Learning objective 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 ID: 1029813
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1. Topic 7Introduction to methods for quality improvement
2. Learning objective describe the basic principles of quality improvement introduce students to the methods and tools for improving the quality of health care
3. Performance requirementknow how to use a range of improvement activities and tools
4. Knowledge requirementsthe science of improvementthe quality improvement modelchange conceptstwo examples of continuous improvement methodsmethods for providing information on clinical care
5. W Edwards Deming The science of improvementappreciation of a systemunderstanding of variation theory of knowledge psychology
6. The Institute for Healthcare Improvement (IHI): different measuresMeasurement for researchMeasurement for learning and process improvementPurposeTo discover new knowledgeTo bring new knowledge into daily practiceTestsOne large "blind" testMany sequential, observable testsBiasesControl for as many biases as possibleStabilize the biases from test to testDataGather as much data as possible, "just in case"Gather "just enough" data to learn and complete another cycleDurationCan take long periods of time to obtain results"Small tests of significant changes" accelerate the rate of improvement
7. Three types of measuresoutcome measures process measuresbalancing measures
8. The quality improvement model-the PDSA cycleWhat 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?
9. ACTPLANWhat 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?DOSTUDYThe model for improvementLangley, Nolan, Nolan, Norman & Provost 1999
10. ACTPLANDOSTUDYDetermines what changes are to be madeSummarizes what was learnedChange or testCarry out the planLangley, Nolan, Nolan Norman & Provost 1999The PDSA cycle
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
12. 9 categories of change eliminate wasteimprove work flowoptimize inventorychange the work environmentenhance the producer/customer relationshipmanage timemanage variationdesign systems to avoid mistakesfocus on the product or serviceLangley, Nolan, Nolan, Norman & Provost 1999
13. Two continuous improvement methods clinical practice improvement methodology (CPI)root cause analysis
14. DPAS3Intervention phaseDiagnostic phase2 1Project phase 4 5Sustaining improvement phaseImpact phaseProject mission Project teamConceptual flow of process Customer gridDatafishbonePareto chartrun chartsSPC charts2 monthsPlan a changeDo it in a small testStudy its effectsAct on the result2 months1 monthAnnotated run chart SPC chartsDPASDPASDPASDPASOngoing monitoring Outcome Future plansSourced 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 controlThe improvement process
15. Identify appropriate interventionsImplement changes identified in the diagnostic phase Undertake one or more PDSA cyclesInterventions phaseDecide on interventionsUndertake one or more PDSA cyclesInterventions phase Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
16. NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)ACTWhat 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 dataDOComplete analysis of dataCompare results to predictionsSummarize knowledge gained•••STUDYHow to use the PDSA Cycleuse plan-do-study-act cycles to conduct small-scale tests of change in real settingsplan a changedo it in a small teststudy its effectsact on what learnedteam uses and links small PDSA cycles until ready for broad implementation
17. Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)PDSA Cycles – single testChanges that result in improvementHunches, theories and ideasASDPASDPASDPASDPPDSA cycle - single test
18. PDSA Cycles – multiple testsASDPASDPASDPPDASPDASPDASDPASDPASDPASTest 1Test 3Test 2PDSA cycle – multiple testsNSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
19. Impact and implementation phase Impact and implementation phaseImplement the changesMeasure impact Annotated run chart SPC charts Other graphsNSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)Measure impact of changes/interventionsRecord the results Revise the interventionsMonitor impact
20. Sustaining the improvement phase Sustaining improvement phaseSustain the gains standardization documentation measurement trainingNSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)Once an intervention has been introduced, the intervention and any improvements need to be sustainedThis may involve:standardization of existing systems and processesdocumentation of policies, procedures, protocols and guidelinesmeasurement and review of interventions to ensure that change becomes past of “standard” practicetraining and education of staff
21. Root cause analysisa multidisciplinary teamthe root cause analysis effort is directed towards finding out what happenedestablishing the contributing factors of root causes
22. Performance requirements Know how to use a range of improvement activities and tools flowchartscause and effect diagrams (Ishikawa/fishbone)Pareto chartsrun charts
23. Evidence for there being a problem worth solvingAt the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.
24. Flow chart of processSomething amissReferral to HospitalVisit to general practitionerReferral to surgeonInvestigationsHospital admissionAdmissions officeOperating theatreAdmitted to hospitalPreoperative clinicPost anaesthetic careAllied healthSurgical wardSurgical teamDischarge plannerPre-op wardPain teamHomeCommunity health/Peripheral hospital Return to lifeAccelerated Recovery Colectomy Surgery (ARCS)Jenni Prince Area CNC Pain ManagementNorth Coast Area Health ServiceNCHI Sydney Australia
25. 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 approachCustomer and expectations listsurgical ward staffpost-op anaesthetic care staffphysiotherapy dept dietitianperi-operative unit staffprivate hospital staffpain teamanaesthetistssurgeonsintensivist
26. Cause and effect diagramSocial issuesStaff attitudesComplicationsProcedure Patient perception Post discharge supportProlonged LOSsurgerymobilizationnutritionnil by mouthLOSmobilizationpain controlnutritionexpect long LOShome supportoften weakpoor understanding of procedurelittle knowledge of support servicespain controllocus of control family supportpoor pain controlwound complicationsweak/malnourishedcommunity healthgeneral practitionerinfectionfamilycolon care nurseAccelerated Recovery Colectomy Surgery (ARCS)Jenni Prince Area CNC Pain ManagementNorth Coast Area Health ServiceNCHI Sydney Australia
27. 245742766780100Pareto chart
28. surgical incision trial of transverse incisionpain control wound infusion for transverse incisionsthen patient information booklet surgeon pathway anaesthetic pathway ARCS clinical pathway - surgical technique - pain control - bowel prep/care - nutrition - mobilization 1 surgeon10 patients1 surgeon1-6 patientsPDSA cycles - implementation
29. Run chart Made change here
30. Strategies for sustaining improvement document and report each patient LOSmeasure and calculate monthly average LOSplace run chart in operating theatre, update run chart monthlybimonthly team meetings to report positives and negativescontinuously refine the clinical pathways report outcomes to clinical governance unit Spread - all surgeons - left hemicolectomy - all colectomy surgery - throughout North Coast Area Health Service