1. Disclaimer information here… Click to edit Master title style WHA’s Learning Series: QI 100 for Health Care Clinicians Unit 2: Participating in Improvement Aligning Forces for Quality is supported by the Robert Wood Johnson Foundation, through a grant to the Wisconsin Collaborative for Healthcare Quality. In Wisconsin, Aligning Forces for Quality is a joint project by the Wisconsin Collaborative for Healthcare Quality, the Wisconsin Hospital Association, and other organizations.

2. Disclaimer information here… Click to edit Master title styleQI 100 Rules of Engagement 2 Please read carefully: 1.This powerpoint must be in “Slide Show” mode in order for all links to be active (see the Slide Show menu at the top of your screen). 2.You must complete this unit in one sitting. You will not be able to exit and re-enter from where you left off. 3.This unit has three exercises and a five question quiz at the end. You must complete the quiz to get credit for Unit 2. You will be asked to enter your name. 4.CEU’s will be awarded after you have taken all five units and completed the Capstone Quiz – a link to this quiz is given in Unit 5. 5.The content provided in this unit is for educational purposes only and is not to be interpreted as an endorsement by WHA or any of it’s member or partner organizations. 6.This learning series is supported by the Aligning Forces for Quality grant. Aligning Forces for Quality is supported by the Robert Wood Johnson Foundation, through a grant to the Wisconsin Collaborative for Healthcare Quality. In Wisconsin, Aligning Forces for Quality is a joint project by the Wisconsin Collaborative for Healthcare Quality, the Wisconsin Hospital Association, and other organizations. 7.If you have questions or problems please e-mail: ssobczak@wha.orgssobczak@wha.org

3. Disclaimer information here… Click to edit Master title styleQI 100 Unit Progression 3 Why Quality Matters Unit 1 Participating in Improvement Unit 2 Holding the Gains Unit 3 Health Care Change Systems Unit 4 Capstone & Credit Unit 5

4. Disclaimer information here… Click to edit Master title styleIntroduction to Unit 2 You are about to participate in the QI 100 unit 2: Participating in Improvement After completing this unit you will: Understand your role as a staff person on a QI team. Learn the various improvement approaches QI teams may use. Learn the value of measurement and why it is vital to improvement. Learn about data types and sources Learn some basics about data displays. 4

5. Disclaimer information here… Click to edit Master title styleGetting Credit for Unit 2 5 When you see a light bulb icon, you can access a brief exercise to reinforce the concept. Simply click on the light bulb. When you see a screen icon, you should access a quiz to test your knowledge. Simply click on the question mark. When you are done with an exercise simply close the page by clicking the ‘x’ or In order to officially participate in this unit, and receive continuing education credit, you need to complete the Unit 2 quiz. X Esc

6. Disclaimer information here… Click to edit Master title styleTeam approaches in QI Health Care QI is very complex because there are so many components to the health care systems in which we work: It is not possible for any one position to understand how all of these processes interact. Therefore, we need to work together to improve efficiently. 6 EmergencyAdmissions Radiology & Lab Surgery Inpatient Outpt. Nursing Care Med- Surg ICU Peds Rehab Discharge Planning BillingHome Care

7. Disclaimer information here… Click to edit Master title styleWhy Teams? Teams are often the best way to break down a complex issue because many perspectives can be examined and more expertise can be included. 7 Remember the fable about the Blind Men and the Elephant? Individual perspectives can lead to very different conclusions…

8. Disclaimer information here… Click to edit Master title styleHow teams may work together Disclaimer information here… 8 In face to face meetings. Virtually, as in over the internet or via phone. Through communication boards, or other feedback mechanisms.

9. Disclaimer information here… Click to edit Master title styleLaunching a Team Teams may begin with a few basic tasks that will make the work flow easier throughout: Introductions to get to know each other, if needed. Determining how the work of the team will be documented and who will do these tasks. Developing a clear purpose statement and desired outcomes. Defining phases of the approach. Getting needed approvals to move forward. Taking time to get consensus on key issues. Disclaimer information here… 9

10. Click to edit Master title styleBe Patient… It is important to be patient in the early phases of a new team. Teams that stall or get off track can often trace back to a root cause of not clarifying the team purpose, or not having a clear plan for achieving key milestones. And remember, conflict is a natural part of solving complex issues. Don’t take anything personally if the going gets rough (it’s temporary). Disclaimer information here… 10

11. Disclaimer information here… Click to edit Master title styleBeing a Team Player Here are a few ideas to get the most out of participating on a QI team: Learn, in advance, about the topic – be prepared. Talk to others about the issue the team is working on, especially your supervisor, to get others perspectives. Listen actively in meetings and ask clarifying questions if something is unclear. Complete required tasks on time. Be a positive voice about the work of the team in your work area. Disclaimer information here… 11

12. Disclaimer information here… Click to edit Master title styleResources on Teams Exercise #1 For more information on being part of an improvement team check out the Team Building section under “Tools to Use” on the WHA Quality Center website: Just click on the light bulb  12 WHA X When you are done, simply close out by clicking the or at the top.

13. Disclaimer information here… Click to edit Master title style A Quick History of Quality Improvement Before 1920 – Early mass production required parts of a consistent quality. 1920s – Statistics were applied to measure & maintain quality. 1950s – Japanese companies began using consistent quality improvement approaches, such as PDCA 1970s – American manufacturing companies began using TQM to improve. 1980s – Health Care industry began adopting TQM. 1990’s – Outcome measures for health care were adopted widely. 2000’s -- Public reporting of quality measures becomes more common. Today – Health Care reform movement – quality efforts are impacted by regulation, requirements for public reporting, and quality based financial penalties or rewards. Disclaimer information here… 13 Before 1920 1920’s1950s1970s1980’s1990s2000sToday

14. Disclaimer information here… Click to edit Master title styleImprovement Approaches Methods of improvement were developed to help people approach challenges in a consistent manner. Several approaches have been applied in health care over the years: PDCA Six Sigma Lean 5S BPE Disclaimer information here… 14 OLDER NEWER

15. Disclaimer information here… Click to edit Master title style Improvement Approach: PDSA/PDCA 15 What it means for you: Team meetings are often key to PDSA. May use approaches such as brainstorming, surveys, or feedback white boards to get input from a wider audience. As a team member it is important that you provide input to these processes. It is also important to be a good example for others during the pilot testing or implementation of changes. What it is: A four stage approach: Plan-Do- Study-Act (or Plan-Do-Check-Act). Most commonly used improvement approach. Emphasizes careful definition of the problem before jumping into solutions. Will involve key tools such as Cause & Effect diagrams, checksheets, Pareto charts (80/20 analysis), etc. Involves small pilot tests of changes, then re-evaluation of the impact.

16. Disclaimer information here… Click to edit Master title styleImprovement Approach: Lean 16 What it means for you: You may be asked detailed questions about a work process – this phase is very important. You may be asked to interview others about their work process and then document the findings You or your work area may be asked to pilot a changed or new process and provide feedback on the experience You or your work area may also be asked to measure an aspect of a process What it is: Lean is primarily a process focused approach that seeks to eliminate steps in a process that do not add value. It is focused on driving out ‘wastes’ in the workplace such as: Waiting, Transportation, Rework, Inventory. Often the process in question is mapped so that a visual representation of the work is the focus. This is called value stream mapping. Measures of the wastes, such as turn-around-time are often key.

17. Disclaimer information here… Click to edit Master title styleImprovement Approach: Six Sigma 17 What it means for you: You may be asked to assist with measuring a process over a period of time such as several days, weeks, or months. You may need to learn some basic statistics to assist the data reporting or analysis. You can expect to be involved in a Six Sigma project over a longer period of time compared to other approaches, because the key is to maintain consistent performance. What it is: Six Sigma is a measurement based improvement approach that uses statistics to determine if a measurable process is performing consistently (with little variation). The improvement plan will follow a defined approach called DMAIC (Define-Measure-Analyze-Improve- Control) which is similar to a PDCA cycle. Results of measurement over time will be analyzed for causes of performance variation – a tool called ‘control charts’ When variation is discovered, then a process of root cause analysis is conducted.

18. Disclaimer information here… Click to edit Master title style Improvement Approach: Business Process Engineering 18 What it means for you: You will be asked to assist in documenting processes. You will need to understand the process from another department’s point of view. You will be asked to contribute to the creation the best solution that has the least negative impact on all of the stakeholder departments. You may be asked to participate in a pilot of the changed process. What it is: Focuses on a multi-step process that is often cross-functional, meaning work is handed off between multiple departments. Often, the processes will be diagrammed in a “flow chart” which will help the participants see where there is unneccesary complexity, and where uneeded steps can be “engineered out”. Documentation and training on the new process is important to ensure the needed change happens.

19. Disclaimer information here… Click to edit Master title styleLearning Exercise – Unit 2 19 Exercise #2 Try applying what you have learned about the different improvement approaches by participating in the following exercise: What approach might be most effective in the following scenarios? Just click on the light bulb  X When you are done, simply close out by clicking the or at the top.

20. Disclaimer information here… Click to edit Master title styleAbout Data & You As a staff person on an improvement team, you may be asked to assist in the collection, recording or analysis of data to support the improvement project. There are a variety of data sources to consider, so let’s review a few of those: Disclaimer information here… 20

21. Disclaimer information here… Click to edit Master title styleQualitative vs. Quantitative Data Disclaimer information here… 21 Describe a Latte Qualitatively Qualitative data: Robust aroma Frothy appearance Slightly sweet, taste Small size Describe a Latte Quantitatively Quantitative data: 8 ounces of latte Temperature 150º F. Cost $3.95

22. Disclaimer information here… Click to edit Master title styleTypes of measures Outcome Measures Outcome measures tell a team whether the changes it is making are actually leading to improvement — that is, helping to achieve the stated aim. An example of an outcome measure might be readmission rates. Process Measures Process measures tell a team whether a specific process change has been accomplished and whether it is having the intended effect. A team often establishes several process measures in the course of its work. The assumption is that improvement in a process measure will have an eventual impact on the outcome measure. In this case patients receiving discharge instructions might be a process measure. 22

23. Disclaimer information here… Click to edit Master title styleTypes of Data Displays Bar Chart – Best used when you have counts of data to display or to compare a series of results over time. Line Chart – Best used to display data measured over time and to detect a trend from period to period and can compare sets of results. Pie Chart – Best used to show categories of data for a given population or in one time period. Pareto Chart – Best used to determine frequency of causes; based on the principle that 20% of causes drive 80% of the result. Focusing on the 20% will yield more impact that focusing on lesser contributors. 23

24. Disclaimer information here… Click to edit Master title styleUnit 2 Summary Quiz Congratulations! You have completed Unit 2: Participating in Improvement You can now test what you have learned by taking a short 5 question assessment. Simply click on the screen icon  **Please note: You must take the assessment to get full credit for Unit 2 24 X When you are done, simply close out by clicking the or at the top.

25. Disclaimer information here… Click to edit Master title styleUnit 2 Resources Articles: New Reports Show Weak Progress on Health Quality. Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy, June 2, 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/cc/cc060209.htm http://www.ahrq.gov/consumer/cc/cc060209.htm Books: The Problem Solving Memory Jogger, GOAL/QPC press Websites: www.whaqualitycenter.orgwww.whaqualitycenter.org, www.asq.org, www.wchq.org,www.asq.orgwww.wchq.org 25