"Quality Improvement (QI) in Healthcare

1. "Quality Improvement (QI) in Healthcare Department of Family Medicine Faculty Meeting November 12, 2008

2. Why should we get involved? • Number of patients who die from breast cancer every year: 42,297 • Number who die from automobile accidents: 43,458 • Number who die from medical errors: 44,000 – 98,000

3. Why should we get involved? % of Americans who report they or a family member experienced a medical error: 22 Annual cost of preventable patient injury resulting from medical errors: $17-29 billion

4. Why should we get involved? % of health care workers who don’t wash their hands between patients: 50-80 # pts who acquire infections in US hospitals each year: 1.7 million

5. Why should we get involved? Rank of US among major industrialized nations in per capita spending: # 1 Rank of US in death rates from conditions we know how to prevent: # 1

6. Why should we get involved? • ACGME Core Competencies • PATIENT CARE • MEDICAL KNOWLEDGE and SKILLS • INTERPERSONAL AND COMMUNICATION SKILLS • PROFESSIONALISM • SYSTEM-BASED PRACTICE • PRACTICE-BASED LEARNING AND IMPROVEMENT are also now JC requirements for credentialing! • MOC – maintenance of certification

7. INTRODUCTION • The proposed project will develop and implement a formal curriculum and experiential learning process to train residents in quality improvement (QI) of primary care . . . through two major objectives Objective 1: Incorporate Evidence-Based Quality Improvement Process into the curriculum to (2) Prepare family medicine residents with the knowledge, skills and attitudes to utilize an evidence-based quality improvement process in their medical practice

8. Tentative Topics / Content 1. Basics of QI (definition of terms) 2. History of QI and why now in health care 3. Basic tools of QI 4. Nationally recognized resources for QI 5. Analyzing quality data 6. Patient-centered approach to QI (Chronic Disease Model) 7. Role of information technology in QI 8. Discussion of outcomes measures and QI 9. Association of QI and patient safety, reduced costs, etc. 10. QI applied to different cultures and healthcare disparities

9. What is "Quality Improvement"? • Quality Improvement (QI) is a method that organizations use to increase the quality and value of their goods or services. • By understanding the basic principles and tools of QI and applying them to your work, quality and excellence will become a part of your everyday life. "We are what we repeatedly do. Excellence, then, is not an act, but a habit." -- Aristotle

10. Barriers to Improvement “Good enough? “Inertia”

11. “Every system is perfectly designed to achieve the results it gets.” Donald Berwick, M.D.

12. Quality Improvement and Excellence rely on both the system and the individual. The system is responsible to the individual and the individual is responsible to the system (i.e., interdependence). "The achievements of an organization are the results of the combined effort of each individual." -- Vince Lombardi

13. Today’s Focus:Brief overview and introduction to approaches to and models for quality improvement

14. Underlying Principle • Quality improvement, in order to be implemented and effective, must incorporate principles that support a simple, common sense approach to problems.

15. Quality Improvement “Models/Models” • Organizational Frameworks / Quality Management Models • Baldrige Evaluation Process • ISO 9001 Certification • Balanced Scorecard Approach • Quality Improvement Methods • Six Sigma • Human Factors • Lean or TPS (Toyota Production System) • PDCA / PDSA Cycles or Model for Improvement • Quality Improvement Theories • Reliability Theory • Spread Theory

16. Review of the Main Concepts • Baldrige: Performance Excellence (value/quality service) • ISO 9000: Performance Excellence (internal processes) • Balanced Scorecard:Performance Excellence(measurement of business processes and external outcomes) • Lean: Waste;  Efficiency(internal processes) • Human Factors:Performance; Variation (staff abilities) • Six Sigma: Performance;  Variation (cost saving, business goals) • MFI: Processes

17. Design of health care systems and processes Elements configured by ‘designers’ include: • People – education, training, orientation, … • Materials – medications, supplies, … • Tools – medical equipment, information technology, forms, communication media, … • Methods – procedures, diagnostic and treatment processes, management practices, policies, communications practices, coordination of effort,

18. Sources of design failure in complex systems Design flaws are expected because (for example): • Actual operations are more complex than our design models • System elements interact in unexpected ways • Procedures, tools, and materials are used in ways not anticipated • Multiple designers with potentially different goals and assumptions • Safety features, defenses become degraded over time • Environmental conditions, expectations, and demands change over time

19. The world points out our design flaws to us In the course of actual operations, design flaws will produce: • Errors, unsafe acts, procedure violations • Glitches • Near-misses • Accidents • Injury • Sentinel events/catastrophes (We may also learn from other people’s failures)

20. Model for Improvement (MFI) Definition • The MFI is based on a “trial and learning” approach. This trial and learning approach revolves around three questions. • What are we trying to accomplish? (AIM) • How will we know that a change is an improvement? (Criteria or Measures) • What changes can we make that will result in improvement? (Testing Changes) • Focusing on these questions accelerates the building of knowledge by emphasizing a framework for learning, the use of data and the design of effective tests or trial.

21. Setting Aims Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected. Establishing Measures Teams use quantitative measures to determine if a specific change actually leads to an improvement. Selecting Changes All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement. The Plan-Do-Study-Act (PDSA) Cycle Testing Changes The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning.

22. Steps in the PDSA Cycle • Step 1: Plan - Plan the test or observation, including a plan for collecting data. • State the objective of the test. • Make predictions about what will happen and why. • Develop a plan to test the change. (Who? What? When? Where? What data need to be collected?) • Step 2: Do - Tryout the test on a small scale. • Carry out the test. • Document problems and unexpected observations. • Begin analysis of the data.

23. Steps in the PDSA Cycle • Step 3: Study - Set aside time to analyze the data and study the results. • Complete the analysis of the data. • Compare the data to your predictions. • Summarize and reflect on what was learned. • Step 4: Act - Refine the change, based on what was learned from the test. • Determine what modifications should be made. • Prepare a plan for the next test.

24. “MFI” vs. “Scientific Method” • P - Hypothesis • D - Methods • S - Results • A - Conclusions

25. Ideas for change • Can come from a variety of sources: • Critical thinking about the current system • Creative thinking • Observation of the process • A hunch • Scientific literature • Insight gleaned from a completely different situation

26. Develop and pilot test a change • The plan for the test should cover who will do what, what they will do, and where it will be done. • Testing a change allows a preview of the effect that one or more changes would have if they were implemented.

27. Testing changes is an iterative process: the completion of each Plan-Do-Study-Act (PDSA) cycle leads directly into the start of the next cycle.We learn from the test — What worked and what didn't work? What should be kept, changed, or abandoned? — and uses the new knowledge to plan the next test. The team continues linking tests in this way, refining the change until it is ready for broader implementation.

28. Continue and Reinforce changes that lead to an improvement • Previously labeled "trial-and-error", these cycles of implementing change and reviewing the effects should be thought of as "trial-and-success" or "trial-and-learning".

29. METRIC stands for Measuring, Evaluating and Translating Research Into Care. • It is an innovative online practice improvement program that allows you to earn CME credit in your office, while improving patient care. The program is designed to assist family physicians in fulfilling the requirement for Part IV of Maintenance of Certification.

30. Resources • Institute for Healthcare Improvement • http://www.ihi.org/ihi • IHI Open School • http://www.ihi.org/IHI/Programs/IHIOpenSchool/IHIOpenSchoolforHealthProfessions.htm • AAFP Clinical QI Resources • http://www.aafp.org/online/en/home/practicemgt/quality.html • AHRQ • http://www.ahrq.gov/