1. QI, in a nutshell
Quality and Safety Educator’s Academy, Society of Hospital Medicine
and
Georgia McIntosh, MD

2. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

3. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

4. Process Modeling Tools
Cause and Effect Diagram or Fishbone diagram
Standard Flow diagram
Deployment Flowchart or Swim-lane Diagram
Mind Map

5. Process Modeling Tools
Cause and effect diagram ( “fishbone or ishikawa”)
Process Map

6. Process Modeling Tools Mind Map

7. Process Modeling Tools Deployment Flowchart or Swim-lane Diagram
Deployment flowchart- AKA swim-lane diagram. Standard flowchart but looks at each individual who interacts with the patient at certain stages. Includes columns ofr measures of each stage of the process and opportunities for improvement at each stage of the process.

8. Error Reduction Strategies
Strong actions
Intermediate Actions
Weak Actions

9. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

10. Donabedian’s Topology of Quality Measures
Structure How was care delivered to the patient Process What was done to the patient Outcome What happened to the patient Balancing Unintended, undesirable consequences

11. Structure, Process or Outcome?
30 day mortality after CABG
Bone densitometry ordered in women over 65
Computerized order entry
ACE or ARB for CHF pts with low EF
Last BP of < 140/90 in pts with HTN
Physician boarded in critical care medicine responding to codes at all times

12. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

13. “VCUHS will be the safest hospital in the United States.”
Aim Statement
“VCUHS will be the safest hospital in the United States.”

14. Aim Statement
VCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients, team members and visitors.”

15. Aim Statement
VCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients, team members and visitors.”
For whom?
How good?
By when?

16. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

17. Measurement Payers Demanding Increased Accountability
Voluntary reporting to payer
Pay for reporting to payer
Public reporting
Pay for performance

24. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

31. 6 Steps to QI
1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

32. Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby?
LEAN
Six Sigma
Cause-and-effect diagramming
Swim lane diagramming
Failure mode and effects analysis

33. Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby?
LEAN
Six Sigma
Cause-and-effect diagramming
Swim lane diagramming
Failure mode and effects analysis

34. LEAN Developed by Toyota Aim to eliminate waste in the system
Most common waste is patient wait time

35. Six Sigma Invented by Motorola
Designed to remove defects and variations from a system
Six sigma means 6 standard deveiations from the mean which represents 3.4 defects per 1 million opportunities
Utilizes DMAIC methodology
Design, Measure, Analyze, Improve, Control

36. Cause and effect diagramming
AKA Fishbone diagram
Uncovers the factors that influence an outcome
Hypothesis-generating tool

37. Deployment Flowchart or Swim-lane Diagram
Deployment flowchart- AKA swim-lane diagram. Standard flowchart but looks at each individual who interacts with the patient at certain stages. Includes columns ofr measures of each stage of the process and opportunities for improvement at each stage of the process.

38. Failure mode and effects analysis
Tool for classifying errors by severity and likelihood of recurrence for use in prioritizing quality initiatives

39. Failure Mode and Effects Analysis
systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.

40. 2. You serve on the sentinel event review committee
2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect?
Online education module on heparin dosing
Distribution of a heparin dosing pocket card
A heparin order set
A new institutional policy on heparin dosing
A physician education conference on heparin dosing

41. 2. You serve on the sentinel event review committee
2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect?
Online education module on heparin dosing
Distribution of a heparin dosing pocket card
A heparin order set
A new institutional policy on heparin dosing
A physician education conference on heparin dosing

42. Error Reduction Strategies
Strong actions
Intermediate Actions
Weak Actions

43. How do you prevent customers from leaving behind their ATM cards?
Strong Action- Swipe card only
Intermediate Action- Beeping
Weak Action- signs