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Topic 7 Introduction to methods for quality improvement.

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1 Topic 7 Introduction to methods for quality improvement

2 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

3 Performance requirement know how to use a range of improvement activities and tools

4 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

5 W Edwards Deming The science of improvement appreciation of a system understanding of variation theory of knowledge psychology

6 Measurement for researchMeasurement for learning and process improvement Purpose To discover new knowledgeTo bring new knowledge into daily practice Tests One large "blind" testMany 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 The Institute for Healthcare Improvement (IHI): different measures

7 Three types of measures outcome measures process measures balancing measures

8 The quality improvement model-the PDSA cycle 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 an improvement?

9 ACTPLAN 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? DOSTUDY The model for improvement Langley, Nolan, Nolan, Norman & Provost 1999

10 ACTPLAN DOSTUDY Determines what changes are to be made Summarizes what was learned Change or test Carry out the plan Langley, Nolan, Nolan Norman & Provost 1999 The PDSA cycle

11 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

12 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

13 Two continuous improvement methods clinical practice improvement methodology (CPI) root cause analysis

14 D PA S 3 Intervention phase Diagnostic phase 2 1 Project phase 4 5 Sustaining improvement phase Impact phase Project mission Project team Conceptual flow of process Customer grid Data -fishbone -Pareto chart -run charts -SPC charts 2 months Plan a change Do it in a small test Study its effects Act on the result 2 months 1 month Annotated run chart SPC charts D P A S D P A S D P A S D P A S Ongoing monitoring Outcome Future plans Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf SPC – statistical process control The improvement process

15 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 Interventions phase Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

16 NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) ACT What changes can be made for the next cycle (adapt change, another test, implementation cycle?) PLAN Objective Prediction Plan for change (who, what, when, where) Plan for data collection (who, what, when, where) Carry out the change Document observations Record data DO Complete analysis of data Compare results to predictions Summarize knowledge gained STUDY 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

17 Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) PDSA Cycles – single test Changes that result in improvement Hunches, theories and ideas A S D P A S D P A S D P A SD P PDSA cycle - single test

18 PDSA Cycles – multiple tests A S D PA S D PA S D P P DA S P DA S P DA S D P A S D P A SD P A S Test 1Test 3Test 2 PDSA cycle – multiple tests NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

19 1.Measure impact of changes/interventions 2.Record the results 3.Revise the interventions 4.Monitor impact Impact and implementation phase Implement the changes Measure impact Annotated run chart SPC charts Other graphs Impact and implementation phase NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

20 1.Once an intervention has been introduced, the intervention and any improvements need to be sustained 2.This may involve: standardization of existing systems and processes documentation of policies, procedures, protocols and guidelines measurement and review of interventions to ensure that change becomes past of “standard” practice training and education of staff Sustaining improvement phase Sustain the gains standardization documentation measurement training Sustaining the improvement phase NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

21 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

22 Performance requirements Know how to use a range of improvement activities and tools flowcharts cause and effect diagrams (Ishikawa/fishbone) Pareto charts run charts

23 At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales. Evidence for there being a problem worth solving

24 Flow chart of process Something amiss Referral to Hospital Visit to general practitioner Referral to surgeon Investigations Hospital admission Admissions office Operating theatre Admitted to hospital Preoperative clinic Post anaesthetic care Allied health Surgical ward Surgical team Discharge planner Pre-op ward Pain team Home Community health/ Peripheral hospital Return to life Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince Area CNC Pain Management North Coast Area Health Service NCHI Sydney Australia

25 Multidisciplinary meeting to: -ask opinion -brainstorm process of care -how to improve the process -who to include in the process of change -how to communicate progress standardization Evidence-based practice team approach Customer and expectations list surgical ward staff post-op anaesthetic care staff physiotherapy dept dietitian peri-operative unit staff private hospital staff pain team anaesthetists surgeons intensivist

26 Cause and effect diagram Social issuesStaff attitudesComplications Procedure Patient perception Post discharge support Prolonged LOS surgery mobilization nutrition nil by mouth LOS mobilization pain control nutrition expect long LOS home support often weak poor understanding of procedure little knowledge of support services pain control locus of control family support poor pain control wound complications weak/malnourished community health general practitioner infection family colon care nurse Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince Area CNC Pain Management North Coast Area Health Service NCHI Sydney Australia

27 24 57 42 76 67 80 100 Pareto chart

28 surgical incisiontrial of transverse incision surgical incisiontrial of transverse incision pain control wound infusion for transverse incisions pain control wound infusion for transverse incisionsthen patient information booklet surgeon pathway anaesthetic pathway - surgical technique ARCS clinical pathway - surgical techniqueARCS clinical pathway - pain control - - bowel prep/carebowel prep/care - nutrition - mobilization 1 surgeon 10 patients 1 surgeon 1-6 patients PDSA cycles - implementation

29 Run chart Made change here

30 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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