Quality Improvement MethodsCHPCA 2014 Learning Institute

Banff, Alberta

Brigette Hales, M.Sc.Department of Quality & Patient SafetySunnybrook Health Sciences Centre

Canadian Hospice Palliative Care Association Learning Institute 2014

Presenter Name : Brigette Hales

Relationships with commercial interests:No relationships with commercial interests

Faculty/Presenter Disclosure

Learning Objectives

• Establish a clear improvement goal for an improvement project

• Plan effective rapid cycle improvements using the PDSA cycle model

• Understand the importance of QI measurement and how to select indicators

• Appreciate the importance of good survey design, data collection and the ethics of quality improvement

• Incorporate change management skills in order to enhance improvement projects

Pulse Check

• How many of you have had some formal training in QI?

• How many of you have ‘done’ QI?

• How many have an improvement project / goal in mind this morning?

Theory & Science of Quality Improvement

• Total Quality Management• Lean / Six Sigma• CQI• Theory of constraints• TRIZ• The Model for Improvement / PDSA • FOCUS• Knowledge Translation / Evidence Based Medicine• Complex Adaptive System (Complexity Theory)• Human Factors / Systems Thinking• SQUIRE

Common Themes

• Importance of planning and preparation• Stakeholder engagement• Understanding your environment/culture• Effective communication• Importance of measurement /evaluation

The Importance of Stakeholders

• Identification of internal, external and key stakeholders is critical to ensuring successful change

• Stakeholders are your partners in refining what improvements need to happen

• They will also determine how well your improvement is sustained

Assessing your environmental readinessReference: RNAO Clinical Guideline Implementation Toolkit

• Structure• Workplace culture• Communication systems• Leadership support• Knowledge, skills & attitudes• Resources• Interdisciplinary relationships

What are we trying to accomplish?

How will we know a change is an

improvement?

What changes can we make that will result in

improvement?

AIM

CHANGES

MEASURES

Model for Improvement & Rapid Cycle Improvement

Plan

Do

Study

Act

PDSA Cycles for rapid testing & implementation of

changes

The Model for Improvement(Langley, Nolan, et al. Improvement

Guide, 1996)

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make that will result in improvement?

AIM

CHANGES

MEASURES

Model for Improvement

The Model for Improvement (Langley, Nolan, et al. Improvement Guide, 1996)

Aim Statements

A good Aim Statement will: • Be clear, concise and specific• Define WHAT we are accomplishing, not HOW we will

accomplish it• Allow us to know when we have accomplished the

task• Direct us on what we will need to measure• Answer the question: what problem are you trying

to solve?

Aim Statement examples

• Reduce the incidence of hospital-acquired pressure ulcers to below the provincial benchmark by March 31, 2015

• Eliminate opioid-related critical incidents by end of FY2014/15

• Increase satisfaction with end of life care (overall score) to above provincial ‘high performer’ by December 2014

• Reduce wait time for palliative care beds to below best quarter performance by April 2016

SMART Objectives

SPECIFIC

MEASUREABLE

ACHIEVABLE

REALISTIC

TIMELY

Creating an Aim Statement

• At your table: select one project and take 5 minutes to create an Aim Statement

• Remember: what problem are you trying to solve?

• Aim Statement: _____________________________________________________________________________________________________________________________________________

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make that will result in improvement?

AIM

CHANGES

MEASURES

Model for Improvement

The Model for Improvement (Langley, Nolan, et al. Improvement Guide, 1996)

What do you measure?Type of improvement measures (indicators): • Outcome measures are tracked over time to

monitor whether the goal / aim has been achieved. • Process measures are tracked to ensure changes to

the process/system are taking place. • Balancing measures are tracked to ensure other

parts of the process/system are not being disrupted by the changes (adverse effects)

In other words…

Outcome Measures What’s the problem you’re trying to fix?

Process Measures

What NEW behaviours or practices are you trying to promote to fix that problem?

Balancing Measures

What unintended / unforeseen problems might we cause if wemake this change?

Example of indicatorsAim: Improve satisfaction with end of life care (as measured by the

end of life survey tool) to greater than the provincial highest performer by December 2014

Outcome Measures

Percent positive score (8 – 10): “Overall satisfaction with end of life care”

Process Measures

Percentage of patient receiving all comfort measures (as defined by standard order set) Percentage of family members who received the “What to expect…” support materials Percentage of patients/families with automatic spiritual care and palliative care consult

Balancing Measures Workload

Selecting your indicators

TAKE 5 MINUTES:

• What would the ‘outcome measure’ be for the initiative you are supporting?

• What might a possible ‘process measure’ be?

Exercise: The Standard Pig

• Your customer wants a drawing of a pig• Your supplies are a plain piece of paper and a

pen or pencil• You have 40 seconds

Reference: Kaiser Permanente 2013: Center for Health System Performance (Lisa Schilling)

Define what you are collecting

• Clear definition of what you are capturing and how you’re capturing it:– Sample (all patients or subset?)– Date / timeframe (per shift? per day?)– Inclusions / exclusions (eligibility)– Bundle or individual measures?

– Could someone take your data collection tool or graph of your data and collect EXACTLY the same information?

Ethics of QI Data Collection

• Fair participant selection (surveys)• Positive benefit/risk ratio• Respect for participants

– Privacy / confidentiality– Sharing of results (where possible)

• Informed consent• Rule of rescue• Data storage / protection

Is consent required?Initiatives that typically require implied* or verbal consent

Initiatives that typically require written consent

Initiatives that do NOT typically require expressed (verbal or written) consent

Surveys

Quality initiatives that require direct patient contact to test a new practice/idea that is not yet evidence-based (not yet a common standard of care)

Research projects

Focus Groups

Use of patient/family images, videos or quotes

Auditing charts or using data from electronic patient records to monitor compliance with a new best practice

(i.e. practice audits)

Still not sure if your project requires participant consent? Contact the Ethics Centre at x4818

*Implied consent = by choosing to participate they give their consent

“Ethical” survey design

• Is a survey the best tool to gather the required data? • Design based on “what problem are we trying to

solve?” • Ask only what is required to answer the question• Anonymity of responses• Identification of patients for before / after projects

(will they need to be assigned a number?)• Follow-up process for any concerns arising

Plotting data – tell a simple story

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make that will result in improvement?

AIM

CHANGES

MEASURES

Model for Improvement

The Model for Improvement (Langley, Nolan, et al. Improvement Guide, 1996)

“If I had an hour to solve a problem I'd spend 55 minutes thinking about the

problem and 5 minutes thinking about solutions.”

- Albert Einstein

Diagnosing the problem

Root causes & contributing factors

Gather data to answer some questions:• What is the problem you’re seeing?• How bad/frequent is this problem?• Why is it happening?• What factors are contributing to the problem? • How often are these contributing factors

occurring? • Is it happening broadly or in a subgroup?

Flow Chart Tool

• A FLOW CHART is a powerful tool for understanding: – How a system or process currently performs– Where deviations exist (due to design or error)– Where the greatest complexity exists – Where there are waits, delays, bottlenecks– What areas might be targeted for improvement

Flow Chart: visualizing your current state

Basic Flowcharting Symbols

Decision or question leading to a ‘Yes’ or ‘No’ response

A step or task in the process

The beginning or end of the process

Yes

No?

Root Cause Analysis

Reference: Canadian Incident Analysis Framework 2012 (CPSI)

Root Cause Analysis

Reference: Canadian Incident Analysis Framework 2012 (CPSI)

Experience-based design

• Do I understand the patient’s path? • Do I understand their experience/feelings along the

path (‘touchpoints’)? • Do I understand what triggered those feelings?

• Work with patients, caregivers and frontline staff to redesign these experiences rather than just systems and processes.

Reference: NHS Institute for Innovation & Improvement (2006 – 2013)

http://www.kingsfund.org.uk/projects/ebcd/experience-based-co-design-description

Hierarchy of Effectiveness

Forcing and constraining functions

Automation and computerization

Simplification and standardization

Independent double check system/ other redundancies

Policies and procedures

Training and education

Most

Least

Based on a bulletin from ISMP. Medication error prevention tool box. ISMP Medication Safety Alert. 1999 (June).

Recap: Model for Improvement

• Start with a clear aim statement• Understand how you’ll use data to guide you

in selecting & monitoring improvements• Choose changes wisely and with the right

input

Act

What changes are to be made?

Next cycle?

Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when)

Study Complete the analysis of the data

Compare data to

predictionsSummarize what

was learned

DoCarry out the planDocument problems and unexpected observations Begin analysis of the data

The PDSA Cycle

Key Principles of PDSA Method

• Iterative cycles• Initial small-scale testing• Prediction-based testing of change• Use of data over time• Documentation

Taylor MJ, et al. BMJ Qual Saf 2013; 23: 290 - 298

Why test using PDSA?

• Increase the belief that the change will result in improvement in your environment (with your team)

• Predict how much improvement can be expected from the change – learning in action

• Learn how to adapt the change to different conditions and settings (refine and moving forward)

• Evaluate costs and side-effects of the change• Minimize resistance upon implementation• “What can we do by next Tuesday?”

PDSA Cycle Worksheet

Repeated Use of the Cycle

Change ideas to be

tested

Changes That Result

in Improvement

A P

S D

APS

D

A P

S DD S

P ADATA

Increasing ---complexitynumber of peopledifferent situations

Time

Multiple tests of change

http://www.youtube.com/watch?v=osUwukXSd0k

Multiple root causes = multiple tests of change

Tips for Successful PDSA Cycles

• Engage early adopters• Keep it small• Reflecting on what is learned with each test of

change is the key to improvement• If at first you don’t succeed, try something else*• Lack of success is not failure if, in doing so, you

learn something new• Improvement requires change

* Six Sources of Influence, Joseph Grenny, et al. – Influencer

Reflection Point

• Improvement requires change….

….but not all change leads to improvement

Change experience

Exercise – 5 minutes:

• Individually, describe the feelings or issues you have experienced when in a change situation

Are your experiences with change reflected in the following definition?

• Change is an event • It happens every time something stops or

something new starts• It happens outside us and can be measured in

chronological time• It can happen fairly quickly• It is usually concrete and tangible

Reference: William Bridges & Associates

• No.

That’s because we don’t experience change …we experience transition.

Transition is…different

• Transition takes place inside us• It engages our emotions, feelings, thoughts• It is a gradual, psychological reorientation

to what is new and different • We all go through this transition when a

change impacts us • Change is on the outside

W. Bridges: Managing Transitions

• It starts with Endings, a disengagement from what is now

• Neutral Zone, an uncomfortable, disorienting, chaotic time that we all move though

• New Beginnings, where we finally settle into a feeling of being

“with it” or “on track” again (new norm)

EventsSituationalOutcome-focusedRelatively quick

TRANSITIONExperiencePsychologicalProcess-basedGradual and slow

Reference: William Bridges & Associates

CHANGE

The Science of Change

Source: Everett Rogers – Diffusion of Innovations Model (Rogers 1962, p. 150)

Mindset vs. Skill Set

Mindset of a Change Leader• We experience transition, not change• People adapt to change at different speeds

Skill Set of a Change Leader• Diagnose the people and the situation• Plan & prepare: use a structured approach

Kotter Change Management Model

1. Establish a sense of urgency

• Create a sense of urgency; burning platform

• What are the driving forces that make this change necessary for success?

John Kotter: Leading Change

2. Creating the guiding coalition

• Behaviour, not personality, is crucial• Consider who will be impacted by the change

– both upstream and downstream• Whose support is required?• Whose input is required?• Whose influence is required?• What information do I need to engage each member of

the team?• Have you addressed “What’s in it for me?” and “What’s

in it for us?”

Additional information available at: www.kotterinternational.com

3. Develop a vision and strategy

A vision should be: • Simple: No techno babble or jargon. • Vivid: A verbal picture is worth a thousand words

– use metaphor, analogy, and example. • Repeatable: Ideas should be able to be spread by

anyone to anyone. • Invitational: Two-way communication is always

more powerful than one-way communication.

Leading Change, John Kotter

4. Communicate the change

Key elements in the effective communication of vision• Keep it simple• Use metaphors, analogies and examples• Leverage multiple forums• Repeat the message• Lead by example• Explain inconsistencies• Listen to feedback

www.kotterinternational.com

Communication is in the eye of the beholder…

What we have here, is afailure to communicate…

What’s in it for me?

• Role Play Exercise• Characters

1. Change Leader2. Frontline staff

• Scenario: see handout

Exercise:

• Change Leader:________________________________________________________________________________________________________________________________________________________________________

• Frontline Staff:________________________________________________________________________________________________________________________________________________________________________

Polarity Management

BENEFITS BENEFITS

DISADVANTAGES DISADVANTAGES

OLD WAY NEW WAY

BENEFITS BENEFITS

DISADVANTAGES DISADVANTAGES

OLD WAY NEW WAY

5. Empower broad-based action

Get rid of any obstacles which threaten the project. Remove systems or structures that undermine the change vision.

Implementing Change

• Coach and role model desired behaviours• Provide tools and training• Answer questions ASAP• Provide resources and give authority for decision-making• Provide data to make decisions and recognize progress• Seek input and suggestions• Ensure active involvement / visibility if team• Develop policies & procedures • Establish performance standards

6. Generate short-term wins

• Provide evidence that the sacrifices are paying off• Increase the sense of urgency and the optimism of

those who are making the effort to change• Reward the change agents by providing positive

feedback that boosts morale and motivation• Help fine tune the vision and the strategies• Allow guiding coalition to course-correct

www.kotterinternational.com

7. Don’t Let Up(Consolidate the gains & produce more change)

• Highlight/engage good change ‘adopters’• Communicate progress with data (set milestones –

mark their achievement)• Share stories & discuss/analyse setbacks• Solicit feedback (new ideas) that align with the vision• Empower ‘adopters’ to lead new projects• Ensure adequate oversight/governance• Constant effort to keep urgency high

Maintaining momentum…

8. Make it stick!

• Anchor the new approach into culture

Culture Change

• Cultural change comes last, not first • You must be able to prove that the new way is

superior to the old • The success must be visible and well communicated • You will lose some people in the process • You must reinforce new norms and values with

incentives and rewards• Reinforce the culture with every new employee

www.kotterinternational.com

Sustaining the Change

• Align structures to reinforce new goals & behaviours: policies, processes, performance reviews, hiring criteria

• Assist with “unlearning” • Reward & recognize good behaviour• Communicate positive results – use concrete data and

anecdotes to celebrate progress and milestones• Institute formal processes for measuring and monitoring

progress (information & governance)• Revise ongoing education, recertification and

orientation/training of new employees

Mobilizing change starts with the individual

Head

Heart

Hands

Understanding the need for change

“Commitment” to thechange

Translating thoughts and feelings into actions

Reference: Mercer Delta Consulting

head heart hands

Understanding Commitment Execution

Learning Objectives

• Establish a clear improvement goal for an improvement project

• Plan effective rapid cycle improvements using the PDSA cycle model

• Understand the importance of QI measurement and how to select indicators

• Appreciate the importance of good survey design, data collection and the ethics of quality improvement

• Incorporate change management skills in order to enhance improvement projects

Final Reflection

• What new skill might you apply to your quality improvement efforts going forward?

• What resonated with you today?

Additional Resources and References• www.ihi.org • www.ouricebergismelting.com • http://heathbrothers.com/ • Langley, et al. The Improvement Guide – A Practical Approach to Enhancing

Organizational Performance, San Francisco, CA (2009)• SQUIRE Guidelines http://squire-statement.org/guidelines • Vital Smarts, Joseph Grenney

http://www.crucialskills.com/2009/09/all-washed-up• Canadian Patient Safety Institute – Tools & Resources:

http://www.patientsafetyinstitute.ca/English/Pages/default.aspx • Experience-based design – Health Quality Ontario:• http://www.hqontario.ca/Portals/0/Documents/qi/qi-voc-primer-en.pdf

Contact Information

Brigette Hales, M.Sc. Manager, Patient Safety & Performance ImprovementSunnybrook Health Sciences CentreToronto, OntarioBrigette.Hales@sunnybrook.ca

Blair Henry, M.T.S. (Bioethics)Ethicist, Sunnybrook Health Sciences CentreFaculty Member, Dept of Family & Community Medicine, Member Joint Centre for Bioethics at University of TorontoBlair.Henry@sunnybrook.ca

APPENDIX

Additional materials / information

How much data do you need?

Sample size considerationsMeasurement for Research Measurement for Learning and

Process Improvement

Purpose To discover new knowledge To bring new knowledge into daily practice

Tests One large "blind" test Many sequential, observable tests

Biases Control for as many biases as possible

Stabilize the biases from test to test

Data Gather as much data as possible, "just in case"

Gather "just enough" data to learn and complete another cycle

Duration Can take long periods of time to obtain results

"Small tests of significant changes" accelerates the rate of

improvement

 

www.ihi.org

Sample Size Estimation• Quarterly Sample Size:

Average Eligible Patient Population per Quarter

Minimum Required Sample Size

>= 1551 311

391 – 1550 20% of the eligible population

78 – 390 78

6 – 77 No sampling; 100% of the eligible population required

0 – 5 No sampling; 100% of the eligible population required*

Slide Reference: Monique Lloyd, RN, PhD – RNAO

Reference: www.thunderfly.co.uk

Characteristics of a good graph

• Clear title• Simple axis labels• A legend explaining

graph elements• Elements that allow

the reader to get the point

• Reduce clutter (space between bars)

• A scale appropriate to the data

• Dates over time• Benchmark & Target• Mean and median• Annotated events,

process changes, etc. (tells a story)

Plotting Data

Change Implemented

Implementing Change

Knoster Change Model (1991) – Diagram adapted by www.gregorydenby.com