1. The Quality Improvement Project MODULE 3: LOOKING AT THE SYSTEM OF CARE & ROOT CAUSES OF GAPS IN CARE October 2015

2. Objectives 1. Understand the concept of a system of care 2. Learn 3 Quality Improvement “tools” to explore the system of care and root causes of care 1. 5 why’s 2. Process Map 3. Cause and Effect/Ishikawa diagram October 2015

3. My Practice audit found a gap in care….. Now what? October 2015

4. System based thinking…. How does this statement apply to healthcare? October 2015

5. Why think about systems? Two ingredients for improvement: 1. Subject matter knowledge (e.g. how do I do a pap?) 2. System knowledge (e.g. why aren’t all my patients getting paps?) October 2015 EASY Tricky!

6. What is a system? Is this (a patient and physician?) October 2015

7. and this? (a lot of smart doctors)

8. System thinking exercize 1…pair..share Step 1: Think on your own 2 min Step 2: Pair…(share with partner) 2 min each Step 3: Share…(share with group) 2 min For the gap in care you identified: What are the parts of the system? How do the people react in your system? What motivates them? How does the system lead them to do the wrong thing? The right thing? October 2015

9. Root causes: Really understanding WHY something is happening October 2015

11. System analysis & Root causes: QI Project  3 tools: i)5 Why’s, ii) Process map, iii)Cause and Effect/Ishikawa/Fishbone diagram  You need to demonstrate that you used at least 1 tool for your QI project  You can take a photo of the finished tool to include in your project  Word document templates for the tools are available in the resident QI project document, also online support (HQO and IHI), links at the end of the presentation October 2015

12. 5 Why’s - Find the root cause in the system  The 5 Why’s  Why? October 2015 12

13. Process mapping or flow diagram October 2015 Guyanese Family Medicine Residents working on a process map for their QI projects

14. Process map  Tool to identify and organize the steps in a process, also identifies opportunities for improvement  Map out the existing system in your practice (don’t map out the “ideal” system)  Start point: trigger for the process (for this QI project it may be easiest to start with patient arriving in clinic to help make the process mapping manageable)  Stop point: the desired outcome (ie: pap test done) October 2015

15. Process mapping – key components October 2015 START POINT Trigger for the process, should focus on the patient (ie: patient arrives in clinic) ACTION STEPS Direction/Flow DECISION POINT (yes/no) STOP POINT Ideal end point/outcome in your system (ie: pap test completed)

16. Cause and Effect/Fishbone diagram/Ishikawa  Organizes the causes of a particular effect  Good brainstorming tool, can be used with the process map  “Head” of the fish is the effect which is the NEGATIVE OUTCOME (ie: pap test not done)  Bones: typically Process/Policies, Patient, Provider, Equipment, and Educational Materials October 2015

17. Effect: Poor Patient Education / Understanding Effect: Poor Patient Education / Understanding Policies ProvidersEducational Materials/Equipment Barriers to Patient Education / Understanding Education resources difficult to understand Outdated patient education resources Preference in discussing topics in person vs handouts Clinicians not recognizing “teachable” opportunities Lack of time to teach patients Patient unable to recall clinic conversations Poor access to education resources Clinicians using jargon Clinicians not explaining thoroughly Lack of available education resources Procedures Patients Timing of patient education may not be conduciv e to patient learning Lack of emphasis on patient education October 2015

18. Resources: Health Quality Ontario http://www.hqontario.ca/quality-improvement/primary-care or http://qualitycompass.hqontario.ca/ http://www.hqontario.ca/quality-improvement/primary-care October 2015

19. Resources: Institute for Healthcare Improvement (IHI) – Look within the IHI “Open School” http://www.ihi.org October 2015