Introduction to methods for quality improvement Topic 7 Introduction to methods for quality improvement

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

PERFORMANCE REQUIREMENT know how to use a range of improvement activities and tools

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

THE SCIENCE OF IMPROVEMENT appreciation of a system understanding of variation theory of knowledge psychology W Edwards Deming

THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI): DIFFERENT MEASURES Measurement for research Measurement for learning and process improvement Purpose To discover new knowledge To bring new knowledge into daily practice Tests One large "blind" test Many 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

THREE TYPES OF MEASURES outcome measures process measures balancing measures

THE MODEL FOR IMPROVEMENT 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? ACT PLAN STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999

THE PDSA CYCLE ACT PLAN STUDY DO Determines what changes are to be made Change or test ACT PLAN STUDY DO Summarizes what was learned Carry out the plan Langley, Nolan, Nolan, Norman & Provost 1999

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

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

TWO CONTINUOUS IMPROVEMENT METHODS clinical practice improvement methodology (CPI) root cause analysis

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

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

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

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

PDSA CYCLE – MULTIPLE TESTS Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

IMPACT AND IMPLEMENTATION PHASE Measure impact of changes/interventions Record the results Revise the interventions Impact and implementation phase Measure impact Annotated run chart SPC charts Other graphs Implement the changes

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

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

EVIDENCE FOR THERE BEING A PROBLEM WORTH SOLVING At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.

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

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 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

CAUSE AND EFFECT DIAGRAM Social issues Staff attitudes Complications poor pain control LOS home support wound complications mobilization often weak weak/malnourished pain control family support nutrition infection Prolonged LOS nutrition expect long LOS poor understanding of procedure general practitioner mobilization community health nil by mouth little knowledge of support services family surgery colon care nurse pain control locus of control Procedure Patient perception Post discharge support Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince , Area CNC Pain Management, North Coast Area Health Service, NCHI Sydney Australia

PARETO CHART

PDSA CYCLES - IMPLEMENTATION surgical incision trial of transverse incision pain control wound infusion for transverse incisions 1 surgeon 10 patients patient information booklet surgeon pathway anaesthetic pathway surgical technique ARCS clinical pathway pain control bowel prep/care Nutrition mobilizatioN 1 surgeon 1-6 patients

RUN CHART

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