basics of quality improvement - healthinsight · the model for improvement pdsa cycles . what are...

Learning & Action Networks Session

Basics of Quality Improvement

Basics of Quality Improvement

Nov. 14th, 2013

David Cook Director of Operations [email protected]

This material was prepared by HealthInsight, the Medicare Quality Improvement Organization for Nevada and Utah, under contract with the Centers for Medicare & Medicaid

Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-UT-2013-PO-78

mailto:[email protected]

Jordan Meadows Clinic Deb Bowen, Billing Manager

Quality Improvement Example Deb Bowen, Billing Manager

Objectives

1) Introduction Blame Free Culture 2) Gap Analysis 3) The Model for Improvement (PDSA) 4) Workflow Analysis/Flowcharting Basic

What would you like to gain from todays

session?

Questions?

Introduction Blame Free

The best people can sometimes make the worst errorsWe cannot change the human condition. People will always make errors and commit violations. But we can change the conditions under which they work to make these unsafe acts less likelyBlaming people for their errors though emotionally satisfying will have little or no effect on their future fallibility..Errors are largely unintentional. It is very difficult for management to control what people did not intend to do in the first place.

James Reason Managing the Risks of Organizational Accidents, p.153.

Quality Assurance vs. Quality Improvement

Embracing Quality in Public Health: A Practitioners Quality Improvement Guidebook p. 18

The Model for Improvement PDSA cycles

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 improvement?

Set the AIM

Establish MEASUREMENT

PLAN for Improvement

Identify the Gap

The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996

Lean Domestic Goddess - Video

http://www.cfmc.org/lanncc/files/dlg_5-10-13.html

http://www.cfmc.org/lanncc/files/dlg_5-10-13.htmlhttp://www.cfmc.org/lanncc/files/dlg_5-10-13.htmlhttp://www.cfmc.org/lanncc/files/dlg_5-10-13.htmlhttp://www.cfmc.org/lanncc/files/dlg_5-10-13.htmlhttp://www.cfmc.org/lanncc/files/dlg_5-10-13.htmlhttp://www.cfmc.org/lanncc/files/dlg_5-10-13.html

Recognition of Quality Gap Opportunity for Improvement

Can be a vague impression (hunch) Report review Adverse events We want a better outcome (hope)

Cause and Effect Tools Quality Gaps

Fishbone 5 Whys Toyota Root Cause Analysis (RCA) not covered today

(see www.healthinsight.org) Failure Modes and Effects Analysis (FMEA) not

covered today Event Tree and Fault Tree Analysis

http://www.healthinsight.org/

PDSA Worksheet for Testing Change Instructions: Fill out for each test conducted. Replace Italicized statements Cycle#:_ Date: ____

Gap: Statement of improvement opportunity or gap in quality.

Aim: Statement of achievable goal including numerical measure and timeframe.

Overall Plan: Statement of overall improvement action plan or strategies.

Jrl Plan First (or next) change: Describe your first (or next) test of change. What is the first tactic? tan

Prediction: What will happen when the test is carried out? Do

.. ~ Tasks Needed: List the tasks needed to set up this test of change (who, what, where, when)

Data Collection: Plan for collection of data (who, what, where, when)

Do Describe what actually happened, including problems and unexpected observations, when you ran the test.

Study

Describe the measured results and how they compared to the predictions. Summarize and reflect on new knowledge learned.

Act :\.. ..Describe what modifications to the plan will be made for the next cycle from what you teamed. / r . .Y.

Adapted from lnst1tute for Healthcare Improvement FOSt>. worksheets -www.ihi .erg

Exercise #1

Take a minute and review from your recent experience one opportunity for improvement or

quality gap

Please write it down

The Model for ImprovementPDSA cycles




Set the AIM

Establish MEASUREMENT

PLAN for Improvement


Step #1 - Setting the AIM What are we trying to accomplish?

State the aim clearly (SMART acronym) Include numerical goal and time frame that

require fundamental system change Set stretch goals Avoid aim drift Be prepared to refocus the aim

Step #2 - Establishing measures How will

we know that a change is an improvement?

Plot data over time Seek usefulness, not perfection Use sampling Integrate measurement into the daily routine Use qualitative and quantitative data

Exercise #2

Take a minute and write an AIM statement based on the improvement opportunity

identified in Exercise #1

Remember to include a numeric goal (measure)

and time frame

Step #3 Overall Plan for Improvement

Avoid the same responses Implement recommended practices guidelines Think processes and systems of work

Simplify processes Reduce waste or unnecessary redundancies Strengthen hand-offs

Creative thinking Appropriate use of new or existing technology

Step #3 Overall Plan for Improvement

1) Describe change (strategies) 2) Predict outcome 3) List steps needed 4) Plan for collection of data

http://www.ihi.org/knowledge/Pages/Changes/UsingChangeConceptsforImprovement.aspx

http://www.ihi.org/knowledge/Pages/Changes/UsingChangeConceptsforImprovement.aspx

Exercise #3

Take three or four minutes and outline

your Global Plan

1) Describe change (strategies) 2) Predict outcome 3) List steps needed 4) Plan for collection of data

The Model for Improvement PDSA cycles




Global AIM, Measure, and Plan (Strategies)

Smaller Tests (Tactics)


PDSA (Plan-Do-Study-Act)

Also known as: PDCA (Check instead of

Study) The Deming Cycle/Wheel The Shewart Cycle The Learning and

Improvement Cycle


1) Describe first (or next) change (tactic)

3) List tasks needed 4) Plan for collection of data

Plan

Sequence:

2) Predict outcome

Implement (preferably on a small scale) Document problems and unexpected

See plan through to completion Motivations to carry it out

DO Carry it Out

observations

Study or Check What did we learn?

not?

Review the data / take survey Compare the data to your predictions What worked or went well? What did

Summarize and Reflect on what was learned -- Draw Conclusions

ACT

Adopt it Abandon it More study

needed Modify overall

aim, measure, or plan

Create new plan

The Team Handbook (Scholtes, Joiner, Streibel). Madison, WI, USA: Oriel Incorporate, Inc.; 2003 page 5-27

Rapid Cycle - Multiple Cycles

Overall AIM Increase documented eye exams for our diabetes population by 45% in the

next 12 months

Time

Expect Challenges and Barriers

Cycle #1 Contact Eye Doctors

Cycle #2 Patient Fax Back Form

Cycle #3 Front Office track down eye results

Cycle #4 Computer Network with eye doctors

Cycle #5 Reminder letter from PCPs

Implement Final Changes

The Model for Improvement PDSA cycles - Summary





Every system is perfectly designed to

get the results it gets.

Paul Batalden, M.D.

Tool - Workflow Analysis/Flowcharting

Opportunity for end user to step back and evaluate current processes and methods

Linear visual representation of a process to facilitate discussion and improvement

Complete previous to causal analysis Various types (e.g. Swim Lane, Simple, Process

Mapping) Current State/Future State

Basic Flowchart Symbols

Start or End Symbol

Flow of Control Symbol

Process Step Symbol

No

Decision Symbol Yes

Connector Symbol (end of page)

Delay or Wait Symbol

Flowcharts can be created with stickies, whiteboards in Microsoft PowerPoint, Word, Visio and many others

Workflow Flowcharting

Examples

(Names removed)

Process Analysis

Pathologist-on-Call Process- HAND-OFFS (Accept, Control, or Eliminate)

c 1 Step1 1 1 Step2 1 I Step3 I I Step4 I I Step5 I I StepS I I Step7 I

c (0 Places call to tocal l 'ACcEPT May be able to Fields call for u Receives answer . !:!.1 'iii lab or directly control somewhat wilh clarification (3 >. marketing and educational

(\ \ .s::. / (i e. website and phone D.... number on reports) ~ 2:-

CONTROL - ~w CS tomplate to COf'fTROL - I \ ELl lit INA TE ~most) TIME \ be developed lncluoo. among Conference PRS and WASTE AREA - Control c .9 rs 11 time expectation for then conference (dtrecl I j Fields call for\ measures of conferencing .!:!.1 ~ Takes physician .tum call. 2) Pushing Pathnet ca I) pathologist before clarlncauon patholog sts and recording (3 0

qu9SIIon. passes eport to Pathologist Printer 3) page Racorded phone

(\ \ phone calls could hal p to

.0 on to rinl other supporting . : ca Is would help eliriWlale k:Jis ol this waste . (0 -I /l : docurnentatoon 4) Record Phone elimonate some pages -Call 5) Conforonco PRS -

c.. / ~ \ Q) I TakE!$ call; a::: gets patien11 a1hologis Yes PagePalh I lOllS call j required? on can I c""""'----'-'"re '""""" 'J U) lest info. \ () )) on call with robust yearly training. Including: 1) [~ Meetings and conferences allowed while on call. 2) Unaoceptable tune frame to research and respond to Issue client. 3) Somple proc. as resodenls change yearly. 4) CIIGnt c larfcatlons soer.anos c v . .....___ I 0 \

-(ii COf'fTROL - Should the Researches question.

patholOgist on call be .I Calls lab and/or , ~ Calls physician or o, = ... 1 Receives page; 1 May require one or more 0 (0 pl1ysocally localod c losor calls back 1o gol I I physldan to clarify calls 1o resources. -to client lab back --1 Logs call I c;o to CS?? will\ answer to

.r::: call info questoo. e g. technical section and/ question -ro - or medical director a... l't

] ""':.~"~, 1\ P::::;n I ro C) aboullesl .red Yes Logs call 1 = c . availability requr call I

Workflow for Troubleshooting

- Prescription refi ll Timeslots:

Patient

I Needs RX refill I

Front office staff

Patient call Charts to be fi led

I Request routed to Nurse/MA I File chart I

/ EHR can streamline this process I No more lost charts!!

Nurse/MA / I I Calls Office I Phone call from FO or Fax Pulls Chart Review request, look at notes Request can be reviewed from ~

EHR messaging system

Medication drug-drug and drug-allergy interactions built into

Consult with Doctor (as needed) Note in chart

I Calls PharmacyJ Provider " Pharmacy ~ Patient call

Take Rx request Fax request to office

MA or Provider

Insurance (Paula)

Billing (Roger/Craig)

Workflow (Swim Lane)

Simple Workflow Example

Step 1 Step 2 Step 3 Step 4 Step 5

MAIN SCOPE

Doctor Requisitions lab test

Lab packs and Sends Sample

Specimen Receiving processes sample

Bench Tech gets Bucket and Bring to Lab

The sample is digested and run

STEP 4 Bench Tech Gets Bucket and Brings to Lab. 4a. Bucket with blue lined samples is obtained *4b. The Samples are wanded at the computer *4c. Sample goes to the cardboard box until next run. *4d. Sits in Box for up to a week 4e. Every Monday new worklist built 4f. Samples prepared for run

* Focus area for failure modes

Exercise - Lets Try a Workflow

Flow chart how you would triage email coming to your inbox

Starting circle Message in Inbox

Bibliography

Cook, David - National Diabetes Education Program Improve Practice Quality website http://ndep.nih.gov/hcp-businesses-and-schools/practicetransformation/improve-practice-quality/index.aspx

Embracing Quality in Public Health: A Practitioners Quality Improvement Guidebook

The Team Handbook (Scholtes, Joiner, Streibel). Madison, WI, USA: Oriel Incorporate, Inc.; 2003

Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619622. Available at http://www.bmj.com/content/312/7031/619.full

Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009.

Moen R and Norman CL. "Circling Back: Clearing up myths about the Deming cycle and Seeing How it Keeps Evolving." Quality Progress, American Society for Quality. 2010; 22-28. Available at http://www.apiweb.org/circling-back.pdf

http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-practice-quality/index.aspxhttp://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-practice-quality/index.aspxhttp://www.bmj.com/content/312/7031/619.fullhttp://www.apiweb.org/circling-back.pdf

Questions ???

Contact Info: David Cook, HealthInsight

801-892-6623 [email protected]

mailto:[email protected]

7 Step Process PDSA - IHI

1. Form a Team 2. Set an Aim 3. Establish Measures 4. Identify Changes 5. Test Changes 6. Implement Changes. 7. Spread Changes

Classifying PDSA cycles

Model The Chronic Care

(Mid-level Theory) Clinical Information

Systems Delivery System

Design Community Decision Support Self Management Organizational

Support

Human Factors Science (Micro-level Theory) Actors Behaviors Decisions Habits

R Oil

he b o ic

. 1f-

ID rmrot u port

0 n

p

:re odcl

h re

up port

http://www.improvingchroniccare.org

http:http://www.improvingchroniccare.org

6 Sigma

Developed by Motorola - used extensively by GE

Zero defects (3-4/million in healthcare) Emphasis on quantitative results. Process

Improvement is the backbone DMAIC for improvement (define, measure,

analyze, improve, control) DMADV for new processes (define, measure,

analyze, design, verify)

Lean (Toyota)

Value chain: remove waste from processes, do only what adds value

Root cause analysis Exploit technology Some unique tools (Poke Yoke, A3 form) Just in time production

Standardized work Continuous flow Pull

Basics of Quality ImprovementBasics of Quality ImprovementJordan Meadows ClinicDeb Bowen, Billing ManagerObjectivesWhat would you like to gain from todays session?Questions?Slide Number 6Introduction Blame Free Quality Assurance vs. Quality ImprovementThe Model for ImprovementPDSA cyclesLean Domestic Goddess - VideoRecognition of Quality Gap Opportunity for ImprovementCause and Effect Tools Quality GapsSlide Number 13Exercise #1Slide Number 15The Model for ImprovementPDSA cyclesStep #1 - Setting the AIM What are we trying to accomplish?Step #2 - Establishing measures How will we know that a change is an improvement?Exercise #2Slide Number 20Step #3 Overall Plan for ImprovementStep #3 Overall Plan for ImprovementExercise #3Slide Number 24The Model for ImprovementPDSA cyclesPDSA (Plan-Do-Study-Act)PlanDO Carry it OutStudy or Check What did we learn?ACTRapid Cycle - Multiple CyclesThe Model for Improvement PDSA cycles - SummarySlide Number 33Slide Number 34Tool - Workflow Analysis/FlowchartingBasic Flowchart SymbolsWorkflow Flowcharting Examples (Names removed)Process AnalysisWorkflow Identify hand-offsWorkflow for Troubleshooting Workflow (Swim Lane)Simple Workflow ExampleExercise - Lets Try a WorkflowSlide Number 44Bibliography Questions ???7 Step Process PDSA - IHIClassifying PDSA cyclesSlide Number 496 SigmaLean (Toyota)

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