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

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

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

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

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

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

7. THREE TYPES OF MEASURES
outcome measures
process measures
balancing measures

8. 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

9. 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

10. 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

11. 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

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

13. 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 (
SPC – statistical process control

14. 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 (

15. 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 (

16. 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 (

17. PDSA CYCLE – MULTIPLE TESTS
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (

18. 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

19. 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

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

21. 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.

22. 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

23. 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

24. 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

25. PARETO CHART

26. 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

27. RUN CHART

28. 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