INTRODUCTION TO

QUALITY IMPROVEMENT

BOSTON EMA PART A

ALL PROVIDERS TRAININGAPRIL 25, 2018

BOSTON PUBLIC HEALTH COMMISSION

OFFICE OF ACCREDITATION AND QUALITY IMPROVEMENT

LEARNING OBJECTIVES

Understand the importance of quality

improvement.

Understand systems thinking and process

improvement.

Understand the model for improvement and

the Plan-Do-Study-Act (PDSA) cycle.

Understand the adapted 10 step improvement

process.

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WHAT IS OUR VISION?

99%

3

WHAT DO WE TELL CLIENTS?

4

Take your

medications

See

your

doctor

Eat

well

SYSTEMS THINKING

A network of processes and input that work together to

accomplish a purpose

A process is a series of steps directed toward some end

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5

DETERMINANTS OF HIV OUTCOME

6

BPHC Health Inequities Framework

WHAT IS QUALITY IMPROVEMENT?

QI is a deliberate process to continuously improve

Efficiency, Effectiveness, Equity, Satisfaction in the

current process/system.

BPHC model: Adapted model for improvement

10 step improvement process

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MODEL FOR IMPROVEMENT

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Associates for Process Improvements

Institute for Health Improvement

The PDSA Cycle

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WHY TEST?

Increase the belief that the change will result in

improvement

Predict how much improvement can be expected

Learn how to adapt the change

Increase knowledge by learning

Minimize resistance upon implementation

Engage staff by starting small with willing team

members

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The Improvement Guide, Second Edition, Jossey-Bass, March, 2009

TYPES OF CHANGE THAT LEAD TO

IMPROVEMENT

1. Reactive Change• E.g. Hiring 10 additional case managers

2. Chance Improvements• E.g. “Unexplained” 5% improvement in

eligible Ryan White clients receiving

Housing Search and Advocacy Services

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3. Fundamental Change• E.g. Adjusted housing process that resulted in 5% improvement

in eligible Ryan White clients receiving Housing Search and

Advocacy services

EXAMPLE 1

• A Fishbone diagram and Pareto chart revealed patient contact information was not updated in a timely manner, preventing reminder calls for appointments

Plan

• Mail bins were mounted on clinicians doors so that updated contact information could be included in patient charts immediately

Do

• After 8 weeks, the no-show rate dropped from 22% to 12%Study

• The clinic will continue to use file folders to ensure accurate filing of update formsAct

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Background: Analysis showed that 78% of HIV positive patients showed for

appointments at the HIV Positive Patient Care Clinic in Portland, OR. The 22%

who did now show cost the clinic valuable staff time and money

AIM: Reduce the no-show rate among HIV positive health care patients by 50%

(from 22% to 11%) over 6 months

Increase in the Patient Show Rate at the HIV Positive Health Care Clinic; PHQIX;

https://www.phqix.org/content/increase-patient-show-rate-hiv-positive-health-care-clinic

IMPROVING QI JOURNEY

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NACCHO’s Roadmap to a Culture of Quality Improvement

Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6

No

Knowledge

of QI

Not

Involved

with QI

Activities

Informal

or Ad Hoc

QI

Activities

Formal QI

Activities

Implemented

in Specific

Areas

Formal

Agency-

Wide QI

QI Culture

Leadership

and staff do

not

understand

QI

Leaders

understand

and staff are

beginning to

understand

QI

Staff may

view QI as an

added

responsibility

Multiple QI

champions are

well known

among staff as QI

experts and

mentors

Several QI

champions

exist

throughout the

agency

QI knowledge

and skills are

strong across

majority of

staff

Agency

performance

is not

monitored;

decisions are

not data-

driven

Simple,

informal

elements of

QI exist

(evaluation

activities,

some data

collection)

Discrete QI

projects may

occur but not

fully aligned

with steps in

a QI model

Use of formal QI

is well used in

certain areas of

the agency

Progress and

outcomes

related to QI

and strategic

goals are

reported widely

and routinely

Every staff

member is

held

accountable

with QI

competencies

in evaluations

BREAKOUTS

Time Red Blue Green Yellow

(30’) Red Bead

Game

AV1

Red Bead

Game

AV1

Mr./Ms.

Potato Head

activity

AV2

Building

Healthy

Communities

AV3

(10’) Break

AV1

(30’) Mr./Ms.

Potato Head

activity

AV2

Building

Healthy

Communities

AV3

Red Bead

Game

AV1

Red Bead

Game

AV1

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RED BEAD GAME

AV1

Round 1: Red and Blue

Round 2: Green and Yellow

RED BEAD GAME

Reflection questions:

How did it feel to work for the bead company?

Were the supervisor interventions helpful? Why or

why not?

Why did we get the results we got?

If we wanted to get different results, what are some

things we could do?

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MR. AND MS. POTATO HEAD AV2

Round 1: Green

Round 2: Red

Adapted from Mr. Potato Head PDSA Collaboration, David M. Williams, Ph.D.

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1. A room with round tables of 6-8 participants.

2. A Mr. Potato Head. (See Figure 1)3. Flip chart paper visible to all

participants displaying the accuracy score operational definition:

• 3 – All pieces on Sam & positioned correctly

• 2 – All pieces on Sam, but one or more is out of place

• 1 – One or more pieces are not on Sam.

4. Flip chart (adhesive or with masking tape) with a pre-drawn table for PDSA atiowo run charts at each table. (See Figure 2)

5. Markers for each table for documenting on flip chart paper.

6. A timekeeper able to capture minutes and seconds at each table.

Each team should have

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BUILD 2 MR. AND 1 MS. POTATO HEADS

FROM HEAD TO TOE IN 2 MINUTES

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ROLES

20

THE PERFORMANCE MEASURES

OF YOUR TESTS

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Effectiveness (rank 1-5)

5: All pieces are on Mr. Potato

Heads and positioned and oriented

correctly

4: All pieces on Mr. Potato Heads

but one or more is not well

positioned or oriented

3: One piece is missing from Mr.

Potato Heads

2. Two - five pieces are missing

from Mr. Potato Heads

1. More than 5 pieces are missing

from Mr. Potato Heads

Efficiency (time)

Start: When time keeper says go

Stop: When Ryan White Expert

indicates last piece is in place or at the

end of 2 minutes.

Equity (rank 1-5)

5. Mr. and Ms. Potato Heads have all

pieces completely

4. Difference of one piece

3. Difference of two or three pieces

2. Difference of four or five pieces

1. More than five piece difference

Before running the first test, teams

discuss and complete their PLAN:

What questions are you trying to

answer? (will building from head to toe

be the fastest and most equitable way

to complete Mr. and Mrs. Potato

Heads?)

What are your predictions for this

current process?

Teams will repeat this cycle 4 times.

INSTRUCTIONS

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REFLECTIONS

Reflections

BUILDING HEALTHY

COMMUNITIES

AV3

Round 1: Yellow

Round 2: Blue

RULES OF THE GAME

1. Teams will have 2 Healthy Community Builders, 1 Time Keeper, 1

Building Inspector, and 1 Change Agent

2. Each team will be responsible for assembling two components of a

healthy community: a community garden, and a fresh produce

truck.

3. Using plastic blocks, assemble the two sets accurately and in the

shortest amount of time possible

5. Repeat for rounds 2, 3, and 4

6. Record your time for each cycle25

ROLES OF THE GAME

➢Ready?

➢Set.

➢GO!

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CYCLE 1

Time:

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CHANGE AGENT: IMPLEMENT

CHANGE 1

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CYCLE 2

Time:

30

CHANGE AGENT: IMPLEMENT

CHANGE 2

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CYCLE 3

Time:

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CHANGE AGENT: IMPLEMENT

CHANGE 3

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CYCLE 4

Time:

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REFLECTIONS

Reflections

WHAT SMALL CHANGES HAVE YOU APPLIED?

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