CITE THIS CONTENT: RYAN MURPHY, “QUALITY IMPROVEMENT”, ACCELERATE UNIVERSITY OF UTAH HEALTH CURRICULUM, JANUARY 30, 2019. AVAILABLE AT: HTTPS://UOFUHEALTH.UTAH.EDU/ACCELERATE/EXPLORE/PLAYLISTS/IMPROVEMENT/QUALITY-IMPROVEMENT.PHP. https://uofuhealth.utah.edu/accelerate/explore/playlists/improvement/quality-improvement.php

ABOUT THIS LESSON Health care is full of opportunities for improvement, but how do we get started? This lesson introduces quality improvement (QI): They systematic and continuous approach to improvement. Learning Objectives: define quality improvement (QI) explain when you should an should not use a QI approach List two concrete steps you can take to get started with your QI project

What is quality improvement? The department of Health and Human Services defines quality improvement (QI) as: “systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.” WHAT IS QUALITY IMPROVEMENT? The Department of Health and Human Services defines quality improvement (QI) as “systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.” Within this definition, three words should be emphasized. The systematic approach of QI helps create effective interventions that lead to sustainable improvement without leading to adverse effects elsewhere in the system. The continuous nature of QI recognizes that the work is never done and embraces the merits of constant improvement. Lastly, the emphasis on measurement in QI ensures that actions taken lead to demonstrable change for the better. Source: https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf These three words are key! SOURCE: https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf (accessed online 21 Feb 2019)

Manufacturing introduces QI “Crossing the Quality Chasm” Background Manufacturing introduces QI mid – late 20th Century Health care adopts QI early 2000’s “Crossing the Quality Chasm” NAM 2001 Background Quality improvement as a concept rose to prominence in the mid- and late-20th century as part of a shift in manufacturing management philosophy that focused on improving product quality while reducing production costs. The concept reached national prominence in health care in the early 2000s following the release of two landmark reports from the National Academy of Medicine (To Err is Human and Crossing the Quality Chasm). The reports highlighted the gap between what we define as high-quality care and what patients actually experience, providing a call-to-action around health system redesign. As in manufacturing, quality improvement in health care is one part of a larger strategy around leadership, management, and policy reform. For the purposes of this series, we will focus specifically on quality improvement as an approach to local improvement. + Quality - Cost Quality/Safety + Service - Cost “To Err is Human” NAM 1999

Common methods PDSA Lean Six Sigma / DMAIC In health care, we often have little trouble identifying outcomes we wish to improve — patient falls, medication errors, readmissions, etc. — but struggle to implement effective, sustainable solutions. Often, the problems we face are complex, and are not easily addressed with simple interventions. Or interventions that we previously deployed fail. Structured quality improvement approaches – or improvement methods – provide processes and tools for measuring and managing your efforts in a way that helps sustain improvements in your local environment. You may have heard of different models for quality improvement, like Lean, DMAIC, or the Model for Improvement/PDSA cycle. PDSA: Plan-Do-Study-Act (PDSA) is a cyclical approach that supports small tests of a change. The most commonly used approach to improvement. Great to use for first-time improvers and low-stakes problems, but insufficient with increased complexity. Lean: Systematically eliminates waste in every process, procedure, and task. Lean identifies 7 Wastes and is full of helpful process tools. Six Sigma / DMAIC: Systematically decreases variation in processes to achieve a consistent outcome. Define, Measure, Analyze, Improve and Control (DMAIC) is Six Sigma's data-driven strategy for improving processes. Typically for high-stakes, high complexity projects. A cyclical approach that supports small tests of change Best for low-stakes, low- complexity problems Focuses on systematically eliminating waste in every process, procedure and task Full of helpful improvement tools Systematically decrease variation in processes to achieve a consistent outcome Best for high-stakes, highly complex problems

When to use quality improvement JUST DO IT (rapid improvement) COMPLEX & STRUCTURED (problem solving) RESEARCH STUDY (generalizable or innovative) Implementing a solution to improve a straightforward process based on known solution, common sense, or curiosity You know that a process doesn’t already have standard work, so you implement it Ask: how can I make this process better? To immediately improve a problem or process where there is an identified gap in performance The problem is acknowledged, but the cause is unknown Data-driven analysis and monitoring plan are necessary Team-based: Multiple stakeholders or departments need to be involved Identify and share new, generalizable knowledge Data and statistical analysis are necessary and part of the study Human subjects participation and IRB approval is required It may consist of in-house research or externally funded projects WHEN TO USE QUALITY IMPROVEMENT Use it to solve complex problems: Complex problems: Quality improvement excels when one is faced with complex problems, where there is an identified gap in performance, the cause is unknown, data-driven analysis is necessary, and it is a team-based dilemma – multiple stakeholders or departments need to be involved. Don’t use it to solve simple or research problems: Simple problems: Any QI effort will require an investment of time and resources. Save that investment for those problems that are important to you and your organization and are complex enough to require a collaborative, longitudinal commitment to develop interventions that stick. Research problems: QI is not the same as research, and differentiating between the two can be confusing. If your primary intent is to contribute to generalized knowledge, a research approach may be more appropriate. If your primary intent is to improve delivery of care or health outcomes for a local population, a quality improvement approach may be right. COMPLEXITY EASY HARD

How to get started Continue your independent learning Accelerate U of U Health: uofuhealth.utah.edu/accelerate/explore/ IHI Open School: www.ihi.org/education/IHIOpenSchool Find a mentor or coach Talk to your manager, program director, and/or colleagues to learn about mentors, projects, training, and other opportunities unique to your area Contact U of U Health’s Value Engineering (value@hsc.utah.edu) Have a plan Try using the Vision Summary, 15-questions to help think through your project (http://healthsciences.utah.edu/accelerate/img/strategic/vision-summary-questions.docx) HOW TO GET STARTED If you’re thinking about leading or participating in a quality improvement effort, here are three concrete steps to get started: 1. CONTINUE YOUR INDEPENDENT LEARNING •  Explore other lessons on Accelerate •  Take the Value Improvement Leaders course (internal resource) •  Explore external resources (like IHI Open School) 2. FIND A MENTOR OR COACH •  Talk to your manager, program director, and/or colleagues to learn about mentors, projects, training, and other opportunities unique to your area •  Contact U of U Health’s Value Engineering for information on their coaching methods (internal resource) 3. HAVE A PLAN •  Try using the Vision Summary, a 15-question guide to help think through your project

DISCUSSION THINK ABOUT IT For more on this and other topics, explore: https://uofuhealth.utah.edu/accelerate/