Topic 7

Introduction to methods for quality improvement

Learning objective

• the objectives of this topic are to:

– describe the basic principles of quality improvement– introduce students to the methods and tools for improving the

quality of health care

Performance requirement

• know how to use a range of improvement activities and tools

Knowledge requirements

• the science of improvement• the quality improvement model• change concepts• two examples of continuous improvement methods• methods for providing information on clinical care

W Edwards Deming

The science of improvement

• appreciation of a system• understanding of variation • theory of knowledge • psychology

Measurement 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" accelerate the rate of improvement

The Institute for Healthcare Improvement (IHI): different measures

Three types of measures

• outcome measures • process measures• balancing measures

The quality improvement model-the PDSA cycle

• 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 an

improvement?

ACT PLAN

What are we trying to accomplish?

How we will know that a change is an improvement?

What change can we make that will result in an improvement?

DOSTUDY

The model for improvement

Langley, Nolan, Nolan, Norman & Provost 1999

ACT PLAN

DOSTUDY

Determines what changes are to be made

Summarizes what was learned

Change or test

Carry out the plan

Langley, Nolan, Nolan Norman & Provost 1999

The PDSA cycle

Change concepts …

… are general ideas, with proven merit and sound scientific or logical foundation that can stimulate specific ideas for changes that lead to improvement.

Nolan & Schall, 1996

9 categories of change

• eliminate waste• improve work flow• optimize inventory• change the work environment• enhance the producer/customer relationship• manage time• manage variation• design systems to avoid mistakes• focus on the product or service

Langley, Nolan, Nolan, Norman & Provost 1999

Two continuous improvement methods

• clinical practice improvement methodology (CPI)• root cause analysis

DP A

S

3

Intervention phase

Diagnostic phase

2

1

Project phase

4

5

Sustaining improvement phase

Impact phase

Project mission Project team

Conceptual flow of process Customer gridData-fishbone-Pareto chart-run charts-SPC charts

2 months

Plan a changeDo it in a small testStudy its effectsAct on the result

2 months

1 month

Annotated run chart SPC charts

DP

AS

DP

AS

D PASD

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

Identify appropriate interventionsImplement changes identified in the diagnostic phase Undertake one or more PDSA cycles

Interventions phase

Decide on interventions

Undertake one or more PDSA cycles

Interventions phase

Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

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

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

ACTWhat

changes can be made for the next cycle (adapt change, another test, implementation cycle?)

•

PLAN• Objective

• Prediction

• Plan for change (who, what, when, where)

• Plan for data collection (who, what, when, where)

• Carry out the change

• Document observations

• Record data

DOComplete analysis of data

Compare results to predictions

Summarize knowledge gained

•

•

•

STUDY

How to use the PDSA Cycle

• use plan-do-study-act cycles to conduct small-scale tests of change in real settings– plan a change– do it in a small test– study its effects– act on what learned

• team uses and links small PDSA cycles until ready for broad implementation

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

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

PDSA Cycles – single test Changes

that result in improvement

Hunches, theories and ideas

A

S D

P

AS

DP

AS

DP

A

SD

P

PDSA cycle - single test

PDSA Cycles – multiple tests

A

S D

P A

S D

P A

S D

P

P

D A

S

P

D A

S

P

D A

S

D

P A

S D

P A

S D

P A

S

Test 1 Test 3Test 2

PDSA cycle – multiple tests

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

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

1. Measure impact of changes/interventions2. Record the results 3. Revise the interventions4. Monitor impact

Impact and implementation phase

Implement the changes

Measure impact • Annotated run chart

• SPC charts

• Other graphs

Impact and implementation phase

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

(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)

Root cause analysis

• a multidisciplinary team• the root cause analysis effort is directed towards finding

out what happened• establishing the contributing factors of root causes

Performance requirements

Know how to use a range of improvement activities and tools

• flowcharts• cause and effect diagrams (Ishikawa/fishbone)• Pareto charts• run charts

0

2

4

6

8

10

12

14

LOS days

Hospital NSW Health Kehlet et.al

At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.

Evidence for there being a problem worth solving

Flow chart of processFlow chart of process

Something amiss

Referral to Hospital

Visit to general practitioner

Referral to surgeon

Investigations

Hospital admission

Admissions office

Operating theatre

Admitted to hospital

Preoperative clinic

Post anaesthetic care

Allied health

Surgical ward

Surgical team

Discharge plannerPre-op wardPain team

Home

Community health/Peripheral hospital

Return to life

Accelerated Recovery Colectomy Surgery (ARCS)Jenni Prince Jenni Prince Area CNC Pain ManagementArea CNC Pain ManagementNorth Coast Area Health ServiceNorth Coast Area Health ServiceNCHI Sydney AustraliaNCHI Sydney Australia

Multidisciplinary meeting to:

-ask opinion

-brainstorm process of care

-how to improve the process

-who to include in the process of change

-how to communicate progress

standardization

Evidence-based practice

team approach

Customer and expectations list

• surgical ward staff• post-op anaesthetic care staff• physiotherapy dept

• dietitian• peri-operative unit staff• private hospital staff• pain team• anaesthetists• surgeons• intensivist

Cause and effect diagram

Social issues

Staff attitudes Complications

Procedure Patient perception Post discharge support

Prolonged LOS

surgery

mobilization

nutrition

nil by mouth

LOS

mobilization

pain control

nutrition

expect long LOS

home support

often weak

poor understanding of procedure

little knowledge of support services

pain controllocus of control

family support

poor pain control

wound complications

weak/malnourished

community health

general practitioner

infection

family

colon care nurse

Accelerated Recovery Colectomy Surgery (ARCS)Jenni Prince Jenni Prince Area CNC Pain ManagementArea CNC Pain ManagementNorth Coast Area Health ServiceNorth Coast Area Health ServiceNCHI Sydney AustraliaNCHI Sydney Australia

45

34

28

18

16

8

38

0

5

10

15

20

25

30

35

40

45

poor patie

nt knowledge

non-standardized pain control

imbedded staff a

ttitudes

poorly coordinated discharge

slow to m

obilize

undernourished patients etc

24

57

42

7667

80

100

Pareto chart

surgical incisionsurgical incision trial of transverse incisiontrial of transverse incision pain control pain control wound infusion for transverse wound infusion for transverse incisionsincisions

thenthen

• patient information booklet• surgeon pathway• anaesthetic pathway• ARCS clinical pathway - surgical technique- surgical technique

- pain control- pain control- - bowel prep/care- nutrition- nutrition- mobilization- mobilization

1 1 surgeosurgeon10 n10 patientpatientss

1 1 surgeosurgeon1-6 n1-6 patientpatientss

PDSA cycles - implementation

Average LOS (days) per month

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10 11 12

month

day

sRun chart

Made change here

Strategies for sustaining improvement

• document and report each patient LOS• measure and calculate monthly average LOS• place run chart in operating theatre, update run chart

monthly• bimonthly team meetings to report positives and

negatives• continuously refine the clinical pathways • report outcomes to clinical governance unit • Spread - all surgeons

- left hemicolectomy- all colectomy surgery- throughout North Coast Area Health

Service