CA to QI: Advanced skills session
Nancy Dixon, Director of Strategic Services
Healthcare Quality Quest (HQQ)
www.hqip.org.uk
Copyright © Healthcare Quality Quest, 2014
ClinicalAudit toQualityImprovement — Advanced skills
How can benchmarking, statistical processcontrol tools and demand-capacityanalysis support clinical audit
What’s involved in benchmarking
What’s involved in SPC
What’s involved in demand-capacityanalysis
The way forward
How can benchmarking, statistical processcontrol tools and demand-capacityanalysis support clinical audit
What’s involved in benchmarking
What’s involved in SPC
What’s involved in demand-capacityanalysis
The way forward
Quality improvement tools — How can they support clinical audit?
What is the nature of the cause of the variation in practice?
Do clinical audit findings ever question —
Do we have the resources needed to meetthe quality expectations measured by theclinical audit?
How do other NHS Trusts have so muchbetter results on a national clinical audit?
How can benchmarking, statistical processcontrol tools and demand-capacityanalysis support clinical audit
What’s involved in benchmarking
What’s involved in SPC
What’s involved in demand-capacityanalysis
The way forward
Benchmarking is the process of measuring and improving
products, services and practices in comparison tothe toughest competitors
or those organizations that are recognized as industry leaders
Benchmarking is about searching for ‘best-in-class’, finding out how they achieve
best performance and learning from the processes that
produce best performance
Establish improvement objectives based on aninformed view of what others do and achieve
Benefits of benchmarking
Learn about best practices in the field
Challenge thinking about what can be achieved
Learn about options for improvement
Provide a basis for decision-making on changesin practice
Achieve performance that is comparable orsuperior to others
Apply valid measures of quality
Provide an evidence-based approach to test performance
Benchmarking Benchmarks
Process of measuring and learning
Comparative data or targets=
=
Define what is to be benchmarking and the objective of benchmarking
Identify the best performers
Identify your organization’s performance onwhat is being benchmarked
How to do benchmarking — properly
Identify the performance of the best organization
Find the ‘gaps’ in care
Learn the process of the best organizationin relation to the gaps
Learn your organization’s process inrelation to the gaps
Identify where changes can be made in yourorganization’s processes to be closer to the processof the best organization — and implement changes
Measure the impact of the change
Work collaboratively with yourbenchmarking ‘partner’
How could you use benchmarking withnational clinical audits?
Can you identify best performance fromthe report?
Can you find the best performers?
For a national clinical audit —
Can you identify gaps between best andyour organization’s performance?
Can you arrange to learn from the best?
How can benchmarking, statistical processcontrol tools and demand-capacityanalysis support clinical audit
What’s involved in benchmarking
What’s involved in SPC
What’s involved in demand-capacityanalysis
The way forward
The team has to guess at the nature of any variation
Single-value statistics —such as a percentage —can hide variation
The team has a method for identifying the nature of the variation
SPC tools — run chartsand control charts —can highlight variation
Statistical process controlis a way of thinking about work
processes and tools —run charts and control charts
— to analyse variation in work processes
Types of variation
Common cause
Special cause
Common cause variation is variation in a process that –
results from the way a process is usually carried out
is random – no one cause
A process with common cause variation —
Is stable statistically
Has a known capability — you know how or how well the process works
Is predictable — you can tell how the process will work in the future
Is in statistical control
Special cause variation is variation in a process that –
results from factors that are not the way a process is usually carried out
has a special cause
A process with special cause variation —
Is not stable statistically
Does not have a known capability
Is not in statistical control
Is not predictable
A run chart is a display of data points in chronological order of the events represented by the
data, that is, the data points are plotted in the order in which
they occurred, for the purposes of finding the amount and type
of variation
Apply rules to your run chart
A rule appears special cause
A rule doesn’t appear common cause
=
=
Rule 1 — Shift
4
3
2
1
8
7
6
5
10
9 n = 25
0
11 13 15 17 19 21 23 251 3 5 7 9
MeasureMedian
Observations over time
Mea
sure
Median = 4
Rule 2 — Trend
Median = 10n = 25
11 13 15 17 19 21 23 251 3 5 7 9
MeasureMedian
8
6
4
2
16
14
12
10
18
0
Mea
sure
Observations over time
Rule 3 — Repeating pattern
0
20
15
10
5
35
30
25
Median = 17n = 25
Mea
sure
11 13 15 17 19 21 23 251 3 5 7 9
MeasureMedian
Observations over time
How to anticipate the type of action needed
Type of action
Commoncause Fix the process
Specialcause
Find and fix the special cause
How could you use run charts for clinical audits?
Can you identify consecutive caseperformance?
Can you plot a run chart?
For a clinical audit —
Can you plan the right type of action?
Can you apply the rules?
How can benchmarking, statistical processcontrol tools and demand-capacityanalysis support clinical audit
What’s involved in benchmarking
What’s involved in SPC
What’s involved in demand-capacityanalysis
The way forward
A team may need to know —
How much service does the current process actually deliver?
How much service could the current process deliver?
How much resource does this current process take?
How does the current amount of service compare with the amount of service needed?
What can be done to meet demand?
Demand-capacity analysis is a process to determine the
demand for and the capacity of a process or service in order to
make decisions on actions needed to balance
demand and capacity
Demand (workload to be met)
Capacity (potential
workload that can be met)
Activity(actual
workload met)
Demand is the amount of service required — the workload to be met expressed as:
Count of people or things or
Amount of time needed to meet the demand,that is, provide amount of service required
Demand may fluctuate — but if a process is capable of meeting demand, a smooth demand
results in a smooth process flow
Capacity is the amount of servicethat could be delivered by a current process
and available resources — the potential workload that could be met expressed as:
Count of people or things or
Amount of time the service is able to provide
Capacity varies according to theresources available and how well a process
works
Activity is the amount of service actually delivered — the actual throughput or
workload met by a current process and available resources expressed as:
Count of people or things or
Amount of time the service was provided
Activity varies by needs, number and experience of staff, functioning of needed resources and
the efficiency of processes
Queue is the number of people or thingsthat are waiting for a service to begin
Queues form when a process is operating close to or at capacity or when there is a
high degree of variation in demand
When to use demand–capacity analysis — to improve
Continuous process flow — avoiding stopping
Cycle time of a process — how long the process takes from beginning to end
Access to a service including waiting times
Ensuring that resources are provided at the right time in the right amount and in the
most efficient way
Demand–capacity analysis relies on —
Non-value-added steps
Process analysis
Bottlenecks
Run charts
Statistical process control
Control charts
How could you use demand-capacityanalysis for clinical audits?
Can you identify demand, capacity andactivity?
Can you identify shortcomings in demand,capacity and activity?
For a clinical audit —
Can you plan the right type of action?
How can benchmarking, statistical processcontrol tools and demand-capacityanalysis support clinical audit
What’s involved in benchmarking
What’s involved in SPC
What’s involved in demand-capacityanalysis
The way forward
The way forward
Benchmarking
Statistical process control charts
Demand-capacity analysis
What are opportunities for using the qualityimprovement tools in clinical audit —
What are the barriers?
www.hqq.co.uk
Copyright © Healthcare Quality Quest, 2014
ClinicalAudit toQualityImprovement — Advanced skills