must be blended into the flow of clinical care
        • Important variables to consider: staffing, training, supplies, physical layout, information flow, and educational materials
engineering change55
Engineering Change

Improve incrementally. Learn through action.

Plan Do Study Act

PDSA PDSA  PDSA  PDSA PDSA  PDSA

Test your changes. Assess their effect.

Then re-work the changes and do it again…and again…

engineering change pdsa the benefits of repeated cycles
Engineering Change: PDSA (the Benefits of Repeated Cycles)
  • Increases belief that change will result in improvement
  • Allows opportunities for “failures” without impacting performance
  • Provides documentation of improvement
  • Adapts to meet changing environment
  • Evaluates costs and side-effects of the change
  • Minimizes resistance upon implementation
engineering change pdsa
Engineering Change: PDSA
  • Overview:
    • scientific method for action-oriented learning: shorthand for testing a change in the real world setting
    • test a change by: planning it, trying it, measuring its results… and then trying to do it better the next time
    • multiple rounds of changes – some failures and some successes - should lead to improved aggregate outcome
engineering change pdsa58
Engineering Change: PDSA
  • Principles for Success:
    • start new changes on the smallest possible scale, e.g. one patient, one nurse, one doctor
    • run just as many PDSA cycles as necessary to gain confidence in your change – then expand
    • expand incrementally to more patients
    • expand to involve more nurses, more doctors, more departments
    • balance changes within system to ensure other processes not adversely stressed
slide59

What do we want to achieve?

What changes will drive our progress?

How will we measure our progress?

How should we modify our latest changes?

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

engineering change60

“Function Expansion”

Engineering Change

What do we want to achieve?

Set an outcome aim.

(It should be ambitious, must be measurable and must specify a time-period and a definite population in your hospital.)

List the outcome aim again, then:

  • ask “why” three times,
  • ask “how” three times,
  • look at the new aim statements, and
  • pick the best one

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

engineering change61
Engineering Change

What changes will drive our progress ?Select change(s) to your system, the one(s) most likely to improve outcomes.

(Recognize that not all changes improve outcomes or offer balance.)

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

engineering change62
Engineering Change

How will we measure our progress?Define what you will measure quantitatively.

(Collect data, chart measures regularly over specified time-period, and chart against benchmarks & goal lines.)

Principles of Measurement:

Seek usefulness, not perfection.

Integrate measurement into the daily routine.

Use qualitative and quantitative data.

Use sampling.

Plot data over time.

  • Three Types of Measures:
  • 1) Outcomes
  • 2) Process
  • 3) Balancing measures
    • (Use a balanced set of measures for all improvement efforts.)

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

engineering change64
Engineering Change

How should we modify our latest changes?

Test your changes.

(Run PDSA cycles to learn from the work setting.)

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

engineering change hints for success
Engineering Change:Hints for Success
  • Empower nursing
  • Expedite order set and protocol passage through appropriate medical staff committees
  • Better to implement an imperfect, compromise change than no change at all
  • Pilot newest changes on smallest scale
  • Provide hot line or support for difficult implementation situations
  • Use your new system as a shared baseline, with clinicians free to vary based on individual patient needs
  • Follow metrics continuously as you implement
  • Feed metrics back into subsequent PDSA cycles
  • Measure, learn, and over time eliminate variation arising from professionals; retain variation arising from patients
  • Keep big picture in mind
  • Negotiate ‘speed bumps’
    • Time delays in getting data
    • Incomplete buy-in
    • Go around obstacles instead of through them (can always go back to them later)
    • Some who disagree with you may be correct
    • Make changes painless as possible: make it easy to do the right thing
qi theory quality improvement in the hospital
QI Theory:Quality Improvement in the Hospital
  • Suggested next steps:

1) Share this primer in QI Theory with other hospitalists in your group

2) Identify an important QI project at your hospital

3) Lead the QI project using all available resources

4) Learn from your experience and be among the first to mentor other hospitalists

Use SHM’s topic-specific resource rooms to ask questions, share experiences & tools, review the literature, and to download presentations to help you educate others.

acknowledgments
Acknowledgments
  • Brent James, MD, MStat (Intermountain Health Care's Institute for Health Care Delivery Research): concepts, content, figures
  • Thomas Nolan, PhD (Institute for Healthcare Improvement): concepts, content, figures
  • Greg Maynard, MD, MSc (University of California, San Diego): editorial composition and review
  • Jason Stein, MD (Emory University School of Medicine): editorial composition