1. HEALTH CARE SYSTEMS
Every system is perfectly designed to achieve exactly the results it gets

2. The Healthcare Process
133 People to take care
of the patient
The Patient

3. Avedis Donabedian (1919 – 2000)
Outcome
Process
Structure

4. Introducing New Policy?
Strategy A
Strategy B
Form the committee of experts
Spend at least 6 months and many hours developing the perfect solution
Educate all the staff over 2-3 days
Implement house-wide tomorrow
Look for it in 12 months!
“Stack the deck”
1 doc, 1 nurse, 1patient, one PDSA
Reassess and learn from initial test
Repeat, progressively increasing confidence in solution then….
Test under varying conditions before….
Spread

5. The Centers for Medicare & Medicaid Services
QI is a "set of related activities designed to achieve measurable improvement in processes and outcomes of care. Improvements are achieved through interventions that target health care providers, practitioners, plans, and/or beneficiaries."6,7
The Centers for Medicare & Medicaid Services
Quality Improvement aims at “raising the bar” taking performance to a new improved level
Patient Safety aims at raising existing standards of care improving safety and process that already exist
The focus need be on both ends

6. How do we know change is an improvement?
“You can’t fatten a cow by weighing it”
- Palestinian Proverb
Improvement is NOT just about measurement…
…but you can’t improve something without measuring it!

7. The Improvement Skeleton
Engaging Clinicians
The Model for Improvement
Data Collection and Analysis
Understanding Variation
Reliable Design