1. Introduction to methods for quality improvement
Topic 7
Introduction to methods for quality improvement
When Rabia first mentioned this conference to me in September I was impressed with her commitment, vision and energy for this international event. But frankly, I was a little nervous at how much work was needed to deliver such an ambitious programme in such a short time. It is an amazing testament to Rabia, Mustafa and other members of the organising committee and staff that this impressive programme has been realised here in this fantastic venue. I am delighted to be able to support this congress and the initiatives that are being shared to improve patient safety globally
In my presentation I will draw on
the global work on patients safety, reflecting on how patient safety affects us all
how we should and can learn from error
the work of the WHO World Alliance for Patient Safety and
the personal experience of some clinicians, professionals, policy makers and patients in their efforts to make healthcare safer across the world
I will be expending on this introduction in two interactive workshop sessions, one on Patients for Patient Safety and patient engagement and the other, a Learning from Error workshop

2. 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
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

3. Performance requirement
know how to use a range of improvement activities and tools
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

4. 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
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

5. The science of improvement
appreciation of a system
understanding of variation
theory of knowledge
psychology
W Edwards Deming
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

6. 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
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

7. Three types of measures
outcome measures
process measures
balancing measures
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

8. The quality improvement model-the PDSA cycle
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an improvement?
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

9. 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

10. The PDSA cycle ACT PLAN STUDY DO Determines what
changes are to be made
Change or test
ACT
PLAN
STUDY DO
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.
Summarizes what
was learned
Carry out the plan
Langley, Nolan, Nolan Norman & Provost 1999

11. 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
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

12. Langley, Nolan, Nolan, Norman & Provost 1999
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

13. Two continuous improvement methods
clinical practice improvement methodology (CPI)
root cause analysis
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

14. The improvement processD P A S 3
Intervention phase
Diagnostic phase 2 1
Project phase 4 5
Sustaining improvement phase
Impact phase
Project mission Project team
Conceptual flow of process
Customer grid
Data
fishbone
Pareto chart
run charts
SPC charts
2 months
Plan a change
Do it in a small test
Study its effects
Act on the result
1 month
Annotated run chart SPC charts
Ongoing monitoring Outcome
Future plans
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (
SPC – statistical process control

15. Interventions phase Interventions phase
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (
Identify appropriate interventions
Implement changes identified in the diagnostic phase
Undertake one or more PDSA cycles
Interventions phase
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.
Decide on interventions
Undertake one or more PDSA cycles

16. 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
What changes can be made for the next cycle (adapt change, another test, implementation cycle?) •
PLAN
• Objective
• Prediction
• Plan for change (who, what, when, where)
• Plan for data collection (who, what, when, where)
• Carry out the change
• Document observations
• Record data DO
Complete analysis of data
Compare results to predictions
Summarize knowledge gained
STUDY
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (

17. 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 (

18. PDSA cycle – multiple tests
PDSA Cycles – multiple tests
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (

19. Impact and implementation phase
Measure impact of changes/interventions
Record the results
Revise the interventions
Monitor impact
Impact and implementation phase
Annotated run chart
SPC charts
Other graphs
Measure impact
Implement the changes
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (

20. Sustaining the improvement phase
Once an intervention has been introduced, the intervention and any improvements need to be sustained
This may involve:
standardization of existing systems and processes
documentation of policies, procedures, protocols and guidelines
measurement and review of interventions to ensure that change becomes past of “standard” practice
training and education of staff
Sustaining improvement phase
standardization
documentation
measurement
training
Sustain the gains
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (

21. 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
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

22. Performance requirements
Know how to use a range of improvement activities and tools
flowcharts
cause and effect diagrams (Ishikawa/fishbone)
Pareto charts
run charts
Launched in 2004 following the WHA Resolution which called for Member States to
"pay the closest possible attention to the problem of patient safety"
Promote awareness and political commitment
Expert-led technical programmes to improve patient safety worldwide
The Alliance will be publishing its Forward programme shortly.

23. 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.

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

25. Customer and expectations list
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
surgical ward staff
post-op anaesthetic care staff
physiotherapy dept
dietitian
peri-operative unit staff
private hospital staff
pain team
anaesthetists
surgeons
intensivist

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

27. Pareto chart 24 57 42 76 67 80
100

28. PDSA cycles - implementation
surgical incision trial of transverse incision
pain control wound infusion for transverse incisions
then
patient information booklet
surgeon pathway
anaesthetic pathway
ARCS clinical pathway - surgical technique
- pain control
- bowel prep/care
- nutrition
- mobilization
1 surgeon10 patients
1 surgeon1-6 patients

29. Run chart
Made change here

30. 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