An Introduction to Quality Improvement

Day 1

6th November 2014

Welcome

• Tom Downes

- Clinical Lead for Quality Improvement

• Nicola Platts

- Improvement Facilitator

@sheffielddoc

@nicola_platts

Aims / Objectives

To teach some of the basics

of Quality Improvement…

Agenda – Day 1 - Morning • 09.30 Welcome & Feedback on Self Assessment ( 20 mins )

• 09.50 Patient Story (10 mins)

• 10.00 Complexity (20 mins)

• 10.20 Patient Story Part 2 (10 mins)

• 10.30 The Structure of Improvement (20 mins)

• 10.50 Pull the Lever (10 mins)

• 11.00 Coffee (20 mins)

• 11.20 Systems Thinking & Activity (20 mins)

• 11.40 Microsystems and ownership (20mins)

• 12.00 The 5Ps (10 mins)

• 12.10 Themes and Global Aims (20 minutes)

• 12.30 Lunch

Agenda – Day 1 - Afternoon

• 13.10 Process mapping (60 mins)

• 14.10 Theory of Constraints (10 mins)

• 14.20 The Model for Improvement (10 mins )

• 14.30 Specific Aims Activity (10 mins)

• 14.40 Coffee

• 14.50 M & M Challenge (30 mins)

• 15.20 Measurement (10 mins)

• 15.30 Weight Loss Activity (30 mins)

• 16.00 Evaluation

• 16.10 Close

Key Elements Required for Improvement

Will to do what it takes to change to a new system

Ideas on which to base the design of the new system

Execution of the ideas

A patient story

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Surg

ery

IV

antibio

tics

Dis

charg

e

Pain

ful hand

Ora

l antibio

tics

COMPLEXITY

Ford Mustang

1968 2015

Royal Hallamshire Hospital

1968 2015

Age-standardised five-year relative survival rate,

female breast cancer, England and Wales, 1971-2009

0

10

20

30

40

50

60

70

80

90

100

1971-1975

1976-1980

1981-1985

1986-1990

1991-1995

1996-1999

2001-2006*

2007-2009*

% s

urv

ival

Period of diagnosis

* England only

Chance of Successful Outcome

Time

Surgery Post-Op

Potential

Actual: Great

Actual: Poor

Health care: Good News / Bad News

A patient story

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Surg

ery

IV

antibio

tics

Dis

charg

e

Pain

ful hand

Ora

l antibio

tics

Wound e

xam

ined

Wound r

edre

ssed

Antibio

tics late

Antibio

tics late

3 h

ours

to a

ccess

Second o

pera

tion

Sta

ph / S

trep m

op

Calls

unansw

ere

d

No a

ntibio

tics

No a

nitbio

tics

Work

aro

und a

dm

issio

n

Within 2 weeks two adults died of

identical strain of streptococcal

infection

Successful outcome: • due to fantastic individuals • despite the system If ‘ideal’ systematic had been care delivered: • Would patient satisfaction have been higher? • Would length of stay have been shorter? • Would second operation have been

necessary? • Were the two deaths avoidable?

QUALITY IMPROVEMENT? What is

High Quality care is care that is:

• Safe – no needless deaths

• Effective – no needless pain or suffering

• Patient-Centered – no helplessness in those

served or serving

• Timely – no unwanted waiting

• Efficient – no waste

• Equitable – for all

Quality: The IOM’s Six Aims

Improvement

The combination of a ‘change’

combined with a ‘method’ to

attain a superior outcome

Model I: Bad Apples

The

Problem

Quality

Frequency

The Simple, Wrong Answer

Blame

Somebody

The Cycle of Fear

Increase

Fear

Micromanage Kill the

Messenger

Filter the

Information

Model 2: Positive deviance

Quality

Frequency

Model 2: Continuous Improvement

“Every Defect is a Treasure”

Quality

F

req

ue

nc

y

Quality Improvement -

The structure

Assessment - 5Ps

Diagnosis - Change Ideas

Treatment

- PDSA

SDSA

‘Standardise’

The Value of

“Failed” Tests

“I did not fail one

thousand times; I found

one thousand ways how

not to make a light bulb.”

Thomas Edison

SYSTEMS THINKING

• Step 1 – Everyone stand up

• Step 2 – Without speaking; pick two people but

don’t say who they are or point at them (Keep it a

secret)

• Step 3 - Move to be equidistant between both of

the people

Understanding Systems

• What is a “system”?

• How do we define a “system”?

A collection of parts and processes organised

around a purpose.

Processes?

• How is a process different from a “system”?

• Can we brainstorm a series of processes which

make up the “systems” we might encounter in our

improvement work?

Elements of a Process

33

Suppliers Outcomes

Thing being passed along

Inputs Outputs

Sequence of steps

MICROSYSTEMS: AN OVERVIEW

Microsystems

• 1992 – Quinn – ‘Intelligent Enterprise’

• Studied the ‘best of the best’

• They are organised around the frontline

interface with the customer

• ‘Smallest replicable unit’

Microsystems

• Nelson, Batalden, Godfrey 2000 – 2007

• Looked at the characteristics of high

performing clinical microsystems

• Formulated a curriculum to develop high

performing microsystems

High Performing Clinical Microsystems

Information

&

Information

Technology

Staff • Staff focus

• Education &

Training

• Interdependence

of care team

Patients • Patient Focus

• Community &

Market Focus

Performance • Performance

results

• Process

improvement

Leadership • Leadership

• Organizational

support

38

What is a Clinical Microsystem?

• ‘The Place where Patients, Families and

Clinical Teams meet’

• The essential frontline building blocks of any

healthcare system. It is where the quality

is delivered.

It’s where everything happens with, for and

to the patient and family

Clinical Microsystem Outputs Inputs

Pharmacy

People with Healthcare Needs Met

People with Healthcare

Needs

X ray IT Supplies Medical

Records

Supporting Microsystems

Supporting Microsystems

Have Many Roles:

Within their own microsystem

and as members of other

microsystems

41

Chest

Medicine

STH

• Some of you have a red card

• Read out in turn

• Is this a Microsystem?

Is this a

Microsystem?

“The principal task of the mesosystem is

to enable the work of the microsystems

for the population(s) of patients served.”

Paul Batalden

THE MICROSYSTEMS

APPROACH TO IMPROVEMENT

- ‘OWNERSHIP’ VS. ‘BUY IN’

These are not the same thing

Why?

‘Ownership’

• Is where you share the ownership of an

idea, a decision, an action plan.

• You have participated in it’s development,

you have chosen it of your own accord and

you endorse it.

• You understand it and believe in it and are

willing to implement it

‘Buy In’

‘Buy – In’ is the opposite

• Someone else has done the development,

the thinking

• They are now telling you or convincing you

to implement their ideas

REDESIGN FROM

THE INSIDE - OUT

Microsystems is about

ownership

Team Coaching

Improvement

Science

Microsystem

Improving Microsystems - Elements

QI

18

Quality Improvement -

The structure

Assessment - 5Ps

Diagnose – Change Ideas

Treat

PDSA

SDSA

‘Standardise’

Define Themes

Just like a patient…

To improve a patient’s health status

A clinician:

• Assesses

• Diagnoses

• Treats

• Follows-up

based on biomedical science,

patient preferences,

and their outcomes.

Assessing the system • We need data to understand the system

Purpose

5 Ps

Know Your Patients

• What conditions do they present with?

• What are the demographics? Where

do they travel from?

• What do they think about the service?

• What do they think we can do better?

• What is like in daily to life to have the

condition(s) you treat?

Use Trust Information, Recent surveys,

Talk to patients!

Know Your Professionals

• Who works here?

• How many of each role?

• What do staff think about the service?

-What do they love about their microsystem?

-What drives them nuts?

Involve staff by asking them what they think

Know Your Processes

• What are our key processes that patients go

through in the department?

• How do we get patients into the microsystem?

• How long do things take?

• What help do they depend on from other

support/clinical microsystems?

Create a high level process map (7-12 boxes)

Know Your Patterns

• How is the microsystem performing?

• What are the metrics that matter in this

microsystem? The outcome measures?

• What are the trends over time?

• What are we proud of? What needs improving?

• What data are we tracking? What data is

missing?

- Referrals, DNA, Follow-up queue, Wait for

appointment, 18 Weeks

A Real 5Ps Story – Cystic Fibrosis Unit

Pre Phase – The Work Before the Work

• March 2011

• Met clinical leaders – ‘challenging’ team dynamics

• Lots of time invested in discussing the approach

with the Doctors, manager and senior nurses

• Sought support from Clinical Director

• Agreed expectations, set a regular weekly

meeting, communication plan, who would be

involved, Patient representation

• Coach – visit

Initial Meeting - April 2011

• Introduced what quality improvement is

• Introduced effective meeting skills and roles

• Set up the ground rules

59

2

Service Improvement

There’s so much talk about

the system. And so little

understanding

Robert Pirsig

Zen and the Art of Motorcycle Maintenance

3

Service Improvement

Ground Rules

You are all equal•System, NOT individuals•Treat others as you would expect to be treated

•All contributions are valuable•Please don’t interrupt•Don’t say it can’t be done!•If you oppose, you must propose•No meddling•Please have fun

Patients -

Hello to

Brandon

60

The 5Ps develop.....

Purpose

• What is the purpose of the microsystem?

• Lots of debate!

‘To enable people with CF to live

as normal a life as possible’

Remember that the aim of the 5Ps is.......

To understand the system well

enough to generate your first

for improvement

How to create the 5Ps - tips

5Ps review – May 2011

• Meeting dedicated to reviewing the 5Ps

• Team stuck post its – where they saw

something to improve for Brandon

• Grouped these to form ‘Themes’

How to create the 5Ps - tips

• Don’t spend too long in this phase!

• Some Ps can be done in weekly meetings

(Purpose, Processes)

• MCA has useful templates

• Doesn’t have to be pretty

• Use as much existing data, resources and

information support as is available (ecat,

surveys, reports, datix, information services

etc.)

Remember that the aim of the 5Ps is.......

To understand the system well

enough to generate your first

for improvement

How to create the 5Ps - tips

Diagnosis – Selecting a theme

Can be tested without

permission from others

Most important for our

patients

No cost High impact for low effort

Must do –strategic importance.

Global Aim Statement

• Clarifies and connects the improvement theme to

your work

• The starting point

• Sets the scope

• Increasing clarity of focus

CF Clinic Global Aim

•We aim to improve the efficiency and quality of

the service of the CF outpatient clinic for staff and

patients. The process begins with first contact

with the patient and ends with them arriving back

to their home after the visit. By working on the

process we expect; the DNA rate to improve, for

there to be less waiting for patients, improved

efficiency for patients and staff and to achieve a

greater standard of our quality markers. It is

important to work on this to improve the clinic

experience for patients, meet CF trust standards,

and to provide an area of clinical excellence.

69

Template for writing a global aim

Write a Theme for Improvement: _________________________________________

Global Aim Statement Create an aim statement that will help keep your focus clear and your work productive:

We aim to improve: _________________________________________________________________ (Name the process)

In: _______________________________________________________________________________ (Clinical location in which process is embedded)

The process begins with: _____________________________________________________________ (Name where the process begins)

The process ends with: _______________________________________________________________ (Name the ending point of the process)

By working on the process, we expect: __________________________________________________ (List benefits)

It is important to work on this now because: ______________________________________________ (List imperatives)

Create Flowchart

PROCESS MAPPING

PROCESS

Processes

“Every system is perfectly

designed to get

the results it gets”

Paul B. Batalden

Process Mapping

• Simple exercise.

• Picture of the sequence of steps in the process.

• Opportunity to bring multidisciplinary teams together.

• Identify what actually happens now in a process.

• Overview of how complicated the process can be for

patients.

High Level Example – Renal OPD

Referral Grading Admin—New Appointment

Prep clinic, Notes

Reception New and Fol-

low Up

Specimen Room

Dr or SPR or MDT Review

Dietician Re-view (Some

Patients)

Bloods Reception, Book Follow

Up

Visit Phar-macy for

Meds

Iron Clinic

Referral Grading Admin—New Appointment

Prep clinic, Notes

Reception New and Fol-

low Up

Specimen Room

Dr or SPR or MDT Review

Dietician Re-view (Some

Patients)

Bloods Reception, Book Follow

Up

Visit Phar-macy for

Meds

Iron Clinic

Analyse the process

• Number of steps

• Order

• Transfer of ‘object’ from one person to

another (loss and probability of error)

• Delays

• Added Value

• Bottlenecks

Added ‘value’

Produce a process map

for making a paper airplane

Referral Grading Admin—New Appointment

Prep clinic, Notes

Reception New and Fol-

low Up

Specimen Room

Dr or SPR or MDT Review

Dietician Re-view (Some

Patients)

Bloods Reception, Book Follow

Up

Visit Phar-macy for

Meds

Iron Clinic

Referral Grading Admin—New Appointment

Prep clinic, Notes

Reception New and Fol-

low Up

Specimen Room

Dr or SPR or MDT Review

Dietician Re-view (Some

Patients)

Bloods Reception, Book Follow

Up

Visit Phar-macy for

Meds

Iron Clinic

500 grains/30 secs

270 grains/30 secs

170 grains/30 secs

270 grains /30 secs

Bottlenecks

500/30 secs

270/30 secs

170/30 secs

270/30 secs

InputOutput

Using Process

Maps to generate

change ideas

Regional anaesthetic

used.

Consultant transports patient back to

the ward and discusses surgery.

Time in recovery

not required.

Consultant returns

patient to TAU and

consents the next

available patient

Member of theatre

team collects patient

directly from TAU

THE MODEL FOR

IMPROVEMENT

The Model for Improvement

• A framework for testing ideas

• Fundamental questions come first –

Aim – What are we trying to accomplish?

Measures – How will we know the change is an

improvement

Changes – What changes can we make that will

result in an improvement?

Plan

•Objective

•Questions and

predictions (Why)

•The plan – who what

where when

Do

•Do the Plan

•Document problems,

observations

•Begin analysis

of the data

Study

•Complete analysis of

data

•Compare data to

predictions

•Summarise the

learning

Act

•What changes

are to made now?

•What is the next

cycle

PDSA

PDSA - experimentation • Always start with a specific aim - What are we trying to accomplish?

• How will know if this is an improvement? – Data.

• Small tests of change over a short time

• Debrief frequently

• Communicate results

• Repeated Cycles

• When we meet our aim? –

SDSA = Standardise

SDSA

1

3

2

P

DS

A

P

DS

A

P

DS

A

P

DS

A

P

DS

A

P

DS

A

4

5

6

Flowchart – A detailed process map

• Took three sessions

• Everybody understood the process by the end!

• Generated lots of change ideas – Car Park

Specific Aim – June 2011

• After reviewing the 5Ps and the Flowchart the

team chose to reduce Patient waiting as their first

Specific Aim

‘We aim to reduce average total patient waiting time

within the 2 CF outpatient clinics by 50% from our

baseline measure of 40 minutes by the end of

October 2011’

90 90

Service Improvement

Why are Patients waiting in

the CF clinic?

Late & early arrivals Communication

Treatments Finding Things

Scheduling

Interruptions

Mismatch of arrivals and

resources

Don’t know how long

things take – cycle times

Non standardised –

variation in content

Waiting for other

professionals to finish

Culture – it’s accepted

See early patients

early (sometimes)

See patients even if

late

Patients don’t have

own transport

Hospital transport is

late Reliant on others for

lifts

Fax machine doesn’t

work properly

Dictation delays clinic,

always get out of sync

Trials

PEG changes,

not planned

into timings

Going to find

nebuliser from the

ward

Notes

Scales

X ray

Going to the Pharmacy if

patient too unwell

Pharmacy

Taking patient off for a

ward tour

Answering the doorbell

Telephone Calls

Calls from the ward

Lots of paperwork -

delays the clinic

Change Ideas

• Review of Fishbone and Process map

• Brainstormed ideas to reduce waiting – top 4

91

Reschedule

the clinics

Standardise

the

paperwork

New Clinic

Whiteboard

Get

everything

we need

PDSA - Plan

1.15 1.30 2.00 2.30 3.00 3.30 4.00 4.30 5.00

Patient 1L L L W N D D D D Dr Dr Dr Dr O O O

Patient 2L L L W N D D D D Dr Dr Dr Dr O O O

Patient 3L L L W N D D D D Dr Dr Dr Dr O O O

Patient 4L L L W N D D D D Dr Dr Dr Dr O O O

Patient 5L L L W N D D D D Dr Dr Dr Dr O O O

Patient 6L L L W N D D D D Dr Dr Dr Dr O O O

Patient 7L L L W N D D D D Dr Dr Dr Dr O O O

Patient 8L L L W N D D D D Dr Dr Dr Dr O O O

Patient 9L L L W N D D D D Dr Dr Dr Dr O O O

Patient 10L L L W N D D D D Dr Dr Dr Dr O O O

Patient 11L L L W N D D D D Dr Dr Dr Dr O O O

Patient 12L L L W N D D D D Dr Dr Dr Dr O O O

Patient 13L L L W N D D D D Dr Dr Dr Dr O O O

Patient 14L L L W N D D D D Dr Dr Dr Dr O O O

Patient 15L L L W N D D D D Dr Dr Dr Dr O O O

Patient 16L L L W N D D D D Dr Dr Dr Dr O O O

Patient 17L L L W N D D D D Dr Dr Dr Dr O O O

Patient 18L L L W N D D D D Dr Dr Dr Dr O O O

PDSA – Do & Study

CF - Themes, Aims and PDSA Cycles

1

ThemesCapacity &

DemandAdherence

Clinic

Process &

Flow

5Ps

Global Aim Global Aim Global Aim

Specific Aim 1

Reduce Waiting

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Specific Aim 2

Reduce DNA

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Specific Aim 1

Increase nurse

led activity

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Specific Aim 2

Reduce

Variation in

follow up

frequency

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Specific Aim

Shorten Annual

Review

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Specific Aim 1

Increase use of

iNebs

Specific Aim 2

Increase use of

MI

Flowchart FlowchartFlowchart

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Always start with a Specific Aim…

An aim should be ‘impossible’ within our current

system – meaning we will need to completely

transform how we work in order to accomplish

what we set out to do

PROCESS

Key Components of an AIM

• ambitious

• measureable

• operationally specific

• time-limited

Transformative

“The greatest danger for most of us is not that our aim is

too high and that we miss it, but that it is too low and we

reach it”. Michaelangelo

Setting an Aim

• What are we trying to accomplish?

•Having a clear understanding of your Aim is critical

-Key points:

How Much?

By When?

Global Aim

Specific Aim

Change Idea

Conceptual Definition

Measurement

Plan

‘The How’

Operational

Definition

“The Big Picture”

“The Component Parts”

“How you will do it”

The Measure (Abstract Idea)

The Measure

(“Specify and Quantify”)

The “How, What, Where, When and

Who”

Workbook Page 156

AIM STATEMENT

• Less is not a number, soon is not a time

• We aim to reduce catheter associated UTIs among patients on Ward A1 by 50% by September 2013

What is a catheter associated UTI?

Is it bacteria in urine?

Or above plus fever or abdo tenderness or pyuria?

Or confusion?

Or above with other sources of infection excluded?

Where, by whom, when – rigorous specificity

Example Specific Aims

• We aim to achieve 50% of all daily TTOs are

written, checked and delivered to Pharmacy by

10am from the four Brearley Respiratory wards by

1st September 2012. Our current baseline

measure is 15% by 10am.

• We will decrease waiting times in Clinic DT247J

by 75% compared to our baseline measure by

March 2012

What is a specific aim from your global aim?

THE M&M CHALLENGE

The M&M Challenge

• Aim – to be left with one M&M at the end

• Measure – number of M&Ms left

Operational definitions:

•DO NOT EAT THE M&Ms

•Remove one to start

•Jump over one at a time and remove it

MEASUREMENT FOR

IMPROVEMENT

Measurement for Improvement

Improvement

Research Assurance

/Judgement

Sampling Water Content

TIME

Measurement for Research

•eg Peak flow of patients receiving active inhaler and placebo inhaler

• One large test / blinded / controlled

• Number of patients calculated to give power to results (usually p<0.05 or 5%)

• Inclusion and exclusion criteria to control for bias as far as possible

Measurement for Assurance

•eg HSMR

• All data included (100% of hospital admissions)

• No statistical testing

• Adjust to reduce bias

• Used by CQC and DH to monitor for poorly performing hospitals (bad apples)

Measurement for Improvement

•eg patient waiting time in clinic

• Sequential measurements

• ‘Just enough’ repeated small samples

• Accept consistent bias

• Test data using time series analytical statistics (SPC or run charts)

The Three Faces of Performance Measurement

Aspect Improvement Assurance Research

Aim Improvement of care

(optimise application of

knowledge)

Comparison, choice,

reassurance, spur for

change

Generate new knowledge

Methods:

•Test Observability

Test observable

No test, evaluate current

performance

Test blinded or controlled

• Bias Accept consistent bias Measure and adjust to

reduce bias

Design to eliminate bias

• Sample Size “Just enough” data, small

sequential samples

Obtain 100% of available,

relevant data

“Just in case” data

• Testing Strategy Sequential tests No tests One large test

• Determining if a change is an improvement

Time Series Data

(Run charts or Shewhart

control charts)

No change focus Hypothesis, statistical

tests (t-test, F-test, chi

square), p-values

Three Types of Measures for Improvement

• Outcome Measures

• Process Measures

• Balance Measures

Outcome Measures

• Outcome Measures:

• What is the outcome or result?

• How is the overall system performing? (Voice of the customer)

• What might some examples of outcome measures be?

Process Measures

• Process Measures:

• What is the system telling you about how well it is working?

• Are the parts/steps in the system performing as planned? (Voice of the system)

• What might some examples of process measures be?

Balance Measures

• Balance Measures:

• Unrelated Processes which might be affected by the changes we make

• What happened to the system as we improved the outcome and process measures?

• What might some examples of balance measures be?

Weight loss and developing

measures exercise Background: A friend has come to you and asked you to help develop measures for a group she is working with

Aim: The aim of the improvement project is for participants to lose weight. They need regular feedback to keep them on task

Develop a Family of 4 to 6 measures that could be reported each week for the project:

• Outcome Measures – 1-2 measures

• Process Measures – 2 measures

• Balance Measures – 1 or 2 measures

Agenda – Day 1 - Morning • 09.30 Welcome & Feedback on Self Assessment ( 20 mins )

• 09.50 Patient Story (10 mins)

• 10.00 Complexity (20 mins)

• 10.20 Patient Story Part 2 (10 mins)

• 10.30 The Structure of Improvement (20 mins)

• 10.50 Pull the Lever (10 mins)

• 11.00 Coffee (20 mins)

• 11.20 Systems Thinking & Activity (20 mins)

• 11.40 Microsystems and ownership (20mins)

• 12.00 The 5Ps (10 mins)

• 12.10 Themes and Global Aims (20 minutes)

• 12.30 Lunch

Agenda – Day 1 - Afternoon

• 13.10 Process mapping (60 mins)

• 14.10 Theory of Constraints (10 mins)

• 14.20 The Model for Improvement (10 mins )

• 14.30 Specific Aims Activity (10 mins)

• 14.40 Coffee

• 14.50 M & M Challenge (30 mins)

• 15.20 Measurement (10 mins)

• 15.30 Weight Loss Activity (30 mins)

• 16.00 Evaluation

• 16.10 Close