improvement science made simple€¦ · improvement science made simple ... recipients ) of goods...

Brought to you by Hamad Healthcare Quality Institute

Improvement Science Made Simple

Dr. Moza Alishaq-Ph.D

Dr. Jameela Alajmi-MD


Objective :

To gain an understanding of:

Quality

Quality improvement

Profound Knowledge

Model of change

Describe the basic principles of quality improvement

introduce the methods and tools for improving the quality of

health care by using Model for Improvement, PDSA and its

Journey

Creativity thinking & Improvement in Decision Making


- UNDERSTAND QUALITY :

Institute of Medicine, is often used:

• [QUALITY is] the degree to which health

services for individuals and populations increase

the likelihood of desired health outcomes and are

consistent with current professional knowledge.


HOW OTHERS LOOK AT QUALITY

`Institute for Healthcare

Improvement (IHI):

“Quality-

is as outcomes management,

minimizing unnecessary variation so

that outcomes become more

predictable and certain.


What does quality in healthcare means?


The Institute of Medicine has identified six dimensions of

healthcare quality.

These state that healthcare must be:

Therefore, leaders need to actively

consider these six dimensions when

setting their priorities

for improvement.

Safe

Effective

Patient

Centered

Timely

Efficient

Equitable


WHAT DO YOU THINK IS QUALITY IMPROVEMENT

Quality improvement. it as a systematic approach that uses specific

techniques to improve quality.

The conception of improvement

better patient experience and

outcomes achieved through

changing provider behaviour and organisation through

using a systematic change method and strategies.

They are combination of a ‘change’ (improvement) and a ‘method’

(tools), in order to achieve better outcomes.


How can we improve a system to achieve better results in the

dimensions of quality

You need to : Know the place of care/service

Know your patients

understand the system is failing –Identify what is wrong.

make sure it is the step that needs fixing.

`Identify processes that can be improved and lead to

better quality of care.

`Then you can implement a change to the “system”.


What would improve quality?

4

1

2

3


1 Understanding the problem,

what the data tell you -

understanding the processes

and systems within the

organisation –patient pathway


Analysing

The demand, capacity and

flow of the service1

2


choosing the tools to

bring about change, and

include:

leadership and

clinical engagement,

skills development,

staff and patient

participation

1

3


Evaluating and

measuring

the impact of a

change

4

1

2

3


Enhance the

relationship

Manage

Time

Manage

variation

9 Categories of Change for Quality Improvement

eliminate

waste

improve

work flow

change

work

environment

design systems

to avoid

mistakes

focus on the

product/service


Knowledge

Of a

System

Knowledge

Of Variation

Knowledge

Of

Psychology

Theory Of

Knowledge

The Deming System Of Profound Knowledge

- Appreciation of a system : understanding the overall

processes involving suppliers, Producers, and customers ( or

recipients ) of goods and services ( explained below );

- Knowledge of variation : the range and causes of

variation in quality, and use of statistical sampling in

measurements;

- Theory of knowledge : the concepts explaining

knowledge and the limits of what can be known.

- Knowledge of psychology : concepts of human nature .

W Edwards Deming


Common Variation=is always present

Is inherent in the process

Special cause =It is irregular causes that are not

inherent in the design of process


Group Activity


Appreciation of a system

What are the resources required to improve

system?

Knowledge of variation

What is your predication about type of

variation?

Theory of knowledge

What are the ideas you would like to implement

to reduce waiting time?

Knowledge of psychology

How are you going to reward the

team?

Reduce Outpatient Waiting Time


Five Deming Principles That Help Healthcare Process Improvement

1. Quality improvement is the science of process

management .

2. If you cannot measure it…You cannot improve it .

3. Managed care means managing the processes of care,

not managing physicians and nurses .

4. The right data in the right format at the right time in

the right hands.

5. Engaging the “smart cogs” of healthcare .


Exercise on Quality

What is the benefit for:

Patients

Staff

Organization


What is ‘‘quality improvement’’ and how can it

transform healthcare

- better patient outcomes (health),

- better system performance (care) and

- better professional development (learning). Everyone

Better

Professional

development

(Learning)

Better patient

(and population )

Outcomes

(Health)

Better

System

Performance

(Care)


Enter

The Stages

Of

Change Model

Precontemplation (Not yet

acknowledging that there is a problem

behavior that needs to be changed)

Contemplation (Acknowledging that there

is a problem but not yet ready or sure of

wanting to make a change)

Preparation/Determination (Getting

ready to change)

Action/Willpower (Changing behavior)

Maintenance (Maintaining the behavior

change)

Relapse (Returning to older behaviors

and abandoning the new changes)


Exercise

• Thinking of not smoking but not now I still thinking

about it

• Stop Smoking didn’t help me to be healthy there is

no difference

• I am thinking of stop smoking, can you help how to

do this?

• It is not the time for me to stop Smoking

• It is my time to keep doing exercise and follow up


S P O- Facilities

- Staff

- Equipment

- Evolutions

- Treatments

- What gets done to

patients

- Survival

- Degree of health

- Time to recovery

- Disability due to care

- Sustainability of health

- Long-term adverse

consequences of care

Donabedian Quality Framework

Structure

Outcome

Process


The Patient Journey Through Hospital System

Emergency

Department

Theatre

P.I.C.U

Ward

Specialist

Clinics

Pharmacy

Medical Imaging

Pathology

Allied Health

Support Services

The Patient experience is a

direct result of how the

different hospital systems

interact and the way staff

work within these systems

to provide patient care.

Please note : The purpose of this diagram is to demonstrate the large number of systems that a patient could pass through on their healthcare journey.

Patient Arrives


Interaction


A female patient 23 years old was admitted to the medical intensive care unit at MBX

hospital due to sudden loss of consciousness and seizures. At the time of admission

observed lack of consciousness, seizures and severe critical condition was

observed. Meningitis and septic shock were diagnosed. Based on computed

tomography performed on the first day--inflammation of the sinuses soft tissues was

diagnosed.

Suspected cause of infection was performed 6 weeks earlier surgical correction of

the nasal septum. In the next stage of treatment on the seventh day after admission

the functional endoscopic sinus surgery was performed.

Due to massive tissue hypoperfusion the necrosis in the skin of the lower limbs

occurred. Due to the lack of effectiveness antimicrobial therapy use of intravenous

ceftaroline was administrated. Effective treatment allowed in day 11 to wean the

patient from the ventilator. At the day 26 the patient was transferred to a hospital in

the place of residence.


Break Time 15 Minutes


- Have you ever attempted to make a change in your personal or professional life and failed;

perhaps a New Year’s resolution?

- Your failure to improve was probably not due to a lack of motivation or a desire to improve,

but rather to a lack of utilizing a good method proven to be effective at implementing change.


We all work with

and within systems:Systems of

communication

1

Reporting

systems

2

Systems for

complaints

3

Systems for distributing

information

4

Systems for issuing

prescriptions or

medication

5


How it has been done so far…

What is the best way to approach change that results in improvement?

Trial & Error?

Chaos

Too much action,

not enough thinking

“Something must be done,

this is something,

therefore we must do it…”

Detailed prior study?

Paralysis

Too much thinking,

not enough action

“We can’t do anything

until we know exactly

what to do…”

“Trial and Learning” Approach


Trial and Learning’ Component Parts

-Setting challenging aims

-Identifying principles/change ideaswhat has worked for someone? What might work for us?

-Measuring progressknowing what’s happening

-Testing changesstarting small; reducing risk

-Implementing and sustaining changechange in systems and routines; developing skills and abilities


Embedded PowerPoint VideoBy PresenterMedia.com


Three fundamental questions for

model of improvement

THE THINKING PART


The 3 Questions

The Model for Improvement begins with three fundamental questions:

◦What are we trying to

accomplish? (How

good do we want to get

and by when?)

1. The Aim:

How will we know a

change is an

improvement?

2. The Measures:

What change can we

make that will result in

improvement?

3. The Changes:


PDSA CYCLE : The Doing Part of the Improvement Model

( test changes)

Plan a change

Do the change

Study the results

Act on the result

Walter Shewhart was the first person to propose a version of the PDSA cycle.

W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "check" with "study.

P

DC

A

P

DC

A

P

DC

A

Hig

her

Qual

ity

Rotation 1

Rotation 2

Rotation 3


What is a PDSA?

• A structured approach for making small incremental changes to systems

• A full cycle for planning, implementing, testing and identifying further changes

• A common sense, easy to understand tool for bringing about change

• A tool which can reduce anxiety to change


PLAN

DOSTUDY

ACT

What changes

are we going

to make

based on our

findings

What were

the results?

What

exactly are

we going

to do?

When and

how did

we do it?


Process Of Applying Model of

Improvement

Example: Quality Improvement Project on

Antimicrobial Stewardship

Heart Hospital-HMC


PLAN

DOSTUD

Y

ACT

What are we trying to

accomplish ?

How will we Know if a

change is an Improvement?

What changes can we make that

will result in improvement ?

Mod

el F

or

Imp

rov

emen

tStep.1

1. Define the problem

2. What exactly are you trying to achieve

3. Refer to the Nolan questions (thinking )

AIM

The aim should be time-specific and measurable; it should

also define the specific population of patients that will be

affected, applicable to specific system.

MEASURE

Working out what to measure, How to measure and collect it

SELECT CHANGES

Organizations therefore must identify the changes that are

most likely to result in improvement. In this section you

will


• A Performance Measure is a quantitative tool that provides an indication of an

organization’s performance in relation to a specified process or outcome.

• Set goals for measures:

A SMART goal is a goal that is specific, measurable, attainable, relevant and

time based.


Process

Compliance with checklist

Outcome

Infection rate

Balance

Cost reduction


BASELINE MEASURES

OUTCOME MEASURES:•The number of VAP/1000 device days will be calculated in monthly basis by using infection control

surveillance form, microbiology lab, and CDC, NHSN standards/guideline

PROCESS MEASURES:•% compliance with VAP bundle

•% Hand Hygiene

•% adhered to the respiratory therapy and sedation vacation protocol.

•% of adherence to intubation guidelines.

•Average Reduce LOS related to VAP.

BALANCEE MEASURES:•Average Patient/relative satisfaction


Main Issue 1

Factor

Factor

Factor

Main Issue 2

Factor

Factor

Factor

Main Issue 3

Factor

Factor

Factor

Factor

Factor

Factor

Main Issue 4

Factor

Factor

Factor

Main Issue 5

Factor

Factor

Factor

Main Issue 6

Problem

or Effect

FISH DIAGRAM – Up to 6 Causes

Scenario-Fishbone

You are working with group of staff from an outpatient clinic wanted to understand what

caused the common problem of long waiting times for outpatient appointments. The

facilitator ask the team involved in the outpatient clinic to meet together and to write the

fishbone analysis tool to clearly on a flipchart and document all the causes of waiting times


Antibiotic

stewardship

infrastructure

Preauthorization

& Restriction

Develop

( clinical Audit )

strategy

Data Monitoring

& surveillance

Global Aim

Implementation

antibiotic

stewardship

program

Specific Aim

Timely and

appropriate use of

antibiotic in acute

care setting by

100% by End of

Dec2015

Outcome measures:

prevalence of

MDRO

Incidence of CD

Process Measures:

Compliance % to

surgical prophylaxis

Utilization rate of

( promoted and

restricted antibiotics)

% De-scalation

Balance Measure:

Mortality rate

Cost reduction %

- Develop anti stewardship multi-displinary team Create Clean lines of accountability:

- Between chief executive

- Clinical governance

- Therapeutic committee

- Infection prevention and control committee

- Periodic release of anti-biogram

- Share surveillance with point of care

- Education point of care

- Develop Antimicrobial review methods

- Use of diagnostic tools

- Audit and direct feedback to prescribers

- Formulary restrictions / approval system

- Antimicrobial Prescribing Policy

- Care pathway /Checklist


To test your change use the PDSA cycle. step.2

Start with a PLAN

Who?

What?

Where?

When?

How?

Predication of the answers to the questions What are you going to measure? Data collection

Do: the action part of the process

Observations are made and recorded include things that were not part of the plan

CONTINUOUS

IMPROVEMENT


Step.2 Aim : Right drug, right dose, right time, right duration for Surgical patients

.

Review in line with HMC guidelines

with H.H OR

SAP

D

PDS

A

SAP

D

PDS

A

PDS

A

Cycle 5: Implement in other all surgical cases

Cycle 1: Testing

prescribing in

CABG pilot

population based

on local policy

Cycle 2: Testing administration

in anesthetic room

Cycle 3: Testing recording timings ; Surgical

prophylaxis ONE DOSE within 60 minutes

before knife to skin

Cycle 4: Testing repeat and /or postoperative doses –

pharmacist /surgeon

*A repeat dose of prophylaxis may be required for prolonged procedures or where there is significant blood

loss. A treatment course of antibiotics may also need to be given in cases of dirty surgery or infected wounds.


Study

- Study the outcome of your measures What worked? Do you need to carry out another PDSA?

- Do you need to involve more people?

- Do you need to generate more ideas?

• What didn’t work and why?

Do you need to change the plan?

Do you need to tweak the original PDSA?

CONTINUOUS

IMPROVEMENT


Act• What changes are you going to make based on your

findings? This will inform your next PDSA cycle

• Document the change you are going

to make and identify future plans

CONTINUOUS

IMPROVEMENT

Brought to you by Hamad Healthcare Quality InstituteMonths


P

DC

A

P

DC

A

P

DC

A

Hig

her

Qual

ity

P

DC

A

P

DC

A

P

DC

A

P

DC

A

P

DC

A

P

DC

A

P

DC

A

P

DC

A

P

DC

A

Create Multiple PDSA Ramps


Scottish Primary Care Collaborative

Borders GP Practice

0

10

20

30

40

50

60

70

80

90

Bas

eline

Mon

th 1

Mon

th 2

Mon

th 3

Mon

th 4

Mon

th 5

Mon

th 6

Mon

th 7

Mon

th 8

Mon

th 9

Mon

th 1

0

Mon

th 1

1

Mon

th 1

2

Mon

th 1

3

Mon

th 1

4

Mon

th 1

5

Mon

th 1

6

Mon

th 1

7

Mon

th 1

8

Mon

th 1

9

Mon

th 2

0

Mon

th 2

1

Mon

th 2

2

Mon

th 2

3

Mon

th 2

4

% o

f P

eo

ple

wit

h D

iab

ete

s

% of Diabetes Patients with a BP<140/80

Diabetes (blood pressure)

Improvements with PDSAs

PDSAs to improve shared

diabetes information with

Secondary Care

PDSA to contact all

Patients who have not

had a BP check in the

last year

PDSAs

PDSAs PDSAs

PDSAs to improve

current patient

recall system

PDSAs to

Validate

Diabetes

Register


Step. 3

Implementing Changes

After testing a change on a small scale, learning from each test, and refining the change through

several PDSA cycles, the team may implement the change on a broader scale — for example, for an

entire pilot population or on an entire unit.

e.g.: Antibiotic prophylaxis in all CBAG patients in TICU


Step. 4

Spreading Changes

After successful implementation of a change or package of changes for a pilot population or an entire

unit, the team can spread the changes to other parts of the organization or in other organizations


The Principles Of PDSAs

- Breaks down change into manageable, bite-sized time-limited chunks

Not audits – snap shots in time

- Small changes can be tested without causing upheaval to the whole system

Tell others what you are doing

- If it doesn’t work, try something different based on your learning

Document what did/didn’t work

D

P A

S

3

Intervention

phase

Diagnostic

phase2

1

Project

phase

4

5

Sustaining

improvement

phase

Impact

phase

Project mission

Project team

Conceptual flow of process

Customer grid

Data

-fishbone

-Pareto chart

-run charts

-SPC charts

2 months

Plan a changeDo it in a small test

Study its effects

Act on the result

2 months

1 month

Annotated

run chart

SPC charts

DP

AS

DP

AS

DP

ASD

PA

S

Ongoing monitoring

Outcome Future plans

Sourced 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 control

The improvement process

http://www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf

1. Once an intervention has been introduced, the intervention and any improvements need to be sustained

2. This may involve:

• standardization of existing systems and processes

• documentation of policies, procedures, protocols and guidelines

• measurement and review of interventions to ensure that change becomes past of “standard” practice

• training and education of staff

Sustaining

improvement phase

Sustain the gains• standardization

• documentation

• measurement

• training

Sustaining the improvement phase

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)


Ali Baba GameDescription: Ali Baba is going to the market to sell all his stock

But he need your help to load his crazy dromedary

Learning Objectives: At the end of this activity, you

will be able to describe how assembling Ali Baba stocks with

a team can help teach the value of iterative tests of change.

Discussion Questions:

Why is assembling something such as with Ali Baba

with a team a valuable way to learn about iterative tests of change?

Why is measurement a critical component of PDSA cycles?

Did you find Ali Baba it effective? Why or why not?


Break time for 15 minutes


The Six Thinking Hats


Six Thinking Hats – Team

Decision Making

Early in the 1980s Dr. de Bono invented the Six Thinking Hats method

The six hats represent six modes of thinking and are directions to think rather than labels for thinking. That is, the hats are used proactively rather than reactively

The method promotes fuller input from more people. In de Bono's words it "separates ego from performance".

The key theoretical reasons to use the Six Thinking Hats are to:

encourage Parallel Thinking

encourage full-spectrum thinking

separate ego from performance


Logical Positive

Think of sunshine: this stands for

optimism and the logical positive view

of things

The yellow hat looks for feasibility and

how something can be done

Example:

This might work if we moved the

production plant nearer to the customers

The benefit might come from repeat

purchases


Feelings & intuitions

Color of fire

Has to do with feeling, emotions, and high

intuitions

The red hat gives permission to put these

forward without apology or explanation

Example:

this is what I feel about this project,…

I don’t like the way that this is being done


Critical Judgement

This is the caution hat

Th black hat prevents us from making

mistakes or doing silly things

Example

The regulation don’t permit us to do

that

We don’t have the production capacity

to do that


Creative Thinking

Is the color of vegetation

The green hat is for creative idea,

new idea, additional alternative

Example

We need some new ideas here….

Are their any additional alternative?


Information & Data

The white hat is neutral: it caries

information.

it has to do with data and

information.

Example

What information do we have here?

What information is missing?

How we are going to get the information?


Control of thinking process

Think of the sky

Blue hat is for process control

This hat ask about how we are thinking

the blue hat set the agenda for thinking,

summary, conclusion, decision,…..

Example

Could we have a summary

Could we have decision


Main benefits of Six Thinking Hats Methods:

1.Allow to say things without risk2.Create awareness that there are multiple perspectives on the issue at hand3.Convenient mechanism for “switching gears”4.Rules for the game of thinking5.Focus Thinking6.Lead to more creating thinking7.Improve communication8.Improve decision making


• Scenario:

Increase numbers of surgical site infection post Cesarean

section from Jan 2016- April 2017


1

2

3

4

5

6

7 leadership for change

spread of innovation

improvement

methodology

transparent measurement

system drivers

engagement to mobilise

rigorous delivery

Change Model, highlights the following key areas for consideration:

improvement science made simple€¦ · improvement science made simple ... recipients ) of goods...

Documents